Content Page
Title page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract vi
Table of Contents vii
List of Tables x
List of Figures xi
List of Appendices xii
1.1 Background to the Study 1
1.2 Statement of the Problem 6
1.3 Objective of the Study 8
1.4 Research Questions 8
1.5 Hypotheses 9
1.6 Significance of the Study 9
1.7 Scope of the Study 9
1.8 Operational Definition of Terms 10
1.9 Chapter Outlay 11
2.0 Introduction 12
2.1 Policy 12
2.2 Health policy 14
2.3 Hospital policy 15
2.3.1 Educational development 16
2.3.2 Wage and salary 17
2.3.3 Nurse to patient ratio 17
2.3.4 No work, no pay 18
2.4 Attitude and work attitude 18
Content Page
2.4.1 Causes of employee attitude 19
2.5 Service delivery 21
2.5.1 Health care service delivery 23
2.6 Employee performance 25
2.6.1 Employee participation and performance relationship 27
2.7 Patients’ satisfaction 28
2.8 Health sector organization and their environment 29
2.8.1 Conceptual model 31
2.9 Empirical review 33
2.9.1 Attitude and service delivery 33
2.9.2 Motivation and service delivery 35
2.9.3 Management and service delivery 37
2.9.4 Service delivery through patient-centred care 39
2.9.5 Barriers to patient-centred care 41
2.10 Theoretical framework 43
2.10.1 Motivation theory – Herzberg two factor theory 43
2.10.2 Behavioral organizational theory 46
2.11 Gap in Literature 48
2.12 Conclusion 49
3.0 Introduction 51
3.1 Research design 51
3.2 Population 51
3.3 Sample size and sampling Technique 52
3.4 Instrumentation 53
3.5 Reliability test and validity of instrument 54
3.6 Method of Data Collection 54
3.7 Method of Data Analysis 55
3.8 Ethical consideration 55

4.0 Introduction 56
4.1 Socio demographic analysis of respondents 56
4.2 Analysis of questionnaire items 60
4.3 In-depth interview 71
4.4 Test of hypotheses 77
5.1 Summary 85
5.2 Conclusion 85
5.3 Recommendations 86
5.4 Limitation of the Study 86
5.5 Contribution to Knowledge 86
5.6 Implications for Policy 87
5.7 Suggestion for Further Studies 87

Table Page
1 Summary of reliability test 54
2 Socio Demographic data of the respondents 56
3 Questions addressing Policies 60
4 Questions addressing nurses’ work attitude 64
5 Questions addressing patients’ satisfaction 66
6 Questions addressing service delivery 68
7 In-depth interview guide 71
8 Regression result for policies vs nurses’ attitude 77
9 Regression result for nurses’ attitude vs service delivery 79
10 Regression result for nurses’ attitude vs patients’ satisfaction 81
11 Regression result for service delivery vs patients’ satisfaction 82

Figure Page

1 Conceptual Model 31
2 Herzberg’s two factor theory 45

Appendix Page
1 Raw Pilot Study data 97
2 Informed consent form 98
3 Questionnaire for nurses 99
4 In-depth interview consent form 104

  1. In-depth interview guide 105
  2. Turn it in report

1.1 Background to the Study
Despite bold plans and massive injections of international and domestic resources, public service delivery is still failing in many areas in several developing countries. This according to Mcloughlin and Bately (2012) suggests there is a need to revisit approaches to rendering assistance to service delivery sectors. It is also necessary to focus on understanding how a range of institutional and governance arrangements can shape service delivery processes and outcomes. They went further to say that while the number of political economy studies on different service delivery sectors and different countries is growing, these remain largely one-off or ad hoc studies. Thirdly, their study tends to talk in fairly generic terms about political and governance constraints. For example, concepts like ‘political will’ or the existence of ‘weak incentives’ are often referred to but rarely further developed in terms of the specific institutional and governance arrangements that contribute to these factors, and in terms of which of these may offer strategies for overcoming common bottlenecks or gaps ( Mcloughlin, Batley, 2012). Therefore, the justification for a service delivery reform may lie on the need for efficiency, effectiveness, and accountability (Lufunyo, 2013)
The tools and strategies used by stakeholders to achieve their policy objectives have also evolved and it is now common place to refer to governance as a range of old and new tools and instruments through which public policy goals may be achieved and/or delivered (Zito, Radaelli, Jordan, 2003; Hood, 2006). The very concept implies that the ways to govern the public sector and the tools for doing so have changed (Salamon, 2002) and – implicitly or explicitly – should change further from old command-and-control, public administration or management models (Bovaird, Löffler, 2003). The importance of policy or its implementation cannot be overemphasized particularly as it relates to health. This is becausehealth is an essential component of development, necessary for a nation’s economic growth and internal stability. It is a necessity for everyday life, not the object of living, but a positive concept emphasizing social and personal resources as well as physical capabilities. This may be said to explain the popular saying that a healthy nation is a wealthy nation. It is further emphasized by the definition of World Health Organization (WHO), (1946), that good health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.
To ensure that everyone has access to quality health, the Universal Declaration of Human Rights (1948), recognizes health as a fundamental human right. This means that the relief or cure of ill health is universally important and this makes it imperative to ensure that high quality services are provided in response to developments in medicine and the desire of the caring professions to aspire to clinical excellence (Sewell, 1997). Governments therefore have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. It may not be wrong therefore for one to reason that health and healthcare delivery can be viewed from a system perspective characterized by complexity and interconnectedness, where everything affects everything else.
Healthcare in communities and hospitals have become increasingly important, even as they face fundamental changes in their service delivery patterns (McKee & Healy, 2002; Lee, Chen & Weiner, 2004). The hospitals are governed by a set of processes and tools related to decision-making in steering the totality of institutional activity, influencing most major aspects of organizational behaviour and recognizing the complex relationships between multiple stakeholders otherwise called policy (Richard, Saltman Antonio Durán Hans, & Dubois, 2011). The policies governing hospital according to Ricard et al (2011) has a scope that ranges from normative values (equity, ethics) to access, quality, patient responsiveness, and patient safety dimensions. It also incorporates political, financial, managerial as well as daily operational issues.
In view of the foregoing, issues in healthcare need to be viewed holistically as integrated system of multiple components (people, organization, technology and resources) and perspectives (Health Systems, 2012). In furtherance of this, several researchers have posited on the challenges faced in the provision of evidence-informed health care, one of which is the right intervention to the right people at the right time in routine settings. While Marchal, Cavalli, and Kegel, (2009), Green and Collins, (2003) have observed that this challenge is particularly acute in low income settings, English, Ntoburi, Wagai, Mbindyo, Opiyo, Ayieko,…Irimu (2009) have gone on to describe the specific major failures in hospital care in Africa.
Here in Nigeria, staff attitude has been attributed to the poor health care delivery (Akerele, 1986; Maduabum, 1990; Afolabi & Erhun, 2003). Affirming this, the Federal Ministry of Health (2007), reported that the poor state of Nigeria’s health system is traceable to several factors; organization, stewardship, financing and provision of health services.
Attitude is an internal state that influences individual’s choices of personal action (Bianey, Ulloa, Adams, 2004). The attitude of the health care employee can affect service delivery either positively or negatively. In other words, attitudes are good predictors of behavior and they provide clues to an employee’s behavioral intentions or inclination to act in a certain way. According to Newstrom (2001), positive job attitude helps predict constructive behaviors, while negative job attitude helps predict undesirable behavior. Employee attitudes and behaviors are important factors in service encounters, with committed employees, particularly the frontline staff, linked with increased levels of customer satisfaction (Ballout, 2007). This is to ensure that organizational values such as the provision of quality service is established and sustained.
The Royal College of Nursing of the United Kingdom (GB) explains the difference between a professional nursing attitude, which is, values nurses hold as well as their thoughts and feelings; to behavior, which is what nurses actually do. It is therefore suggesting that a factor like working environment can prevent nurses from enacting their professional values, while affirming that sometimes things can go wrong. In hospitals, interaction between nurses and stakeholders has always been critical in determining whether patients experience satisfaction or dissatisfaction in the provision of inpatient and outpatient healthcare services (Zangaro & Soeken, 2007). The provision of poor-quality care has often been attributed to inadequate knowledge and skills compounded by broader system failures and low staff numbers. This has given rise to the need to tackle inadequate human resources for health (HRM), which also was noted as an essential part of strengthening health system and emphasized in the 2006 World Health Report.
However, the focus of attention has been on macro-level issues related to workforce, training, recruitment, retention, skill mix and distribution. More recently, attention has turned to the capacity of health workers, their motivation and other structural and organizational aspects of systems that influence performance than ways to satisfy the needs of the patients (Bradley, Youngkyoo, Cook, Sache, Donabedian, 1996). Notwithstanding the catalogue of researches carried out on the healthcare delivery system and several recommendations proffered, the perception of Nigeria’s hospitals, particularly the public ones are still very far from being impressive.
The aim of this study is to highlight the effect of service delivery policy on the work attitude of nurses and go on to investigate how this affects patients’ satisfaction in two Nigerian hospitals, Lagos University Teaching Hospital (LUTH) and Babcock University Teaching Hospital (BUTH). Both hospitals come under tertiary or referral hospitals which provide health care by different specialists after referral from primary care or secondary care centers.
A tertiary or teaching hospital is a hospital or medical center that provides clinical education and training to future and health professionals. Teaching hospitals are often affiliated with medical schools and work closely with medical students throughout their period of matriculation and especially during their internship. In most cases, teaching hospital offer Graduate Medical Education (GME), physician residency programs, where medical school graduates train under a supervising specialist to assist with the coordination and provision of highly specialized clinical care to the most severely ill and injured. In addition to this, many teaching hospitals also serve as research institutes. Teaching hospitals exist under two categories – public and private. A public teaching hospital or government hospital is a hospital owned by government and receives government funding. In some countries, this type of hospital provides medical care free of charge, the cost of which is covered by government reimbursement. In Nigeria, the cost of treatment is not entirely free but highly subsidized. An example is the Lagos University Teaching Hospital.
Lagos University Teaching Hospital started in 1962 with three hundred beds but today has more than eight hundred beds and has through the years provided health personnel to Nigeria’s health sector with about 32,488 doctors and more than 3,819 nurses having undergone training in the institution. When it took off, LUTH had ninety four nurses of all cadres in its employment and by its 50th anniversary in 2012, it had seven hundred and twenty seven nurses comprising of, Assistant Director, Nursing Services (1), Chief Nursing Officers (119), Asst. Chief Nursing Officers (112), Principal Nursing Officers (142), Snr. Nursing Officers (52), Nursing Officer (8), Nursing Officer 1 (60), Nursing Officer II (72), Staff Nurse Midwife/Nursing Sister (99), Midwife Sister/ Nursing Supt. (6), Temp. Staff Nurse/Staff Nurse/Staff Midwife (57).
Mrs Adewunmi, one of the first nurses of LUTH in an interview in 2012, described the nurses’ relationship with patients at that time as friendly. This is exhibited such that twenty five years after retirement and fifty years after the inception of the hospital, she could still remember the name of the first surgical patient of the hospital as Mr. Apanisile, who according to her, after his hospital discharge sought and got employed as the hospital’s barber for many years. To the nurses at that time, the patients came first in the hospital and because they were well looked after, patients enjoyed coming to the ward/ hospital.
A private teaching hospital is a hospital owned by a private university and privately funded through payment for medical services by patients themselves, by insurers, governments through national health insurance programs, or by foreign embassies. An example is the Babcock University Teaching Hospital established by the Seventh Adventist Church, and an upgrade of the former Babcock University Medical Center. it officially took off in 2011 with a total of 34 nurses and by 2015, the number had increased to 178. This is made up of, Director of Nursing Services (1), Chief Nursing Officers (6), Assistant Chief Nursing Officers (7), Principal Nursing Officers (11), Nursing Officers 1 (13), and one hundred and Nursing Officers (135).
Observably, the highest cadre, chief nursing officer, in the Lagos University Teaching Hospital, has the highest number of nurses, 119, as against the highest number of 135 nurses being in the lowest cadre, nursing officer, in the Babcock University Teaching Hospital. It may be pertinent to also note that that the nitty gritty of the nursing care is usually undertaken by the nursing officers while the chief nursing officers act mostly as supervisors.

1.2 Statement of the Problem




Content                                                                                                     Page

Title page                                                                                                 i

Certification                                                                                              ii

Dedication                                                                                                    iii


Abstract                                                                                            v

Table of Contents                                                                                    vi

List of Tables                                                                                          viii

List of Figures                                                                                        ix


  1. Background to the Study                                                1
  2. Statement of the Problem                                                                         3
  3. Objective of the Study                                                                             4
  4. Research Questions                                                                      5
  5. Hypotheses                                                                                   5
  6. Scope of the Study                                                                                             5
  7. Significance of the Study                                                                    5
  8. Operational Definition of Terms                                                            6


2.0. Introduction                                                                                     8

2.1. Maternal and Child Health Service                                                8

2.2. Incidence of Maternal and Child Mortality                                                10

2.3. Maternal Mortality in Nigeria                                                                     11

2.4. Availability of Skilled Personnel for MCH Services in Nigeria                                12

2.5. Health Facilities Assessment                                18

2.6. Quality of Maternal and Child Health Services                                      19

2.7. Client Satisfaction with Maternal and Child Health Services              23

2.8. Factor that Determine Client Satisfaction                                                 27

2.9. Conceptual Model             29                                                           


3.0 Introduction                                                                                        33

3.1 Research Design                                                                                      33

3.2 Population                                                                                            33

3.3 Sample size and sampling Technique                                        33

3.4 Instrument for Data Collection                                                                    36

3.5 Validity and reliability of the Instruments         36

3.6 Data Collection Procedure                                                               37

3.7 Method of Data Analysis                                                                  37

3.8 Ethical Consideration                  



4.0 Introduction                                                                                         39

4.1 Result Presentation    39

4.2. Data Analysis                                                                                                39

4.3. Discussion of Findings                                                                                56


5.1 Summary                                                                                                62

5.2 Conclusion                                                                                                     63

5.3 Recommendations                                                                            63

5.4 Limitation of the Study                                                                             64

5.5 Suggestion for Further Studied  64

REFERENCES                              65

APPENDICES                                       73                                                                                      


Table                                                                                                         Page

1: Demographic data of the Participants (Structure and Process)                              39

2: Demographic data of Respondents on client satisfaction (Outcome)                    41

3: Structure of MCH in Primary and Secondary health facilities       43

4: Process of MCH in Primary and Secondary health facilities                        47

5 Client’s satisfaction with MCH services in Primary and Secondaryhealth facilities           50

6: Categories and Number of personnel for MCH services in health facilities                        53

7: T-Test for the structure of MCH in Primary and Secondary health facilities                       54

8: T-Test for the process of MCH in Primary and Secondary health facilities.                      54

9: T-Test for the client satisfaction of MCH in Primary and Secondary facilities                  55                                                                              


Figure                                                                                             Page

1: Conceptual Framework for quality of MCH services                                                       31

2: Bar chart showing the percentage of Personnel with Training in MCH services   44

3. Bar Chart showing Physical facilities that are available and in good working conditions in percentages                                            45

4. Bar chart showing the percentage distribution of Maternal and Child health care services (Process) rendered by selected heath facilities     48

5. Bar charts showing clients satisfaction with MCH services in Health facilities in percentages                                                                                   51



1.1 Background to the Study

The quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality. Improving and sustaining the quality of care in healthcare institutions has been an area of concerns and recurrent issue over the year. The client’s expression of satisfaction with the quality of health care can provide insightful feedback for healthcare providers, managers and policy makers to direct quality improvement efforts in a right direction (Beattie, Lauder, Atherton, Murphy 2014). Quality assessment is an important aspect of quality assurance which focus on identification of barriers and challenges in a system and not just bad performers (Tobin-West and Anastasia 2016).

 On yearly basis, an average of 289 000 women reportedly die as a result of complications associated with pregnancy and child delivery. Also, about 6.6 million under 5 year old children death resulted from complications in the neonatal period and early childhood illness (World Health Organization (WHO), 2013). These deaths are preventable with provision of quality and optimal maternal and child health care in health facilities.

Although remarkable achievement has been recorded in some areas of reproductive, women and children health interventions over the years, little progress has been recorded in efforts directed towards improvement of maternal and child health outcomes due to a wide gap between the scope and the quality of health care provided in facilities (WHO, UNICEF, 2014). Quality of care is considered very important in the international initiatives and Global Strategy for Every Woman and Child.

Yearly, about 500,000 women and girls die due to complications arising from pregnancy, labour and or the 6 weeks post- delivery. Majority of these mortality happen in less developed countries (United Nations Millennium Development Goals 2009), making the process of delivery one of the most dreaded journeys for women of child bearing age. This is worrying some as statistical findings showed that the extent of maternal mortality in low and middle income countries resulting from pregnancy and childbirth is on the increase (United Nations Children Fund     (UNICEF) Nigeria, 2014).

Similarly, the risk of death from conception and child delivery in Nigeria is ratio 1 to 13.On daily basis, about 2,300 under-five year old children and 145 women in their reproductive years die in Nigeria. With these figures, Nigeria was rated the second largest country contributing to the under–five and maternal death in the world. Many of these deaths could be prevented but for Nigeria’s coverage and quality of health care services that continue to fall short of expectation for women and children. According to United Nations International Children Fund (UNICEF), Nigeria (2014) report, less than 20% of health facilities in the country provide emergency obstetric care (Eoc) and about 35% of deliveries are taken by health professionals.

 A national health policy formulated for Nigerians in 1988 was targeted at achieving quality health for all.  Emerging health issues and the realities to focus on new trends prompted the review of the policy over the years to improve quality in health care services across the nation (Nigeria Demographic Survey, 2013). A health delivery system targeting reduction in maternal morbidity and mortality must ensure quality reproductive care for this group of people (United States Agency for International Development (USAID), 2013).

Donabedian model was developed in 1966 for assessing healthcare services and to evaluate quality of health care.  The model was revised in 1988 and provides information about quality of care using three categories which are structure, process, and outcomes. Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment. Process involves the transactions between patients and healthcare professionals throughout the delivery of healthcare. Outcomes refers to the effects of healthcare on the health status of client and client satisfaction. Since then other quality of care frameworks, including the World Health Organization (WHO) recommended Quality of Care Framework and the Bamako Initiative etc. have been developed but the Donabedian Model continues to be the dominant framework for assessing the quality of health care up till today (Lawson and Yazdany 2012). In 2013, World Health Organization and Partnership for Maternal, Newborn, and Child Health used Donabedian model to develop key indicators for quality in Maternal, Newborn, and Child Health care.

Maternal health care is the care a woman receives during conception, delivery, and post- delivery, it is crucial for the survival and well-being of mother and child. It comprises a broad range of services like family planning, prenatal, intrapartum, and postpartum care with the focus of minimizing maternal death and disability (Franny, 2013).

 Improving the quality of obstetric care in facilities has recently been identified as a neglected and essential approach to reducing maternal deaths and enabling developing countries to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well- being especially for women (Van den Broek and Graham 2009). Postpartum hemorrhage is the most frequent cause of maternal deaths globally and in developing countries, accounting for 25% of maternal deaths. Next are hypertensive disorders in pregnancy (PE/E) at 15%, sepsis (8%) and obstructed labor (7%).2 Effective interventions exist for screening, preventing and treating obstetric and newborn complications, and they can be readily provided by skilled providers in facilities. However, achieving both high quality and coverage of these interventions is essential in order to reduce maternal and newborn deaths globally. International evidence suggests that the most important factor in reducing maternal and early neonatal mortality is the attendance of a skilled birth provider and provision of quality care (USAID/MCHIP 2013).

According to Kana, Doctor, Peleteiro, Lunet and Barros (2015), poor maternal and child health indicators have been a recurrent issue in Nigeria since the 1990s, and many interventions have been instituted to reverse the trend and ensure that Nigeria provides quality maternal and child health care.

However, various intervention reports have documented mixed findings of the successes and challenges as well as threats to the attainment of quality maternal and child health care in Nigeria. It has been observed that Nigeria is lagging behind in meeting MDG 4 and according to the United Nations mortality estimates, Nigeria has only achieved an average of 1.2% annual reduction in under-five mortality since 1990. And in order to meet MDG 4, Nigeria needed to have achieved an annual reduction rate of 10% in the five years leading to 2015 (Rajaratnam , Marcus , Flaxman , Wang , Levin-Rector , Dwyer , et al 2010).

Therefore, improving and ensuring quality of health care services in health facilities, developing strategies for quality serve as an integral component of scaling up interventions to improve health outcomes of mothers, newborns and children is of utmost importance (WHO, 2013).

1.2   Statement of the Problem

The quality of care received during pregnancy and the place of delivery are great determinants of maternal and child morbidity and mortality (United States Agency for International Development (USAID), 2013).Worldwide significant number of women and girls yearly (almost half a million) die as a result of complications during conception, delivery or 6 weeks post childbirth. Majority of these deaths happen in underdeveloped nations (United Nations Millennium Development Goals, 2009). The risk of death from conception and delivery is in Nigeria is 1 in 13, many of these deaths could have been averted with good coverage and quality maternal and child health care (United Nations International Children Fund (UNICEF), 2014).

Increased mothers and newborn death and morbidity has been linked to poor quality of healthcare services (USAID, 2013), and has been evident by increased death rates that inadequate availability of reproductive health services is an important challenge in Nigeria (WHO Nigeria, 2014). Although progress has been made in increasing the coverage of several key reproductive, maternal, newborn and child health interventions over the past two decades, there has been limited progress in improving maternal and paediatric outcomes because of a major gap between coverage and the quality of care provided in health facilities (WHO, UNICEF, 2014).

Also, it has been observed from clinical practice that there are still many cases of preventable pregnancy and delivery complications reporting in the teaching hospital in Ile-Ife on daily bases in spite of many healthcare facilities in the area. Improving the quality of facility-based health care services and making quality an integral component of scaling up interventions to improve health outcomes of mothers, newborns and children is of utmost importance (WHO, 2013).

Hence, the need to evaluate the maternal and child healthcare services in healthcare facilities in Ile-Ife for quality care to achieve Sustainable Development Goal 3 (SDG 3) which is good health and well-being.

1.3   Objective of the Study

The main objective of this study is to evaluate the Quality of Maternal and Child Healthcare Services in selected Healthcare Facilities Ile-Ife utilizing Donabedian model for Quality care

The specific objectives are to:




Content                                                                                                       Page

Title page                                                                                                              i

Certification                                                                                                         ii

Dedication                                                                                                     iii

Acknowledgements                                                                                           iv

Abstract                                                                                       v

Table of Contents                                                                               vi

List of Tables                                                                                              ix

List of Figures                                                                                             x

Abbreviations                                                                                                 xi


1.1       Background to the Study                                                                1

1.2       Statement of the Problem                                                             3

1.3       Objective of the Study                                                           4

1.4       Research Questions                                                                       4

1.5       Hypotheses                                                                                  4

1.6       Significance of the Study                                                           5

1.7       Scope of the Study                                                                           5

1.8       Operational Definition of Terms                                                5


2.1       Global overview of HIV/AIDS                                           6

2.2       Basic facts of HIV/AIDS                                                                 6

2.3       Disease Staging of HIV/AIDS                                                              6

2.4       Antiretroviral Therapy adherence and Quality of life                           8

2.5       Quality of life assessment                                                             9

2.6       Factors that influence Quality of life                                                      10

2.7       Relationship between perceived social support and Quality of life                           12

2.8       Relationship between socio-demographic variables and Quality of life                     14

2.9       Empirical studies on Quality of Life                                           16

2.10     Conceptual Model                                                                    17


3.1       Research Design                                                                              21

3.2       Population                                                                                21

3.3       Sample size and sampling Technique                                                    21

3.4       Instrumentation                                                                             22

3.5       Validity and Reliability of Instrument                                       22

3.6       Method of Data Collection                                                             23

3.7       Method of Data Analysis                                                         23

3.8       Ethical Consideration                                                                  23



4.0.      Introduction                                                                                       25

4.1       Presentation of Results: Socio-demographic information of respondent                   24

4.2       Analysis of Research Questions                                                   26

4.3       Hypothses Testing                                                                              32

4.4       Discussion of Findings                                                     34


5.0       Introduction                                                                                             39

5.1       Summary                                                                                           39

5.2       Conclusion                                                                                           40

5.3       Recommendations                                                                   41

5.4       Contribution to Knowledge                                                                     42

5.5       Limitation of the Study                                                                      42

5.6       Suggestion for Further Studies                                                            42

REFERENCES                                                                                              44

APPENDICES                                                                                                50


Table                                                                                                   Page

4.1 Respondent’s Demographic characteristics                                                 25

4.2 Perceived social support of PLWHA                                                     26

4.3 Quality of life of People living with HIV/AIDS                                     28

4.4a Model Summary for the influence of Gender on Quality of life of PLWHA                30

4.4b Simple linear Regression showing influence of Gender on Quality of life                    30

4.5a Model Summary for the influence of educational level on Quality of life of PLWHA 31

4.5b Simple linear Regression showing influence of educational level on Quality of life     31

4.6a Model Summary for the influence of occupation on Quality of life of PLWHA          31

4.6b Simple linear Regression showing influence of occupation on Quality of life               31

4.7a Model Summary for the influence of HIV serostatus on Quality of life of PLWHA    32       

4.7b Simple linear Regression showing the influence of Gender on Quality of life              32

4.8 Pearson Product Moment Correlation (PPMC) showing relationship between social support and quality of life                                                                                                            33

4.9 PPMC showing relationship between Quality of life and socio-demographic variables  33

4.10PPMC showing relationship between social support and socio-demographic variables 34


Figure                                                                                                  Page

2.1 Adapted Conceptual model of Quality of life among People Living with HIV/AIDS   19


AIDS                          Acquired Immune Deficiency Syndrome

HIV/AIDS                  Human Immunodeficiency Virus

NACA                        National Action Committee on AIDS

OOUTH                      Olabisi Onabanjo University Teaching Hospital

PLWHA                      People Living with HIV/AIDS

QoL                             Quality of Life

WHO                          World Health Organisation

WHOQoL-HIV          World Health Organisation Quality of life for HIV



1.1   Background to the study

            Human Immuno deficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) is a pandemic disease in which the body’s defense mechanism is weak and this makes the body unable to get rid of infection (NACA, 2001). HIV/AIDS is an incurable diseases that makes the casualty susceptible (Rajeev, 2012), and is associated with significant morbidity and mortality despite the availability of treatment and care. (Smeltzer, Bare, Hinkle & Cheever, 2010).  

            As at the end of 2015 – 36.7 million people probably were living with the virus, 2.1 million people were nearly infected; 1.1 million people died from the disease; and 18.2 million people were accessing ART as June 2016. Since the beginning of the epidemic, over 78 million people have become infected; and 3.5 million have died from AIDS related diseases thus challenging improvements to world health today (UNAIDS, 2016). In sub Saharan Africa about 21 million people are living with HIV/AIDS and 32% of this population are presently on ART as at 2012 (UNAIDS, 2013). Also, in Nigeria, estimated 3.1 % adults within the ages of 15 – 49 are living with HIV/AIDS which is equal to about 3.5 million people from about 141 million of the total population (UNAIDS, 2016).

            Nigeria is Africa most populous country with 140,4311,790 population figure as at the last census, and is also rated as tenth largest country in the world with the approximate estimation of 55% literate and 70% poor in the population (UNAIDS, WHO & Nigerian Population Comission 2009). Also, in Nigeria, estimated 3.1 % adults within the ages of 15 – 49 are living with HIV/AIDS which is equal to about 2.6 million people from about 141 million of the total population (UNAIDS, 2008). Another report from NACA (2009) statistics shows average 4.6% prevalence HIV rate among Nigerians (NACA, 2009). HIV/AIDS in Nigeria remains a vital public/ community health issue since Nigeria is a base or environment with many people living with HIV with South Africa prevalence 19.2% as at the end of 2015 (UNAIDS, 2016). The widespread of this disease has negative effect on the psychosocial, cultural, and developmental aspects of life, which makes the diseases a critical public health issue (UNAIDS, 2008).

            One of the variables to be measured in this study is social support which has been associated to better Quality of Life among PLWHA in different studies (Khumaseen, Aoup-por & Thammachak, 2012). Social support is defined as “the view or experience that one is loved and cared for by others, esteemed and valued, and part of a social network of mutual assistance and obligations” (Taylor, 2007, p. 145). Social support assistance, user fees friendly, good patient – health workers relationship can help to curb non-adherence. An in-depth knowledge of the multifaceted interrelationship of the biological sociological factors is required to understand non-adherence, and Quality of life thus creating avenue for more effective non-adherence intervention programs (Olowookere, et al, 2012). Also, Adedimeji & Odutolu (2007) in a quantitative research to determine the extent to which certain factors contribute to improvement in QoL of PLWHA reported that availability of care and social support from spouse friends and family members yielded good QoL with 93%. Social support services is limited and lacking in this country and this makes evaluation of the wellbeing and longetivity of PLWHA important as to how individual perceive their own health using different instrument such as WHOQOL HIV BREF version instrument. (Folasire, Irabor & Folasire 2013).

            The incurable and pandemic nature of HIV/AIDS calls for mobilization of resources such as human, money & material resources to improve quality of life among PLWHA. HIVAIDS is a serious humanitarian problem that could affect the physical, psychological, social status of PLWHA. The Quality of Life (QoL) of HIV/AIDS patient is crucial as well as the disease progression because of their need for adaption to changes in their lives which include financial & societal changes. Therefore, consideration for improving their quality of life is paramount (Fan, Kuo, Kao, Morisky & Chen 2011). According to World Health Organization (2005) quality of life is described as individual’s perceptions of their position in the life in the context of culture and value systems in which they live and in relation to their goals, standards, expectations, and concerns.

            The indicator of physical, mental, social, and spiritual, wellbeing is Health Related Quality of life and this could serve as means of measuring the total wellbeing of PLWHA which include their functions and perceptions based on life experiences (Malucclo, Palemo, Kadliyala, & Rawat, 2015).  However, the HRQOL is regarded as non-medical aspect of living example psychosocial, socio economic aspect etc (Trana, Ohinmaaa, Nguyen, Nguyen & Nguyen, 2011).  Advances in the management of HIV/AIDS makes it a chronic condition thereby causing reduction in morbidity and mortality thus improves QoL (Millard, Elliott, Slavin, McDonald, Rowell, & Girdler 2014).  As HIV treatment and care worldwide is moving from emergency to longer term strategies management, there are structural and contextual factors that influence the outcome of this intervention. The factors include individual, facility based, environmental/cultural etc (Aidala, Wilson, Shubert, Gogolishvili, Globerman, Rueda, et al, 2016).                               

            The changes that result from HIV care and Management conote that individual with the diseases should take responsibility for themselves since it is now a chronic condition. Thus this will help to prevent disability and improve QoL (Millard et al, 2014).  In the care and management of HIV/AIDS wholistic approach is needed to promptly address issues since it remains a chronic diseases. The stress and fear that accompany the diseases has been reduced since it has been addressed in relation to other aspects of life. Focus should now be shifted or adjusted to how individual adjusts to symptoms (Buseh, Kelber, Stevens, & Park, 2008), and Health related QOL which is a determinant of overall personal health (Krause, Butler, & May, 2013).

            According to United States Department of Health and Human Services (HHS) (2011), The two overarching goals of Healthy people 2020 include (1.) Improving the overall quality of life (2.) Improving the health of all groups.  The QoL of PLWHA can be traced to the increase in life span of infected individuals due to availability and access to ART. Socio economic conditions of individuals with HI/AIDS can alter QoL thereby affecting health-seeking behaviours (Mawar, Katendra, Bagul,.Bembalker, Vedamurthachar,  Tripathy, et al., 2015). Another variable of interest in this study is demographic factors which have been proven to improve quality of life and are seen as determinant of quality of life. Socio demographic charasteristics  like income level, Marital status, educational level, occupation when investigated among PLWHA in China was found to influence quality of life which means people with higher income and are married tend to show positive quality of life.( Rajeev etal.., 2012). The explanation for this could be as a result of the knowledge gained from the exposure in the workplace which could impact quality of life. Also employment among other demographic factors like gender, higher income, and gender are associated with improved quality of life as seen among PLWHA in India (Basavaraj etal.., 2010). The reason for the employment may be a source of income, care  and social support to the individual that are affected which means having a good job may directly or indirectly improve QoL.

1.2   Statement of the Problem

            In Nigeria, Joint United Program on HIV/AIDS (2014) reported estimated National HIV prevalence of 4.6% and Nigeria is said to be the  2nd in Africa in terms of People Living with HIV/AIDS (PLWHA) Africa with over 3.2 million (UNAIDS, 2014). Compounding the lack of cure for HIV/AIDS is the fact that PLWHA are still faced with social support issues even being a predictor of QoL. PLWHA are also faced with Poor Quality of Life which has been attributed to certain socio demographic variables like lack of social support system or dissatisfaction with the perceived social support given. Kehinde, Fatiregun, & Osagbemi (2013) reported that certain sociodemographic/ economic factors like occupation, income, educational level have been proven to impact QoL where low income and low educational level brings about poor QoL among the HIV/AIDS patient in Kogii state of Nigeria (Kehinde, Fatiregun & Osagbemi, 2013). Also, gender difference has been documented to influence QoL being a major predictor of QoL where statistical result revealed lower score of QoL among men (Sanyang, 2011) People still struggle with coping with AIDS and related diseases in the recent times and this called for evaluating QoL among PLWHA (Oliveira, Moura, Araujo, & Andrade, 2015). Moreover, limited information about QoL is a major problem in African setting even with ART in place for PLWHA. Little or no information on QoL has been documented in Ogun state despite the high prevalence of 6.1 % which is believed to be one of the highest in the south west Geopolitical zone in Nigeria (NACA, 2014).

            It is in the light of these that the researcher is carrying out this study to explore perceived social support, and socio demographic variables as correlates of Quality of life among Human Immunodeficiency Syndrome patients in a teaching hospital, Ogun State.       

   1.3   Objective of the Study




Content                                                                                               Page

Title page                                                                                            i

Certification                                                                                       ii

Dedication                                                                              iii

Acknowledgements                                                                            iv

Abstract                                                                      v

Table of Contents                                                                   vi

List of Tables                                                                                     xi

List of Figures                                                                                                 x

Appendices                                                                             xi

Abbreviations                                                                                      xii

CHAPTER ONE: INTRODUCTION                                                       

1.1    Background to the Study                                                                      1

1.2    Statement of the Problem                                                                      3

1.3    Significance of the Study                                                                                  4

1.4    Scope of the Study                                                                                            4

1.5    Objective of the Study                                                                                      4

1.6    Research Questions                                                                                            5

1.7    Hypotheses                                                                                                        5

1.8    Operational Definition of Terms                                                            6


2.0    Introduction                                                                                                       7

2.1    Concept of Postpartum Haemorrhage                                       7

2.2    Relationship between Postpartum Haemorrhage and Maternal Mortality         7

2.3    Classification of Postpartum Haemorrhage                                      8

2.3.1 Blood loss Quantification                                                                                  8 Blood loss during and after Delivery                                8 Hematocrit Changes                                                                          9 Blood Loss Rate                                                                                             9 Blood volume insufficiency                                                           9

2.4    Etiology of Postpartum Haemorrhage                                                   10

2.4.1 Atonic uterus                                                                                        10

2.5    Pathophysiology of Postpartum Haemorrhage                                      12

2.6    Evidence based Measures for immediate Management of Postpartum

Haemorrhage   12

2.7    Non-Pneumatic Anti-shock Garment, strategy against Postpartum

 Haemorrhage  13

2.8    History of Non-Pneumatic Anti-shock Garment                                   13

2.9    Mechanism of action of NASG                         14

2.10  Application of NASG                14

2.10.1 Procedure of Application                                14

2.10.2 Procedure for   NASG Removal15

2.10.3  Contra-indications to NASG                          15

2.11  Benefits of the NASG                                                                                       15

2.12  Empirical Studies                                               16

2.13  Evidence based  report of NASG for Postpartum Haemorrhage in

University College Hospital, Ibadan, Nigeria                                                  17

2.14  Misoprostol                                18

2.15  Concept of Active Management of third Stage of Labour                   19

2.16  Trends of Uterotonic drugs used in the Prevention of PPH           19

2.17  Reasons why Misoprostol is Preferred  20

2.18  Misoprostol and its Mode of Action     20

2.19  Benefits of Misoprostol over other conventional Uterotonic drugs in management   of postpartum haemorrhage                                                       21

2.20  Empirical Studies on Misoprostol          21

2.21  Expanding Midwives Skills       22

2.22  Theoretical Model          23

2.22.1 Bloom’s Model                                                                                   23

2.22.2The Cognitive Domain                                                                     24

2.22.3  The Psychomotor Domain                                                     25

2.23  Application of Model to the Study                               25

2.24  Application of the Psychomotor Domain in the Application of NASG            26

2.25   Conceptual Model; source; adapted from bloom taxonomy (1956)27


3.0    Introduction                                                        28

3.1    Research Design            28

3.2    Population          28

3.3    Sample size and sampling Technique                                                                 29

3.4    Instrument          30

3.5    Validity and Reliability of Instrument                                      30

3.6    Method of Data Collection                                                                    30

3.7    Method of Data Analysis          31

3.8    Ethical Consideration    32



4.0    Introduction                                                                                  33

4.1    Data Analysis and Result Presentation                                                    33

4.2    Discussion of Findings                                                                          43



5.1    Summary                                                                                                            52

5.2    Conclusion                                                                                             53

5.3    Recommendations                                                                54

5.4    Limitation of the study                                                               54

5.5    Suggestion for Further Studies                                                              54

REFERENCES                                                                                              56

APPENDICES                                                                                               62


Table                                                                                      Page

2.1    Showing Standardized Classification of PPH as described by Benedetti        10

4.1    Showing Frequency and Percentage on participant’s Socio Demographic data 33

4.2    Showing Pre and Post Intervention Knowledge level of Midwives on

Misoprostol usein the Management of PPH in Control and Experimental

groups 35

4.3 ShowingPre and post Intervention Knowledge level of Midwives in the use of NASG in the Management of PPH in the Control and Experimental Groups           36

4.4Showing Application of NASG by the Midwives in the Management of PPH Pre    and Post Intervention in the Control and Experimental group.                                     37

4.5ShowingRemoval   of   NASG by the Midwives in the Management of PPH Pre and post intervention in the Control and Experimental group.                                  38

4.6Showing Inferential Statistics comparing mean scores of Post Intervention BKnowledge of Misoprostol and NASG in the Control and Experimental group         40

4.7Showing Inferential Statistics comparing mean scores of Post Intervention Knowledge of   Misoprostol and NASG in the Control and Experimental group        41

4.8Showing Inferential Statistics comparingKnowledge mean scores of Misoprostol   use in Experimental group Pre and Post intervention                                                      42

4.9Showing Inferential Statistics comparingPre and Post Skills in the Application of NASG                                                                            43


Figure                                                                                                              Page

1        Conceptual Model                                                                                            27

2.       Research Design                                                                                               28


Appendix                                                                                                        Page 

Informed Consent Form                                                                             62

Questionnaire                                                              63

Pathfinder Teaching Package                         68

Pictures from the field work                                                                           73


PPH                             Postpartum Haemorrhage

NASG                         Non Pneumatic Antishock Garment

BUHREC                   Health Research Ethics Committee

OSHREC                    Ondo State Health Research Ethics Committee

SPB                             Systolic Blood Pressure

UNFPA                       The United Nationsfund for population activities

POPPHI                      Prevention of postpartum haemorrhage initiative

AMTSL                       Active Management of Third Stage of Labour

CCT                            Control Cord Traction

ANC                           Antenatal Clinic

CHWs                         Community Health Workers

FMOH                        Federal Ministry of Health

NASA/AMES National Aeronautics and Space Administration/Ames Research Centre

PASG                          Pneumatic Anti Shock Garment

MDG               Millennium Development Goals

FIGO                          International Federation of Gynaecology and Obstetrics

ICM                            International Confederation of Midwives

UNPD                         United Nation Population Division

MMR                          Maternal Mortality Ratio

UNPF                          United Nations Population Funds

HIV                             Human immunodeficiency virus

AIDS                          Acquired Immune Deficiency Syndrome

UNICEF                     United Nations Children’s Emergency Fund



1.1 Background tothe Study

Pregnancy and delivery are supposed to be a safe process when well-managed, but a number of times it involves major health risks, even to women with no pre-existing health problem. Thousands of women die all over the world from issues directly associated with pregnancy, delivery and its complications (Maya, Buntugu, Lovelace, Emmanuel, & Srofenyoh, 2015). According to World Health Organization, (2012) Sub-Sahara Africa is responsible for approximately 60% of maternal deaths with total lifetime risk as high as 1 in 39 pregnancies when compared with 1 in 2900 in Europe. Although Postpartum haemorrhage affects about 4% of all pregnancies (Combs, Murphy, & Laros, 1991), making it the leading cause of maternal death all over the world.

Recent evidence from World Health Organization, (2008) estimated that postpartum haemorrhage of all etiologies accounts for 25% of the maternal deaths worldwide. However, statistics from the same organization showed disparity in the documentation of findings as record could reach as high as 40% in South East Asia, Latin America and some countries in Africa. Postpartum haemorrhage is responsible for about 50% of maternal mortality in Guatemala and Afghanistan (Miller & Martin, 2008). Every year, a total number of 529,000 women died due to complications of pregnancy and childbirth (Ojengbede, Morhason, Galadanti, Meyer, Nsima, & Gamin, 2010). Similarly, statistics has shown that 358,000 women lose their lives due to negative outcome of pregnancy and delivery(WHO,2010).

According to Adesokan (2010), PPH is excessive bleeding from the genital tract after the birth of a baby up to 6 weeks which is in excess of 500mls or any amount sufficient enough to cause cardiovascular collapse which is dangerous to the life of the woman. According to Reynders Sentennm, Tjalma and Jacquemyn, (2006) majority of these maternal deaths occur within the first four hours after birth. They occur as a result of either lack or poor management of the stage three of labour by skilled midwives and birth attendants, most pregnant women are liable postpartum haemorrhage. Therefore midwives need to possess the knowledge and skill in third stage management of labour, recognize asses, treat excessive blood loss and prevent postpartum haemorrhage.

Postpartum haemorrhage is a killer, and also one of the obstetric complications with established and effective intervention through the use of a low technology device referred to as Non-Pneumatic Anti-Shock Garment or life wrap. NASG is a device in form of a lower bottom suit of an articulated neoprene with Velcro parts which gives lower body circumferential counter pressure that supplies blood to the vital organs of the body, thus reversing hypovolemic shock and decreasing postpartum haemorrhage. Evidence suggests that this promising technology helps overcome further damage and plays a part in sophisticated modern care units by stabilizing women whilst waiting for definitive haemorrhage therapies such as blood transfusion and surgeries.

Uterine atony is the inability of the uterine muscle to effectively contract after delivery which can be managed with the use of appropriate of uterotonic drugs like misoprostol (International Confederation of Midwives and International Federation of Gynecology and Obstetrics, 2007). Misoprostol is a prostaglandin based drug that has aroused the interest of significant others as an effective uterotonic agent due to its ease of administration, safety profile, cost and ease of storage. Though, studies on use of misoprostol as auterotonic agent in management of postpartum haemorrhage have been conducted in many centres (El-Refaey & Templeton, 2006).

Besides, the Nursing and Midwifery Council of Nigeria in the recent past organized workshops and training on the use of NASG for midwives and nurses in Nigeria both in the clinical setting and academia to educate them on the availability and the use of the garment in the control of PPH. However, there is paucity of literature on the appropriate application of their skills on the use of NASG in the Secondary Health Care Facilities in Ondo State. Hence, this study seeks to assess the skills of midwives on the utilization of Anti Shock Garment and administration of misoprostol in the management of postpartum hemorrhage in selected Secondary Health Facilities in Ondo State, Nigeria.

1.2 Statement of the Problem

Postpartum haemorrhage (PPH) is rated among the five leading factors responsible for maternal mortality constituting about 25% of maternal deaths worldwide. Out of these maternal deaths, 99% occurred in developing which is an average of 290 deaths per 100,000 deliveries in contrast to 14 deaths per 100,000 live births in developed countries with uterine atony been responsible for 80-90% of haemorrhage (WHO, 2007).

Nigeria, as a country, constitutes the 4th largest country with highest maternal mortality rate worldwide (The World Bank & United Nations Population Division, 2014). The  Millennium Development Goals (MDGs) performance track in Nigeria, 2015 also reported that maternal death rate was 350 per 100,000 deliveries as at 2013 which was still 40 % short of the 250 maternal deaths per 100,000 deliveries as  projected for Nigeria in 2015 (Nigeria MDG 2013 Report, 2015) 

Postpartum haemorrhage is one of the few obstetric complications with established and effective interventions to reduce maternal death. The midwife require skills in the use and application of non-pneumatic Anti-shock garment, the garment reverses the hypovolemic shock and requires knowledge in the use of misoprostol which is effective in managing post-partum haemorrhage. Despite the introduction of this evidence based and low cost first aid device into Nigeria in 2008, there has not been a significant reduction in maternal morbidity and mortality as both India and Nigeria is rated third worldwide with former at 19% (56,000), and later at 14% (40,000), (United Nations, Population Fund, WHO, UNCF and World Bank 2012), with postpartum haemorrhage still the leading cause of maternal mortality. Thus, Nigeria as a nation has the highest maternal mortality ratios (MMR) with national figure officially at 814 maternal deaths/100,000 live births (United Nations Population Division, 2014).

 Evidence also suggests that Non pneumatic Anti shock garment and misoprostol are not been effectively utilized by midwives  in the course of managing clients with  postpartum haemorrhage in many health care center’s as investigated by Onasoga, Awhanaa,  &Amiegheme, (2012), as maternal mortality indices are still very poor. Hence, this study seeks to assess the midwives skills in the application of Anti-shock garment as well as their knowledge and utilization of misoprostol as a measure of controlling postpartum haemorrhage in selected health facilities in Ondo State.

1.3 Significance of the Study




Health care workers, particularly nurses are at risk of infection because they constantly come into contact with infected tissues, fluid, blood and blood products. By complying with infection control measures a lot of infections can be prevented. Some survey studies have been conducted in Nigeria on knowledge, perception attitude and practice of infection control and they concluded that there was inadequate adherence to infection control practices and this could be addressed by organizing training and retraining programmes. This study therefore examined the effects of a training programme in promoting infection control in two teaching hospitals in Ogun State.

The study adopted a pretest-posttest quasi experimental design.  The sample consisted of 87 participants. They were made up of experimental group which consisted of 42 registered nurses from Babcock University Teaching Hospital (BUTH). Ilishan-Remo, Ogun State. The control group was 45 nurses from Olabisi Onabanjo University Teaching Hospital. The training programme consisted of 4 modules on infection control. The programme lasted 4 weeks. The instruments used for data collection were Knowledge about Infection Control Questionnaire (r = 0.79); Perceptions about Infection Control Questionnaire (r = 0.80); Attitudes towards Components of Infection Control Questionnaire (r = 0.62); Practice of Infection Control Questionnaire (both self-reported and observation checklist) (r =0.62). Four research questions were answered and three hypotheses were tested at 0.05 alpha level. Data were analysed using descriptive statistics and Students’ T-test.

Findings showed that the mean age in the experimental group was 34.92 and SD 8.99 while the control group was 47.43 and SD 6.60. The mean for years of experience in the experimental group was 10.42 and SD 9.95 while in the control group was 21.89 and SD 8.72. On attitude, 30 participants (69.0%) had positive attitude in the experimental group compared to 21 participants (46.7%) in the control group. The mean difference was 4.02. On perception, 32 participants (76.0%) in the post intervention had good perception compared to nonein the control group. The mean difference was 8.36. On knowledge, 26 participants (62.9%) in the post intervention had high knowledge compared to none participant in the pre intervention. The mean difference was 7.24. On infection risk reduction in the intervention group, 28 participants (66.7%) have experienced sharp injury pre intervention and none post intervention. Significant differences were found between mean practice score of participants in the experimental and control (p = 0.001) and between self reported and observed practices (p = 0.000) but there was no significant difference between the mean knowledge score in the experimental and control group (p = 0.149).

The training programme was effective in improving the level of knowledge, attitude, perception and practice of infection control. Based on these findings, it is recommended that there should be adequate provision of facilities for infection control. Training and retraining should be organized for all nurses and other categories of healthcare workers to promote adherence to infection control.


Content                                                                                                              Page

Title Page                                                                                                          i

Certification                                                                                     ii

Dedication                                                                                                      iii

Acknowledgements                                                                                         iv

Abstract                                                                                                     v

Table of Contents                                                                                    vi

List of Tables                                                                                                            ix

List of Figures                                                                                   x

Appendices                                                                                                                 xi

List of Abbreviations                                                               xii                                                                                                                                                                   


1.1    Background to the Study                                                              1         

1.2    Statement of the Problem                                                                  4

1.3    Objective of the Study                                                             5

1.4    Research Questions                                                                          5

1.5    Hypotheses                                                                                             6

1.6    Scope of the Study                                                                                   6

1.7     Significance of the Study                                                                   6

1.8    Justification for the Study                                                                  7

1.9    Operational Definition of Terms                                                             7


2.0    Introduction                                                                                               9

2.1    Overview of infection prevention and control                               9

2.2    Knowledge Attitude and Practice of Infection Control             13      

2.3    Standard Precautions                                                                     17

2.4    Empirical Studies on Infection Control Measures                                    22

2.5    Theoretical/Conceptual Framework Precede Model                              31

2.6   Appraisal of Literature Review                                                 34


3.0   Introduction                                                                                                     36

3.1   Research Design                                                                      36

3.2   Population                                                                                            37

3.3   Sample size and sampling Technique                                                 38

3.4   Instrumentation                                                                                 42

3.5   Validity and Reliability of the Instrument                            43

 3.6 Data Collection Procedure                                                             44

 3.7 Method of Data Analysis                                                             46

 3.8 Ethical Consideration                                                                       46



4.0:   Introduction                                                                                           47

4.1:   Demographic Data of Participants                                                    54

4.2:   Discussion ofEffects of Training Programme on Perception of Participants                55

4.3:   Discussion of Hypotheses                                                                         57



5.1:   Summary                                                                                             61

5.2:   Conclusion                                                                                    63

5.3:  Recommendations                                                                                63

5.4:   Limitation of Study                                                                64

5.5: Suggestion for Further Studies                                                                   64

REFERENCES                                                                                           65

APPENDICES                                                                                                 75


Table                                                                                           Page

3.1:  Sampling Distribution for Intervention Group                                   40

3.2:  Sampling Distribution for Control Group                                            41

4.1:  Demographic Data of Participants                                                          48

4.2: Descriptive statistics showing Effect of Training on Participants’ Attitudes in   the Experimental Group                                                                                                 49

4.3: Descriptive statistics showing Effects of Training on Participants’ perceptions  in the Experimental Group                                                                                              50

4.4: Descriptive statistics showing Effects of Training on Participants’ knowledge in   the Experimental group                                                                                                   51

4.5: Pre Intervention Responses of Participants on Exposure or Injury Experience in  Experimental Group and Control Group                                                                         51

4.6:Post Intervention Responses of Participants on Exposure or Injury Experience in Experimental and Control Group                                                                                  52

4.7: T-test Showing Differences between the Mean Knowledge Score of Participants in Experimental group and Control Group                                                                          53

4.8: T-test Showing Differences between the Mean Practice Score of Participants   in Experimental Group and Control Group                                                                         53

4.9:T-test Showing Differences between Self-reported and Observed Practices of Infection Control in the Experimental Group                                                                54


2.1: The Chain of Infection                                                                                11

2.2: Precede Framework Adapted to Nursing Intervention to promote

Infection Control                                                                                            33


I.                      Informed Consent

II.                    Questionnaire

III.                   Reliability of Instruments

IV.                   BUHREC Approval Letter

V.                    Letter of Introduction to the Teaching Hospitals

VI.                   Letter of Approval from OOUTH

VII.                 Training Programme for Participants

VIII-XI           Intervention Packages

XII.                 Pictures from Field Work

XIII                 Similarity Index (Turnitin)


BUTH-            Babcock University Teaching Hospital

CDC-              Center for Disease Control and prevention

CEU-               Continuous Education Unit

CHER-            Children Emergency

CMPC-            Community Medical Primary Care

COPD-            Casualty Outpatient Department

CSSD-             Central Sterile Supply Department

CVC-              Central Venous Catheter

HBV-              Hepatitis B Virus

HCV-              Hepatitis C Virus

HCW-             Healthcare Waste Management

HIV-               Human Immunodeficiency Virus

ICU-                Intensive Care Unit

NSIs-               Needle Stick Injuries

OOUTH-         Olabisi Onabanjo University Teaching Hospital

PEP-                Post Exposure Prophylaxis

PMTCT-          Prevention of Mother-to-Child Transmission

PRECEDE-     Predisposing, Reinforcing, Enabling, Constructs in

Educational Diagnosis and Evaluation

PPE-                Personal Protective Equipment

SP-                  Standard Precautions

WHO-             World Health Organisation



1.1 Background to the Study

Infection control is an aspect of healthcare delivery that deals with the curtailment of the spread of infection within the healthcare set-up, be it from patient-to-patient, patient-to-staff, staff-to-patients or staff to staff. According to World Health Organisation (WHO, 2011) the components of infection prevention and control are as follows: organisation, technical guidelines, human resources, surveillance, microbiology laboratory support, environment, evaluation and links with public health and other services. Organisation involves setting up a programme, formation of the infection control committee and inter-professional team, which should include physicians, nurses, microbiologists, epidemiologists, infection control specialists, information specialists and others. The committee must have a good working relationship with one another, because their work entails collaboration with other departments, staff and programmes. Technical guidelines involve developing, disseminating and implementing technical evidence-based information in preventing the risks of infection. Human resources involve training and re-training of health care personnel in preventing infections and the training of infection control professionals. It guarantees a pool of adequate staff responsible for infection prevention and control activities.

Surveillance is the tracking of demonstrated or suspected spread of infection. It involves the collection of data on epidemic and detection of outbreaks as well as the assessment of level of compliance with infection control practices, response to outbreaks and documentation of the situation of healthcare associated infection. Surveillance is important in that it causes early detection, identification, isolation and intervention, and results in effective infection prevention. Microbiology laboratory supports generate data, standardised laboratory techniques and promotes interaction between infection control activities. The environment refers to the minimum requirements for infection control. It includes water, ventilation, hand-hygiene equipment, placement of patient as well as isolation facilities, sterile supply storage, building conditions and renovation activities. Evaluation has to do with monitoring, assessment and report of infection prevention and control outcomes, processing and strategizing at national level and in healthcare facilities. It mirrors the impact of the infection control programmes. Links with public health and other services ensures proper coordination and collaboration between staff and departments in the events of mandatory reporting and activities such as waste management and sanitation, bio-safety, occupational health, patients and consumer’s care and the quality of health care (Hebden, 2015; Stempliuk & Eremin, 2015; WHO, 2011).

There are various sources of infections. Healthcare associated infections (HAI) are infections that develop in the course of healthcare and results in aggravating illnesses and may lead to deaths, extends the duration of hospital stay, and calls for more interventions at an added cost to the one already expended by the patient’s initial disease. Its occurrence is an indicator of the quality of patient care, adverse event and an issue of patient safety. The sources includes adverse drug events, surgical complications, microorganism isolates, antimicrobial resistance, decreasing trends in intensive care units, exogenous microorganisms such as bacteria, fungi, viruses, protozoan from other patients, endogenous flora of the patients- residual bacteria residing on the patient’s skin, mucous membrane, gastro intestinal tract, respiratory tract, inanimate environmental surfaces, contaminated objects, patient room touch, surfaces, equipment, medication, individual patient, medical equipment, devices, hospital environment, contaminated drugs and foods and hospital flora in the healthcare environment. Other sources include doctors’ white coats, nurses’ uniform, hospital garments, privacy drapes, stethoscopes, bed rails, common hospital surfaces, contaminated water, compromised immune system, negligence or poor attitude of hospital staff, hands of health care workers. It could be from patient to patient, patient to environment, staff to patient, renovation works in the hospital (Hans, 2012; Stubblefield, 2014; WHO, 2011).

Healthcare workers generally are at risk of infection, because they constantly come into contact with infected materials such as tissues, fluid, blood and blood products. There are several infection control measures aimed at controlling the spread of infectious diseases, such as hepatitis B and C, Human immunodeficiency virus (HIV) and other life threatening infections. Moreover, the hospital waste itself is a potential source of infection hence the need for proper infection control measures. It has been found that healthcare workers do not adhere strictly to the various infection control measures, probably because they do not recognise such, or they lack adequate knowledge, or could be due to poor attitude towards infection control measures, including non-availability of materials and equipment (Amoran & Onwube, 2013).In a study conducted at the Federal Medical Center (FMC), Gombe, in North Eastern Nigeria among nurses, it was found that some respondents were not aware that standard precautions is applied to all patients, and majority of the respondents have poor knowledge of the components of standard precautions (Saidu, Habu, Kever, Dathini, Inuwa, Maigari et al, 2015).

Standard precautions are infection control measures that are put forward by the United States Centre for Disease Prevention & Control (CDC), in 1996. By complying with standard precautions, a lot of infections can be avoided, such as occupational exposure to pathogens. While some health workers are familiar with the infection control measures, some are not. This may be due to lack of awareness or knowledge and moreover, the attitude that some who are familiar with the infection control measures, show towards practice is not encouraging. When one considers the importance of adequate knowledge and practice of infection control measures, by the healthcare workers, one cannot but think of what to do to improve on that knowledge and practice. Jain, Dogra, Mishra, Thakur and Loomba (2012), in their study among doctors and nurses in a tertiary care hospital, found that there is lack of knowledge and practice regarding basic infection control measures. This deficit in knowledge can be improved through educational intervention. Wasswa, Nalwadda, Buregyoya, Gitta, Anguzu and Nuwama (2015), in their study on implementation of infection control in health facilities in Uganda, found that with prior training on infection control, the respondents were more likely to wash their hands. Level of education and a prior nosocomial infection experience will have a role in the practice of infection control measures. In-service training on infection control measures will boost the practice of infection control measures.

Amoran and Onwube (2013) found that inadequate workers’ knowledge on infection control and environment related problems are crucial issues that need urgent attention. According to Gebresilassie, Kumei, and Yemane (2014) in their study, “there is suboptimal and inconsistent practice of standard precautions in the healthcare setting that put patients and healthcare workers at significant risk of acquiring infections”. They also emphasized the need for in-service training for the healthcare workers on infection control. Adly, Amin and Abd El-aziz, (2014) found that intervention influenced the compliance of nurses with infection control measures, because of the knowledge gained during the intervention or training programme. There is a standard of infection control measures that can guarantee infection safety among health workers and patients.

 1.2 Statement of the Problem

Healthcare workers generally are at risk of infection. WHO (2006), reported that among the 35million health workers worldwide, about 3 million sustain percutaneous exposures to the blood borne pathogens each year, including 2 million to Hepatitis B virus (HBV), 0.9 million to Hepatitis C virus (HCV) and 170,000 to Human Immunodeficiency virus (HIV). These injuries may result in 70,000 HBV; 15,000 HCV and 5,000 HIV infections. Nurses are at higher risk of being infected with blood-borne pathogens from clinical blood exposure through injuries with sharp instruments and needle-stick injuries if infection control measures are not strictly followed. This is because they are usually the first contact with a patient on arrival in the hospital and provide 24 hour patient care. Studies have also shown evidence of clinical nurses becoming infected due to occupational exposure (Centers for Disease Control & Prevention, 2012).  Abdulraheem, Amodu, Saka, Bolarinwa & Uthman (2012), in their study, among health workers in North Eastern Nigerian found that the level of knowledge and implementation of standard precautions is below standard to guarantee infection safety. They concluded that there is still much to learn and implement when it comes to infection control measures. 

Furthermore, in some health institutions, the researcher observed that some nurses do not adhere to the components of standard precautions while providing nursing care. For example, few nurses were observed not to wash their hand after removing gloves and before commencing another procedure. In some of the wash hand basins in the outpatient department, liquid soap is not available for health workers and patients to wash their hands. When blood or body fluids are spilled on the floor, the house keepers do not decontaminate with hypochlorite solution before mopping with soap and water. The health institutions infection control units are not well equipped to function effectively to ensure compliance to standard precautions. It is in the light of the gaps that the researcher became interested in planning a training programme on knowledge, perception, attitude and practice of infection control for nurses at Babcock University Teaching Hospital (BUTH), Ilisan-Remo, Ogun state.

1.3 Objective of the Study

The main objective of this study is to determine the effects of a training programme on infection control among nurses. The specific objectives are to:




preventing unintended pregnancy, 4 (40%) had high knowledgeof preventing unintended pregnancy.Theirattitudes were neither positive nor negative 6 (60%).The girls had positive perceptions towards preventing unintended pregnancy. According to the result, the girls said that injection is the most suitable method of prevention of unintended pregnancy.The results of the hypotheses showed that: There is a moderate negative and significant relationship between adolescent’ knowledge and perception towards prevention unintended pregnancy. (r = -060, p < .398) and there wasa weak positive and significant relationship between adolescent’ knowledge and   prevention of unintended pregnancy (r = .500p < .000). There wasa perfect negative and significantrelationship between adolescent’ perceptions and prevention towards unintended pregnancy(r = -138, p < .049).

The study concluded that Knowledge, attitudes and perceptions play a very important role in preventing unintended pregnancy. In the absence of adequate and factual knowledge, adolescents are bound to make unsound decisions that have a bearing on their lives. The perceptions of the girls will give you the clearer picture of how they will act or behave when it comes to prevention of pregnancy. The following recommendations were made: Ministry of education must include sex education as a course in the curriculum that will emphasize more on abstinence and must be thought from elementary, the ministry of health and social welfare should provide dedicated health care facilities with adolescent friendly services, Church heads must encourage Christian dating in any forum contain adolescent girls, ministry of Education must have an age restriction to classes.


Content                                                                                                  Page

Title Page                                                                                                                    i

Certification                                                                                                                ii

Dedication                                                                                                                  iii

Acknowledgements                                                                                                    iv

Abstract                                                                                                                      vi

Table of Contents                                                                                                       vii

List of Tables                                                                                                              x   

List of Figures                         xi                                             


1.1       Background to the Study                                                                               1

1.2       Statement of the Problem                                                              4

1.3       Objective of the Study                                                                                   5

1.4       Research Questions                                                                                         5

1.5.      Hypotheses                                                                                                     6

1.6       Scope of the Study                                                                                         6

1.7       Significance of the Study                                                                               6

1.8       Justification for the Study                                                                              7

1.9       Operational Definition of Terms                                                      7


2.0       Introduction                                                                                                    8

2.1       Adolescents                                                                                                    8

2.2       Adolescent Girls                                                                                             8

2.2.1    Adolescent Girls Development                                                9 Physical Development                                                                                    9 Psychological Development                                                  10 Social/Emotional Development                                                11

2.3       The penalty of bearing child/children on adolescent                                      12

2.4       Interruption of school                                                                  13

2.4       Factors that contribute to adolescent pregnancy                  16

2.4.1    Family Relations                                                                        16

2.4.2    Family planning/ Contraception                                              19

2.6       Theoretical Framework                                                    21

2.6.1    Application of the theory                                                    21


3.0       Introduction                                                                                      25

3.1       Research Design                                                                                            25

3.2       Population                                                                                25

3.3       Sample size and sampling Technique                             26

3.4       Research Instrumentation                                                            27

3.5       Validity and Reliability of Instrument                                28

3.6       Method of Data Collection                                                                           28

3.7       Method of Data Analysis                                                29

3.8       Ethical Consideration                                                         29


4.0       Introduction                                                                            30

4.1       Analysis of the Research objectives                                       31

4.2       Section Two: Testing of Hypotheses                                      39

4.3       Discussion of Findings           41


5.0       Introduction                                                                             46

  • Summary                                                                                                   46

5.2      Conclusion                                                                                                       47

5.3       Recommendations                                                                                      47

5.4       Limitation of the Study                                                                      48

5.5       Suggestion for Further Studies                                                       48

References                                                                                                                  49

Appendices                                                                                                                 55


Table               Page

3.3.1    Sampling of schools in Gardnerville                                                        27

3.3.2    Sampling of classes in the two selected schools               27

3.5.1    Cronbach’s alpha (α)                                                                                    28

4.1.1    Demographic characteristics                                                                     31

4.1.2    Knowledge of prevention towards unintended pregnancy 33 Summary of Table                                                                          34

4.1.3    Attitudinal disposition of adolescent girls towards prevention of

unintended pregnancy                                                                                             35 Summary of Table                                                            36

4.1.4    The level of perception of adolescent girls with regards to prevention of unintended pregnancy                                                                37

4.1.5    Self reported prevention of unintended pregnancy                                        39

4.2.1    Pearson Product Moment Correlation Analysis adolescent knowledge

 and perception of unintended pregnancy                                                      40

4.2.2    Pearson Product Moment Correlation Analysis adolescent knowledge

and prevention of unintended pregnancy                                                       40

4.2.3    Pearson Product Moment Correlation Analysis adolescent perception

and prevention of unintended pregnancy                                                       41


Figure                                                                                    Page

Adapted health belief model of preventing unintended pregnancy               22




Content                                                                                                 Page

Title page                                                                                                              i          

Certification                                                                                                    ii

Dedication                                                                                                         iii

Acknowledgements                                                                   iv

Abstract                                                                                                  v

Table of Contents                                                                                               vi

List of Tables                                                                                                    ix

List of Figures                                                                                                   x


1.1 Background to the Study                                                                         1

1.2 Statement of the Problem       2

1.3Objective of the Study                                                                                          3

1.4 Research Questions                                                                                              4

1.5 Hypotheses                                                                                               4

1.6   Scope of the Study                                                                                             4

1.7   Justification for the Study                                                                                 5

1.8 Operational Definition of Terms                                                   5


2.0   Introduction                                                                                                        6

2.1 Concept Related to Weaning                                                                              6

2.2 Dangers of the weaning period                                                      7

2.2.1 Risks of starting solids early                                                                11

2.2.2 What are the risks for early weaning                                          11

2.2.3 Solid food and iron                                                                         12

2.3. When to start weaning                                                                                      12

2.4 Improvement of weaning practices                                                               13

2.5 Harmful weaning practices                                     16

2.6 Theoretical Framework                                           18


3.0 Introduction                                      23

3.1 Research Design                                                                                       23

3.2 Population                                                                                                   23

3.3 Sample size and sampling Technique                                        23

3.4 Instrumentation                                                                                      25

3.5 Validity and reliability of Instruments                                                   25

3.6 Method of Data Collection                                                                  25

3.7 Method of Data Analysis                                                                         25

3.8Ethical Consideration                                                                          25



4.0 Introduction                                                                                27

4.1 Data analysis and results                                                                       28

4.2 Discussion of Findings                                                           33

Content Page



5.1 Summary                                                                                       36

5.2 Conclusion                                                                                     36

5.3 Recommendations                                                                           37

5.4 Limitation of the Study                                                     37

5.5 Suggestion for Further Studies                                             37

REFERENCES                                                                                38

APPENDICES                                                                                                      41


Table                                                     Page

 1: Mothers Selection from the three Primary Health Centers in Ikenne Local          Government Area      24

 2: Demographic data of participants                                  28

 3: Descriptive statistics on Mothers Knowledge regarding infant weaning                  29

 4: Mothers Knowledge level on infant weaning                      30

5: Descriptive statistics on mothers practices concerning infant weaning                      30

6: Level of mothers practices on infant weaning                            31

7: Inferential statistics on occupation and weaning practices among mothers                31

8: Inferential statistics on educational level and weaning practices among                    32

9: Inferential statistics on ethnicity and infant weaning practices among                     mothers    32

10: Inferential statistics on mothers’ knowledge level and infant weaning       practices among mothers                33


Figure                                                                        Page                              

1: Effect of infections: Practical Mother and Child Health in Developing        Countries          9

2: The food square: Practical Mother and Child Health in Developing                     16

3: Theoretical Framework                                                          20

4: Conceptual Model                                                                           21


Appendix                                                                                              Page

    A: Research questionnaire                                             39                  

    B: Pictures from the field work                                             42



1.1   Background to the Study

Weaning is the introduction of supplementary food to a child’s diet after the first six months of life. Infant weaning with supplementary feeds of breast milk substitutes, early introduction of complementary feeding and incorrect weaning from breast milk are commonly found practices in communities around the world (Inayati, Scherbaum, Purwestri, Hormann, Wirawan, Suryantan, Hartono, Bloem, Pangaribuan, Biesalki, Hoffmann, & Bellows, 2012). The period of weaning could involve a lot of problems and usually information gap exist in relation to how and when weaning takes place. Adequate nutrition during infancy and early childhood is essential for growth and development of children (Ashmika, Deerajen, Prity & Rajesh, 2013). It has been recognized worldwide that breastfeeding is beneficial for both the mother and child as breastmilk is considered the best source of nutrition for an infant (Ku & Chow, 2010). The World Health Organization (WHO) as said by Hanif (2011 recommends that infants should be exclusively breastfed for the first six months after which complementary foods are introduced along with breastmilk for up to two years of age or beyond. The first two years of life are critical stages for a child’s growth and development. Any damage caused by nutritional deficiencies during this period could lead to impaired cognitive development, compromised educational achievement and low economic productivity (Kimani-Murage, Madise, Fotso, Kyobutungi, Mutau, Gitau & Yatich, 2011).

Poor breastfeeding and complementary feeding practices, together with high rates of morbidity from infectious diseases are the prime proximate causes of malnutrition in the first two years of life. Breastfeeding confers both short-term and long-term benefits to a child. It reduces infections and mortality among infants, improves mental and motor development, and protects against obesity and metabolic diseases later in life (WHO, 2010). According to Kimani-Murage et al., (2011), the WHO recommends exclusive breastfeeding in the first six months, beginning from the first hour of life, to meet the infant’s nutritional requirements and achieve optimal growth, development and health. The mother is advised to continue breastfeeding up to two years of age or more and begin nutritionally adequate, safe, and appropriately-fed complementary foods at the age of six months in order to meet the evolving needs of the growing infant. Since weaning is a process by which food other than breast milk is introduced gradually into baby’s diet, first to complement the breast milk and then to wean totally off breast milk involve selecting light nutritious food for easy absorption. Then later replace light nutritious food with thicker feed using hygiene practices when preparing them but majority of nutrition problems in rural areas are due to faulty weaning food (Shadia & Bedor, 2013).

Predictors of breastfeeding and weaning practices vary between and within countries. Factors that influence the weaning process include infant feeding problems such as refusal to eat, colic, diarrhoea and vomiting (Ashmika et al., 2013). These factors represent challenges for mothers and in turn may either directly or indirectly influence the feeding pattern. In view of the identified factors, which are early introduction of complementary feeding and incorrect weaning from breast milk, the researcher would carry out a study on infant weaning knowledge and practices among mothers in ikenne local government area, Ogun State

1.2 Statement of the Problem

Weaning has been one of the most wrongly practiced processes in the developmental stages of the children. It  was observed that mothers give their infant other food apart from breast milk right from birth while some delayed supplementary diet till above Nine months with either cases having negative effect on the infant. WHO (Hanif, 2011) recommends a gradual weaning period from 6 months to 2 years, this allows for the child to still receive the benefits from breastfeeding, while also consuming the necessary nutrients from the complementary foods. But almost half of the mothers (52%) abruptly weaned their children while only 11.6% gradually weaned their children as complementary food is being addedto the children diet (Somiya, 2014). The time of weaning is one of the most critical aspects of child’s life. It is the transition period at which the child whose main food used to be milk changes over to adult food. Usually if this period of change in diet is well-planned and progresses smoothly, there will be no setbacks, but in a large number of children, malnutrition usuallytakes place during this period. Ten million children under the age of 5 years old die each year (Somiya, 2014). More than half of the deaths occur because of poor weaning that leads to malnutrition. If adequate health systems were in place nearly two-third of the deaths could be prevented. The most vulnerable period for developing under-nutrition remains the transition from breastfeeding to family foods. Malnourished children often suffer the loss of precious mental capacities. They fall ill more often. If they survive, they may grow up with lasting mental or physical disabilities (Dinesh & Sushilkumar, 2011).

Poor quality of weaning foods and improper weaning practices predispose infants to malnutrition, growth retardation, infection, diseases and high mortality (Somiya, 2014). Food is expected to be prepared adequately containing the required nutrients as well as appropriate with a suitable texture and temperature. Without the knowledge of proper weaning practices as well as a perception of the child’s hunger needs, malnutrition and illness may ensue. Thus, the weaning period is therefore a vulnerable time when the child should be attentively cared for and observed so as to maintain health (Somiya, 2014). Therefore, information gotten on weaning will improve mother’s practice of weaning since the mother is the most important person in a baby’s life for both its physical as well as its psychosocial care and growth. The mother-infant relationship is the most vital formative relationship for the child. There arises a need to prevent wrong assumption of mothers on weaning process and timing, there is need for sound education, effective information and sufficient knowledge of weaning to be instilled in mothers. Nurses can be agent of carrying out the educational needs for weaning infants in proper way. Therefore, the need for a study on infant weaning knowledge and practices among mothers in Ikenne Local Government Area, Ogun State.

1.3 Objective of the Study

The main objective of this study is to explore infant weaning knowledge and practices among mothers in Ikenne local government area, Ogun State. The specific objectives are to:




Contents                                                                                                       Page

Title Page                                                                                                                    i

Letter of Certification                                                                                                 ii

Dedication                                                                                                                  iii

Acknowledgement                                                                                                      iv

Abstract                                                                                                                      vi

Table of Contents                                                                                                       viii

Appendices                                                                                                                 ix

List of Tables                                                                                                              x

List of Figures                                                                                                             xi


  1. Background to the Study                                                                         1
  2. Statement of the Problem                                                                         3
  3. Objective of the Study                                                                            4
  4. Research Questions                                                                            4
  5. Hypotheses                                                                                           4
  6. Significance of the Study                                                                         5
  7. Operational Definition of Terms                                                                  5


  • Introduction                                                                                           7

2.1. Theoretical Framework                                                                          8

2.2. The Concept and Strategies of Primary Health Care                     12

2.2.1. Definitions of Primary Health Care                                                  13

2.2.2. Strategies of primary Health Care                                                   14

2.3. Nursing Process                                                                                       17

2.3.1. The Phases of the Nursing Process                                                20

2.3.2. Assessment                                                                                                     21

2.3.3. Diagnosis or problem identification                                     22

2.3.4. Planning                                                                                                            24

2.3.5: Implementation                                                                           25

2.3.6: Step 5: Evaluation                                                                26

2.4. Critical Thinking and Nursing Process                                            27

2.4.1. Introduction                                                                        27

2.4.2. Definitions of Critical Thinking                                                                    28

2.4.3. The relevance of Critical Thinking in Nursing Process                         28

2.4.4. Critical Thinking Skills needed in Nursing Process                  30

2.5. Barriers to the successful implementation of Nursing Process                            31

CHAPTER THREE: METHODOLOGY                                               

3.0. Introduction                                                                                             33

3.1. Research Design                                                                                      33

3.2. Population                                                                                                            33

3.3. Sample and Sampling Technique                                                             34

3.3.1. Inclusion and Exclusion Criteria                                                  35

3.4. Instrumentation                                                                                     35

3.4.1. Validity of Instrument                                                                   36

3.4.2. Reliability of Instrument                                                               36

3.5. The Training Module                                                                              36

3.6. Data Collection Procedure                                                                     37

3.6.1. Selection of Research Assistant                                                            37

3.6.2. Design of Intervention.                                                                       38

3.7. Method of Data Analysis                                                                         38

3.8. Ethical Consideration                                                                       39

3.8.1. Post Research Benefits                                                                  39



4.0.      Introduction                                                                              41

4.1.      Data Presentation                                                                        41

4.1.1.    Demogrgraphic characteristics                                                   41

4.2.      Analysis of Research Questions                                                       42

4.2.1. Research Question One                                                                     43

4.2.2. Research Question Two                                                                     45       

4.3. Testing of Hypotheses                                                                             50

4.3.1. Hypotheses One                                                                                  51

4.3.2. Hypothesis Two                                                                              54

4.4. Summary of Findings                                                                       55

4.5. Discussion of Findings                                                                            56

4.5.1. The demographic presentation of the participants        56 objective one(Knowledge needs of participants)                            57 Attitude of the Community Health Nurses                          58 The performance (practice) of community health nurses        58

4.5.3. Discussion on research objective two:                                                  59

4.5.4. Discussion on research objective three                      60

4.5.5. Discussion on Hypothesis one                                                              60

4.5.6. Discussion on Hypothesis two                                                              62


5.0. Introduction                                                                                  63

5.1. Summary                                                                                                  63

5.2. Conclusion                                                                                                           64

5.3. Recommendations                                                                                    65

5.4. Suggestions for further studies                                                                66

REFERENCES                                                                                                    67

APPENDICES                                                                                 73


Appendix                                                                                               Page

1.         The research questionnaire                                                        73

II.        Pre and Post Performance Check-list                                  75

III.       Informed Consent Form                                                              77

IV.       Letter of Introduction                                                                        

V.        Ethical Clearance Certificate                                                                         

VI.       Pictures of events                   


Tables                                                                                               Page

3.1.      The distribution of the community health nurses in the study area                            34

3.2.      Timeline of Activities                                                                  35

3.3.      Outline of Intervention                                                               38

4.1.      Age Distribution of Respondents                                           41

4.2a.    Assessment of Knowledge Needs of Participants on nursing process                       43

4.2b.    Assessment of the participants’ attitude towards nursing process                             44

4.2c.    Assessment of Participants’ Level of Practice of Nursing Process                            45

4.3a.    Summary of Descriptive and inferential statistics of pre-test knowledge of Community Health Nurses on Nursing Process                                                     45

4.3b.    Summary of Descriptive and inferential statistics of post-test knowledge of   Community Health Nurses on Nursing Process                                                          46

4.3c.    Summary of Descriptive and inferential statistics of pre-test Attitude of Community Health Nurses towards utilization of Nursing Process                       47

4.3d.    Summary of Descriptive and inferential statistics of post-test Attitude of Community Health Nurses towards utilisation of Nursing Process        47

4.3e.    Descriptive and inferential statistics of pre-intervention performance(practice) of community health nurses in the control and experimental groups         48

4.3f.     Descriptive and inferential statistics of post-intervention performance of community health nurses in control and experimental groups                               49

4.4.      Descriptive statistics of pre and post-intervention performance scores of participants                                                                        40

4.5.      ANCOVA summary showing the effect of programme on the utilisation of nursing process                                                                 51

4.6.      Estimates of control and intervention treatments                                51

4.7.      Univariate test of the effects of control and intervention training on participants’ post-test scores                                                                                  52

4.8.      Pairwise comparison of treatments on participants’ implementation of nursing process                                         52

4.9.      Cross tabulation of years of experience and performance rating                                54

4.10.    Chi-square test showing relationship between experience and assimilation of training programme                                      54

4.11.    Adjusted and Unadjusted Treatment Means and Variability for Post Implementation Performance of Nursing Process with Pre-test as a Covariate         56


Figures                                                                                               Page

1.         Nursing Process Model                                                                           8

2.         Pre and post knowledge of the participant on the use of nursing process                  46

3.         Pre and post attitude of the participant on the utilisation of nursing process                        48

4.         Pre and post implementation practice of nursing process by participants                  49

5.         Estimated marginal means of post-performance scores                                              53



  • Background to the Study

Primary Health Care (PHC) describes the basic tenets and values that guide professional nurses as the continuous practice of health promotion, illness prevention, prompt diagnosis/care of ailments and restoration of sick people to their pre-illness state (Iita, Small and Van, 2011). According to WHO (2010), the utmost priority and objective of primary health care is to ensure improved health for everyone. The organisation has identified five basic principles for this as reducing segregation and inequalities in social health (global coverage); designing health care services around people’s health needs and aspirations (service delivery); integrating health into all sectors (public policy); the pursuing collaborative ideals of policy dialogue (leadership); and the increasing stakeholders’ involvement. In other words, PHC focuses on a strategy that surpasses the orthodox health care arrangement which stresses on health uniformity-yielding social policy; but rather includes all aspects that directly influence health. This include; prompt and timely access to health services, suitable environment and lifestyle. Hence, primary healthcare and public health strategies may together be considered as the fundamentals of universal health system (Daisy, 2009).

In order to achieve these goals, the core attributes of primary health care which are first contact (accessibility), longitudinality (person focused preventive and curative care overtime), patient-oriented comprehensiveness and coordination (including navigation towards secondary and tertiary care) are factors that should be put in place and to also enhance effective health care delivery (WHO, 2008). Besides taking care of the needs of the individuals, primary health care teams also look at the community, especially when addressing social determinants of health. This is achievable through a community oriented primary care (COPC) experience which integrates public health focus and primary health care. The interaction of the primary health care team with different networks (education, work, economy, and housing) are also important. By using all these methods, the primary health care team promote health equity, increase social cohesion and empowerment through its contribution (Daisy, 2009).

According to Chukwu and Momoh (2010), the nursing process which is a universal phenomenon is fundamental for making nursing a unique profession. Consequently, the process of implementation of the components and attributes of primary health care can be best achieved through the use of this process, being a broadly acceptable, systematic method of planning and delivering individualized care for clients in any state of health or illness; and a scientific means of solving the numerous and dynamic nursing problems (Chiarelli, Costanzi, Moraes, Pokorski, and Rabelo, 2009). The nursing process is made up of a global standard through which nursing problems are identified and solved (Elder and Paul, 2005). It is also a method of thinking critically to solve patient prob­lems within the professional practice. The nursing pro­cess is a series of steps taken to fulfil the goals and objectives of nursing practice” (Walsh and Yura 1983). The nursing process is a dynamic and an organised pattern for rendering nursing care through six interrelated and overlapping phases of assessing, diagnosing, identifying outcome, planning, implementing and evaluating nursing actions. It is an actual task adopted by professional nurses to identify/ solve patient’s problems and deliver a top quality levels of care among families, groups and communities (American Nurses Association, 2009). At the assessment phase, a thorough exploration of the needs of the individual, family, group or community that are of importance to them are made by the nurse in order to arrive at a diagnosis from the numerous data collected.

At the planning phase, nurses’ judgment of the individual, family, or community’s responses to the important life’s activities; or to specific or potential health needs are identified and planned for. This also provide a basis for the choice of appropriate nursing actions (North American Nursing Diagnosis Association, 2007). The implementation phase addresses the problems identified using the most relevant nursing actions and finally assessed for effectiveness at the evaluation phase (Alfaro-LeFerve, 2004).

However, the Implementation of the nursing process in the community and primary health care settings can be achieved through the principles of action research which requires knowledge and understanding of the major aspects of the nursing process, and the platform through which this knowledge can be applied in practical settings (Good and Savett, 2005). If this is implemented, it will amount to good quality of care that enhances the development of scientific cum theoretical knowledge that rests on a quality clinical nursing care, (Almeida, Barra, Debétio, Marinho, Paese, Rios, and Sasso, 2013). Also, to promote and enhance the worth of nursing practice, the use of nursing process is advocated, because it advances, patterns and designs, in addition to promoting the continuous use of information. This gives nursing staff the opportunities to evaluate their work output/productivity as well as revamp the rate at which they perform their job in relation to their consumers’ responses to care (Dal Sasso, et al., 2013).This research implemented a training programme for community health nurses on the utilisation of nursing process, in primary health care in selected primary health care centres in Ijebu-Ode Local Government Area.

  1. Statement of the Problem

Nursing process is a universal phenomenon that is foundational to nursing as a profession. If correctly and effectively utilised, it will promote the quality of health care; and improve the worth of nursing care at all levels of health care including the primary, secondary and tertiary levels (Chukwu & Momoh 2010). However, despite this universal identification and acceptance of nursing process as the major tool for delivering quality health care services, its utilisation in the primary health care centres is still underrated, with the major obstacles being related to the management processes in health services, the resistance of nurses to change, shortage of manpower, administrative/political matters that antagonise the practice of nursing, the administrative design and programme of healthcare institutions, the lack of autonomy of the professional nurse, centralisation of power in institutions; and lack of willingness on the part of nurses to accept and face the tasks of modelling themselves to acquiring new skills and education in nursing practice (Alemseged, Aregay,  Balcha, Berhe & Hages, 2013).

The World Health Organisation (2008) has registered this as a concern; and submits that since health is a fundamental human right, the community has a role to play in contributing to the health of its members and divers groups in the community. Most communities today have at least one health care facility located as close as possible to where they live or work, in all the districts or local government areas of many of the states in Nigeria. Nonetheless, it has been discovered that the establishment of these health care facilities has not in any way led to its utilisation; with the record that one of the major contributory factors to high mortality rate in Nigeria is lack of access to; and non-utilisation of health care services due to unfair treatment of patients and their relatives by the nurses and lack of competencies in providing quality nursing care (Achi, Amos & Olayinka, 2014).

The researcher has noted from clinical practice that most members of the communities where primary health care centres are located, bypass these health centres to seek for health care in secondary or tertiary institutions, when there are primary health care centres in their neighbourhoods which are meant to serve their health needs. Also, when patients are referred from Primary Health Care centres to secondary or tertiary institutions for better and continued health management, they often report at these institutions with more grievous complications than they were originally before they sought care in these Primary Health Centres; with reasons ranging from inhumane and rigid attitude of the community health nurses to lack of competencies in providing quality care, mismanagement of the conditions by care providers, exorbitant prices charged on services when they felt primary health care should be relatively cheap and affordable among other reasons. These has often led to increase mortality, morbidity and irreversible damages on the patients’ lives. Chianca, Miranda, Silveira & Vaz, (2013) support this evidence and affirm that a mismanaged patient in a primary health care or faith-based organisation is often a reason for opening a death record in either a secondary or tertiary health institution.

1.3. Research Objectives

The main objectives of the study isto evaluate the impact of a training programme on utilization of nursing process among community health nurses in primary health care centres in Ijebu-Ode LGA and the specific objectives of the study are to:




Content                                                                                                               Page

Title page                                                                                                         i

Certification                                                                                                             ii

Dedication                                                                                                       iii

Acknowledgements                                                                                         iv

Abstract                                                                                                               v

Table of Contents                                                                                     vi

List of Tables                                                                                     vii

List of Figures                                                                                viii

Appendices                                                                                             ix


1.1       Background to the Study                                                            1

1.2       Statement of the Problem                                                                         2

1.3       Objective of the Study                                                                 3

1.4       Research Questions                                                                          3

1.5       Hypotheses                                                                                        4         

1.6       Scope  of the Study                                                                        4

1.7       Significance of the Study                                                                   4

1.8      Justification to the Study                                                               4

1.9       Operational Definition of Terms                                                        5


2.0       Introduction                                                                                       6

2.1       Umbilical cord care overview                                                        6

2.2Determinant of umbilical cord practices                                  6

2.3     Types of substances used for umbilical cord care                             8

2.4        Possible problems of umbilical cord stump                                       8

2.5      World Health Organization (WHO) recommendations                 9

2:6:0 Related literatures to umbilical cord care practices                              10

2:6:1 Knowledge of mother regarding newborn umbilical cord care     11

2:6:2 Practice of mothers regarding newborn umbilical cord care12

2:6:3 General management of umbilical cord infection                 15

2.1Ramona Mercer: Maternal Role Attainment Conceptual Model                                 16


3.0       Introduction                                                                                      18

3.1       Research Design                                                                          18

3.2       Population                                                                              18

3.3       Sample size and Sampling Technique                                        18

3.4       Research Instrument                                                                       19

3.5 Reliability and Validity of Instrument                                           20

3.6    Method of Data Collection                                                      20

3.7       Method of Data Analysis                                                                   20

3.8       Ethical Consideration                                                           21



4.0       Introduction                                                                                        22

4.1       Socio-demographic information of respondents            22

4.2       Analysis of Research Questions                                                         27

4.3       Hypothesis Testing                                                           32

4.4       Discussion of Findings                                                             35



5.0       Introduction                                                                   39

5.1       Summary                                                                                                         39

5.2       Conclusion                                                                                                      40

5.3      Recommendations                                                              40       

5.4       Limitation of the Study                                                            40

5.5       Suggestion for Further Studies                                                           40

REFERENCES                                                                                                    41

APPENDICES                                           47


Table                                                                                                                  Page

4.1 Socio-demographic data of the respondents                                              23

4.2 Interview guide on knowledge toward umbilical cord care                   25

4.3 Interview guide on umbilical cord care practice                               26

4.4 Mother’s knowledge on umbilical cord cares                               27

4.5Umbilical cord care practices of mothers                                              27

4.6 Substances/materials used for umbilical cord care                        28

4.7 ANOVA table for factors influencing cord practice                         29

4.8 Model summary for factors influencing cord practice                            29

4.9 Coefficient table for factors influencing cord practice             29

4.10Relationship between mother’s knowledge and practice of umbilical care                     30

4.11 Correlations of knowledge and practice                                                 30

4.12 Mean and standard deviation of knowledge and practice                   31

4.13 Relationship between umbilical cord care practice and maternal parity             31

4.14 Correlations of maternal parity and practice                           31

4.15Hypothesis One                                                                          32

4.16 Correlation of practice and income                                                 32

4.17 Hypothesis Two                                                          33

4.18 Hypothesis Three                                                                             34


Figure                                                                                                        Page

2.1       Maternal Role Attainment Model by Mercer                                 17


Appendix                                                                                                Page

Inform Consent Form                                                                                   46

Questionnaire used for this study                                                       47

Ethical Clearance Certificate                                                         50

Letter of Introduction                                                                                51

Evidence of Anti-plagiarism                                                                        52



  • Background to the Study

The first 28days in the infant’s life is a period of great significance as the newborn is fragile and susceptible to infection; hence they need to be handled carefully so as to prevent neonatal death or permanent deformity. Mothers as the primary care providers have very important role to play to ensure that these newborns develop optimally as the new born health and survival is dependant on the essential care received before, during and after delivery (Joel-Medewase, Oyedeji, Elemile, & Oyedeji, 2008)

Neonatal infection is a major cause of neonatal deaths as the mortality rate could be as high as 44 per thousand life-births in the north-east zone of Nigeria. Neonatal deaths, cord infection and sepsis can be prevented with good umbilical cord practices especially in areas where home deliveries are done. In developing countries such as Nigeria, umbilical cord infection accounts for significant number neonatal morbidity and mortality, this accounts for 276,000 neonatal deaths annually the second highest deaths in the world and in Nigeria alone it accounts for about 33% of neonatal mortality (Jabbi, Shoretire, Ojile,  Maishanu & Orobaton, 2014; Soofi, Cousens, Imdad, Bhutto, & Ali, 2012; Orobaton, Abegunde, Abdulazeez, Akomolafe & Ganiyu, 2015; Osuchukwu, 2014).

The umbilical cord is a tissue that has a vein and two arteries of which at term is about 56cm in length and extends normally from the center of the placenta to the umbilicus of the unborn baby. During pregnancy, the umbilical cord connects the fetus to the mother through the placenta. The umbilical cord is responsible for the supply of blood rich in nutrients and oxygen from the mother to the fetus and the removal of carbon dioxide and other metabolites away from the fetus to the mother. Umbilical cord care is one of the most essential cares given to umbilical stump of newborns in the first few days of extra uterine life before the fall-off of the cord and immediately after its fall (Fraser & Cooper, 2009). 

The availability of tetanus vaccine for pregnant women and topical application of antimicrobial agents should help reduce bacterial infection hence newborn deaths and improve the newborn health and wellbeing. Aside cleaning and drying of the umbilical cord stump, daily application of chlorhexidine 7.1% chlorhexidine digluconate aqueous solution or gel to the umbilical cord stump during the first week of life is strongly recommended for newborns who are born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1000 live births) Chlorhexidine digluconate 7.1% gel was used by 36,404 newborns delivered by 36,370 mothers to help reduce such neonatal deaths in Sokoto State, North West Nigeria, this low cost but highly effective gel used for the prevention of newborn sepsis should be made available in all delivery settings so as to reduce umbilical cord infection and then neonatal death (Enang, Ushie, Arikpo, Osonwa, Esu, Odey, et al., 2013; Mullany, Darmstadt & Tielsch, 2003; Orobaton et al., 2015).

Unqualified personnel  provide health care services to majority of women especially during pregnancy, child birth and after child birth as there is lack of skilled personnel, needed resources and  availability of essentialdrugs that has increased neonatal and childhood deaths. To achieve a healthy and productive society it is important to pay attention to the health and wellness of the newborn as this will help reduce neonatal and newborn mortality and morbidity. In 2013, in Johannesburg, South Africa, an International Conference on Maternal, Newborn and Child Health was held so as to bring about concrete actions for improving MNCH in Africa. Maternal and child care during pregnancy, child birth and post partum is a major strategy to improve child survival as low socio-cultural barriers to care, weak health care system and poor socio-economic development influence maternal and child health (Ezechi & David, 2012)

  • Statement of the Problem

The future of any nation lies on the present generation, their health and welfare can be altered by activities that occur either before, during or after delivery. Newborn health and survival is partly dependent on the mother’s decisions on where to deliver and actions or activities taken after delivery. In most rural communities, deliveries and child care activities are mostly managed at home where about 69.8% of care providers used unhygienic and harmful materials for cord care (Osuchukwu, 2014).

In Nigeria, cases of umbilical cord infections are under documented and reported. But for some studies conducted in the hospital, in Port Harcourt, omphalitis constitute 10% reasons of neonatal admissions and 30% of neonatal deaths. In Ibadan it constitute about 18% of neonatal deaths while in Calabar, 49% of neonatal deaths were linked to omphalitis. Neonatal death every year in Nigeria is about 241,000 making it the highest neonatal death rate in African. In Africa, annually about 600,000 infants die of neonatal tetanus. Global annual neonatal deaths constitute about 4million (3.1%) and about (25%) of these deaths are due to umbilical infection. Similar studies have been conducted in other part of the country so the researcher intends to explore the factors influencing umbilical cord care Plateau state, due to the increasing number of mothers returning to the health care facility with umbilical cord complications especially omphalitis in newborns (Federal Ministry of Health, 2009; Osuchukwu, 2014).

1.3 Objective of the study

The general objective is to assess the factors influencing umbilical cord care practices among mothers attending infant welfare clinic in selected primary health care centres in Jos-North Local Government Area, Plateau State. The specific objectives are to:




Content                                                                                                  Page

Title Page                                                                                                                    i

Certification                                                                                                                ii

Dedication                                                                                                                  iii

Acknowledgements                                                                                                    vi

Abstract                                                                                                                      v

Table of Contents                                                                                                       vi

List of Tables                                                                                         viii

List of Figures                                                                                                             ix

Appendices                                                                                                     x

Abbreviations  xi



2.0. Introduction                                                                                                         8

2.1. Concept of Pain                                                                                                   8

2.2. Effects of Pain                                                                                                     10

2.3. Expressions of Pain                                                                       11

2.4. Types of Pain                                                                                                       12

2.5. Physiology of Pain                                                                  13

2.6. Nociception                                                                                                          13

2.7. Pain after Surgery                                                                      15

2.8. Pain Assessment                                                                16

2.8.1. Central Principles of Pain Assessment                17

2.8.2. Roles of Nurses in Pain Assessment                                   18

2.8.3. Standard Tools for Pain Assessment                                        19

2.8.4. Patient Self-reporting Pain Scales                                          21

2.9. Methods of Pain Management                                               24

2.9.1. Non-Drug Techniques to Manage Pain                      24

2.9.2. Pharmacological Methods of Pain Management                   29

2.10. Anxiety                                                                                                              31

2.11. Types of Anxiety                                                                  32       

Content                                                                                                           Page

2.12. Causes of Anxiety                                                                                             32

2.13. Effects of Anxiety                                                                                             33

2.14. Prevalence of Anxiety                                                           34

2.15. Levels of Anxiety                                                                                              35

2.16. Assessment of Anxiety in Surgical Patients                   36

2.17. Management of Anxiety in Surgical Patients                      38

2.18. Empirical Reviews of Surgical Patients’ Anxiety                       42

2.19. Theoretical Model and Framework                                   45

2.19.1. Theory of Health as Expanding Consciousness               45

2.19.2. Application of the Theory to the Study                                  46


3.0. Introduction                                                               48

3.1. Research Design                                                                            52

3.2. Population                                                                                                52

3.3. Sample size and samplingTechnique                                52

3.4. Instrumentation                                                                             53

3.5. Validity and Reliability of Instrument                                                          54

3.6. Method of Data Collection                                                      55

3.7. Method of Data Analysis                                                                    55

3.8. Ethical Consideration                                                    56



4.0. Introduction                                                                                 58

4.1. Data Analysis and Result Presentations                                      58

4.8. Discussion of Findings                                                                67



5.0. Introduction                                                                                             73

5.1. Summary                                                                                                  73

5.2. Conclusion                                                                                   73

5.3. Recommendations                                                                  74

5.4. Limitation of the Study                                                                           75

5.5. Suggestion for Further Studies                                                                75

REFERENCES                                                                       76

APPENDICES                                                                                           108


  Table                                                                                     Page

4.1.Socio-Demographic Data of Study Participants                                 53

4.2. Assessment of Anxiety States and Pain Intensity using a Tool/ instrument by nurses                                                                              55

4.3.Distribution of Study Participants and their Perception of their Anxiety in the Pre-Operative Periods (a & b)            56

4.4.Distribution of Study Participants and their Perception of their Anxiety in the Post-Operative Periods (a & b)                                        58                    

4.5. Baseline and Post-Operative Anxiety and Pain intensity among surgical patients                                                                                   60

4.6. Relationship between nursing intervention for the relief of Pre-Operative anxiety and control of post-operative pain                              62

4.7. Relief of anxiety state levels in response to nursing intervention on the basis of gender and educational levels                            64

4.8. Relief of post-operative pain intensity in response to nursing intervention on the basis of gender and educational levels                65

4.9. Hypothesis testing of the relationship between nursing intervention for the relief of anxiety levels and post-operative pain 66

4.10.Hypothesis testing of relationship of the relief of Anxiety levels in response to nursing intervention on the basis of Gender and Educational    levels                                                                                                66

4.11.Hypothesis testing of relationship of the relief of Post-Operative pain in response to nursing intervention on the basis of Gender and Educational levels                                                                                           67


Figure              Page

Conceptual Framework of Margaret Newman                                                47


Appendix                                                                                            Page

Informed Consent                                                                                               108

Questionnaire                                                                          110

Planned Preoperative Teaching Module                                             113

Ethical Approval                                                                                 115


AIDS              Acquired Immune Deficiency Syndrome

ANOVA         Analysis of Variance

CNS                Central Nervous System

DSM IV-TR    Diagnostic and Statistical Manual of Mental Disorders (4th edition,Text Revision)

HEC                Health as Expanded Consciousness

HIV                 Human Immuno-deficiency Virus

HND               Higher National Diploma

IASP               International Association for the Study of Pain

IBM                International Business Machines

JCAHO           Joint Commission on Accreditation of Healthcare Organizations

NRS                Numeric Rating Scale

NSAIDs          Non-Steroidal Anti-Inflammatory Drugs

OND               Ordinary National Diploma

PCA                Patient-Controlled Analgesia

STAI               State-Trait Anxiety Inventory

VAS                Visual Analogue Scale

VDS                Verbal Descriptor Scale

WHO              World Health Organization



  • Background to the Study

Health has been described as the nonexistence of disease and impairment, as well as a condition of complete wellness in the mental, physical, and social realms. The persistence of the internal environment of any human system is dependent on their physiological, sociological and psychological equilibrium. Nursing care has the primary objective to render service for maintenance of health through the preservation of a stable internal environment, and assisting to ensure the restoration of equilibrium in the condition of illness (Birol, 2005; Şanli, 1991).

There are three phases in the nursing care a surgical patient passes through in the health care services called perioperative nursing. These phases include: pre-operative, intra-operative and post-operative. The pre-operative phase involves the administration of nursing care to the clients who are planned to undergo surgical procedures (Phillips, 2013; Spry, 2005). The primary responsibility of the health care providers as reported in literatures is to assess and educate the patient during this phase, to minimize the dangers during the surgery and have better outcomes of the patients. The main rationale for preoperative phase of care is linked to reduction of defects operative morbidities and decrease stay of patients at hospital (Association of Anesthetists of Great Britain, and Ireland (AABI) safety guidelines, 2010).

Surgery is one of the major life changes that cause anxiety. Hospitalization provokes anxiety in the patient admitted for surgery, even in the absence of disease. Stress resulting from protracted anxiety may eventually endanger the client if not discovered early and slow-down recovery(Goebel, Kaup, & Mehdorn, 2011; Jafar & Khan, 2009; Swindale, 2004; Yilmaz, Sezer, Gurler, & Beker, 2011). Surgery can trigger a panic attack in a patient who is prone to anxiety. The preparative care of surgical patients becomes very challenging with the increasing existence of anxiety before surgery.

Anxiety experience is common to most patients awaiting elective surgery and generally seen as normal response(Jawaid, Mushtaq, Mukhtar, & Khan, 2007). Surgical patients perceived the day of surgery as highly terrifying in their lives. Patients manifest anxiety with varying degrees in relation to what is expected in future and these are associated with many factors which may be type and extent of the proposed surgery, gender, age,  previous surgical experiences, and personal tendency for unpleasant events(Ping, Linda, & Antony, 2012). The intervention for employed by the healthcare providers has been found to promote, comfort, and favorable surgical outcomes. Nurses and other healthcare givers needs to know patients who are prone to anxiety in the population in order to reduce the occurrence of anxiety resulting from surgery.

The Babylonian clay tablets revealed the evidence of thephenomenon of pain as referenced in achieves. The Greek philosopher, Aristotle, in the 4th century B.C., identified pain as an emotion, and a reciprocal of pleasure. Although emotions certainly play an important role in pain perception, there is much more to the experience than the feelings involved. In the Middle Ages, pain had religious interpretations, in which pain was seen as God’s punishment for sins or as evidence that an individual was possessed by demons. This meaning of pain is embraced by some clients with the mindset that the suffering is their “cross to bear.” The relief of pain may not be the goal for individuals who believe in this definition of pain. Spiritual counseling may need to be implemented before this person is willing to work toward relief. The most widely accepted definition of pain is one developed by the International Association for the Study of Pain (IASP). This organization defines pain as an offensive sensation and mind-blowing experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 2008).

Postoperative pain is very common and develops naturally as a warning(Apfelbaum, Chen, & Mehta, 2003).  The development of postoperative pain can be predicted, should be prevented and treated (Power, 2005). Besides the disagreeable aspects and physiological repercussions of postoperative pain, it delays ambulation and hospital discharge. Some authors believe that, despite the drugs and anesthetic techniques available, the prevalence of postoperative pain is still high(Apfelbaum, Chen, & Mehta, 2003; Omote, 2007; Power, 2005). The most unwelcomed outcome of surgery is postoperative pain. This pain can result to prolonged hospital stay and hinder rapid recovery if poorly managed(Schug & Chong, 2009).

Research studies have repeatedly reported that about 20 to 80% of patients having surgical procedures experience pains which are poorly managed (Lorentzen, Hermansen, &Botti, 2011; Marks &Sachar, 1973). Pain is grouped among grievous public health challenges both in the modernized (Stephens, Laskin, Pashos, Pena, & Wong, 2003) and in developing countries(Klopper, Andersson, Minkkinen, Ohlsson, &Sjostrom, 2006; Lin, 2000; Shen, Sherwood, McNeill, & Li, 2008). Pain continues to be poorly controlled and pose a substantial obstacle to the care of surgical patients with the protracted existence of postoperative pain as a serious public health problem, and the increased knowledge and resources for treating pain(Botti, Bucknall, & Manias, 2004; Dihle, Helseth, Kongsgaard, & Paul, 2006; Helfand& Freeman, 2009; Manias, Bucknall, &Botti, 2005).

In Africa, pain associated with HIV/AIDS and cancer has been greatly explored (Dekker, Amon, & Le Roux, 2012; Powell, Radbruch, Mwangi-Powell, Cleary, &Cherny, 2013; Selman, Simms, Penfold, Powell, &Mwangi-Powell, 2013), although greater burden is associated with pain from surgical procedures. Studies in the past have revealed that underdeveloped countries endure lack of analgesia and little priority is given to pain control in these countries.

In Nigeria, 95% of surgical patients were reported by Kolawole and Fawole (2003) to have experienced postoperative pain of various degrees. Another study carried out in Nigeria reported that inadequate pain relief after surgery is suffered among a high percentage of patients in Nigeria (Size, Soyannwo, & Justins, 2007). A Human Rights Watch’s report (Human Rights Watch, 2011) revealed that only 10% of this group of patients is able to receive the best of pain control. Powell, Radbruch, Mwangi-Powell, Cleary, and Cherny (2013), and Vijayan (2011) reported that shortage of clinicians, rigorous law enforcement on morphine access, and insufficient knowledge left millions of people to suffer because of poor pain control, even though various workshops and African Union summits adopted pain relief as basic human right.

Inadequate clinical practice in the post-operative assessment and management of pain has been reported by several studies (Dihle, Helseth, Kongsgaard, & Paul, 2006; Manias, Bucknall, &Botti, 2005; Schafheutle, Cantrill, &Noyce, 2001; Schoenwald& Clark, 2006). It is the duty of nurses to know how to assess pain by appropriate planning and implementing the adequate treatments in pain management. The nurse requires to monitor the adverse effects and advocate for the patient during the assessment of the effectiveness of those interventions. This helps the healthcare giver to know when the interventions are ineffective in relieving pain (Lippincott, 2013).

  • Statement of the Problem



Content                                                                                                    Page

Title Page                                                                                                                    i

Certification                                                                                                                ii

Dedication                                                                                                                  iii

Acknowledgements                                                                                                    iv

Abstract                                                                                                                      v

Table of Contents                                                                                                       vi

List of Tables                                                                                                              ix

List of Figures                                                                                                             xi Appendices                                                                                                

CHAPTER ONE: INTRODUCTION                                                       

1.1       Background to the Study                                                                               1

1.2       Statement of the Problem                                                           5

1.3       Objective of the Study                                                                   5         

1.4       Research Questions                                                                                         6

1.5      Hypotheses                                                                  6         

1.6       Scope of the Study                                                                                         6

1.7       Significance of the Study                                                                               6

1.8       Justification for the Study                                                                              7

1.9       Operational Definition of terms                                                      8


2.0       Introduction                                                                                 9         

2.1       Knowledge and use of the Partograph                                           10

2.2       Partograph Training and Monitoring/Supervision          15

2.3       Use of the Partograph as a Referral tool                    18

2.4       Effect of the partograph on labor and maternal and neonatal outcomes        19

2.5       Use of partograph and incidence of prolonged or   augmented labor and operative delivery                                                         20       

2.6       Impact of partograph use on maternal and perinatal complications               22

2.7       Providers’ attitudes about the partograph and barriers to use          23

2.8       Lack of access to partograph forms                                         24

2.9       Partograph improves quality of health care            25

2.10     Partograph is well used for referral, but transport can be inadequate                        25

2.11     Lack of emotional consideration                                           25

2.12     Adaptations to the who partograph                               26

2.13     Conceptual Model                                                                                          29

2.14     Conclusion                                                                                                      31



  • Introduction                                                                                                    32
  • Research Design                                                                                             32
  • Population                                                                                                       32
  • Sample size and sampling Technique                                          33
  • Instrument for Data Collection                                                    34
  • Pilot Study                                                                                                      35
  • Method of Data Collection                                                           35
  • Method of Data Analysis                                                                               36
  • Ethical Consideration                                                                                     37



4.0       Introduction                                                                              38

4.1       Data Presentation                                                                            39

4.2       Analysis of Research Questions                                                 41

4.3       Test of Hypotheses                                                                    48

4.4       Discussion of Findings                                                                  50



  • Summary                                                                                                   55
  • Conclusion                                                                                             56
  • Recommendations                                                                                          57
  • Limitation of the Study                                                                                  58
  • Suggestion for further studies                                               58

REFERENCES                                                                                59

APPENDICES                                                                                  66

Table                                                                                                                                       Page

  • Showing the Categorization of the Midwives in the Study Area                     34
  • Showing an Outline of the Proposed Training Program                36
  • Showing Demographic Characteristics of Participants                     39

4.2       Showing Descriptive statistics of midwife’s years of experience and average number of nurse-midwives per shift in labour ward                 40                     

4.3a     Showing Knowledge on utilization of partograph               41

4.3b     Showing Definition of partograph                                     42

4.3c     Showing Assessment of midwives skills and knowledge on the utilization     of partograph                    43                                                                                            

4.3d     Showing Summary of Descriptive and inferential statistics of pre-test     knowledge of midwives on the utilization of partograph 44

4.4a     Showing Frequency of usage of the partograph for women in labour ward                 45

4.4b     Showing Percentage response showing the utilization of partograph                by midwives in monitoring the progress of labour 45

4.5a     Showing Training outcome of midwives on the utilization of partograph                                47

4.5b     Showing Summary of Descriptive and inferential statistics of post-test   knowledge of midwives on the utilization of partograph.   48

  • Showing Descriptive statistics of post-test scores and cross tabulation of       participants by treatments 49
  • Showing t-test difference in pre-utilization of partograph by trained and untrained midwives 49
  • Showing t-test difference in post-utilization of partograph by trained
  • and untrained midwives   50


Content                                                                                          Page

  • Wiedenbach’s  model                                                31


Appendix                                                                                            Page

  1. BUHREC Certification                                                                                                         
  2. Informed Consent Form                                                             66
  3. Questionnaire                                                                                67
  4. Pictures from Field Work                                                              72



  • Background to the Study

Globally, labour has been defined as a physiological process characterized by an increase in myometrial activity resulting in cervical effacement and dilatation; followed by the expulsion of the foetus from the uterus to the outside world. It is therefore imperative for midwives to monitor the woman in labour utilising a partograph in order to have a safe delivery; and to avoid obstructed and prolonged labour (Ratchliffe, 2010).

A partograph is an effective clinical tool used during labour surveillance for early diagnosis of complications.  The partograph is a simple chart that, when used routinely for every birth, aids the monitoring of labour and provides early warning of the need for intervention so health workers can provide prompt, appropriate care (World Health Organisation, 2014). Partograph was developed by an obstetrician named Friedman, which he tagged as cervicograph as a result of its usefulness to monitor cervical dilatations. Furthermore, cervicograph was adopted by Philpott in 1972 and he redesigned it as partograph to serve as a practical device in the documentation of all intrapartum observations and not only to monitor cervical dilatation, hence, the phrase “Philpott’s partograph”. This new document contains action lines and alert lines which are used to determine cases of prolonged labour.

In 1988, Safe Motherhood Initiative established the adoption of partograph as a global practical device that is of high quality to monitor labour and avert prolonged labour. Furthermore, extensive examination was conducted in 2014 by WHO and the organisation established a scientific based rationale for the use of partograph as the aversion of maternal morbidity and prolonged labour. However, when correctly implemented, partograph minimize cases of obstructed and prolonged labour as well assist in identifying heart abnormalities which can have intrapartum foetal hypoxia as its consequences.

(Cronje and Grobler, 2012; Dangal, 2011) described the partograph as a graphical representation of progressive stages of labour, related situations or parameters on pregnant mother and foetus, displaying all investigation made during the first stage of labour in a manner that will enable midwives and medical practitioners to analyse, interpret and recognise if the pregnant woman has moved into a high risk category and to respond decisively to the identified problems.

With reference to the World Health Organisation (2014), the utility of partograph to observe pregnant women in labour does not serve as an alternative for proper assessment of conditions that needs instant reference of pregnant women on the arrival at the labour unit.  World Health Organisation (2014) further states that the partograph is developed for timely identification of abnormal progress of labour and the aversion of prolonged labour which would significantly reduce the risk of postpartum hemorrhage and sepsis as well eradicate obstructed labour, prolonged labour, uterine rupture and its sequelae. The organisation further affirm that the purpose of the use of partograph to examine pregnant women in labour is to lessen morbidity and mortality rate of pregnant women globally, to develop the level of care of pregnant women during labour session, to develop the observational abilities and skills of the midwives, to assist in the advancement of team work in a bid to ease the referral to specialist units and promote timely referral from the primary health units.

A randomized study was conducted on 434 women in Mexico in 1966 to test for the effectiveness of the utilisation of the partograph during labour using Friedman’s partograph and a non-graphical descriptive chart. The women were randomized to either Friedman’s partograph or a non-graphical descriptive chart. The study revealed that those who were not put on the partograph had more operative deliveries and more babies with low Apgar scores at 5 minutes.  Another study conducted in Karachi by Bhutta, Javed, and  Shoaib, (2010) tested the role of the partograph in preventing prolonged labour, the objective of the study was to determine the effect of the partograph on the frequency of prolonged labour, augmentation of labour, operative deliveries and appropriate interventions based on the partograph to reduce maternal and perinatal complications.  A case-controlled prospective and interventional study on 1000 women in labour was carried out in the obstetric units of Jinna Postgraduate Medical Centre, Karachi.  Five hundred (500) women were studied before and after the introduction of the partograph. The results showed that there was a reduction in both the duration of labour and the number of augmented labour and vaginal examinations.  It was concluded that by using the partograph to monitor pregnant women in labour reduced the frequency of prolonged labour, augmented labour, postpartum hemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality rates.

In spite of the continual use of the partograph in the health care industry; and wide record keeping of its effectiveness (Chongsuvivatwong & Fahdhy 2015; Fawole & Fadare, 2010)

 recorded variation attainable with the use of partograph across health care facilities in Nigeria. It was revealed that in two separate tertiary hospitals, 84% of midwives had good knowledge on partograph and average of 31% of partograph graphs was correctly filled. Hindrances in the effective utilisation of partograph were discovered by Opiah on cases such as absence on the use of partograph charts (30.3%), and under-staff (19.4%). The absence of knowledge and the use of partograph were discovered by (Fawole et al. (2010); Daniel, Oladapo, & Olatunji, 2016) among different levels of maternity health providers in all three levels of health care. A report was also submitted showing that previous training significantly improved the knowledge and accurate use of partograph.

Researchers also indicated that tertiary health workers employs partograph unlike their counterparts in secondary and primary level health workers. Furthermore, research also indicates that just 33.7% cases of 1,319 deliveries were monitored with the effective use of partograph which influenced decision making as well as associated positive labour result available among low and high risk cases. However the extent of which partograph is being employed neither attitude of midwives as a means to attainment of effective or non-utilisation of partograph is not available in literature. The aim of the utilisation of partograph is to empower midwives with plotting, analysis and interpretation skills when monitoring pregnant women in labour.

In the study conducted by Chongsuvivatwong & Fahdhy (2015), it is stated that the partograph was introduced in Indonesia in 1998, and the new version of the World Health Organisation (WHO) partograph was brought into Indonesia in 2000.  The aim of the study was to assess the effectiveness of promoting the utilisation of the partograph by midwives caring for women in labour.  Previously, before research, it was however discovered that utilisation of partograph was not carried out by midwives because complains were given that partograph’s completion is highly complicating. It was however observed that utilisation of partograph was as a result of midwives education, training and supervision which led to notable reduction in the number of vaginal assessment, augmentation of labour, obstructed labour, poor Apgar score and increased transfer to mention but a few. Furthermore Alfirevic, Lavendor and Walkinshaw (2016) support that if progress of labour crossed the action line; a diagnosis of prolonged labour was made and managed according to protocol. The results of this study showed that the use of the 4 hour action line partograph improved the maternal and neonatal outcomes.

The use of partograph as a device for intrapartum assessment by midwives in sub-Saharan Africa is still a challenge, a notion supported by the study conducted in South West Nigeria by Adekanle, Fawole and Hunyinbo (2008) who found that a partograph is commonly not employed to monitor pregnant women in Nigerian as a result of insufficient idea about partograph.

Furthermore, the authors concluded that the maternal mortality rate in Nigeria is a major public health issue and continues to rise since a partograph is not effectively used as a tool for monitoring labour. Nakkazi (2010) indicates that midwives often feel that completing the partograph is an additional time-consuming task, and they do not always understand how the utilisation of the partograph to monitor pregnant women in labour can be life-saving. Thus, some midwives take the partograph lightly as they plot the partograph when pregnant women who were in labour have already delivered. Midwives often argue that they do not have time to plot the partograph during the monitoring of pregnant women in labour. The National Department of Health (2010) further states that all midwives should employ the partograph when assessing pregnant women in labour so that problems identified during monitoring of labour can be attended to promptly by both the midwife and the attending doctor. Therefore, utilisation of the partograph increases the analysis and interpretation skills of midwives, the monitoring of pregnant women in labour and thus aids in providing standardized fetal and maternal care, and accordingly improves midwifery care.

Researchers ascertained that to effectively use the partograph, requires knowledge and skills. Therefore, education, training and supervision of the midwives will results in a higher rate of the utilisation of the partograph which will reduce the number of virginal examinations, prolonged labour, augmented labour, poor apgar score at first minute, obstructed labour and increased referral.

The focus of this research therefore is to identify midwives’ knowledge on the use of the partograph as a tool to monitor labor, comparatively assess the use of the partograph among midwives in the hospital, assess level of deployment of partograph as a device in each center, identify barriers to its use, determine the existing relationship with the length of years of experience and knowledge of the use of the partograph in the hospitals.

1.2     Statement of the Problem

A number of research studies revealed that there are challenges associated with the correct and consistent use of the partograph (Lester, 2010; Magon, 2011; Mathibe-Neke, 2009; Opiah, 2011).  The findings from these studies reveal that there is poor utilisation of the partograph, which were largely related to the midwives’ lack of competence and knowledge on the use of the partograph. They submit further that non- availability of the partograph, shortage of staff, lack of in-service training and the number of years of experience in intrapartum care are also some of the contributory factors associated with the poor utilisation of the partograph.

(Magon, 2011; Ogwang et al. (2009); Opiah, 2011) argued that caregivers may regard filling of the partograph as an additional chore.  The study conducted by Lavender, Lee, Mathai, Omoni and Wakasiaka (2011) also revealed that partographs were filled in retrospectively, and done only as a defensive practice to avoid being reprimanded by the matrons. The researcher has also observed from clinical practice that midwives do not utilise the partograph appropriately when monitoring pregnant women in labour either by not plotting or incompletely plotting the activities and also not interpreting the findings as appropriate. Consequently, labour cases which carry impending dangers to both mother and the foetus are not usually discovered and managed accordingly. These have often led to an increase maternal/foetal mortality, morbidity and irreversible damages on their lives. The purpose of this study, therefore, is to examine the Effect of training midwives on the utilisation of partograph in General Hospitals in Ogun East Senatorial District.

1.3    Objective of the study

The main objective of this study is to evaluate the effectiveness of training midwives on the utilisation of partograph in General Hospitals in Ogun East Senatorial District. The specific objectives are to:



There after purposive sampling technique was used to select two primary health care centers among the twenty PHCS in Kaduna South. Data was collected with the use of a reliable self-constructed questionnaire before and after the training.Cronbach Alpha was used to determine the reliability of the questionnaire (r=0.990)The training Programme consists of four modules and the training lasted for four weeks. The training comprises of four stages: pre-intervention stage, week 1, week 2, week 3, week 4 and administration of post-test. The study generated four research questions and the three hypotheses which were tested at 0.05 alpha levels. Data were analyzed using descriptive statistics, and t-test.

 Demographic data of participants showed that majority of the maternal respondents with children numbering between 1 and 2 were 28(77.75%) had the highest percentage.        The highest educational attainment of the respondent was secondary school (100%).  The Igbo’s 16, (44.4%) had the highest percentage among the tribes. Majority (52.8%) of the nursing mothers have poor knowledge on adequate breastfeeding positioning, 14 (38.8%) of the participants had moderate level of knowledge on procedure for breastfeeding. 17 (47.2%) of the participants had moderate knowledge level of breast engorgement,). Majority 21 (58.4%) of the participants had moderate level of knowledge on sore nipples. Significant differences were found between the pre and post intervention in the following areas; on adequate positioning for effective latch-on (p=0.009), on procedure for breastfeeding (p=0.011), on breastfeeding problems (p=0.001).

In conclusion, the training was effective in improving the level of knowledge of breastfeeding mothers on breastfeeding related problems and its prevention. Based on the findings, it is recommended that the government should help in minimizing this breastfeeding related problems by organizing seminars, workshop and extension services to enlighten women on breastfeeding problems and early prevention


Content                                                                                                                  Page

Title Page                                                                                                   i

Certification                                                                                                ii

Dedication                                                                                                iii

Acknowledgements                                                                                        iv

Abstract                                                                                                    v

Table of Contents                                                                                       vi

List of Tables                                                                  vii

List of Figures                                                                                                      ix

Appendices                                                                                                                x   

CHAPTER ONE: INTRODUCTION                                                               

1.1 Background to the Study                                                                               1

1.2    Statement of the Problem                                                                        2

1.3    Objective of the Study                                                           2

1.4    Research Questions                                                           3

1.5    Hypotheses                                                           3

1.6    Scope of the Study                                                                                 3

1.7 Significance of the Study                                                                                    3

1.8 Operational Definition of Terms                                                                4


2.0    Introduction5

2.1    Importance of breastfeeding to infants and mothers5

2.2    Implications of knowledge of nursing mothers on breastfeeding techniques                                                                            6    

2.3    Causes, treatment and remedies for nipple pain                                    11

2.4    Good techniques and proper positioning for good latch-on16

2.5    Impact of breastfeeding interventions on breastfeeding related problem                                                                                      19

2.6Conceptual Model                                                                                     24


3.0   Introduction                                                                                           26

3.1    Research Design                                                                                    26

3.2Population                                                                                                27

3.3Sample size and sampling Technique                                               28

3.4    Instrumentation                                                                                28

3.5 Validity and Reliability of the Instrument                                    28

3.6Method of Data Collection                                                               29

3.7Method of Data Analysis                                             30

3.8 Ethical Consideration                                                               31



4.0:   Introduction                                                                                              32

4.1:   Demographic Data of Participants                                                33

4.2:   Discussion of Research Questions                                          34

4.3:   Discussion of Hypotheses                                                             36

5.1:   Summary                                                                                          42

5.2:   Conclusion                                                                                       42

5.3:  Recommendations                                                                      43

5.4:   Limitation of Study                                                                          43

5.5:   Suggestion for Further Studies                                                     44

REFERENCES                                                                                         45

APPENDICES                                                                                          48


Table                                                                                                             Page

4.1 Demographic data of the maternal respondents                                        33

 4.2   Descriptive statistics showing the existing knowledge of nursing mothers on adequate breastfeeding positioning                34
 4.3 Descriptive statistics showing the knowledge level of mothers on procedure for breastfeeding before intervention                      35

 4.4 Descriptive statistics showing the level of knowledge of mothers on breast engorgement                                                                                    36

4.5   Descriptive statistics showing the level of knowledge of mothers on sore    nipples before intervention                                          37

4.6 T-test showing differences between the knowledge level of mothers on adequate positioning for effective latch on pre and post intervention       38  
 4.7T-test showing the differences between the knowledge level of participants on procedure for breastfeeding pre and post intervention             39       
4.8T-test showing the difference between the pre and post intervention knowledge of nursing mothers on breastfeeding problems                39


 Figure 1 Conceptual model adapted from DoreathyOrem’s theoryself care deficit              24       


  1.   Informed Consent Form
  2.  Questionnaire
  3.  Teaching Modules
  4.  BUHREC Permission to conduct research work
  5.  Introduction Letter to PHC where the research work was done.
  6. Reliability Result
  7. Picture taken during the research work with participants.                                                                             

                                                CHAPTER ONE


  • Background to the Study

Breastfeeding is the act of milk transference from mother to baby that is needed for the survival and healthy growth of the baby into an adult (United Nations Children’s Fund (UNICEF), 2009; Heckman, 2011). Breastfeeding provide infant with essential calories and nutrients to nourish the baby (National Institute of Child Health & Human Development, 2009).According to the American Academy of Pediatrics  (AAP) policy Statement on Breastfeeding, women who do not have health problems should exclusively breastfeed their infants for at least the first six months of life (AAP,2012).  The importance of appropriate infant feeding and the vital role played by breastfeeding in child survival, growth and development cannot be over-emphasized (AAP, 2012). The World Health Organization (WHO) has recommended two years breastfeeding; first sixmonths exclusive breastfeeding; more than eight times breastfeeding per day in the first three months of an infant’s life. The AAP suggested that a woman should try to breastfeed her infant for the first twelve months of life.

Despite the documented value of exclusive breastfeeding during the first months of a child’s life and struggles for promoting this practice, rates for exclusive breastfeeding in Nigeria are below those recommended by the World Health Organization (WHO), which advocates exclusive breastfeeding during the first six months of baby’s life. Breastfeeding a baby exclusively for the first six months and then continued breastfeeding in addition to appropriate solid foods until twelve months and beyond has health benefits  for both mother and the child and these include;  reduction of the risk of mothers from developing gestational diabetes, osteoporosis, and breast cancer. It can also assist the women to lose weight after delivery, and also help the uterus of the women to return fast to pre-pregnant state. Advantages to the babies may also include: reduced risk of development of gastro intestinal illness, allergies, asthma, diabetes, obesity, some childhood cancer, respiratory infections and diarrhoea.

Based on the WHO Global data on infant and young Child Feeding in Nigeria, 22.3% of children were exclusively breastfed for less than 4 months, while 17.2% were exclusively breastfed for less than 6 months, in the year 2003. According to the Nigerian Demographic and Health Survey (NDHS), in 2008 17% of children were exclusively breastfed for less than 4 months, while 13% were exclusively breastfed for less than 6 months. The median exclusive breastfeeding period in Southwest Nigeria by months in the year 2003 was 7 months. In the year 2008, it was 6 months. Within the same period, early initiation of breastfeeding among women in the region was 12.7% in 2003, but increased to 35.5% in the year 2008. All these figures are far below the 90% level recommended by the WHO. Child mortality therefore remains high in low and middle-income countries. Nigeria has the highest under-five rural mortality rate of 242.7 per 1,000 among selected sub-Saharan Africa countries. (NDHS, 2008; NPC, 2009; WHO, 2010)

The technique used in breastfeeding, especially mother-infant positioning and attachment or suckling by the infant, has been shown to be important for the effective transfer of milk from the breast to the child as well as for preventing nipple damage. Heckman (2011) evaluated mother-infant pairs in a maternity ward and observed that only 2% of pairs achieved optimal latch performance (chin touches the breast, mouth opens wide, lower lip flared outward ,moderate lip tension, and infant grasps the areola), and only 0.2% achieved optimal mother-infant positioning (mother in a comfortable position, C-hold of the breast [leaving the areola free and making gentle compression of the breast tissue between the thumb and fingers]. infant’s head and body aligned facing the mother and in close contact with the mother’s body, infant’s arm not between the mother and infant, infant’s head and neck supported, infant’s mouth facing the nipple, and infants nose free for breathing).

1.2 Statement of the Problem

Breastfeeding is the natural way to feed a baby but that does not always mean it is easy. Many breastfeeding mothers encounter a few challenges in the course of using one breastfeeding technique or the other (Finello, 2015). According to National Health Service U.K (2013), most breastfeeding mothers have experienced variety of difficulties as a result of some of the techniques used both to the baby and themselves as mothers. It was observed during the child welfare Clinic that many of the nursing mothers failed to practice exclusive breastfeeding as a result of some of the breastfeeding related problems they encountered while breastfeeding. Considering that breastfeeding technique seems to be important for maintaining successful breastfeeding, this project will explore effect of nursing intervention on breastfeeding-related problems among nursing mothers in selected Primary Health Clinics in Kaduna South, Nigeria.

1.3 Objective of the Study

The main objective of this study is to determine the effect of nursing intervention on breastfeeding-related problems among nursing mothers in selected Primary Health Clinics in Kaduna State, Nigeria, in the first six months postpartum. The specific objectives are to:



page                                                                                                     i

Certification                                                                                                                ii

Dedication                                                                                                      iii

Acknowledgements                                                                                        iv

Abstract                                                                                                          v

Table of Contents                                                                                           vi

List of Tables                                                                                                  viii

List of Figures                                                                                                 ix

List of Appendices                                                                                         x


1.1Background to the Study                                                                          1

1.2Statement of the Problem                                                                          3

1.3 Objective of the Study                                                                             3

1.4 Research Questions                                                                                     4

1.5 Hypotheses                                                                                               4

1.6 Scope of the Study                                                                                   4

1.7 Significance of the Study                                                                         4

1.8 Operational Definition of Terms                                                               5


2.0 Introduction                                                                                              6

2.1 Definition, cause, symptoms, complication and types of diabetes mellitus         6

2.2Epidemiology of Diabetes mellitus                        8

2.3 Impact of Diabetes in Nigeria                                                                     9

2.4Organizations of diabetes care in Nigeria  9

2.5 Profile of patients with diabetes in Nigeria                                            11

2.6 The way forward                                                                                        12

2.7 Previous research in diabetes self-management intervention       14

2.8 Diabetes self-management Education      15

2.9 Diabetes self-management                                                                                17

2.10 Barriers to diabetes care                                                                             20

2.11 Conceptual model                                                                               22


3.0 Introduction                                                                                              25

3.1 Research Design                                                                                              25

3.2 Population                                                                                            25

3.3 Sample size and sampling Technique                                                        25

3.4 Instrumentation                                                                         26

3.5 Validity of Instrument                                                                             27

3.6 Reliability of Instruments                                                           27

3.7 Data Collection Procedure                                                                        27

3.8 Method of Data Analysis                                                                         28

3.9 Ethical Consideration                                                                               28



4.0 Introduction                                                                                              30

4.1 Data analysis and results                                                                           31

4.2 Discussion of Findings                                                                             39



5.1 Summary                                                                                                 44

5.1.1 Nursing Implication                                                                               45

5.2 Conclusion                                                                                         45

5.3 Recommendations                                                                                    46

5.4 Suggestion for Further Studies                                                                 47

REFERENCES                                                                                                   48

APPENDICES                                                                                          57


Table                                                                                                              Page

1 Frequency and percentage on demographic data of respondents                                        31

2 Descriptive statistics of diabetic patient’s knowledge regarding self-management            33

3 Comparative frequency distribution of Knowledge Responses from questionnaires          34

4Descriptive statistics of diabetic patient’s practice of self-care activities                            36

5 Comparative frequency distribution of Self-care Activities Responses from         37

6Descriptive and inferential statistic of diabetic patient’s pre/post-intervention       38

Knowledgeregarding self-management                                                         

7Descriptive and inferential statistic difference of diabetic patient’spre/      38

Post-interventionpractice of self-care activities                                             


Figure                                                                                            Page

1 Dorothea Orem self-care conceptual model                        22

2 Self-care conceptual model                                                                                  24


Appendix                                                                                                                       Page

 A: Informed Consent form                                                               57

 B: Questionnaire                                                                               58

 C: Training program hand-out                                                           61

 D: Pictures from the field work                                                                66

 E: Study Setting Clearance                                                                                 68

 F: BUHREC                                                                                             69

 G: Turnitin Report                                                                               70



1.1 Background to the Study

Diabetes mellitus (DM) is a metabolic disease in which glucose level in the blood is high over extended periods (World Health Organization, 2014). DM results when the pancreas is unable to produce insulin or cell of the body is not responding to insulin produced  (Shoback, 2011). In 2013 alone 4.6 million people died of DM (Aschner, Beck-Nielsen, Bennett, Boulton, & Colagiuri, 2013). Low and middle-income countries of the world is being affected by DM, there are more than 77 % morbidity and 88 % mortality (International Diabetes Federation, 2013). Type 2 diabetes mellitus (T2DM) is the commonest form of DM and it account for 90 % of disease (Aschner et al., 2013).

13.2% is the prevalence rate of DM with registered 4,600 people (International Diabetes Federation, 2014). Estimate of the World Health Organization (WHO) states that DM prevalence among adults in 2014 was 9%, a prediction of at least 350 million people with T2DM by 2030 (WHO, 2015). In accordance with a national survey carried out, the prevalence of diabetes mellitus in Nigeria increased from 2.2% to 5.0% by 2013 estimates of the International Diabetes Federation (IDF). Complications of diabetes are common at the time of presentation in Nigeria: neuropathy 56%, erectile dysfunction 36%, nephropathy 9%, and retinopathy 7% (Chinenye & Ofoegbu, 2013). This is partly because diabetes is a progressive illness with an initial asymptomatic phase associated with on-going tissue damage and decline in pancreatic beta cell mass and function.

Ali, Barke, Bullard, Gregg, and Imperatore, (2012) reported that glycemic control at the suboptimal level likely cost diabetic patients increased care requirement, complications and related health care costs. Improper glycemic control has a link with an increased risk of visual impairment, kidney failure and cardiovascular disease (Balkau, Borch-Johnsen, Colagiuri, Lee, Shaw &Wong, 2011). The possible reasons for poor glycemic control includes poor adherence and awareness, manpower insufficiency, time constraint, lack of appropriate guidelines on diabetic education for health practitioners and diabetic patients (Amade, Gudina, Ram, & Tesfamichael, 2011).

Because of lack of awareness, patients with DM suffer from its complications (Gul, 2010). The way to self-management includes testing the blood glucose, adequate diet, regular examination of the foot and eye, all this have shown to reduce complications from DM (Aschner et al., 2013; Biswas, Ferrari, Islam, Islam, Lechner &Niessen, et al., 2015).Therefore, proper blood glucose control among Diabetes Mellitus patients prevents short and long-term complications and reduce cost and long hospital stay.

The aim of self-management of DM is to ensure that the blood glucose level is at a normal range and to reduce the risk of complications. There are seven self-care behavior people having DM must ensure to keep their glucose level normal: they include eating healthy, physically active, self-monitoring of glucose content, compliance with medication, risk-reduction behaviors, good problem-solving and healthy coping skill (American Association of Diabetes Educators, 2010). This measures are useful for physicians managing diabetic patients and it has impacted positively on glycemic control, complication reductions and improvement in quality of life (American Diabetes Association, 2009). Self-management goals and its implementation are written in collaboration with the diabetic patient and health care professionals, it promotes patient self-management, decrease the prevalence of DM and its complications (Ahola & Groop, 2013).

Haidet, Naik, Rodriguez and Teal (2011), also emphasized the importance of patient education for better outcomes of self-management of diabetes, stated that patient education is necessary because it promote high quality diabetic care. Diabetic education programmes stress the importance of patients comprehending the practical approach to self-manage their disease condition. Knowledge and understanding are important in helping patients towards better self-management of diabetes mellitus.

 Education help people having DM initiate good self-management and coping skill. Continuous DM education help people having the disease care for themselves.(American Diabetes Association, 2014).There is good report when intervention is long term, it includes follow-up and patients care is individualized. Intervention which promotes behavioral changes improves clinical outcome (Haidet, Naik, Rodriguez &Teal, 2011).Anderson and Funnell (2013), said that self-management education is a process of facilitating knowledge, skill and ability, is an important component of an effective diabetic management. Self-Management place patients at center of care, empowering patients to make decision that will improve clinical outcome.

1.2 Statement of the Problem

Diabetes Mellitus has significantly contributed to the reduction of life expectancy by 15 years and have increased heart disease incidence by four time (IDF, 2014; WHO, 2014). In Nigeria, diabetes mellitus contributes to medical morbidity and mortality (Chinenye, Ogbera, & Onyekwere, 2013). Patients having diabetes stay long on medical wards and pay high bills with various complications such as stroke, adult-onset blindness, lower extremity amputation from foot gangrene, heart/kidney failure and premature death (Fasanmade, Nwaiwu & Olayemi, 2015; Isezuo, Ohwovoriole,  & Sabir, 2013). An estimated 3.4 million persons died of high glucose level in 2004 & 2010 according to WHO (Fact sheets, 2013).

According to International Diabetes Federation, (2010), the prevalence of DM in Nigeria varies from 0.65% in rural Mangu to 11% in urban Lagos state. World Health Organization, (2014), suggest that Nigeria have the highest number of people having diabetes. In Nigeria, up to 73% of diabetic patients do not practice self-monitoring of blood glucose (Chinenye, Uchenna, & Unachukwu, 2010; Chinenye, et al., 2013). A study done in Malaysia, (Azmi, Barakatun-Nisak, & Firouzi, 2015) show 72 % of patients with poor glycemic control and in Ethiopia  (Abebe, Alemu, Berhane, Mesfin, & Worku, 2015) show two third of patients with poor control.

American Association of clinical Endocrinologist, (2010) report that 1 in 3 patients having T2DM is controlled while one and half of patients comply with medication.  It was obvious from this and other surveys that the status of glycemic control and other targets such as lipid, glycated hemoglobin (HbA1c), blood pressure levels and adequate education were below expectations (Chinenye, et al., 2013; IDF, 2012).Therefore, the need for a study on effect of nurse-led training on self-management of diabetes amongst diabetic patients attending medical outpatient clinic in General Hospital Odan, Lagos.

1.3 Objective of the Study




Content                                                                                                          Page

Title page                                                                                                            i

Certification                                                                                                              ii

Dedication                                                                                                     iii

Acknowledgements                                                                                                iv

Abstract                                                                                                          v

Table of Contents                                                                                                  vi

List of Tables                                                                                                          x

List of Figures                                                                                                         xi

List of Appendices                                                                                       xii

List of Acronyms                                                                                                     xiii


1.1       Background to the Study                                                                     1

1.2       Statement of the Problem                                                                     4

1.3       Objective of the Study                                                                               5

1.4       Research Questions                                                                       6

1.5       Hypotheses                                                                                                 6

1.6       Scope of the Study                                                                                  6

1.7       Significance of the Study                                               6

1.8       Operational Definition of Terms                                                                7


2.0       Introduction                                                                                     8

2.1       General overview of road traffic accidents                         9

2.2       Causative factors of road traffic accidents  10

2.2.1Global trends and projections of road traffic accidents             13       

2.2.2 Types of vehicles prone to road traffic accidents                      13

2.2.3    Age and gender differences in road traffic accidents                     14     

2.2.4    Geographical approach to road traffic accidents        14

2.3       Prevalence of risky driving behaviours and road traffic accidents                          15

2.4       Effects of risky driving behaviours on road traffic accidents 15

2.5       Prevention of risky driving behaviours and control measures                       16

2.5.1 Engineering measures                                        17       

2.5.2    Protective measures                                                    17

2.5.3    Enforcement of traffic laws                                                       18    

2.5.4    Education and training                                   19

2.5.5    The haddon matrix         19

2.6Empirical Study21

2.7Theoretical Framework (precede/proceed model)                      22

2.8     Application to the Study                                                             24


3.0       Introduction                                                                                   26

3.1       Research Design                                                              26

3.2       Population 26

3.3       Sample size and sampling Technique                                           26

3.4       Instrumentation                         27

3.5      Reliability and Validity of Instrument                                                       27

3.6      Development of health education package28

3.7      Method of Data Analysis                                                                          28

3.8      Ethical Consideration                                                              29



4.0       Introduction                                                                                30       

4.1       Answering Research Questions                                               42

4.2       Testing of Hypotheses                                                                        44

4.3       Discussion of Findings                                                                45                                                                          



5.0       Introduction                                                                                           48

5.1       Summary                                                                                           48       

5.2       Conclusion                                                                                    48       

5.3       Recommendations                                                                       49

5.4       Limitation of the Study                                                            50       

5.5       Suggestion for Further Studies                                                      50                   




Table                                                                                                        Page

4.1: Demographic Characteristics of Respondents (experimental and control group) 32

4.2: Pre and post intervention knowledge about driving and traffic regulations                          34

 4.3: Perception of safety consciousness and risk reduction (intervention group)                       35

 4.4: Self efficacy and adherence to safe driving behaviours (intervention group)                     39

4.5: Attitudinal Disposition to road traffic regulations and adherence to safe driving                41

4.21: Experimental group pretest knowledge level about risky driving behaviours         42

4.22: Difference in pre and post knowledge levels of control group         About risky driving behaviours                                                            43

4.23: Experimental group posttest knowledge level    43

4.24: Pre and posttest knowledge levels of intervention group                                   44

4.25:  Differences between posttest knowledge levelsof control and intervention groups          45



Figure                                                                                                         Page

1.1: Global trends and projection of road traffic accidents                         13

2.1: The haddon matrix                                                                                      20

2.2 Precede/Proceed model                                                                            23

2.3 Conceptual model                                                    24                                                                                            



 1:  Questionnaire used in this Study             

 2:   Permission for use of Instrument

 3:   Informed Consent Form

 4:   Ethical Clearance Certificate

 5:   Letter of Introduction


FRSC: Federal Road Safety Corps

RTA:   Road Traffic Accidents

WHO: World Health Organization




Hypertension is the most common non-communicable disease and the leading causeof cardiovascular disease in the world.Many people with hypertension are unaware of their condition making treatment infrequent and inadequate. According to Seven Joint National Committee Criteria (JNC7), the precise rule for the treatment of hypertension begins with lifestyle modifications and ends with medication. Unfortunately, many patients diagnosed to be hypertensive don’t usually have proper education about lifestyle modification.  Lifestyle modification is advised for all patients with hypertension, in respective of pharmacological treatment, because it may reduce or even abolish the need for medications.

The objective of the study was to determine the effect of a training programme on knowledge about hypertension, lifestyle modification and practice .Quasi experimental method was used for this study to determine the effect of a training programme on knowledge and practice of lifestyle modification.  Sample size of 60 participants diagnosed to be hypertensive and registered at the general out-patients and medical out-patients clinics were used. (Control group n=30, intervention group n=30). Two research settings were selected randomly from the three tertiary hospitals in Lagos state. One of the hospitals was randomly selected to be the control group and the other the experimental group. Purposive sampling was used to select the participant from each setting. Data were collected through administered questionnaire using a modified structured questionnaire from World health organization for hypertensive patients and hypertension knowledge-level scale (HK-LS). Data obtained were coded and analysed using SPSS version 21.0 statistical software. Variables and research questions were analysed using descriptive analysis e.g. percentage, mean, and standard deviation and to show relationship between dependent and independent variables. Hypotheses were tested using inferential t-test at 0.05 level of significance.

Demographic data showed that female were more prevalent in the study, level of literacy was fair in both groups. Above ninety three percent were Yoruba in the control group and above 44% in the experimental group. This is because this study was carried out in South-west Nigeria which is mainly dominated by the Yoruba. Results suggested that pre-test general knowledge of hypertension was low in both groups (t=2.836, p=0.065). Knowledge about lifestyle modification was also low in both groups (t=0.256, p=0.7989).  Practice of lifestyle modification as reported by the participant was also inadequate (t=1.390, 0.1705). Intervention was given and there was significant increase in the level of knowledge about hypertension and lifestyle modification (t=2.665, p=0.010) and (t=4.741, p=0.001) and improvement on their practice ((t=5.599, p=0.001)) after intervention.

The study concluded that, there is relationship between knowledge and practice, hence, it is pertinent that health care providers especially the nurses should help provide continuous and focused health education and training for the hypertensive in order to improve their knowledge and practice of lifestyle modification therefore controlling their blood pressure and reducing the risk for cardiovascular diseases. It is therefore recommended that health sector should intensify efforts on health educating the populace on the type of lifestyle that put them at risk of developing hypertension.

                                                TABLE OF CONTENTS

Content                                                                                                           Page

Title Page                                                                                                                     i

Certification                                                                                                        ii

Dedication                                                                                                             iii

Acknowledgements                                                                                                  iv

Abstract                                                                                                                        v

Table of Contents                                                                                              vi

List of Tables                                                                                                        ix

List of Figures                                                                                                         x

List of appendices                                                                                          xi

CHAPTER ONE: INTRODUCTION                                                       

  • Background to the Study                                                           1
  • Statement of the Problem                                                                                                             3

1.3 Objective of the Study                                                                            4

1.4 Research Questions                                                                                 4

1.5 Hypotheses                                                                                               5

1.6 Scope of the Study                                                                                         5

1.7 Significance of the Study                                                                          5

1.8 Justification for the Study                                                        6

1.9 Operational Definition of terms                                                     6         


2.0 Introduction                                                                                    8

Content                                                                                           Page

2.1 Definition, Types, Causes and Signs and Symptoms                8

2.2 Prevalence of Hypertension                                                                9

2.3 Management of Hypertension                                                    12

2.4 Hypertension Morbidity and Mortality                                             14

2.5 Existing Programs/Interventions for Controlling Hbp                          15

2.6 Empirical Review                                                                                    18

2.7 Theoretical Review                                                                      22

2.8 Conceptual Model                                                                         23


3.0      Introduction                                                                                                24

3.1     Research Design                                                                                   24

3.2 Population                                                                                 25

3.3    Sample size and sampling Technique                                         25

3.4Instrumentation                                                                                         26

3.5    Validity of Instrument                                                                                27

3.6   Reliability of Instrument                                                                           27

3.7    Method of data Collection                                                        27

3.8    Method of Data Analysis                                                          29

3.9   Ethical Consideration                                                                          29

Content                                                                                           Page



4.0 Introduction                                                                                              30

4.1 Socio-demographic data of the participants                                 30

4.2 Pre-intervention                                                                                      31

4.3 Post intervention                                                                             42

4.4Hypotheses Testing                                                                                     56

4.5 Discussion of Findings                                                                               57

4.6 Application of the conceptual model (precede procede theory)            60


5.1Summary                                                                                       62

5.2 Conclusion                                                                                  62

5.3 Recommendations                                                                            63

5.4 Limitation of the Study                                                                      64

5.5 Suggestion for Further Studies                                                              64




Table               Page

4.1       Socio-demographic data of the participants   30

4.2.1    Pre intervention knowledge about hypertension        32

4.2.2    Summary of responses on knowledge about hypertension     33

4.2.3    Significance of knowledge about hypertension pre intervention 33

4.2.4    Pre intervention knowledge about lifestyle modification       34

4.2.5    Summary of responses on knowledge about hypertension pre intervention   34

4.2.6    Significance of knowledge about lifestyle modification pre intervention      35

4.2.7    Practice of lifestyle modification pre intervention; Diet section        36

4.2.8    Summary of responses to practice of lifestyle modification pre intervention            42

4.2.9    Significance of practice of lifestyle modification pre intervention    42

4.3.1    Knowledge   about   hypertension post intervention  43

4.3.2    Summary of responses on knowledge about hypertension post intervention 44

4.3.3    Significance of knowledge about hypertension post intervention  44

4.3.4    Knowledge about lifestyle modification post intervention    46

4.3.5    Summary of responses on knowledge about lifestyle modification post        intervention 47      

4.5.6    Significance of knowledge about lifestyle modification post intervention    47

4.5.7    Practice of lifestyle modification post intervention: Diet section     48

4.5.8    Summary of responses on practice of lifestyle modification post intervention          54

4.5.9    Significance of practice lifestyle modification post intervention       54

4.5.10 Effect of the training programme on control group    55

4.5.11  Table Effect of the training programme on Experimental group        55

4.6.1    Effect of the training programme on knowledge about hypertension and lifestyle   modification in both control and experimental groups. (Post intervention).            56

4.6.2    Effect of the training programme on practice post intervention in both groups         57


Figure                                                                                                          page

2.7 Application of Procede-Preced theory                     22

2.8 Conceptual Model                  23


Inform consent


Teaching plan

Notification for ethical clearance

Ethical approval

  2. LUTH


LASUTH – Lagos State University Teaching Hospital

LUTH – Lagos University Teaching Hospital

HIN – Hypertension

BP – Blood Pressure

SBP – Systolic blood pressure

DBP – Diastolic Blood Pressure

DASH – Dietary Approaches to Stop Hypertension 

DALYS – Disability adjusted life years

US – United State

UK – United Kingdom

AHA – American Heart Association

JNC7– Joint National Committee on detection, Evaluation and Treatment of High Blood Pressure (JNC7)

ADA – American Diabetics Association



1.0 Background to the Study

Hypertension is the most common non-communicable disease and the leading cause of cardiovascular disease in the world. Many people with hypertension are unaware of their condition making treatment infrequent and inadequate, which is responsible for it poor control and not always taken seriously (Neutel & Campbell, 2008). Majority who are suffering from hypertension have a type of hypertension called essential hypertension or type one hypertension. Heredity and unhealthy lifestyle have been widely acceptable has being responsible for this type of hypertension. This has become a menace especially in Africa because of the adoption of western lifestyle, coupled with its challenges of unhealthy environment, poverty, lack of health seeking behaviour, lack of health insurance and sedentary life lived by many.

According to Seven Joint National Committee Criteria (JNC7), the precise rule for the treatment of hypertension begins with lifestyle modifications and ends with medication. Unfortunately, many patients diagnosed to be hypertensive don’t usually have proper knowledge about lifestyle modification. Studies on lifestyle modifications have revealed that modifications such as weight loss, taking Dietary Approaches to Stop Hypertension (DASH) diet, exercising and reducing salt consumption would be effective in lowering blood pressure and reducing its complications especially the rate of morbidity and mortality of cardiovascular diseases (Jafari, Shahriari, Sabouhi, Farsani & Babadi, 2016).

Lifestyle modification is advised for all hypertensive, in respective of pharmacological treatment, because it may abolish or even reduce the need for medications. The goal of prescribed lifestyle changes is to lower blood pressure. This lifestyle changes also offers a lot of health benefits and better outcomes for common chronic diseases (Huang, Duggan & Harman, 2008). Yet studies have showed that ignorance and lack of knowledge and awareness are some of the barriers to having a healthy lifestyle and not controlling and preventing high blood pressure. It is assumed that increased knowledge about the role of lifestyle in the occurrence of high blood pressure would cause people to start modifying their lifestyles and enhance their preventive behaviours as supported by the results of a study which says `when the score of knowledge in high blood pressure patients increases by one, their score of practice would increase by 0.12. (Jafari, Shahriari, Sabouhi, Farsani & Babadi, 2016).

However, studies have shown that improving knowledge and awareness alone could not be enough to control the effects of diseases by itself but by increasing the score of attitude toward high blood pressure through reinforcement, systolic and diastolic blood pressures would decrease significantly. There are a lot of other barriers that can prevent individual to modifying their lifestyle but studies have showed that increased knowledge, attitudinal and change of perceptions will all lead to practice of lifestyle modification (Jafari, Shahriari, Sabouhi, Farsani & Babadi, 2016).

The recommended lifestyle modification such as, moderate alcohol intake, weight loss of 3% to 9% of body weight, the DASH diet, regular aerobic exercise, and reduced dietary salt are lifestyle modification that controls blood pressure. Depending on the type of intervention, blood pressure reduction of 3 to 11 mm Hg systolic and 2.5 to 5.5 mm Hg diastolic, are believed to have great influence on blood pressure reduction and ability to potentiate antihypertensive drugs. The recommended diet called DASH diet is low in total and saturated fat, sugar, sugary drinks, refined carbohydrates, and red meat  but high in vegetables, fruits, whole grains, poultry, fish and low-fat dairy products. This DASH diet has long been documented to lower weight, risk of type 2 diabetes, heart rate, apolipoprotein B, homocysteine, C-reactive protein, and is accompanying by a lower incidence of stroke, heart failure, and all-cause mortality (Lochner, Rugge & Judkins, 2006).

In a premier trial, it was also documented that a reduction of 14.2/7.4 mmHg in blood pressure is attained when DASH diet is accompany by salt reduction and alcohol, aerobic exercise and weight loss, which also reduces the prevalence of hypertension from 38% to 12% over the period of six months. Reduce salt consumption by hypertensive patents, possibly the   single most important hypotensive measure, entails regularly checking food labels for salt content, staying away from processed foods, and using spices and herbs for flavour. It is generally acceptable that personal efforts from the patients and reinforcing and enabling environment from health personnel will lead to a great success in diet and behavioural modification (Nicoll & Henein 2010).

Knowledge and practice of lifestyle modification among patients with high blood pressure has however been showed to be inadequate in some studies. In UK, Nicoll and Henein (2010) in their study revealed that many hypertensive patients are unwilling to accept that their lifestyle practices or choices have made a worthwhile contributed to their condition and may refuse advice to change, this may be true of other hypertensive patients. Therefore, health education about hypertension, its consequences and lifestyle modification is been advocated to begin as early as possible in population identified to be at risk (American Heart Association, 2010).

1.1 Statement of the problem

Despite the treatment guideline and numerous drugs available for the treatment of hypertension, having patients bringing their blood pressure under control has always been a mirage. Part of the guidelines for the treatment of hypertension is lifestyle modification. In terms of economic burden, morbidity, mortality, poorly controlled blood pressure is a considerable important public health concern among older adult in the world. High blood pressure is the leading and most significant modifiable risk factor for, stroke, heart diseases, renal diseases and retinopathy. Recent recommendations for the prevention and treatment of hypertension has placed importance on modifying lifestyle. It has been proven that lifestyle modifications that is capable of lowering hypertension include increased physical activity, weight loss, reduced sodium intake. This include, a diet rich in fruit, vegetables, and low-fat dairy products reduced in total and saturated fat (Al-wehedy, Abd Elhameed, & Abd El-Hammed, 2015).

Despite the above fact, it’s been documented in several studies that most hypertensive patients don’t have enough knowledge about lifestyle modification. In a study carried out among 101 participants on perception and practice of lifestyle modification in South-East Nigeria, it was revealed that about 87.1% of the participant were not aware that exercising regularly is part of lifestyle modification while 60% were not aware that alcohol intake should be of moderate consumption. The roles of unsaturated oil and reduction in diary food intake, vegetables, and fruits in the control of blood pressure were not aware by 80% and above. A little above 60% practiced salt restriction among 88% that has some knowledge of salt restriction. This is also applicable to the few with knowledge of weight reduction, regular exercise, fruit intake, cigarette smoking and alcohol moderation, respectively.  The study shows there was a negative relationship between diastolic and systolic blood pressures and the level of practice. This typifies that knowledge level and practice of lifestyle modifications were poor among the studied participants. (Okwuonu, Emmanuel & Ojimadu, 2014).

This is in congruence with the researchers experience with patients, colleagues and family members who are diagnosed to be hypertensive, and are far away from modifying their lifestyle. This may be due to lack of adequate knowledge, belief and lack of reinforcement and enabling environment motivating them to modifying their lifestyle as documented. Jafari, Shahriari, Sabouhi, Farsani & Babadi, (2016), postulated that having knowledge or a partial knowledge and awareness alone will not lead to a change in health behaviours and practical application of knowledge but enhancement of awareness through appropriate educational programs. Therefore, this study is aimed at bridging the gap in knowledge and practice of lifestyle modification through a training programme.

1.2 Objective of the Study

The main objective of this study, is to determine the effect of a training programme on the knowledge and practice of lifestyle modification programme among hypertensive patients attending out-patient clinics in Lagos. The specific objectives are to:





1.1Background to the Study

Pressure ulcer refers to lesion on the skin which occurs as a result of persistent pressure, friction or moisture leading to destruction of the skin and underlying tissue. Over 95% of pressure ulcers develop over a bony prominence and major risk factors for pressure ulcer development are immobility and inactivity (El-Ata & Qalawa, 2016). Pressure ulcer is a common health problem in acute and chronically ill patients and it negatively affects the patients, their relatives and caregivers (Abumrad, Arbogast, Barbul, Fogerty, Nanney & Poulose, 2012). Pressure ulcer development indicates poor nursing care and the negative effect on patient’s health underscores the need to prevent the occurrence in hospitalized patients (Chamanga, 2011).Adebule, Gbadegesin, Idowu and Yinusa (2011) conducted a study on pressure ulcer among spinal cordinjury patients in Lagos University Teaching Hospital and result showed a 57.1% pressure ulcer incidence rate.Ademola, Iyun, Malomo, Oluwatosin and Shokumbi (2011) conducted a study on pressure ulcer among patients with spinal cordinjury in University College Hospital, Ibadan and result showed that 87.5% developed pressure ulcer after the first week of admission.

Obiano, Onche and Yiltock(2014) conducted a study on pressure ulcer prevalence among spinal cordinjury patients in Gombe State Hospital and the resultshowed that 57% of patients developed pressure ulcer on admission.These studies show high incidence and prevalence of pressure ulcer which may be due to low knowledge and practice concerning pressure ulcer prevention and treatment among nurses. Pressure ulcer causes serious harm to patients, limit their performance status, leads to severe infection and pain (Cooper, Courtney & Ruppman, 2012). The burden of pressure ulcer is so serious that efforts have been made in United States to reduce its occurrence through continuous nursing education and in-service training of nurses (Gill, Reddy & Rochon, 2012). Pressure ulcer occurs in all admitted patients but it is frequently seen in patients with head and spinal cord injury, immobile patients, poorly nourished patients and patients in critical condition. Its development has been attributed to poor quality of nursing care across a wide range of healthcare settings despite exposure to continuous nursing education on pressure ulcer prevention and treatment (Cowman& O’Brian, 2011).

Pressure ulcer development has been attributed to poor quality of nursing care and inadequate preventive practice by nurses especially when preventive measures are not implemented early during the period of hospitalization (Chamanga, 2011).Pressure ulcer prevention involves risk assessment, identification, staging, documentation and implementation of pressure ulcer preventive measures. Treatment of pressure ulcer is more expensive than prevention so efforts have been directed towards aquisition of skills in preventive care of pressure ulcer rather than treatment (Alhosis,El-Moneem& Qalawa, 2012).Pressure ulcer preventive measures are implemented on all patients especially those in critical condition because the tendency of pressure ulcer development in such patients is high (Estocado, Landers, Shen & Young, 2012). Pressure ulcer prevention and treatment is often wrongly done by nurses and its development negatively affects the patients’ quality of life (Bergquist-Beringer, Dunton, Gajewski & Klaus, 2011).Estocado, Landers, Shen and Young (2012) stated that increased incidence and prevalence of pressure ulcer has been attributed to low knowledge and practice concerning pressure ulcer prevention and treatment among nurses.

Cherry, Maloney, Midyette and Moss (2012) opined that the prevention of hospital acquired pressure ulcer remains a top priority worldwide with key areas addressed including; training for nurses on pressure ulcer prevention and treatment, nurses training on utilization of standardized risk assessment scale and continuous nursing education on pressure ulcer prevention and treatment. Low knowledge and practice concerning pressure ulcer prevention and treatment among nurses has persisted despite exposure to continuous nursing education and in-service training (Aydin & Karadag, 2010). Tweed and Tweed (2008) stated that despite nurses’ exposure to in-service training programmes and continuing nursing education on pressure ulcer, knowledge and practice concerning pressure ulcer prevention and treatment among nurses has been low. Altun and Zencirci (2011) opined that knowledge and practice concerning pressure ulcer among nurses is low despite exposure to training programmes on pressure ulcer prevention and treatment. According to Beeckman, Boucque, Defloor, Maele and Schoonhoven (2008) knowledge and practice concerning pressure ulcer prevention and treatment among nurses is low despite exposure to training programmes on pressure ulcer prevention and treatment.

Hsu, Sung and Tsao (2013) stated that despite nurses’ exposure to in-service training programmes and continuous nursing education on pressure ulcer prevention and treatment, knowledge and practice concerning pressure ulcer prevention and treatment has been low. Despite initiation of continuous nursing education and training programmes on pressure ulcer prevention and treatment, problems associated with it seem to persist suggesting a fundamental problem. These prompted the researcher to study the effect of a nurse-led training programme on pressure ulcer prevention and treatment among nurses in Olabisi Onabanjo University Teaching Hospital, Sagamu and Babcock University Teaching Hospital, Ilishan remo, Ogun State.

1.2 Statement of the Problem

Despite advancement in pressure ulcer prevention and treatment through discovery of latest preventive measures and treatment approaches, knowledge and practice concerning pressure ulcer prevention and treatment among nurses has been low (Adejumo & Ingwu, 2010).Smith & Waugh (2014) opined that the adverse effect of pressure ulcer has significantly increased leading to worsening wound, increased cost of care, increased period of hospitalization and increasedpressure ulcer incidence and prevalence. Litigation against nurses due to hospital acquired pressure ulcerhas also been on the increase. In Nigeria, 50% incidence of pressure ulcer was found among spinal cord injury patients, 38.6% incidence was found among orthopedic patients and 11.4% incidence was found among head injury patients which has resulted in great burden and negative effect on patients such as poor patients’ care outcome, poor patient care satisfaction, increased cost of hospital care and lenghty hospital stay (Ogunsanya, Onigbinde & Oniyangi, 2013).

Likewise, the researcher through clinical experience has observed high incidence and prevalence of pressure ulcer. These may be attributed to low knowledge and practice concerning pressure ulcer prevention and treatment among nurses. These may also be attributed to a gap in the type of training programmes offered to nurses on pressure ulcer prevention and treatment. Hence, the need for a study on the effect of a nurse-led training programme on pressure ulcer prevention and treatment among nurses in Olabisi Onabanjo University Teaching Hospital, Sagamu and Babcock University Teaching Hospital, Ilishan remo, Ogun State.

1.3 Objective of the Study

The main objective of the study is to evaluate the effect of a nurse-led training programmeon pressure ulcerprevention and treatment among nurses. The specific objectives are to

  1. determine pre-intervention knowledge concerning pressure ulcer prevention and treatment among nurses in the experimental and control group;
  2. ascertain pre-intervention practice concerning pressure ulcer prevention and treatment among nurses in the experimental and control group;
  3. implement a nurse-led training progamme on pressure ulcer prevention and treatment;
  4. determine the effect of a nurse-led training programme on knowledge concerning pressure ulcer prevention and treatment among nurses in the experimental and control group and
  5. identify the effect of a nurse-led training programme on practice concerning pressure ulcer prevention and treatment among nurses in the experimental and control group.

1.4 Research Questions

The following research questions were answered:

  1. What is pre-intervention knowledge concerning pressure ulcer prevention and treatment among nurses in the experimental and control group?
  2. What is pre-intervention practice concerning pressure ulcer prevention and treatment among nurses in the experimental and control group?

1.5 Hypotheses




 Content Page
Title page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract v
Table of Contents                                                                         vi
List of Tables List of Appendices                                                                                                                    ix x
List of Figures xi


1.1 Background to the study  1
1.2 Statement of the study  2
1.3 Objective of the study  3
1.4  Research Questions                                                                                                      3
1.5  Hypotheses                                                                     4
1.6 Scope of the Study                                                                                                      4
1.7 Significance of the Study                                                                                           4
1.8 Operational Definition of Terms                                                                                4


2.0 Introduction 6
2.1 Overview of Breastfeeding                                                                                     6
2.2 Exclusive Breastfeeding practice in developing world                                          9
2.3 Global prevalence of exclusive breastfeeding                                                       10
Content 2.4     Prevalence of exclusive breastfeeding practice in Africa                                       Page 11
2.5 Prevalence of exclusive breastfeeding practice in Nigeria                                   12
2.6 Effect of nursing intervention on exclusive breastfeeding practice                     13
2.7 Theoretical Framework                15
2.7 Conceptual Model                                                    17


3.0 Introduction     18
3.1 Research Design                                                                                                            18
3.2 Population                                                                                                     18
3.3 Sample size and sampling Technique        19
3.4 Instrumentation        20
3.5 Validity of instrument         21
3.6 Reliability of the Instrument        21
3.7 Method of Data Collection                                                                                      22
3.8 Method of Data Analysis                                                                                             23
3.9 Ethical consideration                                                                                                  23


                             AND DISCUSSION OF FINDINGS

4.0 Introduction         24
4.1 Data analysis and result presentation                                                       25
4.2 Discussion of findings                                                                                                        32

Content                                                                                                  Page



5.1 Summary                                                                          36
5.2 Conclusion 37
5.3 Recommendations 37
5.4 Limitation of the Study 38
5.5 Suggestion for Further Studies                                                 38


Table Page
1 Showing Frequencies and percentage on demographic data    25
2 3 Showing Descriptive statistics of Frequency on Obstetric data Showing Participants’ knowledge category                                                 26 26
4 5 Showing Descriptive statistics of pre-test knowledge regarding  Showing Participants’ practice category      28 28
6 Showing Descriptive statistics of post-test practice         29
7 Showing Descriptive and inferential statistics of post-test knowledge                   30
8 Descriptive and inferential statistics of post-test practice  30


  Appendix Page
  Informed Consent Form 46
  Questionnaire 47
  Teaching Module                                                           51
  Pictures from field work    55


Figure    Page
   1 Theory of planned behavior conceptual framework               17



  • Background  to the Study

The importance of the provision of a nursing-based intervention such as breastfeeding-readiness education for mothers during the antenatal visits is crucial to achieving exclusivity among them. Janson (2010) stated that, nurse- based intervention is very important in establishing successful breastfeeding practice. Valine and Apaldia (2014) suggested that the nursing intervention consisting of breastfeeding education is helpful at improving early initiation and thereafter continuation of breastfeeding for the first two months. Despite the nutritional, economic, immunological, and psychological advantages of breast milk, breastfeeding practice appear to remain below recommended level and one thing that plays a role in breastfeeding success may be nursing intervention. According to World Health Organization (WHO) all lactating mothers should exclusively breastfeed their children for the initial six months and go on with breastfeeding up to two years (WHO, 2010). However studies have shown exclusive breastfeeding is practiced below WHO recommendation (Nasserpour, Nouhjak, & Sharifat, 2010). A target of 90% universal coverage for Exclusive breastfeeding (EBF) is recommended by WHO to prevent 13-15% of 9 million deaths of children under-five in low and middle-income countries annually (Jones, 2013). Reports from Agunbiade and Agun, 2012 in Ile-Ife town also showed that only 19% of the breastfeeding mothers practiced exclusively. On the other hand, mother’s breastfeeding practice can be enhanced with continuous interventions such as prenatal breastfeeding education. UNICEF, (2011) describes that breast milk is the standard, healthiest, simplest, and not expensive feeding way that complete all the children’s needs. Knowledge, expertise and advice of nurses are very vital in creating awareness, education and support for mothers and their babies to achieve exclusivity. Nursing intervention strategies is a significant approach to some of the challenges of breastfeeding practice, making mothers informed of the cost effective benefit of exclusive breastfeeding

The global exclusive breastfeeding rate for children aged less than six months between the years 2000 and 2007 was 38% (UNICEF, 2008). Within the same period, only 23% of infants less than six months were breastfed exclusively in West and Central Africa while  Middle East and North Africa recorded a little higher rate of 26% was (UNICEF, 2008), in  Eastern and Southern Africa; East Asia and the Pacific; and South Asia respectively prevalence of  39%, 43% and 44% were observed (UNICEF, 2008).In addition, a study in England showed that infants’ exclusive breastfeeding rate was low, and only 25% of babies remain breastfed until 6 to 8 weeks after birth and 16% of mothers continued breastfeeding for three to five months after birth (Cernadas, Noceda, Barrera, Martinez, & Garsd, 2008). In Nigeria, the practice of exclusive breastfeeding is uncommon with only 13% of infant younger than six months are being exclusively breastfed (Nigerian Demographic and Health Survey, 2008), while in Nigeria, between year 2000 and 2012 merely 15.1% of babies less than six months of age were exclusively breastfed (UNICEF, 2012). Nigeria Demographic and Health Survey 2013 later on reported a a little higher prevalence of 17% EBF rate. A study in Plateau state showed that only 6% of mothers practiced exclusive breast feeding (Amosu, 2010). Niguse, Frehiwot ,  Dinu  and Eyerus (2016) stated that mothers knowlwdge and practice regarding exclusive breastfeeding as been low despite their exposure to training programmes on exclusive programs. According to Agunbiade and Oguunleye 2012, knowledge and practice concerning exclusive breastfeeding among mothers has been low despite exposure to training programmes on exclusive breastfeeding. Tyndall, Kamai, and Changchangi (2016) stated that despite the exposure of mothers to exclusive breastfeeding training, knowledge and practice regarding exclusive breastfeeding among mothers as been low. Despite initiation of exclusive breastfeeding programmes, problem associated with poor exclusive practice seems to persist suggesting a fundamental problem. These prompted the researcher to study the effect of nursing based intervention on exclusive breastfeeding practice among pregnant women attending two primary health care centers in Ikenne local government.

1.2 Statement of the Problem                                                

The rate of infant morbidity and mortality as a result of poor exclusive breastfeeding among mothers as been high (Onah , Osuorah , Ebenebe , Ezechukwu , Ekwochi  & Ndukwu,  2014). The incidence of of childhood communicable disease and infection in infants has significantly increased as a result of poor exclusive breastfeeding knowledge and practice among mothers (Talayero, Lizan-Garcia, Puime, Muncharaz, Soto, Sanchez-Palomares, Serrano & Rivera, 2006). The incidence of diarrhea and lower respiratory tract infections has been persistently high due to poor knowledge and practice regarding exclusive breastfeeding among mothers (Rivera, 2006). According to UNICEF (2013), exclusive breastfeeding knowledge and practice in Nigeria is significantly low. Knowledge and practice of mothers regarding exclusive breastfeeding as been low (Chola, 2011; Rea, 2009).  Problems associated with poor exclusive breastfeeding practice such as infections, diarrhea, upper respiratory tract infections, childhood obesity, low immunity, sudden infant death syndrome and malnutrition has significantly increased due to poor knowledge and practice regarding exclusive breastfeeding among mothers. The researcher through clinical experience as observed high incidence of malnutrition, childhood obesity and infection and diarrhea. These may be attributed to poor knowledge and practice regarding exclusive breastfeeding and it may also be attributed to a gap in the type of training programme offered to mothers on exclusive breastfeeding. Hence the need for a study on the effect of nursing based intervention on exclusive breastfeeding practice among pregnant women attending two primary health care centers in Ikenne local government

Objective of the Study




Content                                                                                                         Page

Title Page                                                                                                             i

Certification                                                                                                        ii

Dedication                                                                                                               iii

Acknowledgements                                                                                                  iv

Abstract                                                                                                                vi

Table of Contents                                                                                            vii

 List of Tables                                                                                                xi

 List of Figures                                                                                                       xii

 Abbreviations                                                                                          xiii


1.1       Background to the Study                                                                         1

1.2       Statement of the Problem                                                       3         

1.3.      Objective of the Study                                                                       4        

1.4       Research Questions                                                                                       4

1.5       Hypothesis                                                                                                      4

1.6       Scope of the Study                                                                           4         

1.7       Justification for the Study                                                                           4

1.8       Operational definition of terms                                                     5


2.0       Introduction                                                                                                  7

2.1       Nature of healthcare waste                                                                    7

2.1.1    Sharps waste                                                                                               11

2.1.2    Infectious waste                                                                                      11

2.1.3    Pathological waste                                                                                11

2.1.4    Pharmaceutical waste                                                                         11

2.1.5    Chemical waste                                                                                12

2.1.6    Radioactive waste                                                                                      12

2.2       Healthcare waste management                                                        14

Content                                                                                                     Page

2.3       Healthcare waste generation                                                                15

2.3.1    Healthcare waste generation in developing countries                        17

2.3.2    Healthcare waste generation in developed countries         18

2.4       Healthcare waste management practices                                              19

2.4.1    Segregation                                                                                    19

2.4.2    Handling and collection                                                                      21

2.4.3    Storage                                                                                                   21

2.4.4    Transportation                                                                                        22

2.4.5    Treatment and disposal                                                               23

2.4.6    Training and education                                                                         25

2.5       Health waste management practices in developed countries   26

2.6       Healthcare waste management practices in developing countries            27

2.7       Potential impacts associated with healthcare waste                           34

2.8       Acts and legislation on healthcare waste management                    37

2.9       Theoretical Framework                                                                         40

2.10     Concept adopted for the study                                                       42

2.10.1  Concept of cleanliness                                                                         42

CHAPTER THREE: METHODOLOGY                                                                  

3.0       Introduction                                                                                             43

3.1       Research Design                                                    43                              3.2            Population                                                                                      43

3.3       Sample size and sampling Technique                                   45

3.4       Research Instruments                                                                    47

3.5.1    Questionnaire                                                                        48

3.5.2    Field Observation                                                               48

3.5.3    Validity and Reliability of Instrument                                        48

3.6       Method of Data Collection                                                             48

3.6.1    Method of Data Analysis                                                   49

3.7.1    Inclusion criteria                                                                                 49

Content                                                                                                          Page

3.7.2    Exclusion criteria                                                                                       49

3.8       Ethical Consideration                                                                  49

3.8.1    Permission for the study                                                                        49

3.8.2    Post research benefits                                                                               49



4.1       Results                                                                                                       50

4.2       Discussion                                                                                       60


5.1       Summary                                                                                                    63

5.2       Conclusion                                                                                         64

5.3       Recommendations                                                                                     65

5.4       Limitation of the Study                                                          65

5.5       Suggestion for further Studies                                                            66

REFERENCES                                            67

APPENDICES                                              75


Table                                                                                                               Page

2.1       Categories of healthcare waste                                                    10       

3.1       Numbers of healthcare facilities in the study area                      44

3.2       Sample size of each healthcare facility in ASLG                               47

4.1: Demographic Characteristics                                                              51

4.2: Types of Healthcare waste generated in each healthcare facility                                    52

4.3:Knowledge of respondents regarding Healthcare waste management and its Segregation                                                                     53

4.4: Practice of healthcare waste management by health workers                              54

4.5: Practices of healthcare facility on final disposal of waste                                   55

 4.6 Relationship between the knowledge and practices of the respondents             58

4.7   Observation made by Researcher on Healthcare Waste Management in

Abeokuta SouthLocal Government.                                                               59


Figure                                                                                                      Page

2.1Healthcare waste compositions                                                           8

2.2      Categories of waste from healthcare facilities                             13

2.3       Differentiation of Waste Management                                             16

2.4      Healthcare wastes with municipal waste in open dump            30

2.5 Burning of Healthcare waste with municipal waste in dumping site at Abeokuta                                  34

2.7      Conceptual Model                   42

4.1      Level of practice of Healthcare Waste Management               56

4.2      Knowledge of respondents on Healthcare Waste Management                      57

4.3Dustbin and Improvised sharp boxes for Segregation on site (Survey Data 2017)                 78

4.4Open vehicle for transportation of healthcare waste (HCW)(Survey Data 2017)                 79

4.5Scavengers with waste at dump site (Survey Data 2017)                         80

4.6Healthcare waste (HCW) at dump site with municipal waste(Survey Data 2017)                                         81


AIDS         Acquired immune-deficiency syndrome

ASLG        Abeokuta south local government

FDA           Food and Drug Administration

HBV           Hepatitis B Virus

 HCW         Healthcare waste                                                 

HCWM       Healthcare waste management

HCV           Hepatitis C virus

 HIV           Human immune deficiency virus

ICO            Infection control officer

LG              Local government

U.S.A         United State America

WHO          World Health Organization

                                     CHAPTER ONE


1.0 Background to the Study

Healthcare waste threatens the public health due to its contagious nature. Most healthcare facilities are located in the heart of the cities and therefore, healthcare waste that are not correctly managed can cause dangerous infection and pose potential threat to the nearby environment, health workers, patients and to the public (WHO, 2014). Dehghani, Azam, Changani and Fard (2008) noted that Healthcare Waste (HCW) if not appropriately managed can be a serious threat to human health due to their infectious attributes.  Nigeria, one of developing countries, has health issues that are competing for limited resources; it is not amazing that healthcare waste management receives less attention and precedence than it merits (Stephen, & Elijah, 2011). Therefore, there is a serious challenge in developing countries, where there are no Institutional provisionsfor healthcare waste management. Clinical wastes are disposed openly in the dumpsite along with municipal waste and the practice make the members of the community gain access to it which may lead to outbreak of infectious diseases (Alagoz,  Kocasay, Abah, & Ohimain, 2010) . Cheng, Sung, Yang, Lo, Chung and Li (2009) noted that as small as healthcare waste is in proportion to the total community waste, its management is considered an important issue worldwide. World Health Organization (2014) reported that 15% of total waste generated in the healthcare facility is hazardous and must be properly segregated at the point of generation to prevent the whole healthcare waste becoming 100% hazardous. The World Health Organization estimates that each year there are about 8 to 16 million new cases of Hepatitis B virus (HBV), 2.3 to 4.7 million cases of Hepatitis C virus (HCV) and 80,000 to 160,000 cases of human immune deficiency virus (HIV) due to unsafe injections disposal and mostly due to very poor waste management systems.

Across the globe, the risk associated with Healthcare Waste (HCW) and its management has gained tremendous attention from health practitioners and non practitioners. If healthcare facilities know the types and quantities of clinical waste generated, it will help them in planning, budgeting adequate revenue for the management of hazardous waste (Bongayi, 2013). A study conducted by Olubukola (2009) in two General hospitals at Lagos reported that due to lack of quantification of healthcare waste, there was no waste reduction plan in the hospitals.

This lack of plan for healthcare waste management eventually leads to inadequate waste segregation at point of use, collection, storage and final disposal. This poor healthcare waste management practice creates health hazards for health workers, patients and the environment. Identified gaps like lack of colour code bags for segregation of healthcare waste at point of use, lack of guidelines on segregation and disposal for health workers lead to poor healthcare waste management in hospitals. The mismanagement of healthcare waste by healthcare facilities does not pose health hazard to health workers and patients alone but also to patients’ visitors and the community where they are improperly disposed by contaminating the soil, air and water. Healthcare facilities are supposed to protect the health of people in their environment, not to be a creator of potential health hazard for them.

Furthermore, increase in patient turned-out has increase the generation of healthcare waste. Mboguwe, Mimereki and Magashula(2008) also reported that increase in population results to increase in healthcare facilities that lead to increased healthcare waste generation. It is expected that because of this increase, more attention should be paid to and priority given to proper healthcare waste management in Abeokuta South Local Government (ASLG). Management of healthcare waste continues to present an array of challenges especially as economic situation of the country deepen daily therefore, healthcare waste management has become a concern.

So many studies have been conducted on healthcare waste management but little or no work has been done concerning segregation of clinical waste which is a vital aspect in healthcare waste management (Coker, Sangodoyin, Sridhar, Booth, Olomolaiye, 2009). Segregation of waste is crucial in healthcare waste management because it is the first step in clinical waste management. Segregation of healthcare waste helps in reduction of the quantity of waste that is hazardous. Once  healthcare waste are segregated, collection will be easy, proper storage will be done and disposal of infectious waste carried out  in the way that it will not pose any harm to health workers, patients and the environment (WHO, 2014). Proper management of healthcare waste depends on good organization, sufficient funding and active participation of trained personnel. It was observed that healthcare facilities were not spending resources on clinical waste management Healthcare facility must allocate resources for colour coded bags and training of generator of healthcare waste for proper segregation and disposal for its sustainability. The intention of this study is to assess healthcare waste management practices at health facilities in Abeokuta South Local Government.

1.2     Statement of the Problem




Content                                                                                                                                   Page

Title page                                                                                                                i

Certification                                                                                                       ii

Dedication                                                                                                                iv

Acknowledgements                                                                                                 v

Abstract                                                                                                          vi

Table of Contents                                                                                                vii

List of Tables                                                                                                         ix

List of Figures                                                                                                         x

List of Appendices                                                                                                 xi

List of Acronyms                                                                                                    xii


1.1       Background to the Study                                                                    1

1.2       Statement of the Problem                                                                           2

1.3       Objective of the Study                                                                               3

1.4       Research Questions                                                                                         3

1.5       Hypotheses                                                                                                3

1.6       Scope of the Study                                                                         4

1.7       Significance of the Study                                                                        4

1.8       Justification for the Study                                                                    4

1.9       Operational Definition of Terms                                                             5


Content                                                                                                              page

2.0 Introduction                                                                                                  7

2.1 The Adolescent                                                                                             8

2.2  Prevalence of sexual violence  among adolescents.                                   9

2.3 Child sexual abuse10

2.4Causes of sexual Violence                                                                          12

2.5 Prevention of sexual violence                                                                       12

2,6 Effect of sexual violence                                                                            17

2.7 Experience of sexual violence                                                                      21

2.8 Burden of sexual violence in Nigeria                                                          24

2.9 knowledge of sexual violence                                                                     26

2.10 Role of community health nurse in reducing sexual violence        27      

2.11 Theoretical frame work                                 28

2.12 Conceptual model                                                                                      31


3.0       Introduction                                                                                              33

3.1       Research Design                                                                                33

3.2       Population                                                                                       33

3.3       Sample size and sampling Technique                                                       34

3.4       Instrumentation                                                                                           35

3.5        Validity of Instrument                                                                 36

3.6       Reliability of Instrument                                                                      37

3.7       Method of Data Collection                                                                           37

 Content                                                                                                        page

3.7       Method of Data Analysis                                                                     37

3.8       Ethical Consideration                                                                         38



4.0 Introduction                                                                                               39

4.1 Demographic analysis of respondents                             39

4.2 Knowledge of adolescents on Sexual violence              40

4.3 Answering of Research questions                                                                42

4.4 Experience of sexual violence                                       46

4.5  Hypothesis testing                                                    51

4.7   Discussion of findings54


5.0       Introduction                                                                                                  57

5.1       Summary                                                                                                 57       

5.2       Conclusion                                                                                         58

5.3       Recommendations                                                                         58

5.4       Limitation of the Study                                                                      59




Table Page

3.1 Distribution of Respondents by school and level of study  35   

4.1 Distribution of Demographic Variables                              40

4.2 Distribution of Respondents ‘on source of knowledge of  sexual violence     41

4.3 Distrbution on respondents knowledge on sexual violence                                                    42

4.4  Computation of Respondents’ level of Knowledge on sexual Violence43

4.5  Distribution of respondents Knowledge of risk reduction in preventing

sexual violence      45           

4.6  Distribution of Adolescents’ Experience of Sexual Violence among Respondents46

4.7 Distribution of  Adolescents form of experience of sexual violence.48

4.8  distribution of adolescents nature of experience of sexual violence                             50

4.9Distribution of Adolescents’ Reaction to  Experience of Sexual Violence51

4.10 Chi Square for adolescent age And knowledge                                                                     52

4.11 Anova  of socio economic status and experience of sexual violence                              53

4.12Pearson Correlation for knowledge and experience of Sexual Violence.                              53


Figure                                                                                                        Page.  

2.1      Model for theory of  reasoned action                                                     30

4.1     Pie chart  showing respondents distribution of  knowledge.             44


Appendix                                                                    Page

1:         Questionnaire used in this Study                                                   61       

2:         Informed Consent Form                                                               67

3:         Ethical Clearance Certificate                                                            69

4:         Letter of Introduction                                                                    70


CDC;Center For Disease Control.

CARE; Community Awareness Rape Education.

SES;Sexual Experience Scale

WHO; World Health Organization

YBSS;  Youth Behavior Screening Survey.

                                                   CHAPTER ONE


  •  Background to the Study

Sexual violence is a major dehumanizing and serious emerging public health problem. It is also a social problem that affects thousands of people each year throughout the world, and adolescents seem to be the most affected victims due to their vulnerability (Center for Disease Control, 2011). About one hundred and fifty  million girls below the age of 18 are said to have  had experience of some  form of sexual abuse  (WHO, 2012).  Researches also shows that 6 out of 10 sexual violence actions is done against girls between the age of fifteen or  younger. Despite these high figures, they are still an underestimation of figures as a good number of sexual violence cases are never reported to the relevant establishment due to fear, shame and bias. (Sandra & Bloom, 2005).  The male counterparts are not left out as well, although females seem to bear the largest brunt of the problem. Sexual violence can have long lasting, harmful consequence on it victims, their relatives, friends, and communities.

 WHO (2012), described sexual violence as any attempt to achieve  a sexual act, unwanted sexual comments, or advances, or act to traffic or otherwise directed against a person’s sexuality using force, by any one  regardless of their relationship to the victim in any setting including   home, school, and work, (Krug, Mercy, Dahlberg, & Zwi, 2002). It involves actions that range from verbal harassment to forced penetration, with various types of social intimidation. Sexual violence is a common phenomenon and occurs worldwide.

Data available suggests that in some countries one in five women report sexual violence by an intimate partner and up to a third of girls report forced sexual initiation (Odu, Falana, & Olotu, 2014) Sexual assault encompasses a range of acts, including coerced sex in marriage and dating relationships, rape by strangers, organized rape in war, sexual harassment (including demands of sex for jobs or school grades), and rape of children, trafficking of women and girls, female genital mutilation, and forced exposure to pornography. It is any act (verbal and/or physical) which breaks a person’s trust and/or safety and is sexual in nature  (Dahlberg & Krug, 2002).

Adolescent women are at a higher risk for sexual violence than any other age group. Globally 40-47 percent of sexual violence is done against girls age 15 and younger. Child sexual abuse accounts for 7% to 8% of the mental health disease burden amongst females globally  (Degue et al, 2014).Studies shows that a large number of date/acquaintance rape accounts for major cases of sexual violence. Poor awareness of the menace among this age group is a major identified risk factors increasing their vulnerability (CDC, 2014). Due to past or ongoing sexual abuse, abused teens are more likely than their non-abused peers to participate in “delinquent” teenage behaviors including those which result in social problems, conflict with authority, early sexual behavior, and eating problems, teenage pregnancy, and other high risk behaviors. (Darlinghton 2014). It is also note worthy that Most reported cases of sexual violence in Nigeria happens to victims of less than 18 years of age  (Adepoju, 2012)

Thus, putting Adolescents at a greater risk of victimization in sexual violence issues. In preventing this menace efforts must be made to reach both the perpetrators and the victims. This is because programs planned towards creating awareness on sexual violence would probably reduce perpetrators choice of committing sexual violence crimes and victims risk of falling into such acts. Therefore assessing the knowledge and experiences of adolescents is imperative in gathering baseline data that would aid appropriate intervention program that is aimed at primarily preventing sexual violence incidence in a developing country like Nigeria were resources to manage cases are limited.

  •  Statement of the Problem



Commercial motorcycling emerged, and has become established, as a popular means of transportation in Nigeria due to the inadequacy of the conventional modes of mass movement to meet commuters’ expectations and demands. Unfortunately, motorcycle crashes continue to escalate the already grim statistics of road traffic morbidities and fatalities. This has not been unconnected with the risky behaviours demonstrated by the motorcycle operators. Although there are advances in roadway construction and vehicular design, knowledge and prevention of these risky behaviours have been low.

Using a quasi-experimental one-group design,72 registered motorcycle operators in Ado – Ekiti were selected to participate in a Nurse-led training programme.The sample size was determined using Leslie Kish formula and multi-stage sampling technique was employed to select the participants. A structured, self-administered questionnaire was used to obtain data on the respondents’ socio-demographic characteristics and their knowledge regarding traffic-, substance abuse- and health-related risky behaviours during their operations, after the research supervisor and a group of experts in the field evaluated, and ascertained its content and face validity. The data collection took place before and after the intervention. The reliability of the instrument was ascertained bya pre-test and the derivation of Cronbach’s alpha coefficient.Prior testing of the training modules was also done before the study was undertaken. The data were coded into, and analysed using the Statistical Package for the Social Sciences (SPSS), version 20.0. With the aid of descriptive and inferential statistics usingthe students’ t-test to determine the difference in mean knowledge scores pre- and post-intervention, the research questions were answeredand the hypotheses tested.

Findings from this study showed that the level of knowledge of the motorcycle operators in Ado – Ekiti regarding risky behaviour was low, as majority of the respondents had a poor knowledge of these risky behaviours pre-intervention.Also, there was a significant improvement in the knowledge of the motorcycle operators on risky behaviours following the nurse-led training programme (P = 0.000).

The study therefore concluded that the nurse-led training programme resulted in an improvement in the knowledge of the motorcycle operators regarding traffic-related, substance abuse- and health-related risky behaviours. The need to scale up awareness campaigns and education regarding risky behaviours among the motorcycle operators cannot be overemphasized.

Keywords: Effect, Nurse-led training programme, Knowledge, Risky behaviours,Motorcycle operators, Ekiti State.



1.1  Background to the Study

Transportation is a basic and indispensable component of all human endeavour, and has strong influence on the interrelations that exist when people with common interests live together. It plays a major function in the continued existence of urban communities by forming the basis for interaction, vocation, leisure and choice of residence (Oluwaseyi, Edward, Eyinda, &Okoko, 2014). Once a nation truly decides to embark on a large scale development of its transportation system, it must ensure that it not only improves access to the citizens’ places of vocation and residential areas, but in a safe and healthy manner, such that the risks of death and long-term disabilities are eliminated or reduced to the barest minimum (Lukasik and Szymanek, 2012).

Nigeria has sought to develop its own transport system that would meet global standards. Various motorized means of transportation have been employed, including buses, mini-buses, and cabs. These conventional means of public transportation were besieged by recurring and worsening problems such as rapid industrialization, poorly planned urbanization, collapsing infrastructure and road networks, population explosion despite progressively decreasing number of vehicles leading to congestion, prolonged waiting and travelling times at bus stations, and inadequate security. This need made the demand for motorcycle higher among many commuters who usually had to struggle to get transported to and from their residential or official quarters (Olubomehin, 2012). It was due to the failure of the regular means of commuting from one part to another that led to the emergence and perpetuation of the commercial motorcycle as an established mode of transportation in Nigeria. The motorcycle operators are part of the communities in Nigeria and this has made access to them easier (Olubomehin, 2012). An estimated 70 percent of urban and semi-urban Nigerian cities depend on commercial motorcycle for transportation within and around the town (Oluwaseyiet al, 2014).

The spread of the commercial motorcycle vocation was also fuelled by the relatively cheaper spare parts, maintenance costs and greater fuel economy which have increased the patronage and made it a thriving vocation (Olubomehin, 2012).Motorcycle crashes continue to add to the increasing fatality and permanent-disability figures annually. Globally, deaths linked with motorcycle accidents is about 1.2 million  while about 50 million injuries are linked with motorcycle accidents yearly, while about half of the people involved in fatal road traffic accidents are pedestrians, motorcycle operators or commuters on motorcycles (Oluwaseyiet al., 2014). It appears that the prevalence of motorcycle-related traffic crashes is directly proportional to the increasing number of motorcycle operators in the nation.Also, for every unit of distance travelled, motorcycles cause far more fatal and permanently-damaging accidents than regular vehicles (Olubomehin, 2012).

Risky behaviour is described as series of activities and lifestyles behaviours that makes a person to be vulnerable to injury that could cause disability (temporary or permanent) or instant death depending on the severity of the injury. It could also mean exposing oneself to danger or possibility of injury or death. This risky behaviour among the motorcycle operators has led to the labelling of the motorcycle as the most dangerous of all motorized means of transportation. Due to the prevailing unemployment and youths’ underemployment in the country, and the relative lucrative nature of the business, it provides an easier and non-formal means of livelihood for many unemployed youths in the face of poverty and inflation. Thus the quest for survival, economically and socially, has forced many unemployed youths to become motorcycle operators, even though a good proportion of them are often untrained or sometimes untrainable due to their poor level of knowledge (Onifade, Aduradola, &Amao, 2012). Unemployed youths now utilize commercial motorcycles for income generation by transporting passengers on roads that are not motorable in remote cities and villages. This mode of transportation became popular and its acceptance began to climb steadily among the populace.

Commercial motorcycle also became popular due to the easy maneuverability in the often chaotic road environments and its low cost relative to four-wheeled vehicles. It now serves as one of the key means of transportation in Nigeria as it provides the citizens with a cheap transportation network. Even in remote villages, the motorcycle operators arrive at regular intervals and are used by all ages and classes of people(Abdussalam&Wahab, 2014). However, the spread of the commercial motorcycle vocation has also resulted in an upsurge in the number of accidents, some of which have resulted into loss of lives and permanent disabilities in the survivors. Motorcycle crashes continue to add to the increasing fatality and permanent disability figures annually. Globally, approximately 1.2 million fatalities and 50 million injuries are linked with motorcycle accidents every year, while about half of the people involved in fatal road traffic accidents are pedestrians, motorcycle operators or commuters on motorcycles (Oluwaseyiet al., 2014). It appears that the prevalence of motorcycle-related traffic crashes has increased in direct proportion to the increasing number of commercially-operated motorcycles in the nation. However, it appears that for every unit of distance travelled, motorcycles cause far more fatal and permanently-damaging accidents than regular vehicles (Olubomehin, 2012), making the motorcycle the most dangerous of all mechanical means of transportation.

In a study in south-western Nigeria (Ogunmodede, Adio, Ebiejuwa, Oyetola, & Akinola,2012), it was discovered that significant contributing factors to the causes of road traffic accidents among motorcycle operators in Nigeria were over-speeding, wrong over-taking, bad roads, sudden mechanical defects, ingestion of alcoholic beverages, non-compliance with road safety highway codes, over-loading by carrying more than one passenger, skidding off a bend due to excess speed or under-cornering, absence of functional horn and headlamps, riding without crash helmet, and riding against the traffic. These account for 95% of the causes of permanent disability and death of motorcycle accident victims (Ogagaoghene, 2011, Ogunmodedeet al., 2012).

Motorcycle accidents, when they occur, could lead to brain injury or severe trauma as the head violently hits the ground or other objects during the collision resulting in convulsion and other severe conditions (Ogunmodede&Akangbe, 2013). Many of these motorcycle operators sometimes know that some of their actions and risky behaviours could result in unpleasant outcomes, but they fail to act or do anything to remedy the situation, thus making themselves and their passengers prone to certain harm or death. There is need for motorcycle operators to be educated on the unpleasant manifestations of the risky behaviours which causes increase in annual motorcycle accidents.Therefore, this study is designed to investigate the effect of a nurse – led training on risky behaviours among motorcycle operators with the aim of reducing to the barest minimum the grim statistics of motorcycle road crashes.

1.2 Statement of the Problem

With a record fatality rate of 162 deaths from road traffic accidents per 100,000 population, Nigeria is placed 191among the 192 world countries with poor and bad roads. The World Health Organization (WHO)  also estimated  that over one million people die every year in road accidents with not less than 50 million people sustaining various grades of injuries from such occurrences (FRSC, 2011).

Motorcycle operators have a 35-fold more likelihood of dying than the passenger car occupants and 8-fold risk of injury. Also, while most of the motorcycle crashes generally lead to injuries to the lower extremities, the fatal crashes are frequently associated with head injuries. Risky behaviours like alcohol abuse, smoking and drug abuse are major contributory factors to motorcycle fatal crashes (Lin &Kraus, 2009).Oluwadiya and Fatoye (2012) posited that the use of locally-brewed intoxicants by motorcycle operators was another potential cause of road crashes which could lead to instant death, loss of limbs and significant economic losses.

According to the FRSC, WHO estimated that should the present unhealthy trends in road traffic accidents continue, fatalities from traffic crashes would increase by a margin of 65% between 2015 and 2020, exceeding the burden created by tuberculosis and malaria (FRSC, 2011).There is thus, an urgent need for tackling the menace of motorcycle accidents in our environment and this would require a multi-faceted approach which health workers like nurses can provide. Therefore, the index study is aimed at investigating the effect of a nurse-led training programme on risky behaviours among motorcycle operators in Ado – Ekiti.

1.3 Objective of the Study

The main objective of the study is to assess the effect of a nurse-led training programme on the risky behaviours of motorcycle operators in Ado-Ekiti. The specific objectives are to:

1.      assess the level of knowledge of motorcycle operators on risky behaviours in Ado-Ekiti;

2.      give a training programme on risky behaviours to motorcycle operators in Ado-Ekiti and

3.      assess the effect of the training program on risky behaviours among motorcycle operators in Ado-Ekiti.

1.4 Research Questions

1. What is the level of knowledge of risky behaviours among motorcycle operators in Ado-


2. What is the effect of the training programme on risky behaviours among motorcycle operators in Ado-Ekiti?

1.5 Hypotheses

H01:There is no significant difference in the knowledge level of motorcycle operators about

       risky behaviours pre- and post-intervention.

H02There is no significant effect of the training program on risky behaviours among

        motorcycleoperators in Ado-Ekiti.

1.6 Scope of the Study

The study was delimited to the registered motorcycle operators within the capital city of Ekiti State. It also employed didactic power-point lecture in the training of the motorcycle operators. The researcher delimited the evaluation of the participants to the use of pre-test and post-test questionnaire administration, since this has proven to be a standard way of achieving the research objectives.

1.7 Significance of the Study

Clearly, the causes of road traffic crashes revolve around the motorcycle, the roadway and the cyclist. Great efforts have been made to improve the design of motorcycles such that they are less accident-prone. Countries have invested heavily in roadway networking, infrastructural development and improvement in traffic-security consciousness among the motorcyclists, but rarely has the psycho-mental status of the riders ever been on the front burners of these efforts. The current drive towards reducing the unpleasant statistics of motorcycle-related morbidities and mortalities can be given a boost by including measures to curb risky behaviours in the operators. These interventional measures can only be effective if the level of knowledge of the motorcycle operators on risky behaviours is known, as well as the impact of a training intervention evaluated.

The results of the study might create awareness on risky behaviours among motorcycle operators, particularly in developing nations where commercial motorcycling is a major source of transportation and livelihood to many. It may also provide a basis for reference in the field of nursing and other allied health professions for further studies. The results might help to reduce motorcycle related accidents as well as diminish hospital admission rates of motorcycle operators and commuters of motorcycles. It may also help to reduce workload of the already short-staffed nursing units of hospitals where motorcycle related accident victims are being nursed.

1.8 Operational Definition of Terms

1.      Effect: This is the difference in the mean knowledge scores on risky behaviours

2.      Nurse-led training programme: teaching on risky behaviours among motorcycle operators designed and given by a nurse to improve the level of knowledge of the motorcycle operators

3.      Risky behaviours: These are series of activities and lifestyle behaviour that makes a person to be vulnerable to injury or harm that could cause disability (temporary or permanent) or instant death depending on the severity of the injury.

4.      Motorcycle operator: A man who rides motorcycle for commercial purposes.

5.      Motorcycle: A name commonly used for a two-wheeled machine.

6.      Knowledge of risky behaviour: Being able to recognize thata behaviour is good or bad. It also means having awareness that a behaviour can cause harm.

7.      Traffic –related risky behaviour: involving violation of road traffic laws and regulations.

8.      Substance-abuse related risky behaviors: pertaining to the use things like alcohol-based product or drugs that can influence mental alertness.

9.      Health-relatedrisky behaviours: pertaining to the health of the motorcycle operators that can cause harm.