PROVISION, UTILIZATION LEVELS AND TRENDS OF CHILD HEALTH SERVICES IN PRIMARY HEALTH CARE CENTRES IN ENUGU URBAN OF ENUGU STATE

Table of Contents
Title page – – – – – – – – – i
Certification – – – – – – – – – ii
Approval Page – – – – – – – – – iii
Dedication – – – – – – – – – iv
Acknowledgements – – – – – – – – v
Table of Contents – – – – – – – vi
List of Acronyms and Abbreviations – – – – – – viii
List of Table – – – – – – – – – x
List of Figures – – – – – – – – – xi
List of Appendices – – – – – – – – xii
Abstract – – – – – – – – – xiii

CHAPTER ONE: Introduction 1
Background to the Study – – – – – – 1
Statement of the Problem – – – – – – – 11 Purpose of the Study – – – – – – – – 12
Research Questions – – – – – – – – 13
Hypotheses – – – – – – – – 13
Significance of the Study – – – – – – – 14
Scope of the Study – – – – – – – – 15
CHAPTER TWO: Review of Related Literature 17
Conceptual Framework – – – – – – – 17
Factors Associated With CHS – – – – – – 30
Theoretical Framework – – – – 39
Empirical studies on utilization level and trends of child Health
Services – – – – – – – – – 42
Summary of Literature Review – – – – – – 50
CHAPTER THREE: Methods – – – – – – 52
Research Design – – – – – – – – 52 Population for the Study – – – – – – – 52
Sample and Sampling Techniques – – – – – – 53
Instrument for Data Collection – – – – – – 54
Validation of the instrument – – – – – – – 55
Reliability of the instrument – – – – – – – 56
Method of data collection – – – – – – – 56
Method of Data Analysis – – – – – – 57
CHAPTER FOUR: Results and Discussion – – – – 58
Summary of findings- 79
Discussion of major findings – – – – – – – 80
Availability/provision of CHS – – – – – – 81
Utilization levels of CHS – – – – – 82
Trends in utilization of immunization services from 2000 to 2007 87
Influence of maternal socio-demographic factors on
Utilization level of CHS (age, parity, educational attainment and
Occupational Status) – – – – – – – 88 Socio-economic factor(s) that could influence level
of utilization of CHS – – – – – – – 90
Implications of the findings for health of the child and
Childhood morbidity mortality rates – – – – – – 91
CHAPTER FIVE: Summary, Conclusion and Recommendations 94
Summary – – – – – – – – – 94
Conclusions – – – – – – – – 94
Recommendations – – – – – – – – 96
Suggestions for Further Studies – – – – – – 97
Limitations of the study – – – – – – 98
References – – – – – – – – – 99
Appendices – – – – – – – – – 107

List of Acronyms and Abbreviations

AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
ARI Acute Respiratory Tact Infection
BCG Bacillus Carm Guarine
BHFI Baby Friendly Hospital Initiative
BHSS Basic Health Service Scheme
CCCD Combating Childhood Communicable Diseases
CDD Control of Diarrhea Disease
CHS Child Health Services
CIDA Canadian International Development Agency
CSM Cerebro-Spinal Meningitis
DFID Department for International Development
EPI Expanded Programme on Immunization
ESMOH Enugu Ministry of Health
EU European Union
FMOH Federal Ministry of Health
GAVI Global Alliance for Vaccine Immunization
HBV Herpatitis B Virus
HIV Human Immune Deficiency Virus
ICC International Child Congress
IEC Information Education and Communication
IITA International Institute of Tropical Agriculture.
IMCI Integrated Management of Childhood Illnesses
IMR Infant Mortality Rate
IRCS International Red Cross Society
JICA Japanese International Cooperation Agency
LGA Local Government Area
MCH Maternal and Child Health Services
MICS Multiple Indicator Cluster Survey
MPS Making Pregnancy Safer Initiative
NDHS National Demographic and Health Survey
NFCN National Committee on Food and Nutrition
NHP National Health Policy
NIDs National Immunization Days
NMICS National Multiple Indicator Cluster Survey
NPC National Population Commission
NPHCDA National Primary Health Care Development Agency
NPI National Programme on Immunization
OPT Diptheria Pertusis and Tetanus
OPV Oral Polio Vaccine
ORT Oral Re-hydration therapy
PHC Primary Health Centre
PNC Post Natal Care
Polio Poliomyelitis
TT Tetanus Toxoid
U5MR Under Five-Mortality Rate
UNFPA United Nations Family Planning Agency.
UNICEF United Nation Children Fund
USAID United State Agency for International Development
VPD Vaccine Preventable Diseases
WHF World Health Forum
WHO World Health Organization

List of Tables

Table
1. Availability of CHS in PHC facilities in Enugu urban.
2. Utilization levels of CHS in the PHC facilities in Enugu urban.
3. Trends in the utilization levels of immunization services 2000-2007. In PHC Facilities in Enugu Urban
4. Influence of maternal age on the utilization of CHS.
5. Influence of maternal educational attainment on the utilization levels of CHS.
6. Influence of maternal parity on the utilization levels of CHS
7. Influence of maternal occupation on the utilization levels of CHS

List of Figures

Figure
1. Trends in utilization of BCG 1st and 2nd doses (0 – 11m, 12 – 23m)
2. Trends in utilization OPV vaccine 1st dose (0 – 11m)
3. Trends in utilization OPV vaccine 2nd dose (12 – 23m)
4. Trends in utilization DPT vaccine 1st dose (0 – 11m)
5. Trends in utilization DPT vaccine 2nd dose (12 – 23m)
6. Trends in utilization Yellow Fever vaccine 1st, 2nd and 3rd doses
7. Trends in utilization HBV 1st dose (0 – 11m)
8. Trends in utilization HBV 2nd dose (12 – 23m)
9. Trends in utilization measles vaccine 1st and 2nd doses
10. Trends in utilization CSM (12 – 59m)

List of Appendices

Appendix A: Immunization Inventory
Appendix B: Information on field work
Appendix C: Questionnaire
Appendix D: Trends in Immunization 2000 – 2007

Abstract
This study was aimed at determining the provision, Utilization Levels and Trends of Child Health Services in the Primary Health Care Centres in Enugu Urban. The independent variables investigated were maternal age, parity, occupation and educational attainment. Other socio-economic factor(s) that could influence utilization of CHS were also considered in the study. The study was limited to eight components of CHS available in the area of study, while immunization service, which is one component of CHS, was used to trace the trend of CHS. Descriptive survey research design was used for the study. Four research questions and four hypothesis tested at .05 level of significance were formulated for the study. The population of study was 11,200 mothers of reproductive age on Enugu State and 310 mothers and their babies that utilize CHS in PHC facilities in Enugu Urban. Instrument for data collection were provision and utilization of CHS questionnaire and Trends in utilization of immunization inventory both designed by the investigator. Mean, frequencies, percentages and chi-squire statistical techniques were employed to analyze data collected. The findings of the study are as follows: CHS was available in the three PHC in Enugu Urban. All of the eight components of CHS except exclusive breast-feeding were utilized effectively. The trend of immunization services utilization over the years 2000 – 2007 was full of fluctuations. Maternal Demographic factors studied: Age, parity, occupation and educational attainment had no statistical relationship to the level of use of available CHS. Availability of medical personnel in the neighborhood 77.15 percent, ignorance of need of CHS, 40.06 percent, cultural belief 25.83 percent, bad attitude of health care provides 18.54 percent and procrastination of immunization/clinic days 13.58 percent were socio-economic factors that affected level of utilization of available CHS.

CHAPTER ONE
Introduction
Background to the Study

Children are the future of any nation or community. They are essential for the survival of any group of people. For this reason and more the focus of international public health concern has been on reducing child mortality and morbidity in order to propagate, preserve, nurture and ensure continuity of the human race. This is rightly so as WHO (2000) reported that recently in the mid 1980s, some fifteen million children under five years of age died each year, representing 30 per cent of all deaths in many countries. This evil trend was addressed through the provision of Child Health Services (CHS).
According to William (1984), CHS are that aspect of medical services that provide essential health services to protect, promote and maintain health and well-being for child bearing families as a unit and for each individual child within that family up to school age (from birth to five years). World Health Organization WHO (1993) stated that CHS is a channel through which medical and health services can be organized to improve the health of the child, prevent diseases and promote growth and development. Tabah (1987) had earlier noted that CHS is an integral part of community health services and has been adopted as Maternal and Child Health Services (MCH).
Starfeiled (2002) asserted that CHS is an integral part of Primary Health Care (PHC) which is concerned with the provision of accessible, integrated, bio-psychosocial health care service by the health care personnel who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients and participating in the context of family and community. According to Guagilardo (2004) PHC is recognized as the most important form of health care delivery system for maintaining populations health including child health, because it is relatively in-expensive, can be more easily delivered than specialty an in-patient care (if properly distributed) and most effective in preventing disease progression in a large scale.
The health of the child and services offered to protect it are influenced by factors classified by Cleason, Edward, Mawiji, and Pathmanathan (2000) as proximate factors (such as non-medical and medical care during the antenatal period, care at birth, preventive and curative care in the post-natal periods) and non-proximate factors such as maternal factors (age, parity and birth intervals). Household and community level factors (such as water supply, sanitation, and housing) then socio-economic development and health services. Diamond (2000) pointed out that there is little doubt that high child mortality rates are associated with high rates of child bearing early child bearing, short birth spacing and high-parity birth. He suggested that effort to reduce high child mortality should not only end in health intervention but should include improvement in women’s education.
Gabr (1985) identified the components of child health care services as follows: immunization services, growth monitoring, oral re-hydration therapy, promotion of breastfeeding, treatment of minor illness and outreach services. These activities are aimed at protecting child health and preventing ill health. Immunizations are given to protect the child against childhood killer diseases. The Federal Ministry of Health of FMOH (2004) identified these diseases as: whooping cough, measles, tuberculosis, tetanus, poliomyelitis, diphtheria and the additional package namely hepatics B and cerebrospinal meningitis. United Nations Children Fund) UNICEF (2002), reported that although most of these childhood killer diseases have been reduced in the developed countries, other diseases and conditions such as malaria, human immunodeficiency virus (HIV), cerebro-spinal meningitis, diarrhea, hepatitis B virus and malnutrition are now topping the lead as childhood killer diseases.
Other CHS includes; growth monitoring, using a standardized chart aimed at assessing the physical development of the child. Oral re-hydration therapy given for the treatment of diarrhea of any aetiology, promotion of breastfeeding to prevent malnutrition, health education on nutrition and the use of locally and culturally accepted foods during weaning periods to introduce children under the age of one year to the family food without creating nutritional gap that would result to malnutrition, treatment of prevalent illness such as malaria and outreach health services. In outreach services, trained health personnel go out to reach children in schools and churches or mosque to delivery child health services such as immunization, health screening and inspection, identification and referral of children with physical or psychological impediments for proper management.
The objective of child health care services according to Nelson (2000) is to reduce child morbidity and mortality to enhance mental, physical and psychological well being of the children to permit them to come to adulthood at their optimal stage of development as to complete with life struggle at their affective level. It is worth noting, however that not withstanding the provision of all these services, their utilization are essential for accomplishing of the objective of child health care services. In other words, the provision of the services is considered a necessary factor for the accomplishment of the objective of the child health care services, while the utilization is also another factor.
Child health services among other health services are provided by the government at all levels: federal, state and local government levels. Each has her responsibilities in turn for providing these services either single-handedly or in collaboration with non-governmental agencies such as UNICEF, United State Affair for International Development (USAID), World Bank, WHO, DFID. According to Cleason and Waldman (2000), health care services are provided at government levels, community levels and family levels. It is the responsibility of the government to provide some of these health services, while it is the responsibility of the community to make them accessible, bearing in mind the cultural health practices and attitudes of the families to health issues.
The CHS provided at home/family level includes: Breast-feeding, good nutrition by good weaning practices, hygiene and other health promoting behaviours. Clearson and Waldman (2002) maintained that the ability of the mother to recognize illness, provide appropriate and quality care and seek medical help early in sickness, goes a long way to save and keep the child alive.
WHO (2000) reported that at the community level, the extent of utilization of child health services will depend on community factors such as culture, values, beliefs norms, ecology and geography among other things. Factors such as availability of those services, accessibility, quality of other health services (private and public) around, food, energy, water supply and sanitation will determine and influence the extent of use of CHS. Similarly at government level, factors such as government policies and actions on health, nutrition, population, health financing and expenditure, provision, stewardship, inter-sectorial linkages, evaluation and monitoring will make a way for availability and accessibility of CHS. Other governmental policies such as infrastructure, transport, energy, agriculture, water supply and sanitation can also influence the extent of use of CHS.
Child health services as part of maternal and child health services evolved through ages and is noted in the bible (Exodus 1:15 – 22). According to Nelson (2000), it reached its peak in 19th century following industrial revolution and discovery of antibiotics in the treatment of childhood ailments. In Nigeria the traditional child care based on myths, customs and belief was improved up on by the colonial medical services and the Christian missionaries respectively. The Christian missioners abolished some of the harmful practices in child care such as killing of twins and educated the people on improved child care. Donor agencies and international organizations such as World Health Organization, UNICEF, International Red Cross Society) played very important role in child health service in Nigeria, especially during Nigerian civil war and thereafter.
Trends in the utilization level of CHS in this study therefore imply the level of use of CHS over the years from 2000 – 2007. This is because from literature reviewed, implementation of the new CHS reforms especially on immunization started from 1990, and consolidated in 2000s.
Prior to 1980s CHS was focused on the disease specific strategies, such as immunization against six deadly childhood killer diseases (Tuberculosis, Tetanus, whooping cough, poliomyelitis, measles, diphtheria) using vaccines only. This involved technology of cold chain for potency and efficiency and required technological preservation for potency, which made the programmes and the strategies difficult and the result was very low immunization coverage, especially in the remote areas. WHO (1989) reported that in the mid 1980s five million children under five years of age died each year. Foster (1998) noted that this ugly trend aroused the concern of public health and WHO. This brought about re-organization and reformation of CHS from the disease specific strategies and programmes to preventive, promotive and early treatment care seeking behaviour aimed at diseases prevention and control and the subsequent reduction of infant/childhood mortality rates.
These new trends include strategies for strengthening health system through the provision and expansion of primary health care facilities, as well as training health care providers in the use of appropriate, effective and affordable strategies to save the lives of children. Such strategies reform includes additional immunization against hepatitis B virus, cerebro-spinal-meningitis, house-to-house immunization to eradicate poliomyelitis, deworming exercise carried out in government owned primary schools and school meal programme. Emphasis is no longer only on the six childhood killer disease using vaccines only to but also includes prevention of diseases that contribute directly and indirectly to childhood mortality.
The subject of this new initiative of CHS aimed at reducing emphasis on technical programmes that are disease specific to include and incorporate other programmes aimed at disease prevention and control in a more integrated and more manageable packages of basic child health services. In this new trend, emphasis is on both prevention of childhood killer diseases as well as early detection and prompt treatment of major communicable diseases such as cerebro-spinal-meningitis, pneumonia, diarrhea, malaria, measles and hepatitis B virus infection which have taken top lead as childhood killer diseases. Emphasis is also on addressing malnutrition which has been shown to contribute to more than half of all childhood deaths as well as Human immunodeficiency virus (HIV). In addition to improved immunization strategies, the new package includes: oral re-hydration therapy, exclusive breastfeeding for the first six months of life, nutrition education and outreach services. CHS in practice prior to the reform include antenatal services, postnatal services, immunization against six childhood killer diseases as well as growth monitoring.
The benefits of effective CHS have become an increasing concern, as relationship between health during early life and later developments have become more clearly understood. Foster (1998) stated that decrease in childhood disease through efficient CHS have led to decreased social burden of having to look after children and individuals whose lives are damaged either physically, mentally or both. His statement agreed with that of Akintola (1993) who ascerted that effective CHS in any nation ensures healthy citizens. In the same way, the absence and inability to make use of these available child health care services implies un-healthy citizens. It should therefore be a matter of concern to determine the provision and level of utilization of child health care services in view of the report of Nigerian Demographic and Health Survey (2004) which stated that despite these new reforms in CHS, infant mortality rate still remains as high as 100 deaths per 1000 live birth. This situation puzzles the mind of the researcher in view of so much efforts and resurgence of interests in PHC by the federal, state and local government authorities in collaboration with donor agents such as DFID, UNICEF and World Bank aimed at providing quality health care to reduce to its barest minimum the ever high rate of childhood mortality. It is worth noting that it is one thing to provide these services and another to make use of them for the purpose meant for it. In other words, provision of these CHS is essential for accomplishing the objectives.

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