Inequity in the Bamako Initiative programme--implications for the treatment of malaria in south-east Nigeria

An exploratory study was carried out to examine the utilization of malaria treatment services in the Bamako Initiative (BI), the exemption practices and the cost recovery of user-fees for treatment of malaria in south-east Nigeria. Structured questionnaires were used from 1594 households to collect socio-economic and demographic information, the utilization of health care services and experience with user fee exemption. Historical data on malaria utilization rates from 1991 to 2000 were obtained from health centres. In addition, financial information was collected on the annual BI revenue. Health centres for malaria experienced a drop in outpatient attendance when the programme started which later rose again. The more affluent population, as assessed by household belongings and education, used the health centres more often than the poorer population, were more aware of exemptions and benefited from exemptions more than the poorer and lesser educated populations. The sale of anti-malaria drugs was a large proportion of the costs recovered. BI appears to have increased malaria care utilization but has also raised some equity issues. It seems that richer households benefited more than poorer households.     

Attraction and retention of qualified health workers to rural areas in Nigeria: a case study of four LGAs in Ogun State, Nigeria

INTRTODUCTION: A shortage of health workers is a major problem for Nigeria, especially in rural areas where more than 70% of the population live. At the primary care level, trained community health officers provide services normally reserved for doctors or medical specialists. The community health officers must therefore be supported and motivated to provide effective quality healthcare services. This study aimed to determine factors that will attract and retain rural and urban health workers to rural Nigerian communities, and to examine differences between the two groups. METHODS: A cross-sectional survey measured health workers' work experience, satisfaction with, and reasons for undertaking their current work; as well as reasons for leaving a work location. Data were also gathered on factors that attract health workers to rural settings and also retain them. RESULTS; Rural health workers were generally more likely to work in rural settings (62.5%) than their urban counterparts (16.5%). Major rural motivators for both groups included: assurances of better working conditions; effective and efficient support systems; opportunities for career development; financial incentives; better living conditions and family support systems. The main de-motivator was poor job satisfaction resulting from inadequate infrastructure. Rural health workers were particularly dissatisfied with career advancement opportunities. More urban than rural health workers expressed a wish to leave their current job due to poor job satisfaction resulting from poor working and living conditions and the lack of career advancement opportunities. CONCLUSIONS: Motivational factors for attraction to and retention in rural employment were similar for both groups although there were subtle differences. Addressing rural health manpower shortages will require the development of a comprehensive, evidence-based rural health manpower improvement strategy that incorporates a coordinated intersectoral approach, involving partnership with a range of stakeholders in rural health development.     

Health seeking behaviour and household health expenditures in Benin and Guinea: the equity implications of the Bamako Initiative

Curative and preventive care utilization in Bamako Initiative health centres in Guinea and Benin increased significantly. Service based data and household survey results are compared and interpreted to evaluate the equity aspects of the Bamako Initiative programmes in these settings. Improvements in the use of preventive services are shared by the richer and poorer groups of the population. Inequities are more apparent regarding curative area. An important part of the population is not using Bamako Initiative Health Centres for financial reasons. However, the poor were found to use these Health Centres relatively more than richer socio-economic groups. Challenges of the future are identified and recommendations made as to how to tackle the problem of true indigence.     

Rural-urban differences in health and health behaviour: a baseline description of a community health-promotion programme for the elderly

STUDY OBJECTIVE: To (1) describe the setting and design of the Good Ageing in Lahti Region (GOAL) programme; (2) by using the baseline results of the GOAL cohort study, to examine whether living in urban, semi-urban, or rural communities is related to risk factors for chronic diseases and functional disability in ageing individuals. DESIGN: The baseline data of a cohort study of ageing individuals living in three community types (urban, semi-urban, rural). Data were collected by two questionnaires and laboratory assessments. SETTING: Fourteen municipalities in the Lahti region (P?ij?t-H?me County) in Finland. PARTICIPANTS: A regionally and locally stratified random sample of men and women born in 1946-50, 1936-40, and 1926-30. A total of 4,272 were invited and 2,815 (66%) participated. MAIN RESULTS: Elevated serum cholesterol, obesity, disability, sedentary lifestyle (<2 times/week walking), and high fat intake were more prevalent in rural vs. urban and semi-urban communities. After adjustment for sex, age, education, obesity, diet, physical activity, smoking, and alcohol use, rural communities remained the only community type with increased (p<0.05) probability for high BMI (OR 1.33) and high waist circumference (OR 1.43). CONCLUSIONS: The unfavourable health and lifestyle profile, together with an old population, makes health promotion for elderly citizens a special challenge for rural communities such as those in P?ij?t-H?me County, Finland. Most, if not all, of the differences in health between the three community types were explained by educational background, physical activity, and smoking.     

The impact of user fee exemption on service utilization and treatment seeking behaviour: the case of malaria in Sudan

This experimental study was undertaken to assess the effect of different levels of exemption, 25%, 50% and 75%, from health centre user fees on health service utilization and treatment seeking behaviour for malaria by a high risk group of pregnant women and children under 5 years. These are groups in need of special medical attention to prevent progression of the disease into complicated or severe malaria. Sinnar State, one of Sudan's highly endemic malaria regions, was selected to be the experimental area. Exemptions were introduced for one year in six health centres. Two centres for each exemption level, and a further two health centres without exemptions were studied. At the beginning and the end of the trial year, households surveys were conducted in the catchment areas of the health centres, and focus group discussions with pregnant women and mothers of children under 5 years were conducted. Routine data were reviewed for malaria cases in the health centres and six studies on malaria cases were done upon exit from the health centres. In-depth interviews with health staff of the health centres were conducted. Exemption from user fees increased health services utilization, improved treatment-seeking behaviour and promoted early diagnosis. The changes during the experimental year were the largest in the centres with the largest exemption. Therefore, policy changes towards exemptions are necessary to facilitate early diagnosis and treatment of malaria.     

A study of knowledge about malaria and treatment seeking behaviour in two tribal communities of Manipur

The study was conducted on a sample of 250 tribal people of Manipur state, comprised of 125 from the urban valley population and 125 persons from rural tribals settled on hilly area at a higher altitude. The finding shows that knowledge regarding transmission of malaria, self protection and treatment seeking behaviour is still poor among the tribal communities of Manipur. However the urban tribals had better knowledge regarding diagnosis of malaria and prevention of mosquito breeding than their rural counterparts.     

Human behaviour and the transmission of dracunculiasis: a case study from the Ilorin area of Nigeria

Dracunculiasis, infection with guinea worm, Dracunculus medinensis, is a debilitating disease causing considerable human misery and having an adverse impact on food production in affected areas. It can be entirely eradicated by the provision of protected drinking water for all members of the community. There are two phases in the transmission cycle associated with human activities, swallowing the infective guinea worm larvae in infected water and, 10-12 months later, the immersion of a limb with a guinea worm lesion on it in a drinking water source. In planning control strategies it is essential to understand the patterns of behaviour associated with these two phases of transmission. These include water consumption, water use and water treatment, patterns of water collection and population mobility. The recent increase in the levels, frequency and distance involved in population circulation is associated with increased prevalence rates. This analytical framework is used in a study of disease transmission in the area within a 50 kilometer radius of Ilorin, the capital of Kwara State, Nigeria. The conclusion briefly suggests some benefits which might accrue to affected areas as the result of the consideration of behavioural factors involved in disease transmission.     

Neighbourhood renewal and health: evidence from a local case study

This article presents findings from a before-and-after study of the effects of neighbourhood renewal on residents' health. Survey data were analysed using multivariate logistic regression. Before the renewal programme, damp and draughts had significant independent effects on respiratory health problems. Draughts and perceived community safety were associated with mental health problems. Children's mental health was associated with parental mental health. Following the renewal work, improvements occurred in both adults' and children's mental health, and smoking declined sharply. Respiratory health did not improve and there was no change in use of health services. Neighbourhood renewal in deprived areas can have an important role in improving community health.     

Improving quality of malaria treatment services: assessing inequities in consumers' perceptions and providers' behaviour in Nigeria

Background  

Information about quality of malaria treatment services of different healthcare providers is needed to know how to improve the treatment of malaria since inappropriate service provision leads to increased burden of malaria. Hence, the study determined the technical and perceived quality of malaria treatment services of different types of providers in three urban and three rural areas in southeast Nigeria.     

Rural-urban migration and sickness/health care behaviour: A study of Eastern Nigeria

This study is an effort to assess whether the concept of ‘migration personality’ applies in the context of Eastern Nigerian urban dwellers. Sickness and health care behaviour is compared between two groups—migrant urban households living in Uyo and Calabar and non-migrant rural households living in Ediene and Ibiono. The respondents' conceptions and perceptions of illness, disease and health as well as the medical services frequently used are analysed. The findings tend to confirm the existence of marked differences in disease beliefs and related health care behaviour in the two groups. These differences are crystallised along residency, socio-economic, age and income characteristics. The implication of the study is that even though it is not possible meanwhile to determine whether migration is an independent or intervening variable, or one of several other and inter-related variables, the fact that rural-urban migrants are so prone to modern medical practices, raises the desirability of using them as a target population for primary acceptance of modern medical programmes such as those concerning family planning, child nutrition and health.     

Social environment and health behaviour: a case study of Japanese overseas students

The health related problems and issues of overseas studentsstudying in Australia were addressed within the social perspectiveof health and health behaviours. It was argued that a clinical‘one-to-one’ approach to treating somantic illnesswithin the biomedical model and modifying health behavioursthrough traditional health education approaches, failed to bringabout comprehensive changes in health outcomes. Instead, a modelwhich addresses the social perspective of health behaviour andsocial environmental strategies was proposed as a more effectivemeans by which to bring about changes. A case study of 28 Japanesestudents studying English-as-a-Second-Language (ESL) at an Australianrural tertiary education institution is presented to illustratethe effects which the physical and socio-cultural environmentshave upon the health behaviours of a culturally sensitive andisolated population. Factors which were found to influence thehealth status and health habits of Japanese students were thoserelated to community structure and its competencies, socialinteraction, diet, traditional Japanese healing practices andconceptualization of illness within Japanese culture. Thesefactors inadvertently interacted with the Australian physicaland socio-cultural environment resulting in health problems.It was proposed that primary health care policy-based strategies,focusing on the Japanese and Australian socio-environmentalas well as socio-physiological aspects of health, leading toreorientation, would be more successful in inducing change.     

Internet and game behaviour at a secondary school and a newly developed health promotion programme: a prospective study

Background  

This study investigated the Internet and game use of secondary school children, the compulsiveness of their use and the relationship with other health behaviours. It also evaluated the preliminary results of a recently developed school health promotion programme, implemented at a secondary school in the Netherlands in January 2008. This programme is one of the first to combine seven health behaviours in one educational programme and is a pilot project for a case-control study.     

Culturally compelling strategies for behaviour change: a social ecology model and case study in malaria prevention

Behaviour change is notoriously difficult to initiate and sustain, and the reasons why efforts to promote healthy behaviours fail are coming under increasing scrutiny. To be successful, health interventions should build on existing practices, skills and priorities, recognise the constraints on human behaviour, and either feature community mobilisation or target those most receptive to change. Furthermore, interventions should strive to be culturally compelling, not merely culturally appropriate: they must engage local communities and nestle within social and ecological landscapes. In this paper, we propose a social ecology perspective to make explicit the links between intention to change, actual behaviour change, and subsequent health impact, as relating to both theory-based models and practical strategies for triggering behaviour change. A social ecology model focuses attention on the contexts of behaviour when designing, implementing or critically evaluating interventions. As a case study, we reflect on a community-directed intervention in rural Gambia designed to reduce malaria by promoting a relatively simple and low-cost behaviour: repairing holes in mosquito bednets. In phase 1, contextual information on bednet usage, transactions and repairs (the 'social lives' of nets) was documented. In phase 2 (intervention), songs were composed and posters displayed by community members to encourage repairs, creating a sense of ownership and a compelling medium for the transmission of health messages. In phase 3 (evaluation), qualitative and quantitative data showed that household responses were particularly rapid and extensive, with significant increase in bednet repairs (p<0.001), despite considerable constraints on human agency. We highlight a promising approach-using songs-as a vehicle for change, and present a framework to embed the design, implementation and critical evaluation of interventions within the larger context-or social ecology-of behaviour practices that are the bedrock of health interventions.     

Improving the geographical accessibility of health care in rural areas: a Nigerian case study

The paper addresses problems of geographical accessibility of health care in rural areas of Nigeria. It provides analyses of the location, distribution and accessibility of government-provided health care facilities to people and presents a framework for measuring improvements in accessibility and for assessing the efficiency of decisions about location of new facilities. It shows that while accessibility in the study area improved between 1979 and 1982 through the establishment of more dispensaries and maternity and child-welfare centres, the relative efficiency of locations has remained low. It identifies alternate locations for the new facilities introduced in the 1979-1982 period that could have increased the utilization of maternal and child health centres by an estimated 12% and the utilization of dispensaries by 16%.     

Choosing between public and private health-care: a case study of malaria treatment in Brazil

Individuals infected with malaria may be treated either in the public sector in in a private clinic. Private treatment is better, but expensive. Using micro-level data from a colonization project in Brazil, we estimate the factors that determine an individual's choice between the two sectors. Private treatment is (strongly) price sensitive and (weakly) wealth sensitive. Rural individuals are more likely to choose private treatment, but long distances to the treatment source deter private treatment. Individuals belonging to small, literate households are more likely to choose private treatment. Gender, age, and number of previous infections are unimportant. Policy implications are discussed.     

The impact of sporadic campylobacter and salmonella infection on health and health related behaviour: a case control study

The aim of the work was to explore the impact on general and psychological health of those with a proven bacterial gastrointestinal infection and to compare this with controls from whom no bacterial pathogen was identified. A case control study was conducted using an interviewer-administered questionnaire. Thirty-nine cases from whose faeces salmonella or campylobacter had been cultured were compared with matched controls. Reported gastrointestinal symptoms, general health and self-reported hygiene practices were compared. At the time of acute illness the General Household Questionnaire suggested similar levels of morbidity, though by follow up the controls were substantially more likely to be distressed. Cases were more likely to have changed their food preparation practices, to avoid certain eating places and to have been given advice about food preparation. In this small study a positive diagnosis of salmonella or campylobacter seems to have had a reassuring effect when compared with those for whom no diagnosis was made.