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Continental J. Nursing Science 2: 1 - 7, 2010 ISSN: 2141 - 4173 ©Wilolud Journals, 2010 http://www.wiloludjournal.com

THE PREVALENCE OF NEONATAL TETANUS IN UNIVERSITY OF CALABAR TEACHING HOSPITAL (UCTH) MATERNITY ANNEX

1Aniema I. Essien, 2Mary A. Mgbekem, 1Christiana Umo-Otong And 2Emily Eyo-Nsa Whiley

1University of Calabar Teaching Hospital and 2Department of Nursing Sciences, University of Calabar, Cross River State, Nigeria

ABSTRACT Neonatal tetanus is a preventable disease which is still a public health problem in developing countries. The purpose of this study was to determine the prevalence of neonatal tetanus in maternity Annex from 2003 – 2007. One hypothesis and two research questions were formulated to guide the study. The target population for the study was all sick babies on admission within this period. Data was collected through records. Data was analyzed using simple percentages and chi – square statistics. The findings revealed a high prevalence of tetanus cases 39 (15.7%) in 2005 while the highest number of death 22 (61.1%) occurred in 2003. chi square analysis showed a significant relationship between immunization status of mothers and neonatal tetanus development (x2 call 28.05 >x2 tab 7.81, df 3 P ≥ 0.05). It is recommended that intensive antenatal education be given to women in order to reduce the ignorance associated with the causes of the disease. KEYWORDS: Prevalence, neonatal tetanus.

INTRODUCTION AND BACKGROUND OF THE STUDY: Tetanus is an acute, often fatal disease that is characterized by generalized increased rigidity and convulsive spasms of skeletal muscles (Vandelaer et al, 2008). It is caused by the spore-forming bacterium Clostridium tetani. Clostridium tetani spores (the dormant form of the organism) are found in soil (. Neonatal tetanus is one of the six childhood killer diseases and a major contributory factor in neonatal death especially in developing countries. Neonatal tetanus is a preventable disease that is still a public health problem especially in rural areas of the developing countries UNICEF (2003). This disease occurs within a few days or weeks of birth as a result of the infection of the umbilical stump by ‘bacterium-clostridium tetanus’ due to poor hygienic and traditional birth practices. According to World Health Organization (WHO, 2000), this infection occurs due to unskilled attendance at delivery, which is reported to be about 69%. It is also reported that high illiteracy rate, cutting and treatment of the umbilical and with potentially infected materials like “tradition knife” or used blade, cow dung, saliva and lack of immunization of pregnant women against tetanus contribute to the development of neonatal tetanus. WHO (2001) and Garb et al (2008) report that this disease occurs because most deliveries take place at home or in spiritual churches with the assistance of untrained traditional birth attendants. Reduction of child mortality is one of the Seven Points Agenda for Nigeria. This agenda says that for 2015 target to be met, the country would need to reduce the rate of infant/child mortality to less than 28 per 1,000. According to National Demographic and Health Survey (NDHS) (2003) infant mortality rate is estimated at 109 per 1,000. Urban areas according to this survey had infant mortality rates of 81 per 1,000 compared to 121 per 1,000 for rural areas. This confirms that infant mortality rate is higher by communities where health and social services are poor. In a study conducted by Okoromah et al (2003) at Lagos University Teaching Hospital (LUTH), neonatal tetanus was among the highest causes of infant mortality in the hospital. WHO, UNICEF and UNPFA (2000) observed that to achieve the global goal of neonatal tetanus, reduction, renewed commitment from African region and external financial support to immunize 60 million women of child bearing age and proper counseling during antenatal care in high – risk areas is essential. WHO (1999) reports that an estimated 248,000 deaths from neonatal tetanus occurred in 1997 primarily among babies in Africa and South East Asia whose mothers hand limited access to routine health services offering tetanus immunization and hygienic delivery condition. According to the National Demographic and Health Survey (2003) and National Population Commission and ORC Macro, Calverton MD, (2004) the

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Aniema I. Essien et al.,: Continental J. Nursing Science 2: 1 - 7, 2010 neonatal mortality rate (deaths of infants within the first 28 days of life) is reported to be 48 per 1000 live births, with wide regional variations in the distribution of neonatal mortality in a pattern that mirrors that seen with maternal mortality. Neonatal death rate is related to problem arising during pregnancy delivery and after delivery. Neonatal mortality related to maternal and obstetric factors Studies report that the majority of the new born deaths in Nigeria occur within the first week of life reflecting the intimate link of new born survival to the quality of maternal care. Neonatal deaths are also strongly linked in terms of place of birth and access to care. Infant mortality rate is widely used as one of most single measures of health status of a community. Neonatal tetanus was reported to contribute 10.3% in the estimated causes of death in infants therefore ranking 1st in the causes of death (NDHS 2003) among other causes of death in infant like severe infections including pneumonia, sepsis and diarrhoeal disease key determinants of newborn mortality in Nigeria include inadequate coverage and the low quality of essential obstetric care. It is expected that with the establishment of maternal and child health services infant morbidity and mortality should fall from been very high (Lucas and Gills (1990). Since good health can respond dramatically to simple preventive measures. In a study conducted by Federal Ministry Health & United National Population Fund (UNFPA) (2003) on the quality of care, only 18.5% of 4500 facilities surveyed had the capacity to provide obstetric care. Even where the skilled attendants were available, poor inter – personal – relations have been reported to impact negatively on the utilization of services by women. This factor gives rise to most women delivering at home or in churches. Financial access like poverty has significant implications for health and development; low income households generally have poorer health status. It also shows striking differences in different socioeconomic groups. The incidence of poverty is higher in the rural areas where neonatal tetanus rate is reported also to be higher than in the urban areas. Increasing health care costs have resulted in substantial decrease in the utilization of maternal health services. Socio – cultural factors (beliefs and practices) limit the ability of women to utilize ante natal education given to them as well as take independent decision about their babies. The decision making power often lies with mothers or mothers – in-laws or other senior female relatives especially among primiparas makes women helpless in matters concerning their children’s health. Education another key factor has been shown to be highly associated with health seeking behaviour in pregnancy and delivery. Neonatal tetanus rates are much higher in infants whose mothers have no education compared to women with secondary level or higher education. Access to mass media is also important for acquiring information and knowledge on maternal and neonatal health issues. In a study conducted by NDHS (2003) the proportion of women that had access to any mass media was about two to three times that of men in the rural and urban areas. The fact that more than half of the women do not have access to any mass media is likely to affect pregnancy and delivery and consequently neonatal mortality occurrence (UNICEF, 2001). Other channels of communication including interpersonal communication are important in passing on key health messages to the community. If these channels are properly utilized women will turn – up for antenatal care and delivered at the health facilities available (Federal Ministry Of Health (FMOH), 2007). Materials and Methods. This was a retrospective study using records and questionnaire. The records covering a period from January 2003 – December 2007 in the sick Babies’ Unit (Maternity Annex) of the University of Calabar Teaching Hospital, Calabar were used. DATA COLLECTION Data collection was through records of new born admissions and structured questionnaire given to the mothers of babies on admission between January and March, 2008. Data Analysis Data were analyzed using simple percentages and chi-square statistics.

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Aniema I. Essien et al.,: Continental J. Nursing Science 2: 1 - 7, 2010 RESULTS The data in Table 1 shows the record of annual admissions of neonates, admissions with neonatal tetanus and annual neonatal death due to tetanus between January, 2003 and December, 2007. A total number of 1629 neonates were admitted into the maternity Annex. Out of this number, 166 of them were admitted with neonatal tetanus with 87 neonatal deaths. The highest NNT admission occurred in 2005 with 39 deaths representing 18 (9.2%) of the total neonatal mortality caused by tetanus. This was followed by the year 2003 which recorded 36 neonatal tetanus admission with 22 (8.5%) mortality. Table revealed the annual prevalence of neonatal tetanus in the Maternity Annex during the period under study. The result shows that majority of the NNT admission and deaths occurred believes the months of March and June 20 (17%) and 22 (11.2%) respectively. Table shows mortality of neonates from tetanus within the period under study. The mortality occurred mostly in 2003 with 22 (8.5%) of the total death in that year. This was followed by 19 (5%). Table 4 shows the relationship between mothers’ immunization status and the risk of neonatal tetanus development. The result shows a significant relationship as x2cal 28.06> tab x2 3.84) df 1 at probability level of 0.05. In table 5, the relationship between age of mothers and NNT development. The table shows a significant relationship as x2cal 7.94 > x2 tab 5.99, df 2 at probability level of 0.06. Table 6 shows the socio – demographic data of 51 randomly selected files containing mothers’ information. The age distribution shows that majority of the mothers were between the age range 20-29 years 21 (41.2%). This was followed by mothers with age range 30-39 (years 19 (37.3%). The table also shows majority of the mothers to be Christians 38 (74.5%) with 10 (19.6%) being Muslim, 25 (49%) mothers were single 21 (41.2%) married while 29 (56.9%) had their 1st child and 15 (29.4%) had 2 – 3 children. Educational status revealed that 12 (23.53%) mothers had no formal education while 10 (199\61%) had primary education, JSS and SSS each represented 12 (23.53%) occupational status shows that majority of the mothers were students 18 (35.3%).

DISCUSSION AND CONCLUSION The findings of this study indicated that there is fluctuation but with a gradual decline in the number of NNT admissions which also mirrors the number of death in the study. This could be due to some improvement in the quality of care rendered and the availability of Tetanus toxiod immunization activities available in health centers. The results in table 4 shows significant relationship between mothers. Immunization. Status and risk of developing neonatal tetnus. This finding is supported by Udoh (1994) and Antia Obong et al (1992) who report that neonatal tetanus occurs because most deliveries take place at home or in spiritual riches. The findings also show that infant mortality due to neonatal tetanus is high compare to other causes of neonatal mortality. This is in line with the findings of a study by Okoromah et al (2003) in LUTH. Who reported that neonatal tetanus was one of the highest causes of infant mortality. This is typical of infant mortality in rural communities where poverty, illiteracy, cultural practices and lack of access to the health care facilities are partly responsible for the causes of NNT. The high Neonatal deaths due neonatal tetanus may be due to inability to attend antenatal to by unskilled health personnel at home before being taken to the hospital in critical conditions (Garb et al, 2008 and NDHS, 2005). As could be seen in this study table 4, majority of the mothers 126 were not immunized against tetanus during pregnancy thus exposing their babies to the risk developing the disease. Table 2 shows yearly prevalence of the disease. From the findings, it can be observed that neonatal tetanus is expected to be seen occasionally if it must be seen at all, but it is sad to note the high percentage (55.5%) of neonatal morbidity that is due to the disease alone. This is also reported in NDHS (2005) survey where it was observed that only 18.5% of 4500 facilities surveyed in the country had the capacity to provide obsteric care that can reduce the occurrence of some of these problems.

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Aniema I. Essien et al.,: Continenl J. Nursing Science 2: 1 - 7, 2010 Table1: Showing monthly and yearly distribution of neonatal admissions and deaths (2003 – 2007)

2003 TOTAL NNT DEATH ADM

2004 TOTAL NNT DEATH ADM

2005 TOTAL NNT DEATH ADM

2006 TOTAL NNT DEATH ADM

2007 TOTAL NNT DEATH ADM

TOTAL TOTAL NNT DEATH ADM

Jan. - - - 22 2 1 - - - 27 4 3 25 1 1 74 7 5 Feb. - - - 40 3 1 12 2 1 26 4 2 46 2 1 125 11 5 Mar. 32 10 7 34 6 4 28 6 4 34 5 1 38 1 1 166 28 17 April 22 1 - 33 4 3 25 3 2 30 2 - 25 - - 135 10 5 May 26 7 4 37 2 2 30 7 1 41 1 1 27 1 - 161 18 8 June 24 2 1 27 6 2 28 5 3 34 5 3 33 4 2 146 22 11 July 20 2 1 15 2 1 17 5 2 25 4 2 35 1 1 112 14 7 Aug. 25 2 2 25 3 1 26 6 3 49 4 - 59 4 1 184 19 7 Sept. 21 4 3 21 3 1 18 - - 36 3 4 44 2 - 140 12 8 Oct. 29 2 1 18 1 1 16 1 - 31 3 2 44 3 3 138 10 7 Nov. 31 2 - - - - 24 1 - 28 1 1 38 2 1 121 6 2 Dec. 30 4 3 Strike 24 3 2 36 1 - 37 1 - 127 9 5 TOTAL 260 36 22 272 32 17 249 39 18 397 37 19 451 22 11 1629 166 87

Table 2: Showing yearly prevalence of Neonatal tetanus (2003 -2007

Year Total no of infant admission Total no of NNT Prevalence percentage 2003 260 36 13.9 2004 272 32 11.8 2005 249 39 15.7 2006 397 37 9.3 2007 451 22 4.9 Total 1629 116 55.5

Table3: Showing mortality from Neonatal tetanus (2003-2007)

Year No of NNT admitted No of death Total No of admission Percentage 2003 36 22 260 8.5 2004 32 17 272 6.3 2005 39 18 249 9.2 2006 37 19 397 5 2007 22 11 451 5 Total 166 87 1629 34%

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Aniema I. Essien et al.,: Continental J. Nursing Science 2: 1 - 7, 2010

Table 4: Showing immunization status of mothers and risk of neonatal tetanus development Immunization status

Development of tetanus Total Cal x2 df Crit x2 Yes No

Immunized Not immunized

O E 40 105.9 126 60

O E 1000 934.0 463 528.9

1040 589

28.08*

1

3.84

Total 166 1463 1619 X2 cal = 28.6 X2 tab = 3.84 P > 0.05 *Significant at 0.5 probability level Table 5: Showing relationship between age of mothers and NNT development

Age of mothers Neonatal Development Total x2 Cal df Critical x2 Yes No

20 – 29

O E 97 101.5

O E 900 895.4

997

7.9

4

2

5.99 30 – 39 51 37.8 320 333.1 371

40 and above 18 26.5 243 234.4 261 Total 166 1463 1629 *Significant at .05 probability level. X2 cal = 7.94, X2 tab = 5.99, P > 0.05 Mothers’ age was observed to have a significant relationship with the risk of developing neonatal tetanus. From the study most mothers (97) between age range 20 – 29, had babies with the diseases. There was a gradual decrease in the disease occurrence as the mothers age increased. This could be related to the fact that most women under marital status were single and may not have had any support or someone to advice them on the useness of antenatal care. This finding could also be related to the fact that most deaths due to NNT occurred among mothers who were primi para (have 1st child). Implication for nursing practice. The findings of the study show that neonatal tetanus is still a serious public health problem due to the high number of reported cases in UCTH Calabar which is a tertiary health care institution. If this number is observed in this hospital, then number not reported by mothers in the communities will be alarming. Nurses are who are found in all the highways and by way rendering care must ensure that mothers are given care in their door post as one of the primary health objectives emphasis. The nurse thus can play several roles to ensure a reduction in neonatal mortality especially neonatal tetanus. The nurse should make conscious efforts to educate mothers especially in the communities about the changers of not attending antenatal care some socio – cultural practices that results in NNT. The nurses should ensure that proper information is given to mothers during antenatal education.

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Aniema I. Essien et al.,: Continental J. Nursing Science 2: 1 - 7, 2010

Table 6: Socio – demographic data of mothers from the files. Variable No of Respondents Percentage Age 20 - 29 30 – 39 40 and above

21 19 11

41.2 37.3 21.5

Total 51 100 Religion Christianity Muslim Traditional religion

38 10 3

74.5 19.6 5.9

Total 51 100 Marital Status Single Married Divorce Widow

25 21 4 1

49.0 41.2 7.8 2.0

Total 51 100 Number of children 1st child 2 – 3 4 and above

29 15 7

56.9 29.4 13.7

Total 51 100 Educational Status No formal education Primary Junior secondary Senior secondary Tertiary

12 10 12 12 5

23.53 19.61 23.53 23.53 9.80

Total 51 100 Occupation Student Civil Servant Farmer Housewife Trader

18 8 7 9 9

35.3 15.7 13.7 17.6 17.6

Total 51 100 He/she can supply information for health statistics by keeping proper records. The nurse as a patient advocate must ensure proper precautionary measures in the care of clients be it in the hospital or in the community. CONCLUSION The findings of this study revealed that neonatal tetanus is still a public health problem inspite of the fact that so much is preached about National Immunization in the country. RECOMMENDATIONS From the above findings, the following are recommended: Intensive health education programme and public health enlightenment should be embarked upon on the dangers of not attending antenatal care to reduce the rate of neonatal death especially due to tetanus. Adequate qualified midwifes as well as other health personnel should be provided in the communities to provide regular prenatal, antenatal and postnatal care to women.

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Aniema I. Essien et al.,: Continental J. Nursing Science 2: 1 - 7, 2010 Woman should be encouraged to attend antenatal clinic where health education about their health and their unborn babies is given. Women should be encouraged to deliver their babies in the clinic/hospital and also attend postnatal clinics regularly. The traditional birth attendance should be trained especially on the dangers of not using precautionary measures in the management of mothers in labour and delivery. REFERENCES Wassilak SGF, Roper MH, Kretsinger K, Orenstein WA. Tetanus toxoid. In: Plotkin SA, 1. Orenstein WA, Offit PA, eds. Vaccines fifth edition. Philadelphia: Saunders; 2008:805–39. Srivastava P, Brown K, Chen C, Kretsinger K, Roper M. Trends in tetanus epidemiology 2. in the United States, 1972–2001. Presented at the 39th National Immunization Conference, Washington, D.C., March 21–24, 2005. Available at http://cdc.confex.com/cdc/nic2005/techprogram/paper_7813.htm Vandelaer J; Birmingham M; Gasse F; Kurian M; Shaw C; Garnier S (28 July 2003). "Tetanus in developing countries: an update on the Maternal and Neonatal Tetanus Elimination Initiative". Vaccine 21 (24): 3442–5. doi:10.1016/S0264-410X(03)00347-5. PMID 12850356. ^ Brauner JS; Vieira SR; Bleck TP (2002 Jul). "Changes in severe accidental tetanus mortality in the ICU during two decades in Brazil". Intensive Care Medicine 28 (7): 930–5. doi:10.1007/s00134-002-1332-4. PMID 12122532. ^ a b c d Farrar JJ; Yen LM; Cook T; Fairweather N; Binh N; Parry J; Parry CM (2000 Sept). "Tetanus". Journal of Neurology, Neurosurgery, and Psychiatry 69 (3): 292–301. PMID 10945801. ^ World Health Organization (2000-11-01). "Maternal and Neonatal Tetanus Elimination by 2005". http://www.unicef.org/immunization/files/MNTE_strategy_paper.pdf#search=%22neonatal%20tetanus%20rates%22. Retrieved 2007-01-26. Received for Publication: 07/02/2010 Accepted for Publication: 12/04/2010 Corresponding Author: Mary A. Mgbekem Department of Nursing Sciences, University of Calabar, Cross River State, Nigeria achimgbekem@yahoo.com

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Continental J. Nursing Science 2: 8 - 16, 2010 ISSN: 2141 - 4173 ©Wilolud Journals, 2010 http://www.wiloludjournal.com

PREVALENCE OF SCHIZOPHRENIA AMONG PATIENTS ADMITTED INTO NEURO-PSYCHIATRIC HOSPITAL, RUMUIGBO, PORT HARCOURT, RIVERS STATE, NIGERIA.

Joel Adeleke Afolayan, Isu Odo Peter, Alex Nancy Amasueba

Department of Mental Health and Psychiatric Nursing, Faculty of Nursing, Niger Delta University, Wilberforce Island, Amassoma, Bayelsa State, Nigeria

ABSTRACT This study, a retrospective one that was conducted to assess the prevalence of schizophrenia among patients admitted into Neuro-Psychiatric Hospital, Rumuigbo, Port-Harcourt, Rivers State, Nigeria between January 2005 and December 2009. The method used to collect the required data was assessing all the case files of the patients at the Medical Records Department with the assistance of the Chief Medical Records Officer-in-charge. The prevalence was investigated in relation to gender, age range, level of education, occupation and marital status. The study revealed that on the average 58.19 of the patients admitted between the study period were Schizophrenic patients. It is therefore recommended that urgent national survey be conducted to determine the prevalence of all psychiatric disorders as the results will guide both the health policy makers and providers in effective and efficient planning and administration of health of the country either in the prevention, early detection and management of mental disorders in Nigeria as high prevalence is a grave threat to the dividend of our democracy. KEY WORDS : Incidence, mental disorders, prevalence, psychiatric hospital, schizophrenia,

INTRODUCTION Schizophrenia is a disabling group of brain disorders characterized by symptoms such as hallucinations, delusions, disorganized communication, poor planning, reduced motivation and blunted affect (McGrath and Kelly, 2000). Bhugra (2006) defined Schizophrenia as a psychiatric diagnosis that is characterized by abnormalities in perception or expression of reality. Distortions in perception may affect all five senses, including sight, hearing, taste, touch and smell but most commonly manifested as auditory hallucinations, paranoid or bizarre delusion or disorganized speech and thinking with significant social or occupational dysfunction. Boydell, Van and McKenzie (2001) asserted that evidence from nearly a century of epidemiological research indicates that Schizophrenia occurs in all population with prevalence in the range of 1.4 and 4.6 per 1000 and incidence rates in the range of 0.16 and 0.42 per 1000 population. The incidence of Schizophrenia in the United States of America is 10-58 new cases per 100,000 populations. The age group of highest incidence rates for men was younger than women. The incidence of Schizophrenia has been reported to vary with race and ethnicity. The prevalence of Schizophrenia was said to be lower in developing countries compared to developed countries but a better outcome of Schizophrenia has been recorded in developed countries and the incidence of Schizophrenia in urban areas has been found to be higher than rural areas (Boydell et al, 2001). Persons with Schizophrenia are concentrated in urban areas of the poorest living conditions which possibly indicate that industrialization has some effects on the onset and chronicity of Schizophrenia although urbanizations, birth and upbringing have been associated with increased risk of Schizophrenia in developing countries. Kaplan and Sadock (2003) were of the view that Schizophrenia is a very severe mental illness which constitutes a great economic burden all over the world. In the United States of America, it accounts for 2-5% of all health care expenditures and costs about fifty billion dollars annually. Moreover, about 75% of persons with Schizophrenia cannot work and are unemployed and the social drift hypothesis proposes that persons with schizophrenia are unable to compete for resources resulting in a downward social mobility. Schizophrenia is among the top ten disabling conditions worldwide for young, adult patients with schizophrenia struggle with many functional impairments including performance of independent living skills, social functioning and occupational/educational performance

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 16, 2010 and attainment and most patients require some public assistance for support and only about 10-20% of these patients are able to sustain full or post-time competitive employment. Objectives of the Study The study was to determine the prevalence of schizophrenia in relation to years of admission, age, sex, level of education, occupation and marital status and also to make necessary recommendations to the health care providers and health policy makers. Significance of the Study A higher prevalence of psychotic disorders will be translated into a greater disease-burden as measured by personal suffering, disability and increased demand on services. The study will provide information on the prevalence of schizophrenia in relation to location, sex, urbanization and occupation and will also assist the health care providers and policy makers for prompt interventions. Scope of the Study The research was conducted in Neuropsychiatric Hospital, Rumuigbo, Port-Harcourt, River State, Nigeria. It assessed the prevalence of schizophrenia in the hospital from January 2005 to December 2009 with the use of patient case files made available by the Medical Records Department of the hospital. Limitation of Study The study assessed the patients that had records with the hospital only either admitted or treated as outpatients within the study period. MATERIALS AND METHODS American Psychiatric Association (1994) defined schizophrenia as a group of imperfectly understood brain disorders characterized by alterations in higher functions related to perception, cognition, communication, planning and motivation. Schizophrenia is said to be a syndrome which applying diagnostic criteria related to the presence of hallucinations, delusions, thought disorders and negative symptoms such as blunted affect and reduced speech and that symptoms of the disorder usually emerge in early adulthood and many affected persons make a good recover, many have intermittent or persistent symptoms for decades but unfortunately, despite these better treatment options, schizophrenia is still a leading contributor to the global burden of disease. Service improvements and the reduction of stigma can cushion the impact of disability, however, even if unlimited functioning was available to treat schizophrenia, most of the burden would remain unavoidable and that reliability of the diagnosis introduces difficulties in measuring effect of genes and environment, evidence suggests that genetic and environmental factors can act in combination to result in schizophrenia and that evidence suggest that the diagnosis of schizophrenia has s significant inevitable component but that onset is influenced by environmental factors or stressors. To Cormae, et al (2002), the idea of an inherent vulnerability in some people can be unmasked by biological, psychological or environmental stressors known as the stressor-diathesis model while the idea that biological, psychological and social factors are all important is known as biopsychic-social model. Estimates of the heritability of schizophrenia tend to vary owing to the difficulty of separating the effect of genetics and environment, although twin studies have suggested a high level of heritability. It was further suggested that schizophrenia is a condition of complex inheritance with several genes possibly interacting to generate risk for schizophrenia or the separate components that can occur leading to the diagnosis and that these genes may appear to be non-specific, in that they may raise the risk of developing other psychiatric disorders such as bipolar disorder (Kaplan and Sadock, 2003). Brown, et al (2000) asserted that parental exposure to infections increase the risk of developing schizophrenia late in life, providing additional evidence for link between utero-developmental pathology and risk of developing the condition. Goff, et al (2005) stated that living in urban environment has been consistently found to be a risk factor for schizophrenia, poverty, migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing condition are all inclusive.

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 15, 2010 Robinson, et al (2004) were of the view that using strict recovery criteria (concurrent) remission or positive and negative symptoms, adequate social and vocational functioning continuously for two years had about 14% recovery rate while a 5-year community study found that 62 % showed overall improvement on a composite measure of symptomatic clinical and functional outcomes while in retrospective study of Harding, et al (1987) found that about a third of people diagnosed with schizophrenia made a full recovery, about a third showed improvement but not a full recovery and a third remained ill. Hopper and Wanderling (2000) quoted the study conducted by World Health Organization two-long-term studies involving more than 2000 people suffering from schizophrenia in different studies and found out that patients were much better in long-term outcomes in developing countries despite the fact that antipsychotics are typically not widely available in poorer countries raising questions about the effectiveness of such drug-based treatments. Davidson and Mc-Glaghan (1996) said further that several factors are associated with a better diagnosis such as being females, acute onset of symptoms and good pre-morbid functioning and in particular, critical comments, hostility, authoritarianism and intrusive or controlling attitudes from family members have been found to correlate with a higher risk of relapse in schizophrenia across cultures. Green (1999) and Turner (2007) agreed that the treatment of schizophrenia can be divided into medical treatment, psychological and social interventions and alternative approaches such as the use of antipsychotics, psychotherapy like cognitive behavioural enhancement therapy, family therapy, cognitive enhancement therapy, rational emotive therapy and electro-convulsive therapy. Research Design This study, a retrospective one where the case files of the patients involved were collected at the Medical Records Department of the hospital to generate the needed data. Research Setting Neuropsychiatric Hospital, Rumuigbo, Port-Harcourt, Rivers State of Nigeria was used for the study. The hospital is located along Rumuigbo, Port-Harcourt in Obia-Akpor Local Government Area of the State. It is a 50-bedded psychiatric hospital with well-equipped facilities in form of personnel and materials. It is a specialist hospital as well as a referral hospital. The hospital is the only government hospital that basically renders psychiatric management for both River and Bayelsa States with other neighboring states, it is both secondary and tertiary hospital. Target Population The population for this study was all the patients admitted into the hospital (Neuro-Psychiatric Hospital, Rumuigbo, Port-Harcourt) between January 2005 and December 2009. Sample and Sampling Technique A non-probability sampling technique was used. All the records made available for the researchers were used as sample of the study. 4,494 cases were used for this study i.e. 2005: 921, 2006:873, 2007:877, 2008:882, 2009:941 respectively (the patients diagnosed with schizophrenia). Instrument for Data Collection The case files of all the patients diagnosed with schizophrenia were used as instrument for data collection. Validity/Reliability of Instrument The instrument was valid and reliable because the actual case files of the patients were used as collected from Medical Records Department of the Neuro-Psychiatric Hospital. The Chief Nursing Officer, Consultant Psychiatrist-in-Charge and the Chief Medical Records Officer confirmed the data obtained. Method of Data Collection Data for the study was manually compiled using the case files of all the schizophrenic patients admitted into the hospital between January 2005 and December 2009 respectively. Method of Data Analysis Simple Percentages and tables were used for analysis of the data collected at the Medical Records Department of the hospital.

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 16, 2010 Ethical Consideration The researchers officially wrote a letter of permission into conduct the study to the Administration of the hospital, invitation to meet the ethical committee of the hospital was honoured where the aims and procedure for the study were thoroughly discussed and approval was given to the researchers. The researchers promised conveying the result of findings to the hospital authority to assist in their future plans and management. The researchers also ensured that names of the patients were not used for the study to enhance confidentiality and anonymity. RESULTS AND DISCUSSION

Table 1: The total number of the patients per year. Year of admission

No of admission No admitted due to Schizophrenia

Percentage

2005 1684 921 54.69 2006 1573 873 54.50 2007 1462 877 59.99 2008 1440 882 61.25 2009 1564 941 60.17 Total 7723 4494 58.19

Table 1 showed that in 2005, 54.69% of admissions were schizophrenic patients, 54.50 % in 2006, 59.99 % in 2007, 61.25 % in 2008 and 60.17 % in 2009 with overall 58.19 %.

Table 2 : Gender of the participants Variable f % Gender/Year

2005 Male

Female

546 375

59.28 40.72

2006 Male

Female

486 387

55.67 44.33

2007 Male

Female

507 370

57.81 42.19

2008 Male

Female

560 322

63.49 36.51

2009 Male

Female

554 387

58.87 41.13

Table 2 showed 59.28 % of the schizophrenia patients in 2005 were males, 40.72 % were females. In 2006, 55.67 % were males, while 44.33 % were females, 57.81 % were males and 42.19 % were females in 2007. In 2008, 63.49 % were males while 36.51 % were females, 58.87 % were males and 41.13 % were females in 2009 respectively.

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 16, 2010 Table 3 : Age range of the patients

Age range in years

Year of Admission 2005 2006 2007 2008 2009 f % f % f % f % f %

10-19 80 8.69 89 10.19 96 10.95 80 9.07 92 9.78 20-29 360 39.09 440 50.40 310 35.35 400 45.35 442 46.97 30-39 275 29.86 200 22.91 300 34.21 168 19.05 208 22.10 40-49 75 8.14 80 9.17 85 9.69 130 14.74 79 8.40 50-59 131 14.22 64 7.33 86 9.80 104 11.79 120 12.75 Total 921 100 873 100 877 100 882 100 941 100

Table 3 showed that in the year 2005, 10-19 year age range had 8.69%, 20-29: 39.09%, 30-39: 29.86%, 40-49: 8.14% and 50-59: 14.22%, In 2006, 10-19 had 10.19%, 20-29: 50.40%, 30-39: 22.91%, 40-49: 9.17%, 50-59: 7.33%. In 2007, 10.95% were between 10 and 19 years, 35.35% were between 20 and 29 years, 34.21% were between 30 and 39 years, 9.69% were between 40 and 49 years while 9.80% were between 50 and 59% years old. In 2008, 10-19 years were 9.07%, 20-29 years were 45.35%, 19.05% were between 30 and 39 years, 14.74% were between 40 and 49 years, 11.79% were between 50 and 59 and in 2009, 10-19: 9.78%, 20-29: 46.97%, 30-39:22.10%, 40-49:8.40% and 50-59: 12.75% respectively.

Table 4: Occupation of the patients admitted due to schizophrenia Occupation Year of Admission

2005 2006 2007 2008 2009 f % f % f % f % f %

Civil servant 86 9.34 75 8.60 206 23.49 88 9.98 83 8.82 Trading 53 5.75 58 6.64 60 6.84 84 9.52 86 9.14 Student 360 39.09 220 25.20 240 27.37 330 37.42 320 34.01 Farming 64 6.95 80 9.16 56 6.39 60 6.80 62 6.59 Housewives 140 15.20 160 18.33 125 14.25 116 13.15 120 12.75 Unemployed 218 23.67 280 32.07 190 21.66 204 23.13 270 28.69 Total 921 100 873 100 877 100 882 100 941 100

From Table 4, for the year 2005, 9.34 % were civil servants, 5.75 % were into trading, 39.09 % were students, 6.95 % were farmers, 15.20 % were housewives, and 23.67 % were unemployed. In the year 2006, 8.60 % were civil servants, 6.64 % were traders, 25.20 % were students, 9.16 % were farmers, 18.33 % were housewives and 32.07 % were unemployed. For the year 2007, 23.47 % were civil servants, 6.39 % were into trading, 27.37 % were students, 6.39 % were farmers, 14.25 % were housewives and unemployed were 21.66 %. In 2008, 9.98 % were civil servants, 9.52 % were traders, 37.42 % were students, 6.80 % were farmers, 13.15 % were housewives and 23.13 % were unemployed while in the year 2009, 8.82 % were civil servants, 9.14 % were traders, 34.01 % were students, 6.59 % were farmers, 12.75 % were housewives and 28.69 % were unemployed respectively.

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 16, 2010 Table 5 :Level of education of the patients.

Level of education

Year of Admission 2005 2006 2007 2008 2009 f % f % f % f % f %

Primary 53 5.76 83 9.51 49 5.59 39 4.42 95 10.10 Secondary 428 46.47 381 43.64 306 34.89 310

35.15 270 28.69

Tertiary 360 39.09 300 34.36 420 47.89 419 47.51

436 46.33

Non-literate 80 8.68 109 12.49 102 11.63 114 12.92

140 14.88

Total 921 100 873 100 877 100 882 100 941 100

Level of the education of the participants as showed in Table 5 in 2005, 5.76 % had primary education, 46.47 % had secondary education, 39.09 % had tertiary education and 8.68 % were non-literates. In the year 2006, 9.51 % had primary education, 43.64 % had secondary education, 34.36 % had tertiary education and 12.49 % were non-literates. In 2007, 5.59 % had primary education, 34.89 % had secondary education, 47.89 % had tertiary education while 11.63 % were non-literates. For the year 2008, 4.42 % had primary education, 35.15 % with secondary education, 47.51 % with tertiary education and 12.92 % were non-literates and in the year 2009, 10.10 % had primary certificates, 28.69 % had secondary certificates, 46.33 % had tertiary certificates while 14.88 % were non-literates.

Table 6 : Marital status of the patients Marital status Year of Admission

2005 2006 2007 2008 2009 f % f % f % f % f %

Single 550 59.72 540 61.86 490 55.87 600 68.02 560 59.51 Married 260 28.23 150 17.18 140 15.96 126 14.29 175 18.60 Separated 11 1.19 63 7.22 99 11.29 26 2.95 50 5.31 Divorced 100 10.86 120 13.74 148 16.88 130 14.74 156 16.58 Total 921 100 873 100 877 100 882 100 941 100

Table 6 showed the distribution of marital status of the participants as in 2005, 59.72 % were singles, 28.33 % were married, 1.19 % were separated and 10.86 % were divorced. In 2006, 61.86 % were singles, 17.18 % were married, 7.22 % were separated and 13.74 % were divorced. In 2007, 55.87 % were singles, 15.96 % were married, 11.29 % were separated and 16.88 % were divorced. In the year 2008, 68.02 % were singles, 14.29 % were married, 2.95 % were separated and 14.74 % were divorced and in 2009, 59.51 % were singles, 18.60 % were married, 5.31 % were separated and 16.58 % were divorced respectively Social advantages and disadvantages have been found to be a risk factor to schizophrenia including poverty, migration related to social adversity, discrimination, family dysfunction, unemployment and poor housing according to Schrier, Vande Wetering, Mulder and Selten (2001). No wonder the prevalence of schizophrenia is higher among the students and unemployed. They also established the fact that half of the patients with schizophrenia abuses drug or alcohol. Fenton and McGlashan (1987) further asserted that substance use is a consequence of schizophrenia and that mostly students of higher institutions and unemployed for obvious reasons are more engaged in substance abuse than any other group which makes the prevalence of schizophrenia higher in these groups of individuals. In this study, prevalence of schizophrenia is higher in males than in females, Hopper and Wanderling (2000) posited that despite higher prevalence of schizophrenia in males than in females, the prognosis is better in females than in males and that long-term treatment outcomes are better in developing countries than developed countries despite the fact that antipsychotic drugs are typically not widely available in poorer countries although Davidson and

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 16, 2010 McGlashan (1996) said that several factors are associated with better prognosis like being females, acute onset of symptoms and good pre-morbid functioning of the individuals. To Bebbsiyton and Kuplers (1994), negative attitudes toward individuals with schizophrenia can have a significant adverse impact on the patient especially critical comments, hostility, intrusive or controlling attitudes from family members which have been found to have correlate with a higher risk of relapse in schizophrenia across cultures. The prevalence of schizophrenia in this study showed a higher percentage among the secondary and tertiary levels of education, singles and unemployed further confirming the study of Harvey, Jeffreys, McNaught, Blizard and King (2007) that rural/urban disparity in the occurrence of schizophrenia is remarkable and that prevalence and incidence rates have been repeatedly found higher in urban areas. Urban births and upbringing have been associated with increased risk of developing schizophrenia in adulthood although Turner (2007) disagreed with this view and said that Finland appears to be exceptional in this regard as both the prevalence and incidence rates of schizophrenia have been higher in rural areas. According to Brown et al (2000), two early life exposures have been found to be associated with schizophrenia i.e. season of birth and urban (place) of birth although they are very crude risk factors and in the two population-based studies (Holland and Denmark) it has been found that a person’s relative risk of developing schizophrenia when he or she is born in the city versus the country is about 2.4 and that evidence has been found linking schizophrenia to serologically confirmed parental exposure to herpes simplex, it was then suggested that exposure to feminine prenatally is associated with an increased risk of schizophrenia. Bhugra (2006) in the study of association of pregnancy and birth complications with risk of schizophrenia reported that some groups of obstetric complications were associated with an increased risk of schizophrenia which included ante-partum haemorrhage, maternal diabetes, rhesus incompatibility, pre-eclampsia, uterine atony, asphyxia and emergency caesarean section and that a significant association exists between low birth weight (less than 2.5kg) and increased risk of schizophrenia. However, the study also reported an association between heavier birth weights (greater than 14kg) and increased risk of schizophrenia. This study was conducted in just one of the neuropsychiatric hospitals in Nigeria and if the prevalence of schizophrenia for the years under study was 58.19 of the total admissions and if it is almost the same range in all the psychiatric hospitals then it can be said that the prevalence of schizophrenia is high in the country which will impact on the economic, social, physical and religious dimensions of the citizens. RECOMMENDATION The youths, especially the males should be encouraged to dissipate their youthful energy on profitable things that will better their living rather engaging in substance abuses that will eventually affect their health.

Employment should be created for the members of the community as underemployment or unemployment can lead to idleness and illicit behaviours which consequently affects mental health.

The government should encourage programmes that will lead to self-reliance of the youths.

More psychiatric hospitals need to be established especially in each state of the federation, well equipped and made accessible to all.

Mass health education is required on prevention, early detection of mental disorders and better patronage of modern health facilities.

Community-based mental health should be encouraged to enhance individual participation in the care of mental illness.

Mental health-mental illness should be included in the various educational curricula so that students are well taught in school as this will assist in the prevention and early detection of mental illness.

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 15, 2010 REFERENCES American Psychiatry Association. (1994). Practice Guidelines for the Treatment of Patients with Schizophrenia. 2nd Ed. New York: Williams and Wilkins. Bebbisyton, P. E. and Kulpers, E. (1994). The Predictive Utility of Expressed Emotion in Schizophrenia; an Aggregate Analysis. Psychological Medicine. 24, 707-718. Bhugra, D. (2006). The Global Prevalence of Schizophrenia. Plus Medicine. 2(5); 372-373. Boydell, J. Van, O.S. and McKenzie, K. (2001). The Incidence of Schizophrenia in Ethnic Minorities in London: Ecological study into Interactions with Environment. BMJ. 323: 1336-1338. Brown, S., Barraclough, B. and Inskup, H. (2000). Causes of Excess Mortality of Schizophrenia. British Journal of Psychiatry. 177:212-7. Cormae, I., Jones, C. and Campbell, C. (2000). Cognitive Behaviour Therapy for Schizophrenia. Cochrane Database of Systematic Reviews (1): CD0005 24. doi: 10.1002//465/858. CD000524 PMD/1869579. Davidson, L. and McGlaghan, T.H. (1996). The Varied Outcomes of Schizophrenia. Canadian Journal of Psychiatry. 42(1), 34-43. Fenton, W. and McGlaghan, T. (1987). Sustained Remission in Drug-free Schizophrenic patients. Journal of Psychiatry. 144:1306-1309. Goff, D.C., Cather, C., Evins, A.E., Henderson, D.C., Freudenreich, O. and Copeland, P.M. (2005). Medical Morbidity and Mortality in Schizophrenia, Guidelines for Psychiatrics. J. Chin. Psychiatry. 66(2) 183-194 Green, B. (1999). Focus on Olanzapine. Current Med. Res Opin. 1579-85. Harding, C.M., Brooks, G.W., Askikaga, T., Strauss, J.S. & Breier, A. (1987). The Vermont Longitudinal Study of Person with severe mental illness. American Journal of Psychiatry. 144(6), 727-35. Harvey, C.A., Jeffreys, E.E., McNaught, A.S., Blizard, R.A. & King, M.B. (2007). The Camden Schizophrenia Surveys III: Five-year outcome of a sample of individuals from a prevalence survey and the importance of social relationships. International Journal of Social Psychiatry. 53(4); 340-356. Hopper, K, and Wanderling, J. (2000). Revisiting the Developed Versus Developing Countries distinction in Course and Outcome in Schizophrenia: Results from ISOS, the WHO collaborative follow up project. International Study of Schizophrenia. Schizophrenia Bulletin. 26(4), 835-46. Kaplan, H.I. Sadock, BMJ. (2003). Synopsis of Psychiatry. 9th Ed. New York: Williams and Wilkins. McGrath, R.G. and Kelly, C. (2000). Patients with Schizophrenia. Br. J. Psychiatry. 176: 59-97. Robinson, D.G., Woerner, M,G., McMeniman, M., Mendelowitz, A. and Bilder, R.M. (2004). Symptomatic and Functional Recovery from a first episode of Schizophrenia or Schizoaffective disorder. American Journal of Psychiatry. 161, 473-479. Schrier, A.C., Van de Wetering, B.J.M., Mulder, P.G.H. and Selten, J.P. (2001). Point Prevalence of Schizophrenia in Immigrant groups in Rotterdam: Data from Outpatient facilities. Enr. Psychiatry. 16:162-166. Turner, T. (2007). Unlocking Psychosis. Brit. J. Med. 334(suppl)..

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Joel Adeleke Afolayan et al.,: Continental J. Nursing Science 2: 8 - 16, 2010 Received for Publication: 07/02/2010 Accepted for Publication: 12/04/2010 Corresponding Author: Joel Adeleke Afolayan Department of Mental Health and Psychiatric Nursing, Faculty of Nursing, Niger Delta University, Wilberforce Island, Amassoma, Bayelsa State, Nigeria

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Continental J. Nursing Science 2: 17 - 28, 2010 ISSN: 2141 - 4173 ©Wilolud Journals, 2010 http://www.wiloludjournal.com

PROBLEMS AND CHALLENGES OF SCHOOL HEALTH NURSING IN AKWA IBOM AND CROSS RIVER

STATES, NIGERIA

Idongesit I. Akpabio Department of Nursing Science, College of Medical Sciences, University of Calabar, P.M.B. 1115, Calabar, Cross

River State, Nigeria.

ABSTRACT Purpose: This study evaluated the problems and challenges associated with school nursing in Cross River and Akwa Ibom States of Nigeria in terms of coverage, services rendered, adequacy of equipments and supplies, and involvement of other relevant professionals in school health programmes. Materials and methods: A descriptive design was adopted, and sixty schools were randomly selected from the two states. In each school, one nurse was conveniently selected to give a total of sixty respondents from a population of 171 school nurses from both states. Rustia’s school health promotion model guided the study. Validated questionnaire, interviews and review of records were the instruments for data collection. Research questions were analyzed using frequencies and percentages while the Pearson Moment Correlation Coefficient Statistics was used to test the hypotheses determined at a significant level of 0.05. Results: Results showed low coverage of school health programme in Cross River (3%) and Akwa Ibom (7.2%) states. The scopes of the practice were limited to treatment of minor ailments (100%), referral services (81.7%) health education (41.7%) and first aid (16.7%). Only (18.3%) of the respondents were satisfied with equipments available for school health programme. Furthermore, health services provided by the nurses were positively and significantly related to their knowledge of roles (r=.532; df=59; p<0.05) but not on availability of material resources r=.023; df=59; p>0.05). Recommendations: It was recommended that school nurses should be well educated on the roles expected of them. KEYWORDS: Knowledge, Nurses, Practice, Problems, Roles, School-health.

INTRODUCTION The importance of school health nursing cannot be overemphasized. The health of students at all levels of education is very important if they are to excel in their academic pursuit and develop a good attitude towards a healthy living in the future. Although parents have a great responsibility towards the health of their children, the schools, being the second home of the children also need to take their health seriously. The general aim of school health programme is the promotion of well adjusted, physically vibrant children that are without preventable defects, but who could imbibe health practices, attitudes and knowledge that will make them to have a high level of well-being and the ability to make the necessary decision that will affect their families’ health positively. According to Anderson and Cresswell (2003), the purpose of today’s school health programme includes the need to promote, protect and restore the health of school children and staff. It could be in the recognition of this important concept that Nigeria as a nation has also adopted and made a policy declaration concerning adolescents’ health. One objective of the declaration is to provide guidance and service for the promotion of adolescents’ health (Federal Ministry of Health, 2001). Additionally, health risks among adolescents are being brought about by recent trends (e.g. HIV/AIDS) in the wider society and family. Nurses, especially in the more developed nations have responded to these changes through the development of school nursing with focus on health screening, case management and health counseling to mention but a few. In these past

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 years, as opined by Stanhope and Lancaster (1996), school nursing has become more comprehensive in the more developed nations to meet the health care needs of the students. However, with the increasing need for school health nursing as observed in Akwa Ibom and Cross River States, this aspect of care is still in the rudimentary stage and completely lacking in many areas of the states. Statement of the problem The gruesome picture of the health of our children especially in the area of reproductive health in Nigeria can be attributed to poorly developed school health services. According to Fajewonyomi and Afolabi (1999) school health services had been solely limited to posting a few nurses to a few urban secondary schools with their roles not properly defined. The above situation has not improved over the years and similarly gives a true picture of the current situation in Cross River and Akwa Ibom States, thus calling for a new direction for school health programme. For such direction, pertinent questions need to be answered culminating into the study aimed at identifying the problems and challenges of school health nursing in Akwa Ibom and Cross Rivers, with attention on what should be the focus in the resolution of identified problems. Specifically, the study focused on the following objectives:

1) Determine the current coverage of school health programmes within the two states; 2) Determine the services rendered by the school nurses in their various schools; 3) Determine the respondents’ assessment of adequacy of equipments and supplies provided for school

health programmes; 4) Identify other professionals that were performing school health duties; 5) Ascertain the problems encountered by the nurses in the practice of school health programmes; 6) Determine if there was significant relationship between nurses’ knowledge of roles for school health

programmes and health services rendered by them; 7) Ascertain the relationship between nurses’ level of satisfaction with equipments and supplies provided

for school health programmes and the services rendered by them. Significance of the study This study will help to identify the current state of school health services and areas that require interventions, so that the expected goals of school health programmes will be achieved. The findings will assist in providing guidance on needed policies; directions that planning should go and strategies to be put in place for successful provision of school health services. Research questions The study provided answers to the following research questions:

1. What is the current coverage of school health programme? 2. What are the services rendered by the school nurses in their various schools? 3. What are the respondents’ assessment of adequacy of equipments and supplies provided for school

health nursing programmes? 4. Who are the other professionals performing school health programmes? 5. What are the problems encountered by the nurses in the practice of school health? 6. What is the relationship between nurses’ knowledge of roles for school health programmes and

services rendered by them? 7. What is the relationship between nurses’ level of satisfaction with equipments and supplies provided

for school health programmes and the services rendered by them? Hypotheses Two null hypotheses were tested at 0.05 levels of significance: Ho 1: Nurses’ knowledge of roles for the school health programmes has no significant relationship with

the school health services rendered by them Ho 2: Nurses’ level of satisfaction with equipments and supplies provided for school health programmes

has no significant relationship with the school health services rendered by them.

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 Literature review Ademuwagun and Oduntan (2000) asserted that school health is an integral part of community health and it mainly refers to all the health activities and measures that are carried out within the community to promote and protect the health of children of school age and school personnel. Similarly, the school health programmes are viewed as the health programme in the school setting that takes care of the health needs of both staff and more importantly that of the students (Moronkola, 2003). Moronkola further clarified that school health programmes are both educational and health directed, aimed at meeting the needs of students and staff and laying good foundation for their future health status with the support of the home, community and the government. A close look at the definitions reveal that the school health programme embraces the concept of heath as focusing on primary, secondary and tertiary prevention of physical, emotional and or social health problems. For this reason, it would involve the five major activities, which are health promotion, disease prevention, curative care, disability limitation and rehabilitation. As a community health concept, school health directs attention to health care more often provided outside the therapeutic environment and could equally fit into Kiousbusch’s (2004) description of health promotion as a determinant based process of social change, contributing to the goal of human development, building on many disciplines and applying interdisciplinary knowledge in a professional, methodical and creative way. Furthermore, Ajala (2003) described the school health programme as a combination of various procedures and activities designed to protect and promote the well being of students, school administrators and teachers. When viewed in this perspective, school health as a concept defines an area of practice, which is wide in scope, embracing school health education, school health services and healthful school environment (Udoh, 1999). Although the scope of school health programme is well identified with strategies for providing the services clearly documented in literature, practice is often limited to curative care in some cases and lack of any programme in some other cases also. The World Health Organization’s Expert Committee on Health-Promoting Schools identified five broad barriers to the development of school health programmes. According to Kickbusch, et al, (1999), those barriers include: inadequate vision and strategic planning; lack of responsibility and acceptance of programmes; lack of responsibility and accountability; inadequate collaboration and coordination among persons addressing health in schools, and lack of programme infrastructure. Additionally, many schools according to Eke (1998) have no designated facilities with appropriate equipments and supplies that could help in diagnosis, treatment and meeting emergency care and referral services. In his estimation, Nigerians regard schools as only places for academic pursuits, and nothing more, and therefore place minimal priority on school health programmes. Commenting on the roles of the Nurse in school health programme, Modrein-Talbott (2002) asserted that where school health programmes are well developed, as it is in the more developed nations, the roles of the school nurse vary and include carrying out complex arrays of activities to promote health and prevent diseases within a school community. In her estimation, knowledge of roles could foster appropriate practice although other factors should also come to play. A school nurse who is well educated and able to clearly articulate her roles and functions, and who demonstrates clinical expertise to all members of the school health team is more likely to be used appropriately than one who has trouble defining what it is a school nurse has to offer. Thus, problems could arise where the nurses are unaware of their expected roles on account of limited training. According to Modrein-Talbott (2002), the roles of the school nurse include advocacy, case finding, community liaison, consultant, epidemiologist, health counselor, health educator, home visitor, team member and researcher. Thus in a way, there is currently an extension of school health programmes beyond the classic triad of school health education, school health services and healthful school environment. A confirmation of this could be obtained from the submission made by Resnicow and Allenworth (1999) that with the classic triad, healthy environment, staff wellness and community activities to meet the health needs of pupils or students were often neglected because no one had the designated responsibility for addressing them. For this reason, school health was made more comprehensive by including the School Health Coordinator, physical education, counseling, psychology, social

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 services, food services, staff wellness and family/community development. This broadened scope of school health programme directs attention to Rustia’s (2002) school health promotion model (Fig. 1). Description of the model The model clearly identifies the objectives of school health nursing as it fits into the three levels of prevention: primary, secondary and tertiary prevention aimed at meeting the physical, emotional and/or social health problems. Directly below the service objectives are listed specific nursing interventions to achieve the stated objectives. Following directly under the specific nursing interventions are the lists of health outcomes on the family, students, teachers, supportive personnel as well as the community. Relating the model to school health programmes The model clearly illustrates the range of interventions used by nurses to promote healthy lives and to improve quality of life in the school setting. It also reflects the comprehensive nature of school nursing and could be used by school nurses as a framework for articulating roles and functions. With the model, it is easy to identify gaps or problems in the effective planning and implementation of school health programmes. The model also provides a tool not only for stating objectives of school health nursing but for implementing and evaluating the impact of school health nursing programmes. METHODOLOGY A descriptive research design was used and the target population for the study comprised of the two School Health Nursing Coordinators in the two states (Akwa Ibom and Cross River States), 90 available school nurses in Cross River State and 81 in Akwa Ibom State. This gave a total of 171 nurses who were permanently in the school health system. Out of 28 Secondary Schools with School Health Clinics in Cross River State 23 were selected through simple random sampling technique of balloting. Only seven primary schools had school clinics and all were selected thus giving a total of 30 schools from Cross River State. In Akwa Ibom State where there were 47 secondary schools and 30 primary schools with school clinics, simple random sampling method of balloting was also used to select 15 schools each from both the secondary and primary schools, similarly giving a total of 30 schools from the state. In each of the 60 schools selected from both states, a convenient sampling technique was used to select one respondent, giving a total of 60 respondents out of a total population of 171 from Cross River and Akwa Ibom States. Data collection involved interviews, review of records and the administration of questionnaire to school health nurses. A-33 items author developed structured and semi-structured questionnaire was used to collect data for the study. Structured and semi-structured questions were used to allow for accurate assessment of their levels of awareness and also their opinions. The questions on knowledge of roles and services rendered by them involved the listing of ten (10) roles and ten (10) services for respondents to identify those applicable to them. Each correct identification of roles attracted one point with a maximum of 10 points (mean=6). Validation of the instruments involved the use of Content Validity Index (CVI) with a score of 0.91. To test for the reliability of the instrument, a test-retest method was used whereby a sample of ten respondents from schools not included in the study were administered the questionnaire on two consecutive occasions at the interval of two weeks. A computation of both results gave a correlation coefficient of 0.89. The questionnaires were administered through personal face-to-face interaction with the respondents in the various schools and on the spot completion and retrieval of questionnaire. This data collection method ensured 100% return rate. Method of data analysis Socio-economic data and research questions employed descriptive statistics of frequencies and percentages while the Pearson Moment Correlation Coefficient Statistics was used to test the two generated hypotheses. For satisfaction with equipments and supplies, Likert scale questions were used and scores allotted were based on their level of satisfaction. Those who had the mean score of 3.2 or higher were grouped as satisfied, while others who had a lower mean score below 3.2 were grouped as not satisfied with available equipments and supplies for school health programmes.

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 RESULTS Table 1: Socio-demographic data of respondents (n=60) Results from Socio-demographic data presented in Table 1 shows that 53 (88.3%) of the respondents were females while 7 (11.7%) were males. Their age range was between 25 to 49 years with the highest number 21 (35%) occupying the age range of 35-38 years. For professional education, one (1.7%) was a registered midwife, 4 (6.7%) were registered nurses, 20 (33.3%) held the registered nurse/registered midwife certificates, 29 (48.3%) were Community Health Officers, while six (10%) had the Bachelor of Science degree. On their years of nursing experience, majority, 28 (46.7%) had worked for 16 – 20 years while those who worked for the least number of years: 6 -10 years, were 2 (3.3%). The current coverage of school health programme Table 2 shows that out of two hundred and twenty six (226) secondary schools in Cross River State, twenty-eight (28) had school clinics with 21 located in the urban and seven located in the rural areas. Out of nine hundred and forty two (942) Nursery/Primary Schools, seven (7) had school clinics. All the seven Primary School Clinics were situated in the urban areas. On the distribution of nurses, 51 were in urban Secondary Schools, 20 in the rural while 19 were in urban nursery/primary schools (Ministry of Health Records, Calabar, Nigeria; (2004), Etifit, (2004). This translates to a total coverage of 35 out of 1168 schools or 3% coverage in Cross River State. Distribution of school clinics and nurses in Akwa Ibom State Table 3 shows that from a total of two hundred and forty three (243) secondary schools, forty-seven (47) had school clinics while out of eight hundred and thirty (830) Nurseries/Primary Schools, thirty (30) had school clinics (Ministry of Health, Uyo, Nigeria, 2004). This gives a total coverage of 77 out of 1073 schools or 7.2% coverage. 38 of the secondary school clinics were located in the urban areas while nine were in the rural areas. Similarly 26 Primary School clinics were in the urban areas while four were in the rural areas. On the distribution of nurses, 40 were in the urban Secondary schools, ten (10) were in the rural secondary schools, 27 were in the urban primary schools while 4 were in the rural primary schools. Results from interview: On the reasons why most of the schools did not have school health programmes. It was identified that in both states, availability of school clinics and the distribution of school nurses were limited to schools who had made their request and who could meet the given criteria for such consideration. These criteria include the provision of accommodation for the school clinic, regular provision of essential drugs and basic equipments. Additionally, apart from being unable to meet these basic requirements, the information or awareness was lacking in many schools. There was also the problem of dearth of qualified nurses for the school health programme (Etifit, 2004; Umoren, 2004). Health services rendered by school nurses The questions on health services rendered comprised of ten listed services. Table 4 shows that all the 60 (100%) respondents identified treatment of minor ailments as the service they rendered. Referral was identified by 49 (81.7%) of the respondents, 25 (41.7%) identified health education, while only 10 (16.7%) indicated first aid as the service they rendered. All other six (6) services were unidentified as the services rendered by the respondents. Scores were only allotted based on services identified. Respondents’ satisfaction with equipments and supplies: Respondents’ satisfaction with equipments and supplies were measured with five (5) items graded on a four-point Likert type questions. Scores were allotted based on the level of satisfaction and following statistical analysis, respondents who scored 12.5 and above were grouped as satisfied while others who scored below 12.5 were grouped as not satisfied with equipments and supplies as presented in Table 5.Table 5 indicates that 18 (30%) of the respondents viewed the equipments and supplies provided for school health programme as adequate while 42 (70%) assessed it as not adequate and were therefore not satisfied.

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 Professionals that are performing school health duties Table 6 shows respondents’ list of other professionals who also perform school health services. Teachers made up 22 (36.7%) of the professionals, health assistants were identified by 49 (81.7%) of the respondents, nutritionists contributed three (5%) of the professionals, while physicians were mentioned by six (10%) of the respondents. Problems encountered by nurses in the delivery of school health services Referring to Table 7, it is observed that the majority of respondents 52 (86.7%) identified lack of equipments and facilities as the problem they encounter. This was followed by lack of drugs 49 (81.7%), poor staffing 46 (76.7%) and poor accommodation 43 (71.7%). Lack of transport for referral was identified by 42 (70.0%) of the respondents while 16 (26.7%) pointed at lack of co-operation from school heads. Only six (10%) of the respondents identified poor feeding of students as one of the problems. Research hypotheses For the first hypothesis, the result of the Pearson Product Moment Correlation Analysis in Table 8 shows a mean score of 3.20 on respondents’ knowledge of roles. Furthermore, the relationship between nurses’ knowledge of roles for school health services and the health services provided by them was positive, moderately strong and significant (r=.532, df=59; p<0.05). The null hypothesis of no relationship was therefore rejected. This implies that increase in the knowledge of roles was accompanied by increase on health services provided. With hypothesis 2, presented in Table 9, the result of the Pearson Product Moment Correlation Coefficient Analysis shows that the relationship between nurses’ level of satisfaction with equipments and supplies and the school services rendered by them was positive but very weak and not significant (r=.023; df=59; p>0.05). The null hypothesis of no significant relationship was therefore not rejected. DISCUSSION Findings from the study revealed that the current coverage of the school health programme was low. A situation where only 3% of the schools are covered as in Cross River State or 7.2% as in Akwa Ibom State is unsatisfactory. For any future national development, great attention must be paid to adolescents’ development and a sound foundation should be laid for their future health decisions as it is done in the more developed nations. A good proportion of the respondents in this study were not satisfied with the equipments and supplies provided for school health services. A situation where essential materials and facilities are lacking could give an indication that all nursing activities either curative or preventive could only be carried out with great difficulties and on the other hand may not be performed at all. This does not provide an enabling environment for quality care or smooth running of activities relevant to school health programmes. When the respondents were asked to list all the services they rendered, their lists were all limited to four areas of care out of ten (10) roles. All the sixty (60) respondents identified treatment of minor ailments, followed by referral while health education, which is an important component of school health programme was only listed by less than half of the respondents. With the general aim of school health programmes as the promotion of well adjusted, physically vibrant children that are without preventable health problems, it could be said that school health as currently practiced is likely to make limited impact in the lives of our students. School health interventions should cover primary, secondary and tertiary prevention of physical, emotional and/or social health problems as identified in Rustia’s (2002) conceptual model. On other professionals performing school health programmes, the finding indicating inadequate team approach corroborates Kickbusch, et al., (1999) assertion of inadequate collaboration and coordination among persons who should address health issues in schools. Additionally, although it is generally recognized that the nurses have a significant contribution to make in all aspects of school health, no one discipline can meet the needs of all the school-age children. Team cooperation and collaboration are essential for children to receive the health services they deserve. This finding is in line with the observation of Eke (1998) that many schools have no designated facilities with appropriate equipments and supplies that could help in diagnosis, treatment and meeting emergency care and referral services. The findings from this study also corroborate Fajewonyomi and Afolabi’s (1999) observation that a few nurses are usually posted to a few

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 urban schools with their roles not clearly defined and no supervision maintained. It was also very revealing to identify that the relationship between nurses’ knowledge of roles for the school health programmes and the health services rendered by them was positive and significant. This finding is not surprising since one would expect that individuals could only practice roles when they possess knowledge and skills to perform such roles. This result is an indication that availability of resources alone is not enough to determine practice. The nurses themselves have to be knowledgeable about the roles expected of a school nurse. The statistical test, which showed non-significant relationship between satisfaction with equipments and supplies for school health services and the services rendered by the respondents, is rather surprising. It goes to confirm that the availability or lack of resources alone is not enough to determine practice. This shortcoming may not be unconnected with the problems identified by the W.H.O. (Kickbusch, et al., 1999). The W.H.O. Expert Committee asserted that factors such as inadequate vision and strategic planning, inadequate understanding and acceptance of programmes, lack of responsibility and accountability, inadequate collaboration and coordination among persons who should address school health issues, and lack of programme infrastructure could all affect practice. There is therefore a need for advocacy for improved focus on school health programmes. CONCLUSION/RECOMMENDATIONS

i. Coverage of school health programmes should be extended to reach a wider proportion of schools. If specialized nursing services whereby school nurses are posted to schools are not practicable on account of death of nurses, generalized nursing services should be encouraged, whereby nurses working in primary health care centres cover the schools nearest to them until adequate number of nurses are trained to take up the duty. Similarly, functional health programmes including provision of health education machinery should be set up in both urban and rural schools. For the resolution of problems identified in this study, Government at the Federal, State and Local levels should review, articulate properly and enforce identified roles aimed at meeting the health needs of school children. This requires appropriate financial investment and improvement of all resources required for school health. Provision of needed facilities, equipments and supplies should not only be the concern of the school principals.

ii. For improved coverage and collaboration among care providers, each school should be provided with a health team. The health team in collaboration with the service providers could therefore plan for the services to avoid duplications or programmes and non-provision of essential services. Nurses in schools should be well trained on the roles expected of them. This could be achieved through continued education programmes including well-planned seminars and workshops. Since school health programme is broad based, school health nurses should be system designers. This requires nurses with high academic or specialized preparation in school health. Since this later recommendation cannot be met overnight, it is recommended that workshops on school health nursing be planned and implemented in the states for school health nursing practitioners. Specialized school health nursing certificate course should also be developed for school health nursing just as it is done for ophthalmic nursing, orthopaedic nursing to mention but a few. This is to quickly provide the needed manpower to meet the dearth of this category of professionals. Thereafter, a long-term plan of training school nurses at the University as a matter of necessity could be made and implemented.

iii. To broaden the scope of practice, Principals/Headmasters and teachers constituting the organization’s professional grouping and physicians, dentists and other health workers making up the health providers’ grouping should collaborate with each other and with Government representatives/donor agents and families in a very meaningful way to plan and accomplish the identified goals of school health services/programmes.

REFERENCES Ademuwagun, Z. A. and Odunta, S. O. A. (2000). A school health education handbook for teachers and administrators in Nigeria. Ibadan: University Press Limited.

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 Ajala, J. A. (2003). Health education for nursery schools. Ibadan, Nigeria: Mary Best Publications. Anderson, C. L. and Cresswell, W. H. (2003). School health practice (7th ed.) St. Louis: The C.V. Mosby Company. Eke, A. N. (1998). School health education: A neglected primary health component. Nigerian School Health Journal, 7(1):105-109. Etifit, R. (2004). Interview on problems and challenges of school health nursing in Cross River State. Ministry of Health Headquarters, Calabar, Cross River State, 28th January. Fajewonyomi, B. A. and Afolabi, J. S. (1999). Administration of school programme in Nigeria. Nigerian School Health Journal; 8 (1): 40-45. Federal Ministry of Health, Nigeria (2001). National reproductive health policy and strategy to achieve quality reproductive and sexual health for all Nigerians. Abuja, Nigeria: Federal Ministry of Health. Kiousbusch, I. (2004). Think health: What progress? New players for a new era. Jakarta: Bulletin of the 4th International Conferences on Health Promotion. Kickbusch, I, Jones, J. T. and O’Bryne, D. (1999). Health-promoting school: Promoting the World Health Organization’s concept of health. UNESCO International Science, Technology and Environmental Education Newsletter; XXIII, 2, 1-4. Ministry of Health Records, Calabar, Nigeria (2004). Ministry of Health Headquarters, Calabar, Nigeria. Ministry of Health Records, Uyo, Nigeria (2004). Idongesit Nkanga Secretariat, Uyo, Akwa Ibom State, Nigeria. Modrein-Talbott, M. A. (2002). School health nursing. Comprehensive community health nursing; family aggregates and community practice. (6th ed.). U.S.A. Mosby. Moronkola, O. A. (2003). School health programme. Ibadan: Nigeria: Royal People (Nigeria) Limited. Resniscow, K. and Allensworth, D. (1999). Conducting a comprehensive school health programme. Journal of School Health, 66:59-63. Rustia, J. (2002). Rustia’s school health promotion model. In: Clemenstone, A., McGuire, S. L. and Eigsti, D. G. (Eds.). Comprehensive community health nursing, family aggregate and community practice. (6th ed.). Philadelphia: Mosby. Stanhope, M. and Lancaster, J. (1996). Community health nursing: Process and practice for promoting health, U.S.A. Mosby Year Book. Udoh, C. O. (1999). Teaching health education. Lagos: Kitans Academic Industrial Publishers. Umoren, E. O. (2004). Interview on problems and challenges of school health nursing in Akwa Ibom State. Ministry of Health Headquarters, Uyo, Akwa Ibom State, Nigeria, 2nd February.

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 201

Fig. 1: Rustia’s School Health Promotion Model ( Rustia, 2002)

Objectives

Primary prevention

Secondary prevention

Tertiary prevention

Health promotion and welfare

Specific health protection

Early diagnosis

Provide/ Facilitate prompt intervention to resolve problems

To prevent complications and limit disability

To promote rehabilitation and maximal adaptation

Nursing interventions

1. Health education 2. Epidemiological analysis 3. Heath programming 4. Programme evaluation 5. Guidance and support

1. Health and safety standard 2. Communicable disease control 3. Develop skills of health team 4. Facilitate utilization of preventive services and resources 5. Environmental

1. Health interviews 2. Physical assessment 3. Screening and pasting 4. Observations 5. Outreach 6. Conferences 7. Interpret health and safety risk

1. Problem management 2. Referral 3. Communication/ interpretation 4. First aid and emergency care 5. Crises intervention (e.g. counselling)

1. Follow-up 2. Problem-oriented teaching 3. Modification of environment, services and programmes. 4. Definition and communication of management plans. 5. Reassessment

1. Reeducation 2. Reorientation 3. Motivation 4. Support/guidance 5. Reassessment and evaluation 6. Health programming 7. Secure special services/resources

Outcomes

1. Develops appropriate coping mechanism for dealing with children’s health problems. 2. Recognises functions of school health programmes. 3. Recognises importance of heath screening. 4. Assess to appropriate medical care for children with identified health problems. 5. Support health activities.

Students 1. Ability to make responsible and informed health decisions 2. Differentiate concept of health and illness 3. Recognises characteristics of individual health status 4. Ability to locate and use resources to achieve optimal health status. 5. Recognises potential health and safety hazards.

Teachers and supportive personnel 1. Initiate increase number of teacher-nurse conferences for a variety of health-related reasons. 2. Identifies children’s health status 3. Knows the unique contribution of the school nurse in the school curricula. 4. Teaches health education to reflect current health problems of local populations at age-appropriate levels.

Community 1. Develops system of referral responsive to school health programme 2. Develops/provides health services to meet with needs identified by school health programmes. 3. Support legislation responsive to school health needs. 4. Support use of nurses in expanded school health roles.

Family

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010

Table 1: Socio-demographic data (n=60)

Variable Frequency % Sex: Female Male Total

53 7 60

88.3 11.7 100.00

Age in years: 25-29 30-34 35-39 40-44 45-49 Total

3 4 21 17 15 60

5 6.7 35 28.3 25 100.00

Marital Status: Married Single Divorced Total

54 6 - 60

90.00 10 - 100.00

Professional education: R.M. R.N. R.N./R.M. CHO B.Sc Total

1 4 20 29 6 60

1.7 6.7 33.3 48.3 10 100.00

Years of experience: 6-10 11-15 16-20 21 years and above Total

2 11 28 19 60

3.3 18.3 46.7 31.7 100.00

Location of work: Urban Rural Total

47 13 60

78.3 21.7 100.00

Table 2: Distribution of school clinics and nurses in Cross River State School location

Secondary school clinics

Primaryschool clinics

Nurses in sec. schools

Nurses in primary schools

Urban Rural

21 (9.3%) 7 (3.1%)

7 (.7%) -

51 20

19 -

28 (12.4%)

7 (.7%)

71 19

Sec. Schools = 226; Nurseries/primary schools = 942

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 Table 3: Distribution of school clinics and nurses in Akwa Ibom State School location

Secondary school clinics

Primary school Clinics

Nurses in sec. schools

Nurses in primary schools

Urban Rural

38 (15.6%) 9 (3.7%)

26 (3.1%) 4 (5%)

40 10

27 4

47 (19.3%)

30 (3.6%)

50 31

Sec. Schools = 243; Nurseries/Primary schools = 830

Table 4: Health services rendered by school nurses (n=60) Health services Number of nurses involved % First Aid Treatment of minor ailment Referral Health education

10 60 49 25

16.7 100.3 81.7 41.7

Table 5: Respondents’ satisfaction with equipments and supplies provided for school health programmes (n=60)

Equipments and supplies Frequency % Satisfied Not satisfied

18 42

30 70

Total 60 100.00 Table 6: Professionals that are performing school health duties (n=60)

Professionals Frequency % Teachers Health assistants Nutritionists Physicians

22 49 3 6

36.7 81.7 5 10

Table 7: Problems encountered by nurses in the delivery of school health services (n=60)

Problems Frequency % Lack of drugs Poor accommodation Lack of equipments/facilities Poor staffing Lack of transport for referral Poor feeding of students Lack of cooperation from school heads

49 43 52 46 42 6 16

81.7 71.7 86.7 76.7 70.0 10 26.7

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Idongesit I. Akpabio: Continental J. Nursing Science 2: 17 - 28, 2010 Table 8: Relationship between nurses’ knowledge of roles for school health programmes and health services

rendered Variables Mean Std.

deviation n r df Significant

level Remark

Nurses’ knowledge of roles for school health programmes Health services provided

3.20 4.68

.425 2.013

60 60

.532

59

.000*

significant

Sig. = Significant at (P<0.05) Table 9: Relationship between nurses’ level of satisfaction with equipments/supplies and school services provided

Variables Mean Std. deviation

n r df Significant level

Remark

Nurses’ level of satisfaction with equipments and supplies Health services provided

7.34 4.68

4.122 2.013

60 60

.023

59

.083*

Not. Sig.

Received for Publication: 07/02/2010 Accepted for Publication: 12/04/2010

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Continental J. Nursing Science 2: 29 - 35, 2010 ISSN: 2141 - 4173 ©Wilolud Journals, 2010 http://www.wiloludjournal.com EVALUATION OF UTILIZATION OF ANTENATAL SERVICES BY MOTHERS OF BABIES WITH SEVERE

BIRTH ASPHYXIA IN PORT HARCOURT, NIGER DELTA AREA OF NIGERIA.

1H.A.A.Ugboma and 2C.N.Onyearugha 1Departments of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt,

Nigeria. 2Paediatrics, Abia State University Teaching Hospital, Aba , Nigeria.

ABSTRACT Background Birth asphyxia has remained a major cause of avoidable neonatal morbidity and mortality in developing countries including Nigeria. Poor or outright non utilization of appropriate health care services in pregnancy and delivery has been implicated as its major risk factor. Aim: To evaluate the utilization of antenatal services by mothers of babies delivered with severe birth asphyxia at the University of Port Harcourt Teaching Hospital (UPTH) Port Harcourt, Nigeria. Method: A case control study of the utilization of antenatal services by 97 mothers of newborns with severe birth asphyxia delivered at UPTH from 1st February to 31st October 2003 compared with mothers of newborns with normal Apgar scores was done. Relevant pregnancy, birth, family and social history were obtained by personal interviews and referral to case notes. Results: Significantly more of the mothers of babies with normal Apgar score booked early(4 months or less) and had up to 8 or more antenatal visits prior to delivery than mothers of asphyxiated babies 86(88.6%) vs 68(70.2%) p = 0.002; 93(95.7%) vs 68(70.2%) p = 0.001 respectively Significantly more subjects 56 (57.7%) than the controls 45(46.4%) were primiparous p = 0.04. Also, significantly more subjects 19 (19.5%) suffered delay prior to intervention in labour than the controls 5 (5.1%) p=0.004 Conclusion: Primiparity, delayed booking, inadequate antenatal visits and late intervention in labour have been identified as significant contributors to severe birth asphyxia. KEYWORDS. Birth asphyxia. Inadequate antenatal visits. Delayed intervention.

INTRODUCTION : In order to achieve the Millennium Development Goal 4 (to reduce by two-thirds the mortality rate in children aged under five by the year, 2015) neonatal mortality rate needs to be reduced by half (Sule and Onayade ,2006; United Nations, 2001). Birth asphyxia has remained the major cause of avoidable neonatal morbidity and mortality in developing countries (Ade-Ojo et al,2008;Udo et al,2008; Onyiriuka and Okolo,2004; Hyder et al, 2003; Nem Yen,1992;Udoma et al,2001) Though its prevalence in developed countries has decreased drastically, it still remains a major cause of avoidable permanent neurological disability in mature newborns worldwide(Daga and Daga, 2001) Birth asphyxia often results from poor maternal health, improper management of complications during pregnancy and labour and inadequate resuscitation of the newborn at birth ( Fanaroff, 2004; Ellis, 2000; Badawn et al, 1998; Manandhar, 2000) . Lack or inadequate utilization of appropriate antenatal and delivery services has often been implicated as a common origin of these problems. Poor or outright non-utilisation of appropriate health care services by expectant women during pregnancy and delivery has been severally reported from different parts of Nigeria and developing countries in general(Ezechukwu et al, 2004; Oluwatosin and Adekanmbi, 2004; Obi and Onyire, 2004; Welbeck et al, 2003). The high cost of antenatal services and delivery in government and private health establishments unfortunately drives expectant women of the middle and low socioeconomic classes to traditional birth attendants and churches for these services (Lamina et al, 2004; Ayaya et al, 2004; Etuk and Etuk , 2001; Etuk et al,2001).

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H.A.A.Ugboma and C.N.Onyearugha: Continental J. Nursing Science 2: 29 - 35, 2010 This study was therefore undertaken to evaluate the utilization of antenatal services by mothers of severely asphyxiated newborns delivered at the University of Port Harcourt Teaching Hospital, Port Harcourt as none has been done previously here to the best of the authors’ knowledge. The results obtained shall form a baseline data for future analyses and serve as a veritable tool for formulation of policies aimed at curbing the prevalence of birth asphyxia. SUBJECTS AND METHOD: This was a prospective case control study conducted in the main theatre, labour and isolation wards of the University of Port Harcourt Teaching Hospital from 1st February to 31st October 2003. The hospital is a tertiary health institution located in Port Harcourt, the capital of Rivers State. It was founded in 1979 and became baby friendly in the year 1993. Though a tertiary health institution, it also serves as a secondary health care centre since there is only one other secondary health care centre in the densely populated city of Port Harcourt. It is usually well attended because additionally, it serves as a referral centre from peripheral hospitals beyond Rivers State . It has an annual delivery rate of approximately 3000. Ninety eight mothers whose newborns were delivered at the University of Port Harcourt Teaching Hospital and had severe birth asphyxia were serially recruited as study subjects after obtaining informed consent. One of them died postnatally before being interviewed, so 97 were used for further analysis. Birth asphyxia was defined as Apgar score 1-3 in the first minute of life or equal to or less than five at five minutes. Newborns delivered before arrival at UPTH and those with major congenital malformations were excluded. Also 97 mothers whose newborns had normal Apgar score (8-10 in first minute of life) and within identical weight brackets were consecutively enrolled as controls. Relevant pregnancy, birth, family and social history was obtained by personal interview using structured questionnaire and referral to case notes. The total number of live births delivered over the study period was derived from obstetric records in the labour and isolation wards and the theatre. Data was arranged in frequency tables and results were analysed using statistical software EPI- info version 6.04 and SPSS version 11. Student test was used to compare means of variables. P values < 0.05 were considered as significant. Approval was obtained from the ethics committee of the hospital before commencement of the study. RESULTS The total number of live births delivered over the study period was 2064 with 98 being severely asphyxiated giving a prevalence rate of 47 per thousand live births. However, one of the mothers died postnatally before being interviewed so 97 were used for further analysis. Among the newborns with severe birth asphyxia there were 53 males and 44 females with male: female ratio of 1.2:1 and those with normal Apgar scores were 56 males 41 females with male: female ratio of 1.3 :1 with the difference between them not being statistically significant p= 0.76. All the controls were booked in UPTH whereas 70.1% of subjects had their booking there. (Table 1) The median of gestational age (GA) at booking of the subjects was 5 months (range 2 to 9 months) while that of controls was 4 months (range 2 to 7 months). The difference in GA at booking between them is statistically significant. P= 0.02 (Table 1) The mean of antenatal visits made by the subjects prior to delivery was 6.6 (range 2 to 11) while that of controls was 9 (range 3 to 12 months) with the difference between them being statistically significant. P= 0.001 (Table 1).

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H.A.A.Ugboma and C.N.Onyearugha: Continental J. Nursing Science 2: 29 - 35, 2010 The range of parity of the subjects was 0 to 7 with a median of 0 while that of controls was 0 to 6 with a median of 1. The difference in parity between the two categories is statistically significant p= 0.04. (Table 1). Though more controls had tertiary education (30.9%) than the subjects (25.7%) there is no significant difference in educational attainment between the two groups p= 0.64 (Table 2). Overwhelming majority of both subjects and controls (94.7% and 99% respectively) were married. (Table 2). The mean age of the mothers of asphyxiated newborns was 28.85 years (range 20 to 38 years} whereas that of controls was 30.94 years (range 23 to 42 years) with the difference between them being significant p= 0.001. Significantly more subjects (19.5%) than controls (5.1%) suffered delay prior to intervention in labour p= 0.004. (Table 3). Table 1: Antenatal data of subjects and control

Number of % Number of % p subjects controls Place of booking UPTH 68 70.1 97 100 Private maternity 8 8.2 0 0 Private clinic 7 7.2 0 0 PHC 5 5.2 0 0 Church 5 5.2 0 0 TBA 4 4.1 0 0 p = 0.07 Gestational ageat booking (months) 1-3 12 12.4 14 14.4 4-6 56 57.7 79 81.5 7-9 20 20.6 4 4.1 Unbooked 9 9.3 0 0.0 p = 002 Number of antenatal visits 1-3 8 8.2 5 5.2 4-6 21 21.6 6 6.2 7-9 53 54.7 54 55.7 >10 15 15.5 32 32.9 p = 0.001 Parity 0 56 57.7 45 46.4 1-4 38 39.2 48 49.5 >4 3 3.1 4 4.1 P=0.04 UPTH - University of Port Harcourt Teaching Hospital PHC - Primary Health Care TBA - Traditional birth attendant

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H.A.A.Ugboma and C.N.Onyearugha: Continental J. Nursing Science 2: 29 - 35, 2010 TABLE 2: Sociodemographic data of mothers of newborns with severe birth asphyxia and control. Educational Number of % Number of % P value level subjects control Primary 7 7.2 1 1.0 Secondary 65 67.1 66 68.1 Tertiary 25 25.7 30 30.9 P=0.64 Marital Status Married 92 94.9 96 99 Unmarried 5 5.1 1 1.0 P=0.09 TABLE 3 Causes of delay prior to intervention in labour in the subjects and controls Causes of delay Number % Number % In labour before intervention of subjects of controls Delay prior to intervention 19 19.5 5 5.1 Mothers late recognition 5 5.1 4 4.1 of labour Labour initially managed in maternity 5 5.1 1 1.0 Delay in transportation 4 4.1 0 0 Delay in consent for operation 2 2.1 0 0 Labour initially managed by 2 2.1 0 0 TBA Financial constraint 1 1.0 0 0 p = 0.004 TBA Traditional Birth Attendant. DISCUSSION The University of Port Harcourt Teaching Hospital is the only tertiary health care facility in Rivers State, Nigeria. It is located in the metropolitan capital city of Port Harcourt with a secondary health care facility. Being a Teaching Hospital it has by far greater number of specialist and resident doctors and attracts more referrals from peripheral hospitals in Rivers State and beyond. Its clientele cuts across all strata of the society and quite often come from Niger Delta riverine communities with very difficult terrains. This often results in delayed referrals. Also, patronage of unskilled health practitioners especially traditional birth attendants by pregnant women for massage and delivery is quite rife. The traditional birth attendants are in most cases untrained and hence often unable to recognize complications of pregnancy and labour early and have poor delivery and resuscitation techniques. The prevalence rate of severe birth asphyxia of 47 cases/1000 live births in this study is quite high. This is lower than 63 cases /1000 live births reported by Omene and Diejemaoh in Benin but higher than 26.5 cases /1000 live births and 36 cases/1000 live births reported by Airede and Olowu from Jos and Ife respectively(Omene and Diejomaoh, 1978; Airede, 1998; Olowu and Olomu,2006). Perhaps delayed intervention in labour due in part to delay in transit as a result of difficult riverine terrains also contributed to high prevalence of birth asphyxia reported in Benin since both Port Harcourt and Benin city belong to Niger Delta sub region of Nigeria with very difficult riverine topography.

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H.A.A.Ugboma and C.N.Onyearugha: Continental J. Nursing Science 2: 29 - 35, 2010 Significantly, more controls (95%) than subjects (70%) booked in either the first or second trimester of pregnancy. Late booking or outright non utilization of antenatal services by pregnant women has been reported previously by several authors as significant risk factors for birth asphyxia(Oluwatosin and Adekanmbi, 2004; Obi and Onyire, 2004; Welbeck et al, 2003). Some of these patients come to book only when pregnancy is complicated and they perceive that all is not well. Surprisingly, some well educated occasionally fall into this category. Late booking often makes early detection and prompt management of pregnancy disorders such as pregnancy induced hypertension, toxaemia, abnormal lies impossible often resulting in birth asphyxia. The results of this study also revealed that significantly more controls (33%) had 10 or more antenatal visits prior to delivery than the subjects (15.5%). Paucity of attendance of antenatal care by pregnant women delivering asphyxiated newborns has also been previously reported in Ogun State (Oluwatosin and Adekanmbi, 2004). This practice is quite rife in this community with some pregnant women booking only for the purpose of delivering in the health care facility. In curbing the prevalence of birth asphyxia, the essence of early booking and regular antenatal visits for adequate antenatal supervision and early detection and prompt management of pregnancy complications when they arise cannot be over emphasized. Significantly, more of the subjects (57.7%) than the control (46.4%) were primiparous. Primiparity has been previously noted as a risk factor for severe birth asphyxia (Ellis, 2000; Badawn et al, 1998; Manandhar, 2000). Often the primiparous are ignorant of the demands of pregnancy on themselves and their unborn fetus thereby neglecting early booking and regular attendance for antenatal supervision. These may result in complications leading to birth asphyxia not being detected early and adequately managed. There was no statistical difference in the educational and marital status of the subjects and control. This could be explained by the fact that large numbers of subjects (92.7%) and control (98.9%) had either secondary or primary education. Similarly, a large population of subjects (94.9%) and control (99.0%) were married. The mean age of the subjects in this study is significantly less than that of control. Ordinarily, the older the mother the greater the risk of delivery of asphyxiated newborn (Ellis, 2000). This result can be explained by the preponderance of primiparous among the subjects who were generally younger. The result of this study also revealed that significantly more subjects (19.6%) than the control (5.1%) had delay prior to intervention in labour. Major causes of delay were mothers’ late recognition of labour (25%), labour initially managed in a maternity (25%), delay in transportation (20%). The primiparious are often naïve and sometimes unaware that they are in labour even with complications such as abnormal lie, prolonged labour, particularly when they are irregular in antenatal attendance. Often pregnant women have their antenatal supervision and deliveries in private maternities. These maternities are often manned by untrained and inexperienced staff who fail to detect problems in pregnancy and labour early resulting in late referrals. Delay in transportation may be due to lack of vehicle or difficult terrains and roads leading to delayed arrival at an appropriate health facility. All these may result eventually in birth asphyxia or even still birth. CONCLUSION: Mothers of newborns with severe birth asphyxia were predominantly primiparous. They also booked late in pregnancy, had inadequate antenatal visits prior to delivery and delayed intervention in labour. Health education via the electronic and print media, market women organizations, community leaders, community gatherings, faith based organizations and persons concerned with pre-marital counseling emphasizing the need for early booking and regular antenatal attendance as well as delivery in appropriate health care facility by expectant women must be commenced and sustained.

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H.A.A.Ugboma and C.N.Onyearugha: Continental J. Nursing Science 2: 29 - 35, 2010 There must be organization of various seminars and workshops for employees of private health institutions, primary health centers and traditional birth attendants on early recognition of complications of pregnancy and labour and prompt referral of cases to appropriate health care facility. Health care facilities manned by properly trained staff should be sited within 5 kilometres or 30 minutes walking distance from communities. ACKNOWLEDGEMENT We are immensely grateful to the obstetricians, anaesthesiologists and the nursing staff of the main theatre, postnatal and isolation wards and the Special Care Baby Unit for their cooperation in the course of the study. REFERENCES Ade-Ojo I.P, Loto O.M. (2008) Outcome of eclampsia at Ile-Ife, Nigeria. Nigerian Journal of Clinical Practice, 11(3): 279-284. Airede A.I. (1998) Birth asphyxia and hypoxic ischaemic encephalopathy: Incidence and severity. Nig Med Pract 30: 58-62. Ayaya S.O, Esamai F.O, Rotich J, Lietchy E. (2004) Perinatal mortality in the special care nursery of Moi Teaching and Referral Hospital, Eldoret, Kenya. E Afr Med J, 8: 555-561. Badawi N, Kurinczuk J. J, Keogh J. M, Alessandri . M, O’Sullivan F, Burton P. R, et al. (1998). Intrapartum risk factors for newborn encephalopathy: the Western Australian case-control study. BMJ. 5; 317(7172):1554–1558 Daga A.S, Daga S.R. (2001) Antecedent risk factors of neonatal asphyxia in trem newborns. Semin Perinatol, 23: 226-33 Ellis M, Manandhar N. Manandhar D.S.( 2000) Risk factors for Neonatal N Encephalopathy in Kathmandu, Nepal Br Med J, 320: 1229-36. encephalopathy. Br Med J, 317: 1549-53. Etuk S.J, Asuquo E.E.J, Itam I.H, Ekanem A.D. (2001) Reasons why booked women deliver outside orthodox health facilities in Calabar, Nigeria. Int J Social Science and Public Policy 2(1): 90-102. Etuk S.J, Etuk I.S. Relative risk of birth asphyxia in babies of booked women who deliver in unorthodox health facilities in Calabar, Nigeria. Acta Tropica 2001; 79: 143-47. Ezechukwu C.C, Ugochukwu E.F, Egbuonu I, Chukwuka J.O. (2004) Risk factors forneonatal mortality in a regional tertiary hospital in Nigeria. Nig J Clin Pract, 7: 50 – 52. Fanaroff A. (2000) Birth Asphyxia. Neonatol, 4:506. Hyder A.A, Wali S.A, McGuckin J. (2003). The burden of disease from neonatal mortality: a review of South Asia/sub-Saharan Africa. Brit J Obstet Gynae. An International Journal of Obstetrics and Gynaecology, 110: 894-901. Lamina M.A, Sule-odu A.O, Jagun E.O. (2004) Factors militating against delivery among patients booked in Olabisi Onabanjo University Teaching Hospital Sagamu, Nigeria. Nigerian Journal of Medicine, 13(1): 52-55. Manandhar M.S, Wyatt P. (2000) Stillbirth and Neonatal encephalopathy in Kathmandu Nepal. An estimate of the contribution of birth asphyxia to perinatal mortality in a low-income urban population. Pediatr Perinat Epidemiol, 14: 39-42.

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H.A.A.Ugboma and C.N.Onyearugha: Continental J. Nursing Science 2: 29 - 35, 2010 Nem Yen B. (1992) Factors associated with clinically significant Perinatal Asphyxia in Malaysian Neonates J Trop pediatr, 38: 282-289. Obi S.N, Onyire B.N. (2004) Pattern of neonatal admission and outcome at a Nigerian Tertiary Health Institution. Orient J Med, 16: 31-37. Olowu W.A, Olomu S.C. (2006) Birth Asphyxia: Risk factors for Mortality. Nig Med Pract, 31: 69-72. Oluwatosin M.T, Adekanmbi A. (2004) Findings on the use of antenatal facilities in Ogun State. Nig Med Pract, 45:68-71. Omene J.A, Diejomaoh P.M.E. (1978) Analysis of 226 asphyxiated infants at the University of Benin Teaching Hospital (1974-1976). Nig J Paediatr 5:25-29. Onyiriuka N.A, Okolo A.A. (2004) Perinatal outcome in patients with preeclampsia in Benin City, Nigeria. Trop J Obstet Gynaecol,21(2):148-152. Sule A.A, Onayade J. (2006) Community based antenatal and perinatal interventions and newborn survival. Nigerian Journal of Medicine, 15: 108-118. Udo J.J, Anah M.U, Ochigbo S.O, Etuk I.S, Ekanem A.D. (2008)Neonatal mortality and morbidity in Calabar, Nigeria: A hospital-based study.Nigerian Journal of Clinical Practice,11(3): 285-289. Udoma E.J, Udo J.J, Etuk S.J. (2001) Morbidity and Mortality among infants with Normal Birthweight in a Newborn Baby Unit Nig J Paediatr, 28: 13-17. United Nations General Assembly-56th Session: Road map toward the implementation of the United Nations Millennium Declaration: report of the Secretary-General. (2001) New York: United Nations, Welbeck J, Biritwum R.B, Mensah G. (2003) Factors affecting the survival of the “at risk” newborn at Korle Bu Teaching Hospital Accra, Ghana. W Afr J Med, 22: 55-8. Received for Publication: 12/11/2010 Accepted for Publication: 14/12/2010 Corresponding Author: H.A.A.Ugboma Departments of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.