ONYENWEZE AUGUSTINA CHIKAODILI

PG/ M.ED/02/33164

PG/M. Sc/09/51723

PROVISION, UTILIZATION LEVELS AND

TRENDS OF CHILD HEALTH SERVICES IN

PRIMARY HEALTH CARE CENTRES IN

ENUGU URBAN OF ENUGU STATE

HEALTH AND PHYSICAL

EDUCATIONTRATION

A THESIS SUBMITTED TO THE DEPARTMENT OF HEALTH AND PHYSICAL

EDUCATION, FACULTY OF EDUCATION, UNIVERSITY OF NIGERIA, NSUKKA

Webmaster

Digitally Signed by Webmaster’s Name

DN : CN = Webmaster’s name O= University of Nigeria, Nsukka

OU = Innovation Centre

APRIL, 2010

PROVISION, UTILIZATION LEVELS AND TRENDS OF

CHILD HEALTH SERVICES IN PRIMARY HEALTH

CARE CENTRES IN ENUGU URBAN OF ENUGU STATE

BY

ONYENWEZE AUGUSTINA CHIKAODILI

PG/ M.ED/02/33164

DEPARTMENT OF HEALTH AND PHYSICAL EDUCATION

UNIVERSITY OF NIGERIA, NSUKKA.

APRIL 2010

i

Title Page

Provision, Utilization Levels and Trends of Child Health Care Services in Primary

Health Care Centres in Enugu Urban of Enugu State

A Project Report Submitted to the Department of Health and Physical Education

University of Nigeria, Nsukka in Partial Fulfillment of the Requirement for the

award of Master Degree (M.Ed) in Public Health Education

By

Onyenweze, Augustina Chikaodili

PG/ M.Ed/02/33164

APRIL, 2010.

ii

Certification

Onyenweze, Augustina Chikaodili, a postgraduate student in the Department of

Health and Physical Education with Registration number PG/M.Ed./02/33164 has

satisfactorily completed the requirements for the degree of Master (M.Ed.) in Public

Health Education. The work embodied in this Project report is original and has not been

submitted in part or in full for any diploma or degree of this or any other University.

------------------------------------------------- --------------------------------------------

Onyenweze, Augustina Chikaodili Tr. Prof. R.U. Okafor, Ph.D.

Candidate Supervisor

---------------------------------------- --------------------------------------

Date Date

iii

Approval page

This project has been approved for the Department of Health and Physical

Education, University of Nigeria, Nsukka.

By

---------------------------------- ------------------------------

Tr. Prof. R.U. Okafor, Ph.D. Internal Examiner

Supervisor

--------------------------------- -------------------------------

External Examiner Prof. O.A. Umeakuka

Head of Department

-- --------------------------------

Prof.Grace Offorma

Dean, Faculty of Education

iv

Dedication

This work is dedicated to my family members who sacrificed the motherly love

and care I owe them and patiently assisted me to finish this programme.

v

Acknowledgements

My gratitude goes to God who sustained me and my family throughout the course

of this work. I thank God for my husband Pastor D. O. Isabu, and all my children, Aka,

Chidebere and Divinepower for their understanding and assistance during this crucial

period of my academic pursuit. I am also grateful to Tr. Prof. R.U. Okafor, my project

supervisor, and his family for their support and encouragement.

I appreciate the contribution of the lecturers and staff of the Department of Health

and Physical Education University of Nigeria Nsukka, most especially, Professors C.E.

Ezedum and O.A. Umeakuka, Dr Igbokwe and Dr. Dike for their contributions to the

success of this study.

Finally, my gratitude goes also to my class-mates: Pastor Emeh, Miss Agu, Mrs.

Obayi, Mrs. Grace Adama, research assistants, respondents and to Efe and Chika who

typed this project work and all who contributed in one way or another to make this work

a success, may God bless you all. Amen.

Onyenweze Augustina Chikaodili

August, 2009.

vi

Table of Contents

Title page - - - - - - - - - i

Certification - - - - - - - - - ii

Approval Page - - - - - - - - - iii

Dedication - - - - - - - - - iv

Acknowledgements - - - - - - - - v

Table of Contents - - - - - - - vi

List of Acronyms and Abbreviations - - - - - - viii

List of Table - - - - - - - - - x

List of Figures - - - - - - - - - xi

List of Appendices - - - - - - - - xii

Abstract - - - - - - - - - xiii

CHAPTER ONE: Introduction 1

Background to the Study - - - - - - 1

Statement of the Problem - - - - - - - 11

Purpose of the Study - - - - - - - - 12

Research Questions - - - - - - - - 13

Hypotheses - - - - - - - - 13

Significance of the Study - - - - - - - 14

Scope of the Study - - - - - - - - 15

CHAPTER TWO: Review of Related Literature 17

Conceptual Framework - - - - - - - 17

Factors Associated With CHS - - - - - - 30

Theoretical Framework - - - - 39

Empirical studies on utilization level and trends of child Health

Services - - - - - - - - - 42

Summary of Literature Review - - - - - - 50

CHAPTER THREE: Methods - - - - - - 52

Research Design - - - - - - - - 52

Population for the Study - - - - - - - 52

Sample and Sampling Techniques - - - - - - 53

Instrument for Data Collection - - - - - - 54

Validation of the instrument - - - - - - - 55

Reliability of the instrument - - - - - - - 56

Method of data collection - - - - - - - 56

vii

Method of Data Analysis - - - - - - 57

CHAPTER FOUR: Results and Discussion - - - - 58

Summary of findings- 79

Discussion of major findings - - - - - - - 80

Availability/provision of CHS - - - - - - 81

Utilization levels of CHS - - - - - 82

Trends in utilization of immunization services from 2000 to 2007 87

Influence of maternal socio-demographic factors on

Utilization level of CHS (age, parity, educational attainment and

Occupational Status) - - - - - - - 88

Socio-economic factor(s) that could influence level

of utilization of CHS - - - - - - - 90

Implications of the findings for health of the child and

Childhood morbidity mortality rates - - - - - - 91

CHAPTER FIVE: Summary, Conclusion and Recommendations 94

Summary - - - - - - - - - 94

Conclusions - - - - - - - - 94

Recommendations - - - - - - - - 96

Suggestions for Further Studies - - - - - - 97

Limitations of the study - - - - - - 98

References - - - - - - - - - 99

Appendices - - - - - - - - - 107

viii

List of Acronyms and Abbreviations

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care

ARI Acute Respiratory Tact Infection

BCG Bacillus Carm Guarine

BHFI Baby Friendly Hospital Initiative

BHSS Basic Health Service Scheme

CCCD Combating Childhood Communicable Diseases

CDD Control of Diarrhea Disease

CHS Child Health Services

CIDA Canadian International Development Agency

CSM Cerebro-Spinal Meningitis

DFID Department for International Development

EPI Expanded Programme on Immunization

ESMOH Enugu Ministry of Health

EU European Union

FMOH Federal Ministry of Health

GAVI Global Alliance for Vaccine Immunization

HBV Herpatitis B Virus

HIV Human Immune Deficiency Virus

ICC International Child Congress

IEC Information Education and Communication

IITA International Institute of Tropical Agriculture.

IMCI Integrated Management of Childhood Illnesses

IMR Infant Mortality Rate

IRCS International Red Cross Society

JICA Japanese International Cooperation Agency

LGA Local Government Area

MCH Maternal and Child Health Services

MICS Multiple Indicator Cluster Survey

MPS Making Pregnancy Safer Initiative

ix

NDHS National Demographic and Health Survey

NFCN National Committee on Food and Nutrition

NHP National Health Policy

NIDs National Immunization Days

NMICS National Multiple Indicator Cluster Survey

NPC National Population Commission

NPHCDA National Primary Health Care Development Agency

NPI National Programme on Immunization

OPT Diptheria Pertusis and Tetanus

OPV Oral Polio Vaccine

ORT Oral Re-hydration therapy

PHC Primary Health Centre

PNC Post Natal Care

Polio Poliomyelitis

TT Tetanus Toxoid

U5MR Under Five-Mortality Rate

UNFPA United Nations Family Planning Agency.

UNICEF United Nation Children Fund

USAID United State Agency for International Development

VPD Vaccine Preventable Diseases

WHF World Health Forum

WHO World Health Organization

x

List of Tables

Table

1. Availability of CHS in PHC facilities in Enugu urban.

2. Utilization levels of CHS in the PHC facilities in Enugu urban.

3. Trends in the utilization levels of immunization services 2000-2007. In PHC

Facilities in Enugu Urban

4. Influence of maternal age on the utilization of CHS.

5. Influence of maternal educational attainment on the utilization levels of CHS.

6. Influence of maternal parity on the utilization levels of CHS

7. Influence of maternal occupation on the utilization levels of CHS

xi

List of Figures

Figure

1. Trends in utilization of BCG 1st and 2

nd doses (0 – 11m, 12 – 23m)

2. Trends in utilization OPV vaccine 1st dose (0 – 11m)

3. Trends in utilization OPV vaccine 2nd

dose (12 – 23m)

4. Trends in utilization DPT vaccine 1st dose (0 – 11m)

5. Trends in utilization DPT vaccine 2nd

dose (12 – 23m)

6. Trends in utilization Yellow Fever vaccine 1st, 2

nd and 3

rd doses

7. Trends in utilization HBV 1st dose (0 – 11m)

8. Trends in utilization HBV 2nd

dose (12 – 23m)

9. Trends in utilization measles vaccine 1st and 2

nd doses

10. Trends in utilization CSM (12 – 59m)

xii

List of Appendices

Appendix A: Immunization Inventory

Appendix B: Information on field work

Appendix C: Questionnaire

Appendix D: Trends in Immunization 2000 – 2007

xiii

Abstract

This study was aimed at determining the provision, Utilization Levels and Trends of

Child Health Services in the Primary Health Care Centres in Enugu Urban. The

independent variables investigated were maternal age, parity, occupation and educational

attainment. Other socio-economic factor(s) that could influence utilization of CHS were

also considered in the study. The study was limited to eight components of CHS available

in the area of study, while immunization service, which is one component of CHS, was

used to trace the trend of CHS. Descriptive survey research design was used for the

study. Four research questions and four hypothesis tested at .05 level of significance were

formulated for the study. The population of study was 11,200 mothers of reproductive

age on Enugu State and 310 mothers and their babies that utilize CHS in PHC facilities in

Enugu Urban. Instrument for data collection were provision and utilization of CHS

questionnaire and Trends in utilization of immunization inventory both designed by the

investigator. Mean, frequencies, percentages and chi-squire statistical techniques were

employed to analyze data collected. The findings of the study are as follows: CHS was

available in the three PHC in Enugu Urban. All of the eight components of CHS except

exclusive breast-feeding were utilized effectively. The trend of immunization services

utilization over the years 2000 – 2007 was full of fluctuations. Maternal Demographic

factors studied: Age, parity, occupation and educational attainment had no statistical

relationship to the level of use of available CHS. Availability of medical personnel in the

neighborhood 77.15 percent, ignorance of need of CHS, 40.06 percent, cultural belief

25.83 percent, bad attitude of health care provides 18.54 percent and procrastination of

immunization/clinic days 13.58 percent were socio-economic factors that affected level

of utilization of available CHS.

1

CHAPTER ONE

Introduction

Background to the Study

Children are the future of any nation or community. They are essential for the

survival of any group of people. For this reason and more the focus of international

public health concern has been on reducing child mortality and morbidity in order to

propagate, preserve, nurture and ensure continuity of the human race. This is rightly so as

WHO (2000) reported that recently in the mid 1980s, some fifteen million children under

five years of age died each year, representing 30 per cent of all deaths in many countries.

This evil trend was addressed through the provision of Child Health Services (CHS).

According to William (1984), CHS are that aspect of medical services that provide

essential health services to protect, promote and maintain health and well-being for child

bearing families as a unit and for each individual child within that family up to school age

(from birth to five years). World Health Organization WHO (1993) stated that CHS is a

channel through which medical and health services can be organized to improve the

health of the child, prevent diseases and promote growth and development. Tabah (1987)

had earlier noted that CHS is an integral part of community health services and has been

adopted as Maternal and Child Health Services (MCH).

Starfeiled (2002) asserted that CHS is an integral part of Primary Health Care (PHC)

which is concerned with the provision of accessible, integrated, bio-psychosocial health

care service by the health care personnel who are accountable for addressing a large

majority of personal health needs, developing a sustained partnership with patients and

participating in the context of family and community. According to Guagilardo (2004)

PHC is recognized as the most important form of health care delivery system for

2

maintaining populations health including child health, because it is relatively in-

expensive, can be more easily delivered than specialty an in-patient care (if properly

distributed) and most effective in preventing disease progression in a large scale.

The health of the child and services offered to protect it are influenced by factors

classified by Cleason, Edward, Mawiji, and Pathmanathan (2000) as proximate factors

(such as non-medical and medical care during the antenatal period, care at birth,

preventive and curative care in the post-natal periods) and non-proximate factors such as

maternal factors (age, parity and birth intervals). Household and community level factors

(such as water supply, sanitation, and housing) then socio-economic development and

health services. Diamond (2000) pointed out that there is little doubt that high child

mortality rates are associated with high rates of child bearing early child bearing, short

birth spacing and high-parity birth. He suggested that effort to reduce high child mortality

should not only end in health intervention but should include improvement in women’s

education.

Gabr (1985) identified the components of child health care services as follows:

immunization services, growth monitoring, oral re-hydration therapy, promotion of

breastfeeding, treatment of minor illness and outreach services. These activities are aimed

at protecting child health and preventing ill health. Immunizations are given to protect the

child against childhood killer diseases. The Federal Ministry of Health of FMOH (2004)

identified these diseases as: whooping cough, measles, tuberculosis, tetanus,

poliomyelitis, diphtheria and the additional package namely hepatics B and cerebrospinal

meningitis. United Nations Children Fund) UNICEF (2002), reported that although most

of these childhood killer diseases have been reduced in the developed countries, other

diseases and conditions such as malaria, human immunodeficiency virus (HIV), cerebro-

3

spinal meningitis, diarrhea, hepatitis B virus and malnutrition are now topping the lead as

childhood killer diseases.

Other CHS includes; growth monitoring, using a standardized chart aimed at

assessing the physical development of the child. Oral re-hydration therapy given for the

treatment of diarrhea of any aetiology, promotion of breastfeeding to prevent

malnutrition, health education on nutrition and the use of locally and culturally accepted

foods during weaning periods to introduce children under the age of one year to the

family food without creating nutritional gap that would result to malnutrition, treatment

of prevalent illness such as malaria and outreach health services. In outreach services,

trained health personnel go out to reach children in schools and churches or mosque to

delivery child health services such as immunization, health screening and inspection,

identification and referral of children with physical or psychological impediments for

proper management.

The objective of child health care services according to Nelson (2000) is to reduce

child morbidity and mortality to enhance mental, physical and psychological well being

of the children to permit them to come to adulthood at their optimal stage of development

as to complete with life struggle at their affective level. It is worth noting, however that

not withstanding the provision of all these services, their utilization are essential for

accomplishing of the objective of child health care services. In other words, the provision

of the services is considered a necessary factor for the accomplishment of the objective of

the child health care services, while the utilization is also another factor.

Child health services among other health services are provided by the government

at all levels: federal, state and local government levels. Each has her responsibilities in

turn for providing these services either single-handedly or in collaboration with non-

4

governmental agencies such as UNICEF, United State Affair for International

Development (USAID), World Bank, WHO, DFID. According to Cleason and Waldman

(2000), health care services are provided at government levels, community levels and

family levels. It is the responsibility of the government to provide some of these health

services, while it is the responsibility of the community to make them accessible, bearing

in mind the cultural health practices and attitudes of the families to health issues.

The CHS provided at home/family level includes: Breast-feeding, good nutrition

by good weaning practices, hygiene and other health promoting behaviours. Clearson and

Waldman (2002) maintained that the ability of the mother to recognize illness, provide

appropriate and quality care and seek medical help early in sickness, goes a long way to

save and keep the child alive.

WHO (2000) reported that at the community level, the extent of utilization of

child health services will depend on community factors such as culture, values, beliefs

norms, ecology and geography among other things. Factors such as availability of those

services, accessibility, quality of other health services (private and public) around, food,

energy, water supply and sanitation will determine and influence the extent of use of

CHS. Similarly at government level, factors such as government policies and actions on

health, nutrition, population, health financing and expenditure, provision, stewardship,

inter-sectorial linkages, evaluation and monitoring will make a way for availability and

accessibility of CHS. Other governmental policies such as infrastructure, transport,

energy, agriculture, water supply and sanitation can also influence the extent of use of

CHS.

Child health services as part of maternal and child health services evolved through

ages and is noted in the bible (Exodus 1:15 – 22). According to Nelson (2000), it reached

5

its peak in 19th century following industrial revolution and discovery of antibiotics in the

treatment of childhood ailments. In Nigeria the traditional child care based on myths,

customs and belief was improved up on by the colonial medical services and the

Christian missionaries respectively. The Christian missioners abolished some of the

harmful practices in child care such as killing of twins and educated the people on

improved child care. Donor agencies and international organizations such as World

Health Organization, UNICEF, International Red Cross Society) played very important

role in child health service in Nigeria, especially during Nigerian civil war and thereafter.

Trends in the utilization level of CHS in this study therefore imply the level of use

of CHS over the years from 2000 – 2007. This is because from literature reviewed,

implementation of the new CHS reforms especially on immunization started from 1990,

and consolidated in 2000s.

Prior to 1980s CHS was focused on the disease specific strategies, such as

immunization against six deadly childhood killer diseases (Tuberculosis, Tetanus,

whooping cough, poliomyelitis, measles, diphtheria) using vaccines only. This involved

technology of cold chain for potency and efficiency and required technological

preservation for potency, which made the programmes and the strategies difficult and the

result was very low immunization coverage, especially in the remote areas. WHO (1989)

reported that in the mid 1980s five million children under five years of age died each

year. Foster (1998) noted that this ugly trend aroused the concern of public health and

WHO. This brought about re-organization and reformation of CHS from the disease

specific strategies and programmes to preventive, promotive and early treatment care

seeking behaviour aimed at diseases prevention and control and the subsequent reduction

of infant/childhood mortality rates.

6

These new trends include strategies for strengthening health system through the

provision and expansion of primary health care facilities, as well as training health care

providers in the use of appropriate, effective and affordable strategies to save the lives of

children. Such strategies reform includes additional immunization against hepatitis B

virus, cerebro-spinal-meningitis, house-to-house immunization to eradicate poliomyelitis,

deworming exercise carried out in government owned primary schools and school meal

programme. Emphasis is no longer only on the six childhood killer disease using vaccines

only to but also includes prevention of diseases that contribute directly and indirectly to

childhood mortality.

The subject of this new initiative of CHS aimed at reducing emphasis on technical

programmes that are disease specific to include and incorporate other programmes aimed

at disease prevention and control in a more integrated and more manageable packages of

basic child health services. In this new trend, emphasis is on both prevention of childhood

killer diseases as well as early detection and prompt treatment of major communicable

diseases such as cerebro-spinal-meningitis, pneumonia, diarrhea, malaria, measles and

hepatitis B virus infection which have taken top lead as childhood killer diseases.

Emphasis is also on addressing malnutrition which has been shown to contribute to more

than half of all childhood deaths as well as Human immunodeficiency virus (HIV). In

addition to improved immunization strategies, the new package includes: oral re-

hydration therapy, exclusive breastfeeding for the first six months of life, nutrition

education and outreach services. CHS in practice prior to the reform include antenatal

services, postnatal services, immunization against six childhood killer diseases as well as

growth monitoring.

7

The benefits of effective CHS have become an increasing concern, as relationship

between health during early life and later developments have become more clearly

understood. Foster (1998) stated that decrease in childhood disease through efficient CHS

have led to decreased social burden of having to look after children and individuals

whose lives are damaged either physically, mentally or both. His statement agreed with

that of Akintola (1993) who ascerted that effective CHS in any nation ensures healthy

citizens. In the same way, the absence and inability to make use of these available child

health care services implies un-healthy citizens. It should therefore be a matter of concern

to determine the provision and level of utilization of child health care services in view of

the report of Nigerian Demographic and Health Survey (2004) which stated that despite

these new reforms in CHS, infant mortality rate still remains as high as 100 deaths per

1000 live birth. This situation puzzles the mind of the researcher in view of so much

efforts and resurgence of interests in PHC by the federal, state and local government

authorities in collaboration with donor agents such as DFID, UNICEF and World Bank

aimed at providing quality health care to reduce to its barest minimum the ever high rate

of childhood mortality. It is worth noting that it is one thing to provide these services and

another to make use of them for the purpose meant for it. In other words, provision of

these CHS is essential for accomplishing the objectives.

Utilization of the services is also another factor for the accomplishment of CHS

objective. Machanic (1997) stated that utilization of CHS implies both the availability

and willingness of the user of the services to avail themselves of them. He pointed out

that availability depends on the government policy on health, planning, health financing,

availability of manpower and accessibility in terms of nearness. On the other hand,

willingness of the users to use available health care facilities depends on their educational

8

level, awareness, cost of the health care services, cultural attitude to illness,

socioeconomic status as well as the attitude of the health care providers. This also agreed

with the ascertion of Whitehurst and Jaco (1985), that utilization of health care services

by the target population is the willingness of the population to make use of the health care

services to protect and promote health and prevent diseases, in order to achieve optimal

health and well being. It means patronage of health care services by target population.

For example, in the case of CHS here in this study it would mean patronage either by

attending and making use of available CHS offered in the community (Primary Health

Centers or Schools) by mothers and children under five years in order to reduce to the

barest minimum the prevailing high rate of childhood mortality rate in Enugu State (201

deaths per1000 live births).

Utilization levels of CHS in the context of this study is the extent to which

available CHS is being put to use by mothers of child bearing age and their children

under five years of age. Mothers’ involvement here is because they are the custodians of

the children and have the responsibility of protecting and promoting their health and

well-being. Utilization levels will determine whether the available CHS are underutilized,

moderately utilized or effectively utilized.

Enugu Urban is the capital city of Enugu State in Nigeria and is made up three

local government areas namely: Enugu North, South and East local government areas.

Each of these local government areas is privileged to have a registered primary health

center offering child health services in addition to tertiary health institutions such as

University of Nigeria teaching hospital (UNTH) through which child health services are

made available to the target population. The target population here is childbearing

families and their children under 5 years of age. The residents are predominantly

9

Christians with few non-Christian. Enugu state is one state of the 36 states of Nigeria

located in the southeast zone of the six geopolitical zones of Nigeria, with population

density of 360 persons per square kilometer. According to NPC (2006), the population is

relatively young with about 45 percent of the entire population of 3.1 million persons

under 15 years of age and about 15 percent under 1 year. Infant and childhood mortality

rates as shown by Enugu State Ministry of Health (1999) were 74.3 deaths per 1000 live

birth. It was also reported that malnutrition remained a major issue of development

among the children and all living under deprivation. Data collected by Enugu State

Ministry of Health (2002) revealed that 19 percent of children in Enugu State were

stunted, 7 percent wasted and 10 percent under weight and that stunting and under weight

were more prevalent in the rural areas of the state.

In view of the fact, that so much strategies and programmes have been put in

place with the aim of reducing childhood mortality to the barest minimum and still there

have been constant and persistent report of high mortality rate among children. There is

therefore need to determine the provision and utilization levels of CHS in Enugu State as

well as trends in level of utilization of immunization services (2000-2007).

Statement of the Problem

According to Lopez (2000), CHS have been regarded as the aspect of modern

health care specifically designed for health protection and promotion for children to

enhance proper development. Children are important segment in the nation’s population.

Their health status is an important index for evaluation of both the socio-economic status

and health delivery system. CHS is very important in an effort to nurture and preserve

human race, as children are the future of any nation. CHS have received so much concern

from the public health over the years. WHO (1996) reported that in the mid 1980s,

10

precisely 1983 – 1987 about five million children under the age of five years died each

year in Nigeria. This alarming high death rate among children of this age, attracted the

attention of World Health bodies namely WHO, Federal government, donor agencies and

states government ministries of Health as well as non-governmental donor agencies such

as UNICEF, World Bank, United State Agency for International Development (USAID)

among others. Efforts were made by these bodies to combat this evil trend.

Research were initiated and sponsored with the aim of finding solution to ever

increasing high rate of childhood mortality rate. In the course of research it was found

out, for instance that infant and childhood mortality by 1980 were 229 deaths per 1000

live births (UNICEF 1980). Federal Ministry of Health FMH (2000) also reported 201

deaths per 1000 live birth of children under-five year in 1983. Between the year 1983 and

2003, so many strategies and programmes were put in place to enhance child survival and

reduce infant and childhood mortality rate. For example, in 1983, expanded programme

on immunization was launched to improve immunization coverage using a new vaccine

distribution system based on ice-pack-cold boxes to preserve the potency of the vaccines

and ensure efficacy.

In 1987, the Federal Government of Nigeria launched and adopted Primary

Health Care. The PHC approach was to ensure that health care is accessible to the

citizens especially children under 5 years. FMH (2000) also reported that due to inherent

problems that exist in the health care delivery system, World Bank, DFID and other

donor agencies are assisting the Nigerian government in health sector reforms with

particular emphasis on improving immunization and combating high mortality rates

among children under five years. Among other strategies, is the creation of National

Primary Health Care Development Agency (NHCDA). The NPHCDA is expected to

11

strengthen PHC implementation through supervision and technical assistance to the Local

Government Areas (LGAs). In spites all the above mentioned programmes, UNICEF

(2004) still reported that more than one million children die annually from vaccine

preventable diseases in Nigeria and that Nigeria is one of the least successful of African

countries in achieving improvement in child survival in the past four decades, in spite of

advances in the universal immunization and oral re-hydration, therapy as well as the great

wealth of Nigeria is human and natural resources.

It is disheartening to note that despite the policies, and programmes aimed at

reducing childhood mortality rates, high morbidity and mortality rates persists. In view of

this persistent high mortality rates, among children, the Integrated Management of

Childhood illness (IMCI) strategy was developed by the WHO and UNICEF in 1995, in

response to the challenges of providing health care for children. This strategy is a sector-

wide health approach that has been proven effective, cost effective and with the greatest

potential to reducing the burden of childhood morbidity and mortality in other developed

countries. IMCI ensures accurate identification and treatment of childhood illnesses,

prompt referral of severe cases, strengthening of preventive and promotive health

activities at home, communities and health facilities such as routine immunization and

growth monitoring among others. Nigerian government in 1997 with the support of WHO

and UNICEF implemented this strategy.

From the foregoing, and World Bank report (2003) the morbidity and mortality

rates of children under five year of age are still unacceptably high: 140 deaths 1000 live

birth. Again, NDHS (2003) survey revealed that infant mortality rate in Nigeria was 100

deaths per 1000 live birth while under-five mortality rate was 201 deaths per 1000 live

births. This trend calls for the need to find out whether these programmes are actually

12

provided and to determine level of use of these strategies and programmes known as

CHS. Why have the programmes not yielded the desired result of reducing infant and

childhood mortality rate? What is level of use of CHS over the years (2000 – 2007)? The

researcher wants to approach it from the view of level and trends of utilization of CHS in

Enugu State.

Purpose of the Study

The purpose of this study is to determine the provision and utilization levels of

CHS in PHC facilities in Enugu Urban. This has been split into the following specific

tasks to:

1. determine the provision of CHS for children under five years of age in PHC

facilities in Enugu urban;

2. ascertain the level of utilization of each of the eight components of CHS in PHC

facilities in Enugu Urban;

3. find out the trends in the utilization level of immunization services over the years

(2000 – 2007) PHC facilities in Enugu urban and

4. identify out any socio-economic factor(s) that could influence effective utilization

of CHS in PHC facilities in Enugu urban.

Research Questions

The following research questions were formulated to guide this study.

1. What are the CHS provided in the PHC facilities in Enugu Urban?

2. What is the level of utilization of each of the eight components of CHS in the

PHC facilities in Enugu urban?

3. What is the trend in utilization of immunization services from 2000 – 2007 in

PHC facilities in Enugu urban?

13

4. What socio-economic factor could influence effective utilization of CHS in PHC

facilities in Enugu Urban?

Hypotheses

The following hypotheses were postulated to guide the study and each of them

were tested at .05 level of significance.

1. There is no statistically significant relationship in the age of the mothers and

their level of utilization of CHS for their babies.

2. There is no statistically significant relationship between occupational status of

the mothers and their level of utilization of CHS for their babies.

Significance of the Study

The finding of this study provided useful information on the available CHS in

PHC facilities in Enugu State. From data that was generated, useful information on the

utilization level of CHS was obtained. Data generated showed that there was

underutilization of exclusive breastfeeding x=2.15.This information will help midwives

to intensify education on the need for feeding babies on breast milk exclusively to

mothers during antenatal sessions. Government and donor agencies sponsoring

Information, Education and Communication about exclusive breastfeeding also to

channel more resources towards that direction.

Data also revealed fluctuations in trends of utilization of immunization services.

This information will help the donor agencies as well as the government to endeavour to

make vaccines available at all times, to avoid break in continuity of use and the

subsequent high childhood mortality.

14

The data further revealed the influence of mother’s age (> .05), parity(p>.05),

level of educational attainments(p>.05) and occupation(>.05) on the utilization level of

CHS. This information will likely be useful to the midwives and clinic health educators

in determining their focus of attention and the target population in the provision of health

education services on the need for effective utilization of CHS.

The study also provided data on other factors that influenced the level of use of

CHS such as availability of medical personnel in the neighbourhood(77.15%), ignorance

of the need of CHS(40.06%), cultural beliefs(25.85%) among others. This information

may be useful to clinic administrators in the planning and monitoring of the activities of

the clinic such as health education, home visiting and practical demonstration of some of

these CHS services for proper understanding of mothers at all levels.

Donor agencies such as UNICEF, World Bank, European Union, USAID, and

DFID among others, have invested much in CHS in terms of human and material

resources, technical assistance, vaccine supply, among others. It is expected that

information generated will be of use to these agencies to evaluate the effectiveness of

their input in CHS and to make necessary adjustments. Efforts are on going to finding

solution to ever high childhood morbidity and mortality rates.

Scope of the Study

The study determined the provision and utilization levels of CHS in PHC facilities

in Enugu urban. These PHC facilities include Abakpa Nike PHC for Enugu north LGA,

Uwani PHC for Enugu South LGA and Asata PHC, for Enugu east-west LGA. Trends in

utilization of immunization services from 2000-2007, maternal socio-demographic

factors and other socio-economic factors that could influence effective utilization of

available CHS, were studied.

15

The study was limited to components of CHS offered in the clinics and at home

namely: immunization, oral re-hydration therapy, exclusive breasts feeding, growth

monitoring, nutrition education, antenatal and post-natal services. The reason for the

choice of components of CHS offered at home and the clinic is that most often they are

offered simultaneously. For instance when a pregnant mother goes to the clinic in PHC,

to receive antenatal care, she would be given advice and educated on: immunization,

exclusive breastfeeding, need for post-natal services and nutrition education. When she

delivers and comes for post-natal service, the CHS of immunization and growth

monitoring will be done at the same time. As she continues to attend child welfare clinic,

all CHS will be given along. She will be advised on how to give the ones given at home

such as exclusive breastfeeding as well as oral re-hydration therapy and treatment of

minor illness like malaria.

16

CHAPTER TWO

Review of Related Literature

There is abundant literature both local and foreign on CHS. Reviewed literature

was organized under the following headings:

1. conceptual framework,

2. factors influencing CHS provision and utilization,

3. theoretical framework and

4. empirical studies on utilization level and trend of CHS.

Conceptual Framework

WHO (2000) defined CHS as an aspect of modern health services specifically

designed for health promotion, disease prevention and treatment of children under five

years of age. CHS provides a channel through which medical and health care services can

be organized to improve the health and well being of the child, prevent diseases and

promote growth and development. Nelson (2002) added that CHS are geared towards the

totality of medical and non-medical management of children to protect and promote their

health in such a manner that will permit them to come into adulthood at their optimal

stage of development both physically, mentally and socially, so that they can compete

with life struggle at the most effective level. He maintained that concern for child health

should ante-dates conception and extend through the final phase of growth in the period

of adolescence, this is because the care of an unborn child as provided by adequate

supervision of pregnant woman and obstetrical care at time of delivery are directly

reflected and contributes to the well-being of the health of the child. He stressed that CHS

are chiefly concerned with the continual growth and development of the child.

17

According to Okeahialam and Grange (1988) children are vulnerable to diseases

and disabilities, so CHS are mainly concerned with protecting the health of the child to

ensure proper growth and development. They pointed out that CHS are part of Primary

Health Care (PHC). Under the auspices of maternal and child health care (MCH), whose

programmes were selected for optimal health of the child, this incorporates all aspects of

child health care and education and cover the periods of prenatal, natal infancy and early

childhood.

Bennett (2004) stated that the components of CHS cover the whole cycle of child

bearing and rearing in the family. It comprised: immunization services, promotion of

breast-feeding, oral rehydration therapy, nutrition education, antenatal and postnatal

services, treatment of minor prevalent illnesses as well as out-reach programmes.

Brunner and Saddert (2002) described immunization as intentional introduction of

weakened micro-organism in some small dose into the body to stimulate sensitive

reaction that brings about immunity against the invasion of such organism in larger

amount. Ajayi (2005) similarly pointed out that administering life-attenuated micro-

organism, produces antigen-antibody reaction that gives the body active immunity to

diseases. Standfeild (2004) stressed that, immunization is powerful weapon in reducing

childhood morbidity and mortality and that it’s action has been likened to that of an

umbrella shielding the child during perilous nutritional danger period from the onset of

weaning to three years.

Bryce, Fontine and Mansach (2000) described oral rehydration therapy (ORT), as

life saving oral fluid of sodium and water and pointed out that since its inception in 1979

it has rapidly become a corner stone in the programme for control of diarrhoeal diseases.

They maintained that it is the most potentially significant medical advancement in the

18

20th

century. Similarly, World Health Organization (2002) reported that rapid decline in

child mortality is attributed to ORT, which mothers can simply use at home. It is cheap

and always available to save children from dehydration and death and requires no special

expertise to operate. Growth monitoring according to UNICEF (2004) is aimed at

observing the physical growth and development of the child. It helps to detect growth

failure at an early stage, for proper management. Adequate growth will be monitored and

maintained ensuring survival and good health of the child. Standfield (2002) pointed out

that supervision and treatment of children includes observation and recording of child’s

progress using the “Road to Health” chart. Measurement of weight of the child, clinical

examination done, treatment given and immunization received are all recorded in the

chart. Moley (1985) observed that this growth chart is integral with the whole practice of

CHS, as it provides at a glance the child’s weight in graphic form as well as other

necessary information about immunization and family history of the child’s birth.

UNICEF (2004) stated that growth monitoring is an excellent means of interaction

between the mother and the health care workers in the care of the child. It can be

effectively used as a means of communication, education, and support, and maintained

that, of all the parameters used in monitoring growth, weight is the most suitable as it

changes rapidly, especially during infancy and early childhood.

UNICEF/WHO (2004) recommended that children should be exclusively

breastfed for the first four to six months of life and thereafter, introduced to appropriate

and adequate complementary feeds along with breast milk. This campaign has been

vigorously pursued in the hospitals and clinics in an effort to curb persistent high

morbidity and mortality rates, which are made worst by malnutrition.

19

Treatment of minor or prevalent illness was described by Cleason and Waldman

(2000) as medical treatment made available for children attending under five clinic. They

suggested that children brought into the clinic following acute illnesses or diseases should

be treated as quickly as possible. Apart from the curative aspect of treatment, the mothers

are also advised on preventive measures and the use of simple standard medicines such as

oral re-hydration sachet, anti-malaria drugs and simple drugs that could be packed in

envelops with dosage written on it in the language the mothers can understand. World

Health Forum - WHF (2003), reported that there are some progress in the availability of

treatment of common diseases like malaria fever and injures as well as essential drugs at

the first level of contact but that, lack of material and financing resources and poor

transportation system in the rural areas are still the major obstacles. The report suggested

that a good link should be maintained to the nearest hospital for possible and quick

referral of very sick children.

Standfield (2004) stated that health education borders on teaching people about

causes of ill health, persuading them to take action to avoid illness, by convincing them

and making them feel that they themselves want to make changes. He pointed out that

health education of parents in group or as individuals about the health and well-being of

their children is the most important duty of medical workers. He stressed that all health

educators in child welfare clinics, practice what is being preached, especially on matters

of cleanliness, toilet facilities and nutrition. He maintained that some clinics have become

more actively involved and identified in their work with the local communities using

culturally and locally acceptable food for children during weaning period to prevent

malnutrition and stunted growth. He noted that for the teaching to be realistic,

demonstration of methods of preparation and preservation of these foods are necessary.

20

Bennette (2002) stated that outreach services are health care services rendered out

side health care settings. Such as house-to-house immunization, school health

programmes and community health. The aims are to provide health services to

individuals, families and communities in their own environment and with their own

participation. Emphasis usually is on preventive measures and health education on

healthful behaviors and habits.

WHO (1997) defined primary health care as essential health care based on practical,

scientifically sound and socially accepted method and technology made universally

accessible to individuals and families in the society through their participation and at the

cost which the country can afford to maintain at every stage of its development in the

spirit of self reliance and self determination. Similarly, Starfield (2004) defined primary

health care is defined as the provision of continuous, comprehensive and coordinated care

to populations undifferentiated by gender, diseases or organ system. She stated that

primary health care (PHC) is the provision of accessible, integrated, bio-psychosocial

health care services by health care workers who are accountable for addressing large

majority of personal health care needs, developing sustained partnership with the parents

and practicing in the context of family and community. She pointed out that the effort is

to facilitate a shift from the provision of episodic care to delivery of a coordinated

continuum of care, emphasizing on PHC within referral network. She maintained that

primary care should provide the best mechanism to ensure the provision of quality care.

Guaghiardo (2004) stated that PHC is recognized as the most important form of

health care for maintaining population health because, it is relatively inexpensive, can be

more easily delivered than specialty and inpatient care, and if properly distributed, it is

most effective in preventing disease progression on a large scale. He maintained that

21

access to PHC is recognized as an important facilitator of overall population health. The

concept of PHC is a strategy for health for all, based on people and health needs or

problems. The appeal and political commitment of PHC therefore cut across economic

and ideological boundaries. His statement tallied with that of Clearson and Waldman

(2000), that the concept of comprehensive PHC is further enhanced when we consider the

ideas that health for many individual is most meaningful when defined by the individual

himself.

According to the report of World Health Forum (1987), the concept of

comprehensive health care at primary level can be seen in country’s action in

encouraging their health system and expanding the health delivery infrastructure based on

it. An encouraging sign is the increased involvement of communities and non-

governmental organizations in health care decisions. This kind of partnership is just an

expression of democratic principles. It is also a basic requirement for effective and

equitable planning, especially in countries where the ratio of health expenditure to gross

national product is dwindling.

Jelliffe (1992) pointed out that the organization of CHS depends to some extent

on historical and social background of the country to which they apply and not on the

country to which they have reached a high degree of effectiveness, for instance Maternal

and child health services dates back to the Bible times and was recorded in Exodus

Chapter 1:15 to 21.

Ejifugha (2001) pointed out that in Nigeria MCH services were solely the domain

of traditional Health Care Providers and that the advent of colonialism, ushered in

orthodox medical services for members of the colonial master’s family, armed forces and

government officials. Religious missionaries following colonization actually gave

22

meaning to orthodox health care for mother and child. For instance Reverend father

Borgero in 1861 established dispensary that offered MCH services. Later in 1866 Rev.

Sister Maria introduced nursing services for pregnant women and their babies. From

thereon, maternity services spread and midwives were trained on the job. Health

education on harmful traditional health practices against children, and utilization of local

food during weaning and early childhood for good health of the child were done by the

missionaries of the Presbyterian Church. Among them was Mary Slessor who abolished

killing of twins. Akinsola (1993) stated that through the effort of the missionaries,

maternity and hospitals grew and spread nation-wide. The international organizations

mentioned above also extended their services to Nigeria, strengthening and supporting

the health care system and providing human and material resources until the birth of

Nigeria ministry of health in 1900.

UNICEF (2000) reported that the dawn of twenty first century was so tragic that

one out of seven Nigerian children died before his or her fifth birthday. A baby born in

Nigeria was 30 times more likely to die before the age of five than one born in an

industrialized country. Following this trend of high mortality among children, Dr.

Oluwole who was the first Nigerian assistant in the Nigerian Ministry of Health,

embarked on provision of MCH services. In 1925 he established the famous Massey

Street Dispensary to offer health services to children.

According to Ejifugha (2002) the advent of Nigerian civil war between 1967 and

1970, made the health situation of Nigeria children worse. All international agencies

(International Red Cross Societies, DFID, WHO, UNICEF) brought aids to save children.

After the war in 1970, CHS was improved upon in the 3rd development of national health

plan with the support of WHO, UNICEF and International Red Cross Society (IRCS).

23

The provision of comprehensive health care services according to Guaghiardo (2004) was

based on Basic Health Services Scheme (BHSS) and disease control among others.

Health centres were established that offered CHS. Immunization though was existing was

not popular. Only a handful of people were immunized. WHF (1987) reported that

immunization coverage before 1977 was 9 percent in Nigeria. With the establishment of

expanded programme on Immunization (EPI) in 1977 more PHC were also established

and public health workers were trained to deliver health care services to the populace in

their communities. Even then, childhood mortality was still very high as reported by

UNICEF (1980). Infant mortality according to this report was estimated at 85 deaths per

1000 live birth. EPI took off in 1978 in Nigeria, but due to lack of vaccines supply, non-

availability of cold chain system and vaccine delivery, it could not be sustained.

Federal Ministry of Health (2001) stated that EPI pilot programme was launched

in Owo LGA in Ondo State in August 1983 as a corporate effort of local government,

federal ministry of health and UNICEF. The aim was to correct previous deficiencies in

the programme. A new vaccine distribution system based on ice pack cold boxes was

developed. After 12 month of operation in Owo, there was a successful coverage of 83%

from the previous 9%. Based on the success at Owo, a national plan was developed and

approved by federal and state ministries of health. EPI programmes were than launched

nation wide on the 20th

of October 1983 with the support of UNICEF who supplied

vaccines. Since then, CHS especially immunization have been receiving attention by the

Nigeria government. FMH also stated that Nigeria’s national health policy objective is

health care delivery through the provision and expansion of PHC, which was adopted in

1987.

24

The PHC approach is basically similar to BHSS, which had been Nigeria’s

strategy for provision of health for all her citizens prior to adoption of PHC in 1987,

except for a new emphasis on intersectoral linkages and greater community participation.

Strengthening and sustaining the PHC system within the national health policy has been

the focus since early 1990s, which resulted in the creation of National Primary Health

Care Development Agency (NPHCDA). The NPHCDA is expected to strengthen PHC

implementation through provision and supervision of technical assistance to the LGAs.

Recognizing the inherent problems that exist in the health care delivery system, the

World Bank. Agricultural Development Bank (ADB) and DFID are assisting the Nigeria

government in health sector reforms with a particular emphasis on improving

immunization services.

FMH (2004) stated that as part of effort to revitalize PHC, which is basic for

improved CHS, the Nigeria government recently constructed 200 model health center in

200LGA nation wide. Also the NPHCDA is revitalizing Bamako initiative in its model

LGAs. The initiative was in the 1990’s to strengthen PHC through adequate supply of

basic drugs, community involvement in the management of health care and financing.

Presently, routine immunization is implemented in LGA with the state government and

NPHCDA providing supervision, monitoring and evaluation with technical assistance in

capacity building and training.

World Bank (2003) reported that despite all the plans and polices, poor

coordination of these activities between the three tiers of government have been

responsible for unacceptable high mortality and morbidity rate among children under

5years of age. High mortality (140 per 1000 live births) are largely due to five major

childhood illnesses, chief of which is malaria. The other illnesses are acute respiratory

25

tract infection (ARI) Diarrhea, measles and malnutrition. The Integrated Management of

Childhood Illness (IMCI) strategy was developed by WHO and UNICEF in 1995 in

response to the challenges of providing quality health care for children. Prior to the

strategy’s conception, most effort were limited to vertical programmes, such as control of

diarrhoea disease (CDD) and ARI control among others. These programmes were not

very successful in reducing mortality in developing countries, partly because most of the

activities were donor-driven in Nigeria as in most other developing nations.

According to World Bank (2002) this strategy IMCI is a sector-wide health

approach that has proven effective, cost effective and which has been the greatest

potential to reducing the burden of childhood diseases. IMCI ensure accurate

identification and treatment of childhood illnesses, prompt referral of severe cases,

strengthening of preventive and promotive activities in the home and communities health

facilities such as routine immunization and growth monitoring According to that report

the Nigeria government began implementation of IMCI in 1997 with the support of WHO

and UNICEF, following the adoption at the National health council as main trust of all

child survival effort.

UNICEF (2003) reported that vaccine preventable diseases (VPD) and

immunization have received the greatest attention of all child survival strategies recently

owing to the global effort at eradicating poliomyelitis (Polio.) Polio eradication in

Nigeria is being achieved through improving the coordination between partners and

government to ensure effective and efficient implementation of activities, conducting

high quality immunization activities. National immunization days (NIDS), selected

national immunization days (SNIDS) and mop ups as well as vitamin A supplementation

to reach all children less than 60 months of age, using the skills developed and resources

26

mobilized for polio eradication to achieve the greatest possible benefit for routine

immunization services and disease control in general. For effective implementation of the

immunization strategy, NPI has received a lot of international support from partners in

the International Child congress (ICC), especially from WHO for surveillance and

technical issues on immunization, from UNICEF for procurement and supplies of routine

immunization, USAID for social mobilization, finance and training as well as Rotary

International for advocacy and social mobilization at the grass root level.

Other partners as the European Union (EU), Department for International

Development (DFID), Japanese International Cooperation Agency (JICA) and Canadian

International Development Agency (CIDA) have provided support for routine

immunization in Nigeria. Local organizations such as Nigeria Red Cross society are also

collaborating with the national efforts when necessary. Presently, UNICEF (2005) noted

that remarkable progress have been made towards achieving polio eradication goal, with

about 47 million children being reached even in the very difficult and hard to reach areas.

Despite this success the report lamented that there seems to be resurgence in the number

of confirmed wild polio cases in 2002 where about 77 cases were confirmed. It was also

noted that Nigeria’s modest achievement towards polio eradication and coverage rates for

immunization are slowly rising.

According to UNICEF (2004), despite the fact that more than 50 percent of

childhood mortality and morbidity are attributed to the underlying problem of

malnutrition, childhood nutrition has not received attention in Nigeria in comparism to

the magnitude of the problem. For instance, the Food and Nutrition policy approved in

1998 and published in 2001 is yet to be launched and disseminated nationally. Modest

achievements in nutrition include the formation of National Committee of Food and

27

Nutrition (NCFN). NCFN’s institutional framework has been reported weak; therefore

USAID in collaboration with other stakeholders formed coalition of nutrition partners, to

ensure that nutritional issues are placed high on the national agenda. Membership of

nutrition partners includes the NCFN, WHO, USAID, UNICEF, International Institute of

Tropical Agriculture (IITA), BASICS, Policy Project, Nutrition Society of Nigeria, Helen

Keller International and Food Basket of Nigeria. Other accomplishment includes the

approval of the food and nutrition policy in 1998, the launching of National Breast

feeding Policy and the implementation of Exclusive breast feeding through the Baby

Friendly Hospital Initiative (BFHI), and in accordance with other related policies such as

the food and nutrition policy approved in 1998, the MCH policy in 1994 and Health

Sector Nutrition Policy. All these accomplishments have raised awareness of the

advantages of exclusive breastfeed.

UNICEF (2003) stated that recently, in September 2002, the NCFN with the

assistance of UNICEF drew up a draft national action plan for micronutrient Deficiency

Control in Nigeria in order to achieve the target set out in the food and nutrition policy. It

pointed out that there was a plan by the nutrition partners to develop a strategic plan of

action for nutrition to facilitate effective implementation of food and nutrition policy.

According to Federal Ministry of Health (FMH) (2002), the relationship between,

maternal morbidity and mortality and high infant and under five morbidity and mortality

as well as the contributions of underlying factors are described as dependent on each

other. For this reason, the report stated that Nigerian government has identified safe

motherhood initiative as priority strategy for reducing the prevailing high maternal

mortality. Safe motherhood committees have been established at national, zonal and state

levels for advocacy and technical support. The report noted that UNICEF’s also

28

supporting the federal government of Nigeria (FGN) to educate women in public health

institutions about women and child bearing as a follow up to the baby friendly Hospital

initiative (BFHI).

WHO and United Nations Family Planning Agency (UNFPA) gives their support

by training of large number of birth attendants, upgrading the skill of midwives in life

saving skills as well as medical officers. Other components of making pregnancy safer

initiative (MPSI) includes provision of adequate equipment for quality health care

delivery and emergency obstetric care, functioning of referral system between PHC

facilities which are the basic essential obstetric care facilities and secondary health care

facilities which are comprehensive essential obstetric care facilities within the same

LGA. USAID’s contribution includes policy, work strategy development, and advocacy.

Although community based activities are mostly expanding, these activities, the report

pointed out, are mostly inadequate giving the magnitude of most vulnerable population,

especially since the rural communities and some zones in the country are still grossly

underserved. World Bank (2003) stated that in the global attempt towards efficient CHS,

the international Federation of Red Cross 2005 mission is to improve the health of

vulnerable people by mobilizing the power of humanity.

Factors Influencing CHS Provision and Utilization

CHS are influenced and affected by many factors ranging from pre-conceptional

factors to government polices on health care delivery. According to Clearson, Edward,

Mawji and Pathmanathan (2000), childhood and infant mortality rate are direct indication

of general health status of the child and services offered. They pointed out that factors

affecting CHS includes proximate factors such as

29

(1) Medical and non-medical factors during antenatal periods (care at birth,

preventive and curative care in the postnatal periods).

(2) Maternal factors such as maternal age, parity and birth intervals

(3) Household and community level factors such as water supply sanitation and

housing.

(4) Socioeconomic development and availability of health services.

Diamond (2000) pointed out that child health care begins from conception through

labour and there after. He argued that good antenatal care is important to future

development of the child and that attending maternity clinic at regular intervals during

pregnancy will ensure that any problem, which may impede feotal development and

subsequently the health of the child in the future, are detected and prevented or treated at

earliest stage possible. Wellera and Barlow (1983) similarly agreed that in achieving

good health for the child, recognition has to be given to the fact that childhood mortality

for example does not depend on intervention in childhood alone, but antedates

conception. They argued that the health of the mother, father, sibling, grand parents and

blood relatives influence the health of the child through inheritance. For this reason they

suggested that good history taking and proper medical investigations during antenatal

clinic periods is important to elicit and handle such problems that can hamper child health

early. Rustain (2000) similarly stated that regular antenatal care by a physician or a

certified midwife has had a distinct effect in the reduction of both maternal and infant

mortality.

The care given the child in the natal period goes a long way to determine his

health status. According to Bash (1981) the condition of labour, instruments used, the

competence of the health care giver that delivered the woman, all have direct influence

30

on the life and health of the neonate. She stated that the total of these factors are

measured by perinatal mortality and morbidity rates. Butler and Parer (2005) agreed and

stated that the most important goal of obstetrics is reduction of perinatal and infant

mortality and morbidity. They pointed out that infant and perinatal mortality and

morbidity are largely attributed to two courses: Trauma and hypoxia. Traumatic damage

which may be due to precipate uncontrolled intracranial injury or errors of obstetrical

management such as allowing prolonged labour or attempting difficult instrumental

deliveries. Jelliffe (1992) stated that many children suffer from illness about the time of

birth especially in tropical countries where many more infants become sick and die

because medical care is frequently inadequate and expensive, while the health of the

mother is poor and the surrounding into which the child is born are often dirty and

unsanitary. He suggested that good supervision of the mother during pregnancy and child

birth is very important in improving the health of the infant and that competent and

skillful measures should be taken to avoid any form of injury which can leave the child

disabled for life.

Preventive and curative care during postnatal periods ranges from the periods of

birth to other periods of growth and development even to old age. According to Lopez

(2000), the WHO’s challenge of health for all by the year 2000 has been associated with

a number of campaigns aimed at reducing child mortality and improving the health of the

child. In his study, he noted that about an estimate of 15million children under five years

in the developing counties died each year and that majority of these deaths were

preventable with current developed technology as evidenced by extremely low child

mortality prevailing in the developed and rich countries.

31

Kessler, Favin and Melendez (1986) pointed out that the world Health Assembly

in 1994 called for crusade to immunize all children by 1990 against major childhood

killer diseases of which the establishment of expanded programme on immunization in

1977 has laid the grand work for greatly extended coverage. Omar, Ahmed, Alan, Lopez

& Inoue (2000) confirmed that both national and donor resources were aimed more

broadly at achieving further reduction in child mortality through various child survival

programme such as USAID’s child survival initiative. According to them, this initiatives

set loosely defined strategies for achievement of certain child mortality targets among

participating countries. The achievement of these targets was principally sought through

improvement in immunization coverage, greater use of oral re-hydration therapy,

improvement in the health and nutritional status of mothers and children, and a reduction

in the number of high-risk births. Examples of such programme are growth monitoring,

oral re-hydration therapy, Breast-feeding promotion and immunization as initiated by

UNICEF. Expand programmes on immunization (EPI) initiated by WHO, combating

childhood communicable Diseases (CCCD) initiated by united state centre for disease

control and prevention. The specific strategies for achieving these broad objectives were

left to individual countries Demographic and Health Survey (2005) reported that in the

regions of the world, some appreciable progress has been made and reported, in the

control of communicable diseases of childhood although the lack of reliable information

make analysis of actual progress difficult. Some countries have indicated that

immunization, diarrhoeal disease control and better nutrition have direct impact on

infant/child survival.

Maternal factors are very important in relation to the health of the child.

According to federal ministry of Health report (2004) the health of the mother is very

32

important in determining the health of her children and rest of her family members.

Maternal age at birth has a direct relationship with birth out come and the health of the

child. Yannes, Chelala and Blaistein (1994) observed that high risk pregnancy and

childbirth exists in women at either extremes of child bearing age. In their study of

fertility survey of Asian countries, it was shown that mothers aged 18 years and below

and 35 years and above were twice more likely to loose their babies than those aged

between 20 – 30 years. They pointed out that this could be due to reasons that mothers of

upper, 35 years and above have higher tendency of their babies developing birth defects

than those of lower, between 20 – 30 years. Again they argued that problems such as

placental insufficiency and cord prolapse that are leading causes of perinatal deaths exists

more in older women. They also noted that incidence of birth complications are higher in

teenage mothers than in intervening age group. Similarly, Braimoh, Unigbe & Dumeko

(1995) reported that a high proportion of high risk pregnancy exists among women who

have been neglected as children and married off as adolescents, poor, illiterate,

underdeveloped and subject to harmful traditional practices.

The number of children and spacing between each birth are also very crucial

determinants of maternal and child health. Carla, Abouzahr & Erica (1992) reported that

complications of pregnancy and childbirth among African women are compounded by

high parity. Diamond (2000) agreed with them, stating that there is little doubt that high

mortality rates are associated with high rates of childbearing, early childbearing, short

birth intervals and high parity. According to federal ministry of health report (1988),

child spacing of less than 2 years between births is especially hazardous.

National Demographic Health Survey NDHS (2003), reported that pregnancy put

a lot of strain on the woman for which she needs to recover well, physiologically,

33

mentally and nutritionally before another pregnancy. Failure to do that leaves her with

danger of fatigue, malnutrition and physiological complications that can affect the life of

an unborn baby leading to low birth weight. Royston (2000) concluded that poor health

of the woman, complications of pregnancy and child birth and low birth weight of babies

as well as wide spread of malnutrition and infection are largely responsible for many

cases of illness and death among new born babies, infants and young children and their

mothers. All aggravated by too many pregnancies that occur either too early or too late

and too closely together.

Maternal education apart from being a proxy for income level is also a very

powerful factor influencing the health of the child. Tabah (1987) stated that in

implementing child survival strategies, it must not be forgotten that the health of the

newborn, the standard of mortality level depends on the health and educational level of

the mother. He mated that the uneducated woman bears the largest number of children

and loses most, fails to understand growth chart or the importance of breast-feeding and

makes least use of available child health services. She it is that is easily subjected to

erroneous social, economic and cultural constrains and to conflicting advice from

traditional and modern health care systems regarding the care of herself and her baby.

According to Diamond (2000) infant and child mortality rates declines unequivocally as

educational levels of the mother increases.

Material malnutrition has been reported in medical literature to be associated with

low birth weight infants. Carla and Erica (1993) stated that the high incidence of low

birth weight babies in the developing counties is mainly attributed to maternal

malnutrition. They pointed out that low birth weight of babies is direct reflection of poor

34

nutrition and health status of the mother before, and during pregnancy which continuous

to be a major problem.

Parental health behaviour and life style is another factor that affects the wellness

of the child. According to Ama (1986) the physiological factors that affect conception,

pregnancy and delivery have profound influence on the health of the child. These factors

according to her includes: parental genetic make-up, nutritional status, physical structures

of the reproductive organs, life and habits such as cigarette smoking during pregnancy,

alcohol consumption and drug abuse. All these temper with proper feotal development

resulting to low birth weight.

Household and community level factors include: water supply environmental

sanitation, housing as well as availability and cost of health care services. According to

Jelliffe (1985) the world populous population lives in less technically developed

countries mostly. In most of these areas, he noted that water supplies are unprotected and

unclean in addition of not being adequate. Toilets and other facilities for excreta disposal

are also inadequate if they exist at all, so that defecation is often performed in the

adjacent bush, water or other inappropriate places. Household rubbish is frequently

dumped indiscriminately, constituting nuisance and breeding place of flies.

Contamination of water supply according to him has accounted for high incidence of

infantile diarrhea, dysentery and typhoid, at the same time intestinal parasites especially

Ascariasis and Ancylostomiasis, which is widely spread in children often with heavy,

worn burden. He argued that if hygiene is poor in the community, judged by poor

housing, water supply, and refuse disposal, then illness will be common among all ages

especially among children He stressed that poor water supply results in children being

35

dirty and developing various skin diseases and that poor refuse disposal will lead to flu-

breading and likelihood of spread of diarrhea diseases.

Housing plays vital role in the health of individuals. According to Rostein (2000)

housing varies greatly, some dark, leaky and poorly ventilated, especially at night He

pointed out that in most tropical countries, it is customary for all doors and windows to

be tightly shut against thieves, wild animals and evil spirits. Therefore a family of ten or

more may sleep together in one room that is tightly sealed and droplet infections or

respiratory tract infection including tuberculosis develops very easily while skin sepsis is

common as result of hot dirty housing.

Child factors are those factors inherent in the child that can affect and influence

his health and well-being. Such as his genetic make up, immunization status, nutritional

status, birth order and gender preference. According to Cornacchia, Olsen & Nickerson

(1991) heredity is transmission of trait from one generation to another. They pointed out

that the factors which determine the physical, mental and emotional patterns of the child

to be are operative in each parent before conception and that those factors also determines

the child’s survival.

Cranley (1983) pointed out that the environment where the embryo grows and

develops influences the health of the feotal and unborn and that such factors includes

intrauterine oxygenation, nutrition and selected tetratogens. He stressed that the potential

effect of our environment such as polluted air and water on health and well being of the

child cannot be overemphasized and that pollutants such as propellants used in aerosol

cans have been implicated as possible dangerous to the feotus and the increasing

environmental level of radiation can also have an adverse effect on the developing fetus

and on the chromosomal make-up.

36

Birth order has a lot of influence on the health of the child and use of child health

services. According to Okeke (1989) first born usually enjoy attention all round from his

parents and that maters pertaining to his health is not joked with. He noted that as the

number of children increases, economic situation diminishes as the role of proper care of

children increases, resulting to the inability of the parents to give proper attention to

health needs of all the children.

Childhood diseases are health threats to the child survival. A (1999) multiple

indicator cluster survey reported that the major causes of mortality and morbidity in

children under-five years of age are diarrhoae, respiratory infections, malnutrition,

vaccine preventable diseases and malaria. A low birth weight predisposes the child to

attacks of childhood diseases and compromises his survival. Bennette (1992) stated that a

birth weight of 2500g is considered average in obstetrics, less than that is low birth

weight. UNICEF (2001) reported that low birth weight accounts for 20% to 30% of child

mortality in the developing world. That report maintained that low birth weight infants

are generally more susceptible and less resist to infections. Chandrasekhar (1982) also

pointed out that mortality among children weighing 2.500kg or less at birth are many

times more than the mortality among those who weigh more.

Cultural influence of parents and care given reflect directly on the health and well

being of the child. Okeke (1987) stated that the manner in which children have been

cared for from conception through birth depends on how the adult members of the society

thought of the Child. King, King & Mortodipoara (1987) pointed out that the value of a

society is presented in the groups, their religious belief and superstition. They pointed out

that although some of these cultural traits and customs are beneficial; some are very

harmful to the health of the child. The good ones includes: breastfeeding for longer

37

periods and carrying babies on the back while the harmful ones ranges from mixing soil

and saliva to treat baby umbilical stump, an act which can predispose baby to neonatal

tetanus and death.

Gender preference is another factor that affects the use of child health services.

Walter and Ankonah (1995) reported that 70percent of 1, 200 mothers interviewed

preferred male to female babies. The parents will do everything to protect the health of

their preferred child, while the un-preferred child should expect anything.

Theoretical Framework

This study is based on the pathway of survival model. According to Lopez (2000),

this model was first presented by Mosley and Chen in 1984 and recently adopted by the

World Bank as life cycle approach. The model shows the relationship between the health

system, the household and the community, in terms of childcare. Mosley – Chen

Framework therefore includes both social and biological variables related to child health

care. It assumed that all influences on childhood mortality at the individual, household

and community levels operate a set of common mechanism such as maternal factors,

environmental and social factors in health care delivery.

Diamond (2000) pointed out that the pathway of survival is a guide that

distinguishes between preventive behaviors such as breast feeding that can be

implemented entirely at home such as immunization that require more direct effort from

the health care system. He pointed out that this pathway shows how the management of

childhood illness can also be carried out at home in many instances with the mother being

responsible for taking critical decision of when external help and support are required.

Daimod (2002) stated that World Bank in adopting the model included the more distal

role of government policies and actions and so the revised framework includes health

38

system interventions as well as promotion of appropriate household and community

behavior as essential immediate steps between policy and out come. It recognizes that

integrated management of pregnancy, child hood, control of communicable and non -

communicable diseases contribute one set of influence on household behaviors yet

policies that determine the availability of health care supporting, food and sanitation and

other related amenities such as water supply are equally important. This model

recognizes that what happens in the household and the communities are most proximate

determinant of utilization of available health care services.

39

Fig 1. The Pathway to Survival Programme Guide

Source: Bulletin of WHO 78,(10) Ref. 31 WHO 0038 pg 1241

INS

IDE

TH

E H

OM

E

Breastfeeding, Weaning, hygiene,

and other preventive care

behaviours

Wellness Illness

Mother

recognizes

illness

Mother

provides

quality care

Mother

provides quality care

Improved

health

and

survival

Immunization, water/sanitation

and other

preventive services in

community

OU

TS

IDE

TH

E H

OM

E

Provider

giver

quality

care

Mother

seeks

outside

care

Informal

community

services

“Western”

health

services public and

private

Provider

gives quality

care

Mother accepts

referral

Referral

level

facility

40

Fig. 2. Determinants of child health outcomes

Source: Bulletin of WHO 78 (10) Ref. 31 0039 pg. 1241

Empirical Studies on Utilization Level and Trend of CHS

Nigeria’s estimated population of 140 million people makes it the largest country

in the sub-Sahara Africa and the 10th

most populated country worldwide. Out of this

number, 63.7 percent live in rural areas, 45 percent less than 15 years and 20 percent

under five. The sheer number of children in Nigeria, demand that CHS issues be placed

in the forefront of the nation’s agenda. A Demographic and Health Survey conducted by

National Population Commission (NPC) and UNICEF (2001) reported that childhood and

infant mortality rate are exceedingly high and that Nigeria ranks 15th in the world among

countries with high mortality of under fives and that Nigeria is one of least successful of

Government policies and actions Public sector and markets Households/communities

Health nutrition and population polices, e.g.

financing and

expenditure, provision, stewardship,

intersectoral,

evaluation and monitorigng

Other governmental

policies e.g. for

infrastructure, transport,

energy, agriculture,

water and sanitation,

etc.

Availability,

accessibility, prices

and quality of public and nongovernmental

health services

Availability, accessibility, prices

and quality of food,

energy, roads, water

and sanitation, etc.

Household resources:

income, assets, land,

education, etc

Household behaviour: use of the

public and private

health services, dietary and sanitary

practices, maternal

factors, care and stimulation of child,

etc.

Child

health out comes:

health and

nutritional status,

mortality

Community factors:

environment, culture,

values ecology

geography, etc

41

African countries in achieving improvements in child survival in the past four decades in

spite of advances in universal immunization and oral re-hydration therapy (ORT).

UNICEF (1999) Multiple Indicator Cluster Survey (MICS) showed that under

five mortality rate (U5MR) was almost five times higher in rural areas than in the urban

areas and that almost twice as many children die before the fifth birthday in the northwest

than in the southwest of Nigeria. The major causes of such deaths include malaria, ARI,

diarrhea which is made worse by malnutrition and vaccine preventable diseases. The

report stated that the underlying factors include childhood malnutrition, poor

immunization status, and household poverty and food insecurity. Other factors are

maternal illiteracy, poor living conditions: housing, water and sanitation, as well as poor

home practices for childcare during illness. The same report noted that also alarming is

the prevalence of HIV/AIDS among pregnant women with resultant mother-to-child

transmission which adds to the burden of child mortality and morbidity in Nigeria.

Guagliardo (2004) pointed that childhood immunization remains an important

strategy in reduction of mortality and morbidity from common Vaccine Preventable

Disease (VPD), UNICEF, WHO and NPI stipulated that a child should receive

vaccination against tuberculosis (BCG) at birth, four doses of oral polio, and three doses

of DPT against Diphtheria, pertusis and tetanus and one dose of measles vaccine by the

age of twelve months UNICEF (2001) reported that VPD (vaccine preventable diseases)

have been implicated in the death of more than 20 percent of children under five. In that

international comparative data of same report, it was shown that Nigerian immunization

coverage rates is among the worst in the world. The (1993) World Development Report

on the sub-Sahara Africa Model in the burden of disease noted that Nigeria lost 41 years

of healthy life per 1,000 populations due to VPD. The (1999) National Demographic and

42

Health Survey (NDHS) noted that only 14 percent of children had received all the above-

mentioned vaccines by 12 months of age and 17 percent had them by 23 months. It also

revealed that 38% of Nigeria children surveyed had not received any vaccination when

compared with data from the (1990) NDHS, it is distressing that the population of

children less than 23 months vaccinated against childhood diseases have declined from

30 percent in 1990 NDHS report to a shockingly low 17 percent in 1999.

Similarly data from the NPI (2004) revealed that routine immunization coverage

levels of more than 80% (that is BCG 85%, DPT3 65 percent) by 1990, was followed by

decline of 13 percent for BCG and 19 percent for DPT 3. among the counties receiving

assistance from the Global Alliance for Vaccine and Immunization (GAVI). Nigeria

ranked 7th

with decline immunization coverage. Although the decline was reported to be

for all types of vaccines, it was greater for DPT and Polio than for BCG and Measles,

probably because of shortage of vaccines in Nigeria from 1996 to 1998. This decline was

reported to be worse in the rural areas. Urban children are twice more likely to be

immunized than the rural children. This could be probably as a result of awareness of the

importance of immunization and access to health services. Multiple Indicator Clusters

Survey – MICS (1999) also reported that vaccine coverage was lowest among children

whose mothers had no secondary or higher education. UNICEF (2004) reported that the

data of MICS of (2002) stated that immunization coverage in African declined

tremendously in past five years. For instance, Liberia has the immunization coverage of

23 percent, Niger 23 percent, Sierra-Leone 23 percent, Somalia 30 percent, Congo (DRC)

31 percent Afghanistan 31 percent, Nigeria 38 percent, Burkina Faso 42 percent, Togo 43

percent, Ethiopia 45 percent, Djibouti 46 percent and Cameroon 48 percent.

43

WHO (2003) maintained that Nigeria remains one of the largest reservoirs of wild

poliovirus, attracting the attention of World effort to eradicate polio globally by 2002 and

certify the world polio free by 2005. Since the onset of the concerted efforts of the NPI

and the international donor partners to eradicate polio in Nigeria via NIDs and SNIDs,

the trend in the number of confirmed wild polio cases continued to be upward as a result

of obviously better surveillance of acute flaccid paralysis (AFP). Surveillance with 29

and 58 confirmed wild polio virus (WPV) cases in 2000 and 2001 respectively. Between

January and August 2002, a total of 77 WPV cases were reported and confirmed. Polio

eradication in Nigeria still remains a challenge at the end of 2002, as routine

immunization level nationally and throughout some regions (northwest and central

regions) is low.

Nigeria also reported a high incidence of neonatal tetanus. National Multiple

Health Indication Survey - NHMIS (2002) data showed that 11 percent of infant

mortality in 1999 was attributed to tetanus, reflecting low level of antenatal care among

pregnant women. Tetanus toxiod (TT) immunization during the antenatal period has been

shown to have a greatest impact on neonatal mortality from tetanus than place of

delivery. Two doses of TT during pregnancy offer protection for three years; although

this is not optimal, a woman requires five doses during the stipulated period to acquire

full protection during childbearing years. However, the 1999 National Demographic

Health Survey - NDHS reported that only 44 percent of mother with a birth in three years

preceding the survey received two or more doses of TT.

UNICEF (2001) reported that maternal mortality in Nigeria was high varying

between 700 and 800 deaths per 100,000 live births. The report pointed out that apart

from malaria, diarrhoeal illnesses, ARI and VPD, a large proportion of (30-40 percent) of

44

infant morbidity and mortality globally and within Nigeria could be attributed to

preventable factors during pregnancy and delivery. According to Lawoyin (2000) low

birth weight which underlies a significant percentage of early death in infant was reported

to be largely due to poor maternal weight gain during pregnancy, arising from maternal

morbidity especially malaria and HIV/AIDS.

The report of the study conducted by Njokanma and Olarewaju (1994) on MCH

indicated that Asphyxia and birth trauma contributed to high infant mortality and occur in

condition of obstructed labour (from cephelo-pelvic disproportion due to lack of essential

obstetric care. Lack of adequate ANC in most parts of the country particularly in the

northern region and rural areas have resulted in low TT immunization rates and the

consequently high prevalence of neonatal tetanus. The NDHS (1999) reported that two

thirds (64 percent) of woman with birth in the three years preceding the survey had

received ANC from a health professional, however marked urban/rural and zonal

difference exists. The proportion of pregnant woman who had no ANC in the rural areas

was almost four times higher than those in the urban areas (37 percent to 10). Comparing

zones 28 percent of woman received ANC in the northeast in contrast to 82 percent and

89 percent in the southeast and southwest respectively. Poor ANC coverage is reflected in

the utilization of T.T and high level of infant mortality rates (IMR).

Utilization of CHS implies both availability and accessibility of the health

services. According to NDHS (1999) Nigeria has about 18,258 PHC facilities, 3,275

secondary health facilities and 29 tertiary facilities. FMH (2000) stated that although

these numbers seems adequate 9 percent household surveyed in NDHS (1999) had no

access to any health facility, 34 percent had no private doctor and 24 percent had no

45

access to a pharmacy. The report noted that the nation’s health policy launched in 1988

and revised in 1996 has a goal of attaining a level of health that will enable all Nigeria to

achieve socially and economically productive lives with national health system that is

based on PHC. It is distressing to comprehend that only 17 percent of the population

had access to modern health facilities thus available PHC system under the national

health policy (NHP) was expected to correct the unsatisfactory coverage level.

PHC facilities are supposed to provide basic disease preventive and health

promotion services that include immunization services health education and promotion of

adequate nutrition as well as management of simple malaria, diarrhoea and other

common illnesses. PHC also provides ANC, family planning services and basic surgical

services. NDHS (2004) reported that despite the laudable goals of its health policies,

Nigeria continues to spend below the WHO stipulated 5 percent of its annual budget on

health care and that the care system has been plaque by problems of services quality,

including unfriendly staff, inadequate skills insufficient number of skilled workers as a

result of “brain drain” decaying infrastructure, unavailable equipment as well as chronic

drug shortage. Other factors includes a financial barrier, poorly designed cost recovery

mechanism, lack of effective community participation or real decentralization, weak

referral system among primary, secondary and tertiary care, overlapping vertical

programmes, reduced national funding and weak information systems. In addition the

attitude of the populace to public health services are poor. For instance NDHS (2002)

indicated that 26 percent of the house hold survived in Lagos state reported that

dissatisfaction with pubic health services because of cost (56 percent), unavailability of

drugs (33 percent) and long waiting periods to see medical practitioners (33 percent).

46

In the dearth of adequate and accessible health services, immunization is the most

affected child survival intervention. A study conducted by NDHS (2003) on the

availability of health services in the public sector facilities in the relatively well served

southeast zone of Nigeria, showed that most PHC services were not available in more

than 50 percent of the facilities surveyed and that although immunization was the most

widely available services, it only existed in about 45 percent of the survey facilities.

According to that report, factors in health services delivery that led to the previous

success achieved in immunization coverage in the late 1980s and early 1990s included

adequate funding, proper logistics, availability of power generation, information and

education (IEC) materials, and training packages for health staff. The snag at that time

and a lesson to be learned is that all these activities were overwhelmingly donor founded

and managed and also depended on massive and costly single-antigen mobile campaigns,

thus when the donor funding was withdrawn, coverage rates plummeted.

Following the picture above Djukanovie and Mach (1975) reported that not with

standing the shortage of all type of health care resources, the common occurrence is that

of underutilization of the available ones. He also quoted Kohn and White (1976) to have

indicated that many factors accounts for underutilization of available health care services

and includes: low socioeconomic status of the users, ignorance and poverty. The

researchers commonly identified higher correlation of poverty with level of utilization of

health services. Similarly Melatinema pointed out that cultural attitude and taboos are the

most significant correlates of utilization of CHS. Again Sandus in his study (1977) noted

that contact with health workers was the only statistically significant factor capable of

influencing utilization of health care services.

47

Guagliardo (2004) also noted in his study that availability of personal,

accessibility and cost of health services are strong factors influencing utilization of such.

Strivaster and Ramsal (1996) determined in their study that there is a significant

relationship between educational status and level of utilization of available health

services Alakija and Sofoluwe (1980) found out from their study that there was an

association between occupational status and utilization of immunization services.

Chan-Yib and Kraner (1983) conducted a study to determine the association

between education and breast-feeding practice among Chinese women. They found out

that those who were counseled on breast feeding before birth has 59 percent adoption

while those not counseled had 43 percent adoption of breast feeding practice. FMH

(1992) conducted a survey to determine the extent of utilization of ORT for diarrhoea

treatment in the home in 10 out 23 LGA in plateau state of Nigeria using sample of 9,282

children of five years of age from 6,378 households. The finding showed that all the

children had been given oral re-hydration fluid of one form or another. Only 11 percent

utilized Salt–Sugar Solution (SSS).

Royston and Ferguson (1985) conducted a study to determine the utilization of

maternity services world wide as part of global strategies for achieving health for all by

year 2000.They obtained information from 139 countries out of 157 WHO member

countries. They found out that 58 million (55 percent) of the 128 million infants born in

1983 were not delivered in the maternity clinics or units. They also found out that the

percentage of women who utilized pre-natal services exceeded that of those who utilized

intra-partum services. Ogunmekan (1977) conducted a study in Lagos to determine the

extent of utilization of immunization services. He studied a sample of 240 children. He

found a general low level utilization of immunization services. He noted that only 30

48

percent of children had DPT, Polio and measles immunization. 66.7 percent had BCG

and 74.5 percent Small-Pox. According to him, high level of utilization recorded for BCG

and Small-Pox immunization was because they requirement for birth registration.

According to the report of FMH (2002) one of the main reason for the low

utilization rates of public sector clinics has been the poor standard of facilities and care,

user charges also are perceived as high. NDHS (2001) stated that utilization of health

services are complex phenomena. Empirical studies of preventive and curative services in

Nigeria have often showed that the use of health service is related to availability, quality

and cost of the services as well as to social structure, health belief and personal

characteristics of the user. (MHIS 2003) reported that the study on maternal morbidity in

Nigeria showed that both bivariate and multivariate analysis confirmed that the mother’s

age at marriage had a significant and positive impact on the utilization of quality health

care services. Also the husband’s occupation showed a strong impact on the health care

utilization, indicating higher use of quality care for postpartum morbidity by wives of

business and service workers. The bivariate analysis showed that the numbers of

pregnancies prior to the index pregnancy are significantly associated with utilization of

post –partum health care.

Summary of Literature Review

CHS in the literature reviewed are those preventive, health promoting and early

disease treatment services offered to children under-five years of age to curb the scourge

of high childhood mortality rates. They comprise immunization services, growth

monitoring, breast-feeding campaign, oral re-hydration therapy, and nutrition education

and outreach services.

49

The level of utilization of these services was reported by experts to be influenced

by their availability, accessibility, affordability, attitude of users to health issues, attitude

of health care providers to the clients, socio- economic status of the users such as

occupation, social class, level of education and income as well as the country’s level of

development. In the trend of utilization, experts highlighted various reforms brought to

CHS by both government and non-governmental agencies as strategies for child survival

such as; improvements in immunization through EPI, NDI, to reach out to children even

in remote areas, establishment of NPHCDA to strengthen PHC implementation through

provision and supervision of technical assistance to LGA, development of IMCI by WHO

and UNICEF in response to the challenges of quality CHS, I CC for surveillance and

technical issues in immunization.

Also noted in the review of CHS was that the extents of utilization of CHS have

not met expected command of the WHO as various report noted that there is still

unacceptably high childhood mortality in spite of all efforts and strategies put in place

(UNICEF 2004). The review however never showed the level of utilization and the

availability of these new trends, of CHS in Enugu urban hence the need for the study.

50

CHAPTER THREE

Methods

This chapter describes in detail the research design, area of study, population,

sample and sampling technique, instrument for data collection and analysis employed in

the study.

Research Design

To accomplish the objectives of this study, descriptive and retrospective survey

research design were employed. According to Nwana (1982) cross sectional survey

design allows for the description of conditions, as they exist in their natural setting and

current state. While Gray, Polit and Hunger (1985) stated that retrospective studies are

expost-facto investigations used in epidemiological studies to retrieve data from records

on the past trends of health problems and peoples responses to them.

The use of retrospective survey method to collect information from PHC records

of immunization is necessary since the major CHS revolves around immunization

activities. For instance during immunization service programmes in the PHC other CHS

such as exclusive breast feeding campaigns, nutrition education, growth monitoring, oral

rehydration therapy and post-natal services are taught and emphasized. It was therefore

considered appropriate to use records of immunization services as a yard stick for

determining the trend of use of CHS, while questionnaire was used to elicit response to

the provision and level of utilization of CHS services.

Population for the Study

The population for the study was estimated to be 11,200 women of reproductive

age. The figure was arrived at by adapting the claim of Enugu State Plan of Action for

Survival Development Protection and Participation of Children and Women (2002).

51

According to NPC (2006), the total population of Enugu urban was 200,000,while the

total number of women in their reproductive age was 11,000. Fertility rate,therefore

(which is the number of women in their reproductive years, 15-49 years), was 5.5

percent.

Sample and Sampling Technique

There are many PHC situated in Enugu Urban that provide health care services

for the populace of the three LGAs that constitutes Enugu Urban

Stratified random sampling Procedure was employed to stratify the PHCs according to

LGAs. One PHC was selected by random sampling from each of the LGAs. Abakpa Nike

Primary Health care centre for Enugu North local government, Asata PHC for Enugu

East LGA and Uwani PHC for Enugu South LGA. The population of study from each

strata depended on the number of respondents who attend and utilized CHS in the PHC.

A pre-study visit was done by the researcher to find out the actual number of mothers and

their babies under five years of age that attend and make use of CHS in these three PHC

in Enugu Urban.

UNICEF (1999) stated that Enugu urban had a population of 200,000 and that 5.5

percent of this population were women of child bearing age (15- 49 years). By reason, it

is likely that not all women of this age group are still bearing children presently in Enugu

urban. Therefore a pre-study-survey was carried in each of the PHC to determine the

actual number of women and their children under-five years that attend and utilize CHS.

Data collected showed that 90 mothers and their babies attend PHC in Uwani PHC, 152

mothers and their babies at Abakpa Nike PHC and 68 mothers and their babies attend

Asata PHC on twice a week schedule, making a total of 310 mothers and their babies.

52

Nwana (1982) stated that one practice of sampling suggests that if population was

a few hundreds, a forty to fifty percent or more will do. Based on that, the researcher used

100% of the population from each PHC since they were few hundreds. That is 310

mothers and their babies.

Instrument for Data Collection

Two instruments were used for data collection: Provision and utilization of CHS

questionnaire (PUCHSQ) and Trends of immunization service inventory (TUISI) from

2000 to 2007. Both were designed by the researcher from literature reviewed and

contributions by experts in CHS, taking into considerations the objectives of the study.

The questionnaire consisted of four sections: A B C and D. Section A contained

four items on personal and social characteristics of the mothers that could give a clue to

the use of CHS. The mothers responded by ticking the options as it applied to them.

Section B contained 14 items on the provision/availability of CHS in each PHC of study.

The mothers responded by ticking as they applied to the PHC they attend. Section C

contained 8 items on the utilization of the eight components of CHS available in the PHC

facilities. The mothers responded also by ticking the options as applied to them. For

questions on immunization, that is question 7h, the mothers indicated by a tick whether

immunization schedule was completed by their babies. That is, taken up to 12 times and

above, 10-12 times, 7-9 times, 4-6 times, 1-3 times or not even once. UNICEF (2004)

stipulated that a child is expected to receive 12 doses of immunization before 12 months

after birth namely; BCG against tuberculosis at birth along-side with first oral polio

vaccine (OPV). DPT against (Diphtheria, Pertusis and Tetanus) for three doses. Booster

OPV for 4 doses, measles vaccine for 2 doses and HBV (Hepatitis B virus Vaccine) once,

making a total of 12 vaccinations at 12 months of age. During each immunization

53

schedule, vitamin A supplement is supposed to be given along, for all children under five

years. The same report stipulated that after 12 months, booster doses of these vaccines

should be given about five times before five years of age. That is, the booster doses of

OPV, measles, HBV, cerebro-spinal-meningitis, and vitamin A supplements. The

mothers ticked the options. Option 12 times and above, indicated completion of the

schedule. Section D contained 17 items on other socio-economic factors that could affect

and influence effective utilization of CHS.The mothers ticked as applicable to them.

Immunization Inventory designed by the researcher was used to obtain

information on the trends of utilization of immunization services over the years (2000 –

2007) in the three PHC in Enugu Urban.

Validity of the instrument

Face validity of the instrument were obtained through the judgment of five

experts from the Department of Health and physical Education, University of Nigeria

Nsukka. These experts were asked to determine the relevance of the items of the

instrument to the objectives of the study and components of CHS. Suggestions from these

experts were incorporated into the final draft of the instrument for data collection.

The instrument was pre-tested for clarity. It was administered on thirty mothers

attending infant welfare clinic at Asoro PHC in Benin City, outside the study area. The

mothers were asked to note and point out any ambiguity observed in the items on the

questionnaire, corrections were made accordingly.

54

Reliability of the instrument

The reliability of the questionnaire, Provision and Utilization of Child Health

Service Utilization (PUCHSQ) was established using split half method, where twenty

copies of PUCHSQ were administered to 20 mothers attending infant welfare clinic in

Asoro PHC Benin, outside the study area. The completed questionnaires were collected

back on the spot. It was assigned odd and even numbers. The responses of each half of

the numbers were thoroughly studies and compared for degree of correspondence, that is,

the coefficient of internal consistency using the Kudder Richards methods to know

whether it could be used. According to Ogbazi and Okpala (1994) in a reliability test, if

the correlation co-efficient obtained is up to .6 and above, the instrument should be

considered good enough to be used for the study. The correlation co-efficient obtained

was . 9, so the instrument was used for data collection.

Method of Data Collection

To gain access to the respondents, the investigator presented to the head of each

PHC facility a letter of introduction that was obtained from the head, Department of

Health and Physical Education, University of Nigeria Nsukka. At each of the PHC

facility, the investigator solicited the help of each Chief Nursing Officer in charge to

elicit the attention of the mothers in order to administer the questionnaire. They were also

informed on the portion of the questions that needed their response. The completed

questionnaires were collected back on the spot to ensure high return rate.

The officers in charge of statistics and records were also approached by the

investigator to make available the needed record of statistics on immunization utilization

from the year 2000 to 2007.

55

Method of Data Analysis

The copies of completed questionnaire were studied thoroughly to determine the

adequacy of the responses. The data was analyzed item-by-item to indicate the response

frequencies and percentages of various items. The columns on the utilization level were

allotted scores as follows: Very often = 5; often = 4; occasionally = 3; rarely = 2; and

never = 1. The questionnaire responses were coded and analyzed using computer

statistical package for social sciences (SPSS Batch System).

The mean were calculated from the summated ratings. In other words, the

criterions mean score was obtained by adding all the scores assigned to the response

options and dividing the sum by the number of responses options as follows:

5 + 4 + 3 + 2 + 1 = 15 = 3.0

5 5

In order to categorize the extent of utilization of CHS into under utilization and

effective utilization, the criterion group mean response score of 3.0 and above on

utilization level was considered effective utilization while those with mean score

response lower than 3.0 was considered under utilization of CHS. The mean was used to

answer the research questions on level of utilization of CHS.

The chi-square (χ2) statistic was computed using responses to the questionnaire

items relevant to the four stated hypotheses. The computed χ 2

values were used to test

the null hypothesis relevant to each at the .05 level of significance. Summary of data

frequencies, percentages, mean and chi-square tests were presented in appropriate tables.

56

CHAPTER FOUR

Results and Discussion

This chapter presents and discuses the result of the study. Data for the study were

collected from the selected Primary Health Care Centres records of immunization and

responses from mothers who attend and make use of child Health Services in the PHC.

Out of 310 copies of provision utilization levels of CHS questionnaires administered.

There was 100 percent return rate. Eight of the returned copies were rejected due to

incomplete information leaving a balance of 302 copies (97.41 percent) of which the

analysis of the data was based.

Results

The findings are hereby presented in tables and graphs below according to research

questions and hypothesis.

Research Question One

What are CHS provided at the PHC facilities in Enugu Urban?

The data answering the above question is contained in table I below.

57

Table 1

CHS available at PHC facilities in Enugu Urban (n=302)

Variable Response

f %

Antenatal Services 302 100%

Maternity services 302 100%

Post-natal services 302 100%

Growth monitoring services 302 100%

Oral re-hydration therapy (ORT) 302 100%

Nutrition education during ANC 302 100%

Exclusive Breast feeding (BFHI) 302 100%

Immunization 302 100%

Table 1 presents the frequencies and percentage of responses on available CHS in PHC

facilities in Enugu Urban. The table shows that all CHS were available at the PHC

facilities in Enugu Urban.

58

Research Question Two:

What is the level of utilization of eight components of CHS in PHC facilities in

Enugu Urban? The data answering the above research question are contained in Table 2.

Table 2

Level of Utilization of Child Health Services in PHC Facilities in Enugu Urban

(n = 302)

Variable Very Often Often Occasionally Rarely Never Grand

mean

ANC Services f m f m f m f m f m

180 2.98 73 0.98 35 0.34 9 0.06 5 0.02 4.38

Maternity

Services 98 1.6 114 1.5 59 0.59 30 0.2 0 0 3.89

Post-natal

Service 65 1.08 72 0.95 55 0.55 66 0.44 44 0.15 3.17

Growth monitoring

Services 169 2.8 56 0.74 42 0.42 26 0.72 8 0.03 4.71

Oral rehydration

Therapy (ORT) 101 1.8 37 0.5 51 0.5 48 0.32 65 0.22 3.34

Nutrition Education

During ANC/PNC 146 2.4 72 0.95 45 0.45 27 0.18 10 0.03 4.01

Exclusive Breast

Feeding (BFHI) 26 0.43 28 0.37 51 0.51 56 0.37 141 0.47 2.15

Immunization 225 3.7 29 0.38 16 0.16 2 0.01 0 0 4.25

Table 2 shows that all available CHS, except exclusive breast-feeding with mean score of

2.15 are effectively utilized, all having response mean score of above 3 points which is higher

than the criterion mean of 3.0 implying effective utilization.

Research Question Three

59

What is the trend in utilization of immunization services from 2000 – 2007 in PHC

facilities in Enugu Urban? Data in Table 4 and figures one to ten provides answer to this

question

Table 4

Trends in utilization level of Immunization Services (2000 – 2007) in

PHC facilities in Enugu Urban

Vaccines 2000 2001 2002 2003 2004 2005 2006 2007

BCG

0 – 11 M

12 – 23 M

672

927

3684

777

2999

169

3630

602

5052

36

9582

7139

6741

446

60

11098

OPV 0 – 11 M

OPV0

OPV1 OPV2

OPV3

4152

3513 3331

2548

2267

3056 2544

2775

2582

2661 2154

2262

3466

4659 3291

3291

5293

4337 4678

4285

9582

7139 6314

5805

6693

7024 5841

5428

14046

11977 14526

13280

OPV 12 – 24 M

OPV1

OPV2

OPV3

268

423

380

535

355

879

612

713

1004

637

570

470

314

355

273

564

434

423

709

907

979

550

524

540

DPT 0 – 11 M

DPT 1

DPT 2

DPT 3

3185

3011

2650

2565

3373

2418

2131

2167

1917

2598

2479

2109

5035

4721

4622

7212

6329

5799

6993

6002

5109

13994

1568

13003

DPT 12 – 23 M

DPT 1

DPT 2 DPT 3

171 195

170

733 998

748

413 295

662

610 502

314

213 262

207

564 434

423

657 660

826

380 353

409

Measles

0 -11 M 12 – 23 M

2444 448

2514 758

2030 684

3597 819

3286 1366

6723 877

826 1731

409 2115

Y/Fever

9 – 23 M 23 – 59 M

5 Years

94 592

2319

358 37

222

150 5

100

32 333

103

1075 314

147

3765 2857

2354

3226 4152

3380

3226 4157

3380

CSM

12 – 59 M

3733

157

620

342

2405

6801

None

None

HBV

0 – 12 M

HBV 1

HBV 2 HBV 3

None

None None

None

None None

None

None None

1

4 1

1

5 5

7151

3369 3347

8508

8112 6697

7151

3369 3347

HBV

12- 23 M HBV 1

HBV 2

HBV 3

None

None

None

None

None

None

None

None

None

None

None

None

5

95

5

1588

2719

2719

4379

3144

3410

1588

2768

2719

Vit. A Supplement

0 -11 M

12 – 23 M

None

None

None

None

None

None

None

None

None

None

420

80

5538

6534

6741

446

Figure 1: Bar chart showing the trends in utilization of BCG immunization (2000 –

2007). In PHC facilities in Enugu Urban

60

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith B

CG

vac

cin

e

12,000

11,000

10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

2000 2001 2002 2003 2004 2005 2006 2007

Year

Trends in utilization levels of BCG immunization (2000-2007)

Result in figure 1 shows that there is disparity between the BCG 1st and 2

nd dose

in the number of children immunized over the years of study.

BC

G 1

BC

G 2

BC

G 1

BC

G 2

BC

G 1

61

OPV1

OPV2

OPV3

OPV0

Figure 2: Graph showing the trends in utilization levels of OPV (0 – 11 m)

Immunization (2000 – 2007) in PHC facilities in Enugu Urban

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0

2000 2001 2002 2003 2004 2005 2006 2007

Year

Trends in utilization level of OPV 1st dose 2000 – 2007 in PHC

Facilities in Enugu urban

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith O

PV

1st d

ose

vac

cine

62

OPV1

OPV3

OPV2

Figure 3: Graph showing the trends in utilization levels of OPV (12 – 23m)

Immunization (2000 – 2007) in PHC facilities in Enugu urban

1,000

800

600

400

200

0

2000 2001 2002 2003 2004 2005 2006 2007

Year

Trends in utilization level of OPV 2nd

dose 2000 – 2007 in PHC

Facilities in Enugu urban

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith O

PV

2n

d d

ose

vac

cine

63

Figure 4: Bar Chart showing the trends in utilization levels of DPT 1st dose

(0 – 11m) 2000 – 2007 in PHC facilities in Enugu urban

Trends in utilization of DPT 1st dose (0-11m)

Result in figure 4 shows that the trend of use of DPT 1st dose (DPT

1, DPT

2 and DPT

3) are

fairly even.

14,000

13,000

12,000

11,000

10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

02000 2001 2002 2003 2004 2005 2006 2007

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith D

PT

1st d

ose

vac

cine

64

Figure 5: Graph showing the trends in utilization levels of DPT 2nd

dose (12 – 23m)

2000 – 2007, in PHC facilities in Enugu Urban

Year

Trends in utilization of DPT 2nd

dose (12 – 23m).

1,000

900

800

700

600

500

400

300

200

100

02000 2001 2002 2003 2004 2005 2006 2007

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith D

PT

2n

d d

ose

vac

cine

65

Figure 6: Bar chart showing the trends in utilization levels of yellow fever vaccine

1st, 2

nd and 3

rd dose (9 – 23m, 23 – 59m and 5 years) 2000 – 2007, in PHC

facilities in Enugu urban

Year

Trends in utilization level of Yellow Fever Vaccine 1st, 2

nd and 3

rd doses in PHC facilities

in Enugu urban.

Data on fig 6 shows fluctuations in level of utilization of yellow Fever vaccine in

PHC facilities in Enugu Urban.

5,000

4,500

4,000

3,500

3,000

2,500

2,000

1,500

500

0 2000 2001 2002 2003 2004 2005 2006 2007

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith D

PT

2n

d d

ose

vac

cine

66

Figure 7: Graph showing the trends in utilization levels of HBV (Herpatitis B Virus

vaccine), 1st dose (0 – 11m) 2000 – 2007, in PHC facilities in Enugu urban

Year

Trends in utilization level of HBV (Hepatitis B virus vaccine),

1st dose (0 – 11m)

Data in fig 7 shows that there was no HBV vaccine from 2000-2004 in PHC facilities in

Enugu Urban.

10,000

8,000

6,000

4,000

2,000

0 2000 2001 2002 2003 2004 2005 2006 2007

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith H

BV

1st d

ose

vac

cine

67

Figure 8: Bar chart showing the trends in utilization levels of HBV (Herpatitis B

Virus vaccine), 2nd

dose (12 – 23m) 2000 – 2007, in PHC facilities in Enugu urban

Trends in utilization level of HBV (Hepatitis B virus vaccine),

2nd

dose (12 – 23m)

Data on fig. 8 shows fluctuations in trends of utilization of HBV 2nd

dose vaccines

in PHC facilities in Enugu Urban.

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith H

BV

2n

d d

ose

vac

cine

5,000

4,000

3,000

2,000

1,000

0 2000 2001 2002 2003 2004 2005 2006 2007

Year

68

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

02000 2001 2002 2003 2004 2005 2006 2007

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith m

easl

es 1

st a

nd 2

nd d

ose

vac

cine

Figure 9: Graph showing the trends of utilization levels of measles vaccines 1

st and

2nd

dose (0 – 11m and 12 – 23m). 2000 – 2007, In PHC facilities in Enugu urban

Trends in utilization level of measles vaccines 1st and 2

nd dose

(0 – 11 and 12 – 23m)

Measles 12 – 23m

Measles 0 – 11m

Year

69

Num

ber

of

chil

dre

n i

mm

uniz

ed w

ith C

SM

2nd d

ose

vac

cin

e

Figure 10: Graph showing the trends of utilization levels of cerebro-spinal

meningistis vaccine (12 – 59m), 2000 – 2007, in PHC facilities in Enugu urban

Trends in utilization level of CSM, 2nd

dose (12 – 59m).

Result of the study in Figures 1-10 showed that there were inconsistencies in the

trend of utilization of immunization services. For instance the number of children

immunized with BCG 1st dose (0-11 months) was 672 in the year 2000 and 364 in 2001,

dropped to 2999 in 2002 picked up again (3630) in 2003 and maintained a steady upsurge

reaching highest in 2005 (9562) and started to decline again in 2006 (6741) and went flat

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0 2000 2001 2002 2003 2004 2005 2006 2007

Year

70

by 2007 (60). For BCG 2nd

dose (12-23 months), number of children immunized has been

fluctuating ranging from 46 in 2000 to 777 in 2001 and downward to 169 in 2002 and

602 in 2003 respectively, 36 in 2004 and up surge of 7139 in 2005, down again to 446 in

2006 and up-pick in 2007 with 1098 children immunized

Oral polio vaccine OPV 1st dose (0-11 months) the number of children immunized

took a steady upward trend ranging from 2267children immunized in 2006 to 14046

children in 2007.

The 2nd

dose of OPV (12-24 months) data showed fluctuation in the number of

children immunized, from 1541 children in 2000 down to 535 in 2001, up again to 612 in

2002 to 637 in 2003 down again to 314 in 2004 up again to 564 in 2005 and 909 in 2006

and down again to 550 children in 2007.

For DPT 1st dose, data showed up raise in the number of children immunized.

Ranging from 2609 in 2000 to 13994 in 2007, data for DPT 2nd

dose (12-23months)

showed raise and fall in the number of children immunized as 324 in 2000, 733 in 2001,

413 in 2002, 610 in 2003, 213 in 2004, 564 in 2005, 657 in 2006 and 380 in 2007.

The trend of utilization of measles vaccine (0-11months) showed steady raise in

the number of children immunization ranging from. 2516 children in 2006 and reaching a

peak of 15316 in 2007, in utilization of the booster dose, that is (12-23months), data

showed fluctuations in the number of children immunized, ranging from 585 children in

2000 to 758 in 2001, 564 in 2002, 816 in 2003 1366 in 2004, 877 in 2005, 1731 in 2006

and 2115 in 2007.

Data in figure 6 shows that 1st and 2

nd doses of yellow fever vaccines (9-23

months) were scare and only few children were immunized such as 94 children in 2000,

358 in 2001, 150 in 2002, 32 in 2003, 1075 in 2004, 3226 in 2006 and 2007 respectively.

71

For 2nd

dose of yellow fever (23-59 months), there was also a wide disparity in the

number of children immunized rising and dropping such as 592 children immunized in

2000, 37 in 2001, 5 in 2002, 333 in 2003, 314 in 2004 and raised steadily from 2857 in

2005 to 4152 and 4157 in 2006 and 2007 respectively.

For 3rd

dose of yellow fever vaccine, the same pattern of inconsistency

followed, 319 children immunized in 2000, 222 in 2001, 100 in 2002, 103 in 2003, 147 in

2004, then 2354 in 2005, 3380 both in 2006 and 2007.

For CSM vaccines, utilization was marked considerably with inconsistencies 3733

children immunized in 2000, 157 in 2001, 620 in 2002, 342 in 2003, 2405 in 2004 and

6801 in 2005. In 2006 and 2007, it was not available.

HBV vaccines both 1st and 2

nd doses were not available from 2000 to 2003. From

2003 1-5 children were immunized but from 2005 number of children immunized

increased from 7151 to 8508.

Vitamin A supplements were not recorded from 2000 to 2004. In 2005, 420

children were given 1st dose while 80 children were recorded to have received the 2

nd

dose. In 2006 1st dose showed 5538 children and 6534 2

nd dose. In 2007, 674 children

received 1st dose while 446 children 2

nd dose. There was no separate record of number of

children given vitamin A supplement because it is part of vaccine given in house to house

immunization.

72

Research Question Four

What socio-economic factor{s) could influence effective utilization of CHS in

PHC facilities in Enugu Urban? Data in table 3 below provides the answer to the

question four.

Table 3

List of Socio-economic Factors that could Influence CHS Utilization (n = 302)

Variables f %

a. Lack of money 3 0.99

b. Ignorance of the need for CHS 121 40.06

c. Bad attitude of Heath care providers 56 18.54

d. Unavailability of child health services in the clinic 3 0.99

e. Procrastination or postponing the days of going to the

clinic or hospital 41 13.58

f. Availability of health personal at home or the neighborhood 233 77.15

g. Non-availability of clinic equipment e.g. needles and syringes,

thermometer etc. 4 1.32

h. Uncooperative attitude of husband 0 0

i. None availability of medical health personal in the clinic 5 1.65

j. High cost of drugs and services 2 0.66

k. Difficulty in getting transport to the clinic 5 1.66

l. Religious beliefs 2 0.66

m. Cultural beliefs 78 25.85

n. Superstitious e.g. immunization exposes child to HIV 6 1.99

o. Taboos 4 1.32

p. Lack of awareness of available CHS. 7 2.32

q. None 8 2.65

Data in table 3 shows lists of other socio-economic factors that could affect

effective utilization of CHS in the PHC in Enugu urban.

73

From the table 3, availability of medical personnel in the neigbourhood had the

highest influence on the respondents under study. This data depict the picture of health

care delivery system in Enugu urban. This is because in Enugu urban there are so many

private hospitals and maternity clinics. Majority of these private facilities lack qualified

health personnel, but because they are readily available and near to mothers, they are

usually resorted to. The end result would be that the mothers are either not informed or

well informed of the need for CHS.

Next to the availability of medical personnel in the neighborhood is ignorance of

the need for CHS with response of 40.06%

Cultural belief showed response of 25.83% bad attitude of health care provides

show response of 18.54% while procrastination or postponing clinic days show 13.56%.

It is worth noting that these factors with the highest response are related to

information and orientation about CHS.

74

Hypothesis One:

There is no statistical significant influence of maternal age on the level of utilization

CHS. Data answering the above hypothesis are contained in Table 5.

Table 5

Influences of maternal demographic variables on the utilization level of CHS.

Variable Level of variable Of Ef Cal. X2

value

Cal. Table

X2 value

df

Age 15-26 years

27-38 years

39 years & above

Total

73

196

33

302

100.6

100.6

100.6

-

-0.55

1.9

-1.36

0

3.84

3.84

3.84

3.84

1

1

1

1

(P > .05)

Table 5 above shows that for maternal age, calculated chi-square value is 0 less

than calculated chi-square table value of 3.84 df 1 at .05 level of significance. Therefore

hypothesis one which stated that there is no statistical significant influence of maternal

age on level of utilization of CHS is accepted.

75

Hypothesis Two

There is no statistical significant influence of maternal educational attainment on

utilization level of CHS. The data answering the above hypothesis are contained

in Table 6.

Table 6

Influence of Maternal Educational Attainment on Utilization level of CHS.

(n = 302)

Variable Level of variables Of Ef Cal. 2

value

Cal. Table

2 value

df

Educational

attainment

No formal education 1 50.33 -2 3.84 1

FSLSC 58 50.33 0.3 3.84 1

WASC/NECO 113 50.33 2.5 3.84 1

NCE/ND 75 50.33 1.0 3.84 1

BA/BSc. 36 50.33 0.6 3.84 1

Postgraduate 19 50.33 -1 3.84 1

Total 302 - 1 3.84 1

Table 6 above shows that maternal educational attainment calculated chi-

square value is 1 less than calculated chi-square table value 3.84 df 1 at .05 level

significance. Therefore hypothesis 2 is accepted.

76

Hypothesis Three

There is no statistical significant influence of maternal parity on utilization

of CHS. The data answering the above hypothesis are contained in Table 7.

Table 7

Influence of maternal parity of level of utilization of CHS ( n = 302)

Variable level of Of Ef cal. 2

cal. table df

variable

value 2 value

parity once 31 50.33 -0.8 3.83 1

two times 52 50.33 0.07 3.83 1

three times 86 50.33 1.4 3.83 1

four times 77 50.33 1.6 3.83 1

five times & above 56 50.33 0.2 3.83 1

Total 302 - 2.3 3.83 1

From table 7 data shown that calculated 2 value was 2.3 less than

calculated 2 table value of 3.83 df at .05 level of significance. The hypothesis,

which stated that maternal parity has no statistical significant influence on level of

utilization of CHS, is therefore accepted.

77

Hypothesis Four

There is no statistical significant influence of maternal occupational status on

level of utilization of CHS. The data answering the above hypothesis are

contained in Table 8.

Table 8

Influence of maternal occupational status on utilization of CHS (n = 302)

Variable Level of variable Of Ef cal 2

cal df

Value table

2

value

Occupational Farming 15 50.33 -1.4 3.84 1

Status Trading 65 50.33 0.6 3.84 1

Manufacturing 42 50.33 -0.3 3.84 1

Civil servant 78 50.33 1.1 3.84 1

Artisan 48 50.33 -0.9 3.84 1

Unemployed 54 50.33 0.1 3.84 1

Total 302 - -0.8 384 1

Data on table 8 showed that calculated x2

value was -0.8 less than cal, table x2

value of 3.84 df 1 at .05 level of significance. The hypothesis is therefore accepted.

Summary of Major Findings

The study was on provision, utilization levels and trends of CHS in PHC in Enugu

urban. The following major findings include:

1. all the eight components of child health services were available at the PHC

facilities in Enugu Urban,

78

2. the seven components of CHS were utilized effectively except exclusive breast-

feeding. Antenatal services with x score of 4.38 maternity services x = 3.89 post-

natal services x = 3.17 growth monitoring service, x = 4.71, oral re-hydration

therapy x = 3.34, nutrition education x = 4.01, exclusive breast feeding x = 2.15.

Immunization services was effectively utilized x = 4.25:

3. the trends in the utilization of available CHS in the PHC were highly unstable.

There were fluctuations in the trends of utilization CHS, the level of use were

rising and falling over the years,

4. all the independent variables: maternal: Age, occupation, parity and educational

attainment were not statistically significant to utilization level of CHS, and

5. the socio-economic factors found to influence utilization of CHS were:

Availability of medical personnel in the neighbourhood 77.15 percent, ignorance

of the need for CHS 40.06 percent, cultural belief 25.85 percent, bad attitude of

health care providers 18.58 percent, and procrastination of clinic days 13.58.

Discussion of Major Findings

The study focused on the provision, utilization levels and trends of child health

services, in PHC facilities in Enugu Urban, as well as maternal demographic and socio-

economic factors that could influence the utilization level of CHS. The population for the

study consisted of mothers who made use of CHS in the three PHC in Enugu urban that

offer health care services to the populace. Data was collected using questionnaire and

records of immunization services in PHC facilities in Enugu urban and was organized

and presented under the following subheadings.

79

1. Availability/provision of CHS.

2. Utilization levels of CHS.

3. Trends in utilization of immunization services from 2000 to 2007.

4. Influence of maternal socio-demographic factors on utilization level of CHS.

5. Socio-economic factors that could influence level of utilization of CHS.

3. Implications of the findings for health of the child and childhood morbidity and

mortality rates.

Availability/Provision of CHS

Data on table I indicates that the eight components of CHS are provided at the

PHC facilities in Enugu Urban under study. They include: Immunization services,

Antenatal services, maternity services, postnatal services, growth monitoring services,

oral re-hydration therapy (ORT), Baby Friendly Hospital Initiatives (BFHI), and

Nutrition education.

Data generated from the record of immunization revealed that even though this

services exists in all the PHC facilities in Enugu urban, vaccines were not always

available for the exercise. For instance, vaccines against cerebrospinal meningitis was not

available throughout the years of 2006 and 2007 in the PHC. HBV was not available in

2000 to 2003. However, record revealed that it was available in 2004, only few children

were immunized, such like one child immunized with HBV1, five children for HBV

2 and

one child for HBV3 (for HBV 0-12m) and for HBV 2

nd dose (12 – 23 months), five

children for HBV1, 97 children for HBV

2 and 5 children for HBV

3. In similar manner,

DPT booster doses were not also available in 2006 and 2007 as well as Oral Polio

Vaccine. Little wonder the report of UNICEF (2004) that despite remarkable progress in

routine immunization, there seemed to be resurgence in number of confirmed polio cases

80

in Nigeria. The picture is made worst by unorganized record system of immunization

services observed in most of the PHC. In fact in one of PHC, the researcher could not be

provided with record of immunization services undertaken by the PHC for the years

under review.

The fluctuations of availability of vaccines was lamented by NDHS report (1999),

stating that immunization levels attained in Nigeria in 1990 of more than 80 percent

(BCG 85 percent and DPT3 65 percent) was followed up with decline of 13 percent and

19 percent (BCG and DPT3) by 1999. In similar survey, NDHS (2003) on availability of

health services in the public sector facilities in the relatively well served South east zone

of Nigeria revealed that most PHC services were not available in more than 50 percent of

the facilities surveyed and that although immunization was the most widely available

services, it only existed in about 45 percent of the surveyed facilities. According to the

report, factors that led to previous success achieved in immunization coverage in the

1980s

and early 1990s

such as adequate funding, proper logistics, availability of power

generation, available information and education (IEC) materials and training packages for

health staff were all donor founded and managed. Thus when the donor funding was

withdrawn, coverage rates plummeted.

Utilization levels of Child Health Services

Utilization level of CHS was classified into Effective utilization, and

underutilization.

Data on table 2 shows that for Antenatal services, mean score of 4.38 above the

criterion mean of 3.0, indicating effective utilization of ANC services. This observation

contradicts the NDHS (1999) report which pointed out that lack of adequate Antenatal

care ANC in most parts of the country; particularly the northern regions and rural areas

81

resulted in low Tetanus toxoid immunization rates and consequently high prevalence of

neonatal tetanus.

Data on table 2 also shows mean response score of 3.89 above the criterion mean

of 3.0 for maternity services implying effective utilization of maternity services. The

finding of this study in this regard is line with most findings in literature reviewed such

as Rustain (2000), which in his study of factors associated with trends in infant and child

mortality in developing countries during the 1990s indicated effective maternity service

as one of the twelve indicators of child health and survival strategy. He pointed out that

childhood mortality does not depend only on interventions in childhood alone but

antedate conception. He stated that regular antenatal care and care given to the child in

the natal periods such as the condition of labour, instruments used, the competence of the

health care giver that deliver the woman, all have direct influence on the life and the

health of the child. He suggested that supervision of the mother during pregnancy and

birth is very important in improving the health of the infant and that competent skill

should be employed to avoid any form of injury during birth which can leave the child

disabled for life.

This finding seems not to agree totally with the findings of Royston and Ferguson

(1985) in their study of utilization of maternity services. They reported that 55 percent of

children born in 1983 were not delivered in the maternity clinics or units and that the

percentages of women who utilized pre-natal services exceeded those who utilized intra-

partum services. Considering the difference between ANC mean score {4.38} and

maternity service mean score {3.89} in this study, it is obvious that mothers who utilized

ANC services exceeded those who utilized maternity services.

82

Post-natal services (post-natal check after birth) from the data on table 2 shows

mean score of 3.17 above the criterion mean of 3.0 indicating effective utilization of

PNC. When effective utilization of ANC services and maternity services are considered,

it should follow also naturally that PNC services should be utilized effectively.

According to Burtter and Parer (1983) effective use of PNC services is important for

child health promotion, growth and development. The difference in the mean score of

maternity service {3.89} and PNC {3.17} indicates also that number of mothers who

utilized maternity services exceeds those who utilized PNC services.

For growth monitoring, data on table 2 shows mean score of 4.71 above the

criterion mean of 3.0 indicating effective utilization of growth monitoring service. This

finding falls in line with UNICEF (2004) advocate, stating that growth monitoring is

indispensable to monitor the physical development of the child to ensure survival and

good health. It identified growth monitoring as excellent means of interaction between

the mother and health care worker in the care of the child. Effective utilization of growth

monitoring services is necessary for reasons that the growth monitoring of the child will

indicated whether the child is thriving or not. Impediment to physical growth and

development is detected early through growth monitoring. Again in view of the report of

Enugu State, Ministry of Health (1999), that 19 percent of children in Enugu State were

stunted, 7 percent wasted and 10 percent under weight. Under weight, which is a cardinal

pointer to malnutrition, was pointed out by UNICFF (1989) as the underlying factor

accounting for 50% of all childhood deaths. Effective use of growth monitoring service is

a plus, even though more need to be done about it.

For Oral re-hydration therapy (ORT), data from table 2 shows means score of

3.34 above the criterion mean 3.0 also indicating effective utilization of ORT. This

83

finding is encouraging bearing in mind the various strategies employed by both the

federal government and donor agencies such as WHO UNICEF, World Bank and DFID.

For instance, in 1995, WHO and UNICEF embarked on (IMCI) Integrated Management

of Childhood Illness, a strategy to combat the ever-rising childhood mortality, and

enhance child survival. This strategy involves the use of ORT in management of

childhood diarrhea disease among others. Others include routine immunization growth

monitoring, and BFHI, (Baby Friendly Hospital Initiative). This strategy was reported by

UNICEF (2004) as have worked in the developed nations evidenced by reduction to the

barest minimum of childhood mortality and morbidity.

The findings contradict the report of UNICEF (2001) that Nigeria is one of the

least successful African countries in achieving improvements in child survival in the past

decades in spite of advances in universal immunization and oral re-hydration therapy

(ORT) for diarrhoea diseases and the wealth of Nigeria’s human and natural resources.

The findings of this study as regard ORT seems to also agree with the (1999). Multiple

Indicator Cluster Survey report which stated that a huge improvement in promoting ORT,

embarked on in the 1980s by the government has yielded substantial result as depicted by

an increase in the proportion of children receiving ORT in 1999 National Demographic

Health Survey (NDHS) compared with the NDHS data of 1990.

For nutrition education means score was 4.25 indicating effective utilization of

nutrition education. From this data the fact that health care workers have been teaching

mothers about childhood nutrition is evidenced. It is then surprising the report of

Nigeria’s National Health Policy (1996), which stated that despite the fact that more than

50% of childhood mortality and morbidity is attributed to the underling problem of

malnutrition, childhood nutrition has received little attention in comparison to the

84

magnitude of the problem. The policy indicated Health sector policy among the various

policies that could rectify the error, Health sector nutrition policy includes activities of

nutritional health education, by health workers. The result has exonerated the health

workers that they perform their duty as regards nutrition education, the mothers are now

to be blamed for not heeding the teaching of nutrition education given by health workers.

Baby friendly Hospital Initiative also was a strategy to combat childhood

malnutrition, through exclusive breast-feeding. Again from data on table 2, mean score

for exclusive breast-feeding was 2.15 below criterion mean of 3.0 indicating

underutilization of exclusive breast-feeding. It is worth noting that since 1998, Federal

Government of Nigeria, and USAID in collaboration with other stakeholders formed

coalition and nutrition partners to ensure that nutritional issues are placed high on Nigeria

National Agenda following various UNICEF reports that malnutrition was the underlying

factor contributing to 50% death in childhood. Membership of this nutrition partners

include: the National Council for Food of Nigeria (NCTN), WHO, USAID, UNICEF,

International Institute of Tropical Agriculture, (IITA) BASICS, Nutritional Society of

Nigeria, Helen Keeler International and Food Basket of Nigeria. Accomplishment of this

nutrition partners among others included launching of National Breastfeeding Policy and

Implementation of exclusive breast-feeding through BFHI. These policies aimed at

raising awareness of the advantages of exclusive breast-feeding and increase breast-

feeding rate. The underutilization of BHFI in this study agree with (1999) NDHS report

that only 19. 6 percent of infants less than 3 months and 8 percent of infants less than 6

months were exclusively breastfed. This rate suggests that infants are not getting the

maximum benefits of exclusive breastfeeding. Data from that report revealed that 40

85

percent of infants ages 2 – 3 months were already receiving supplements, thus putting

them at risk of diarrhea infection, an underling factor in malnutrition.

Data for immunization service on table 2 shows that mean score was 4.25 above

the criterion mean of 3.0 indicating effective utilization of immunization services. The

finding is in line with the finding of Rustein (2000), which stated that although

immunization services are available, absence of vaccines blurred utilization or coverage.

NDHS (1999) also reported that only 14 percent of children surveyed had received all

vaccinations as recommended by UNICEF, WHO and NPI guidelines by the age of 12

months. 17 percent had received 2nd

dose (Boaster doses) by 23 months of age while 38

percent had not received any vaccination. The same report also pointed childhood disease

declined from 30 percent in (1990) to a shocking 17 percent in 1999. This decline may

have not been improved upon considering the inconsistencies observed in this study on

the availability of those vaccines.

Trends in Utilization of CHS (Immunization Service)

Data on Figure 1 shows fluctuations in the trends of utilization of immunization as

observed from the record of number of children immunized with various vaccines over

the years (2000 – 2007), for instance BCG 1st dose (0 – 11 months), number of children

immunized in 2000 was 672. This increased to 9582 in 2005 and dropped to 60 in 2007.

While contrary should have been expected, that is increase in the number of children

immunized by 2007 considering all the strategy put in place. This finding is in line with

NPI (2004) report that immunization coverage levels in Nigeria of more than 80 percent

(BCG 85 percent and OPT3 65 percent) by 1990 was followed by decline of 13 percent

and 19 percent

86

For BCG 2nd

dose, number of children immunized in 2000 was 46 and increased

to 777 in 2001, 169 in 2002 and 602 in 2003, down again to 36 children in 2004 and up to

7139 children in 2005, down to 446 in 2006 up again to 1098 in 2007.

For 1st dose of OPV

0 (0 – 11 months) the difference in the number of children

immunized was not much. OPV1 was 4152 in 2000 dawn to 2267 in 2001 up again to

2582 in 2002 and increasingly to 14046 children in 2007.

OPV1 dropped from 3242 in 2000 to 3056 in 2001, down to 2661 in 2002, up

again to 4659 in 2003, down to 4337 in 2004 up again to 7139 in 2005, down again to

7024 in 2006 and up 14526 in 2007.Some vaccines were not even available for some

years such vaccine as HBV both 1st and 2

nd doses in 2000-2003.

Influence of Maternal Socio Demographic Factors on Utilization Level of CHS

Table 5 shows influence of maternal Age on the utilization of CHS with

calculated chi-square (χ2) value of 0

which is less than calculated χ

2 table value of 3.84 df

1 at .05 level of significance indicating that maternal age has no statistically significant

relationship to level of CHS utilization.

Maternal occupation from the data on table 6 indicates (cal. χ2 = -0.8 < cal. table

χ2

value 3.84 df 1 at .05 level of significance) indicating that there is no statistically

significance relationship between the occupational status of the mother and level of CHS

utilization. This finding is of surprise, as it would have been expected that women whose

occupation were artisan and traders would not have time to make use of available CHS.

This finding contradicts the findings of Alakija and Sofoluwe (1980), which indicated an

association between occupational status of the mothers and level of utilization of

immunization services.

87

Maternal educational attainment as shown on table 6 has no statistically

significant relationship to level of utilization of CHS. (χ2 = 1) less than calculated table

value of .05 level of significant. This agrees with available literature such as Tabah

(1987), which stated that in implementing child survival strategies, educational level of

the mother matters a lot. This she said was because the uneducated women bears more

children than she can conveniently look after, and so looses most of them, fails to

understand growth chart or importance of breast feeding and makes less use of available

CHS. The respondents in this study had formal education at one level or the other.

Diamond (2000) also agreed that infant and child mortality rates declines unequivocally

as education levels of the mother increases.

Parity from data on table 7 showed that (χ2

= 2.3 < cal. χ2

table value 3.83 df 1 at

.05 level of significance) indicating that there is no statistically significant relationship

between the parity of the mothers and level of use of available CHS. Although literature

revealed that high mother and childhood mortality rates are associated with high parity.

Carla, Abouzahr and Erica (1992). The finding of this study showed that mothers who

had babies five times and above were 56 (18.5 percent) less than those who had four

times and below 246 (84.1 percent), implying that high parity is no longer in vogue,

probably because of woman education and other socio-economic situations.

Socio-economic Factors that could Influence Utilization of CHS

From data on table 4, availability of medical personnel in the neighbourhood had

the highest aggregate influence in three PHC studied (77.15 percent). This could be

attributed to the proliferation of private clinics and private medical practice prevalent in

Enugu Urban. In Enugu Urban there is about 120 private hospitals/clinics majority of

these private clinics lack qualified health personnel but because they are usually readily

88

available and the normal public health facilities bureaucracy are not observed, the

mothers would resort to them, for CHS especially maternity services. The result of which

could be that either the mothers are not informed or well informed on the necessity of

CHS services utilization, especially the need for exclusive breast feeding to combat

childhood malnutrition and the consequences.

Ignorance of the need for CHS with aggregate score of 40.06 percent ranked 2nd

of socio-economic factors that could influence utilization level of CHS. Just as mentioned

above, information on CHS to mothers has a lot of positive role to play on the level of

use of CHS. For instance Chan-Yib and Kraner (1983) conducted a study to determine

the association between education and breastfeeding practice among Chinese women.

They found out that those who were counseled on breast-feeding before birth had 59

percent adoption while those that were not counseled had 43 percent adoption of breast

feeding practice. The finding of this study is in line with the findings of Dulcos and

Hatchor (1993), which determined that underutilization of influenza immunization in

Canada, was attributed to ignorance on the need for the vaccination, fear of side effects

and non-recommendation by health personnel.

From the data on table 4, 25.85 percent of the respondents indicated the influence

of cultural believes on use of CHS especially exclusive breast-feeding. World Bank

(2002) reported that some cultural beliefs and attitudes result in practices harmful to the

survival of children and women. Such practices as infant feeding have deep cultural bias.

For instance in some culture, colostrums is not fed to the newborn, babies because it is

believed to be dirty and thus breastfeeding is delayed and not sustained. There is

tendency to withhold protein rich foods, such as meat, chicken and eggs, from the infants

because of cultural misconception, that feeding children those foods may encourage them

89

to steal later in life, similarly Malatinema (2000) pointed out that cultural attitude and

taboos are the most significant correlates of utilization of CHS.

Bad attitude of health workers shows that 18.54 percent of respondent indicated

its influence on their use of available CHS effectively.

This may not be surprising as the mothers would normally expect that good and humane

approach or treatment be given to them by the health workers, when this is not met

withdrawal is the result.

Implications of the Findings for the Health of the Children under five years

The findings of this study revealed that although all the available CHS are

effectively utilized with exception of exclusive breast-feeding. By implication either

directly or indirectly under-utilization of exclusive breasting pose a big threat to child

survival as persistent high morbidity and mortality rates among children under five of age

are blamed on malnutrition which underlie most childhood conditions. There is still more

to be done by means of information and education as there is need for effective use of

CHS especially exclusive breast-feeding both by the governmental and non-governmental

agencies in charge.

The findings of this study were also that for the immunization service, vaccines

were not always available for use. This implies that those killer childhood diseases

against which those vaccines are given will still continue to be a threat to child survival.

This also calls for the government and donor agencies to ensure their availability if

childhood mortality will be curbed.

Availability of medical personnel in the neighbourhood identified as a factor

militating against effective utilization of CHS, implies that something need to be done

about indiscriminate proliferation of private hospitals/clinics in Enugu urban. There is

90

need for Enugu State Ministry of Health to check this trend, to avoid confusion in health

industry in Enugu State, which is hampering the health of children under five years of

age. Cultural beliefs also identified, as a factor militating against effective utilization of

CHS is an indication that health education programmes in the PHC is not measuring up to

expectation. There is need to address this issues of health education at PHC more

seriously, bearing in mind the great benefit of CHS both to the nation and to the family.

The findings of this study also revealed that bad attitude of health care services

providers militated against the effective utilization of CHS. This indicates a need for in-

house cleaning among health service providers in terms of client and health care service

provider relationship, if the PHC are to serve the purpose for which they were

established. The PHC unit heads have the task of checking the attitude and behaviour of

service providers under their supervision. Unless this is done, they stand the risk of being

redundant and nonchalant on duty with the result of continuous surge of clients to private

hospital/clinics where they are exposed to sub-standard health care services. This also

has the risk of persistent rise in childhood morbidity and mortality rates.

The finding of this study reveals that none of the independent variables studied

had statistical significant relationship with level of utilization of CHS. This can be

explained in the light of mothers’ values for children. The mothers no matter their status

could go any length to safeguard the health of their children. This behaviour is also

traceable to the free medical/health care services for under five children.

91

CHAPTER FIVE

Summary, Conclusion and Recommendation

Summary

This study was carried out to determine the provision, utilization levels and trends

of child health services in primary Health Care Centers (PHC) in Enugu Urban. Four

maternal socio-demographic factors (age, parity, occupation, educational attainment) and

other socio-economic factors that could influence utilization of child health services were

investigated. The study was limited to the components of child health services available

in the area of study. (immunization services, ante-natal, post-natal oral re-hydration

therapy, exclusive breast-feeding growth monitoring, and nutrition education).

The descriptive survey research design was used for the study. To achieve the

purpose of the study, four research questions and four hypotheses were formulated and

tested at .05 level of significance. The population of the study was 11,200 women of

reproductive age in Enugu Urban. The sample was 310 respondents found to be using

child health services in the three PHC facilities in Enugu Urban. A pre-study visit was

paid to the three PHC to determine the number of mothers and their babies under five

years of age that make use of CHS in the three centres. Instrument for data collection

were Provision and Utilization of CHS Questionnaire (PUCHSQ) designed by the

investigator and Utilization of Immunization Service Inventory (TUISI)(2000 – 2007)

also designed by the investigator.

Data collected was analyzed using mean, frequencies and percentages while chi-

square statistic was used to verify the hypotheses at .05 level of significance. From the

process, the following major findings were made:

92

1. all the eight components of child health services were available at the PHC

facilities in Enugu Urban,

2. the seven components of CHS were utilized effectively except exclusive breast-

feeding. Antenatal services with x score of 4.38 maternity services x = 3.89 post-

natal services x = 3.17 growth monitoring service, x = 4.71, oral re-hydration

therapy x = 3.34, nutrition education x = 4.01, exclusive breast feeding x = 2.15.

Immunization services was effectively utilized x = 4.25:

3. the trends in the utilization of available CHS in the PHC were highly unstable.

There were fluctuations in the trends of utilization CHS, the level of use were

rising and falling over the years,

4. all the independent variables: maternal: Age, occupation, parity and educational

attainment were not statistically significant to utilization level of CHS, and

5. the socio-economic factors found to influence utilization of CHS were:

Availability of medical personnel in the neighbourhood 77.15 percent, ignorance

of the need for CHS 40.06 percent, cultural belief 25.85 percent, bad attitude of

health care providers 18.58 percent, and procrastination of clinic days 13.58.

Conclusion

Based on the result of the study the following conclusions were made:

1. All the eight components of child health services were available in PHC in Enugu

urban.

2. The number of users of these CHS has been fluctuating over the years.

3. Vital CHS such as exclusive breast-feeding was not effectively utilized, even

though they are available.

93

4. The number of utilizers of immunization services which is expected to be on the

increase with most vaccinations over the years was on the decreased. For instance,

(BCG 1st dose, which recorded 672 users in 2000 and 60 users in 2007.

Cerebrospinal meningitis vaccine (CSM) with 2347 users in 2000 was not even

available in 2006 and 2007). Although, some few vaccines had upward number of

users over the years. For instance, (1st dose OPV 0 – 11 months).

5. Maternal age, parity, occupation, educational attainment had no statistical

significance to the level of use of CHS.

6. Availability of medical personnel in the neighbourhood, ignorance of need of

CHS, cultural belief, bad attitude of health care providers and postponing of days

of going to the clinic were factors identified to affect and influence level of

utilization of CHS.

Recommendations

On the basis of findings and conclusions of this study the following

recommendations were made:

1. Community and hospital based health education programme should focus more

attention on exclusive breast feeding campaign to educate mothers on the need of

exclusive breast feeding and also address cultural bias in infant feeding.

2. Government and non-governmental agencies in charge of vaccines should

endeavour to produce and make them always available to the PHC facilities for

use.

3. State government should ensure that private practitioners of health care services

are duely registered and monitored. This will help to minimize quackery and

94

unsure that qualified health personnel deliver health care services in the

neighbourhood, where the mothers would always resort to for CHS utilization.

4. Health workers in the community should be properly trained both on their duties

and on their relationship to their clients to avoid scaring away mothers by their

attitude.

5. Health education programme in the Antenatal clinic should include and focus

more on other child health services (Growth monitoring, ORT and Post natal

check up) since the mothers make effective use of Antenatal service, it should be

used as a contact point to get the attention of mothers to educate them on the need

for use of other CHS.

6. Statistics officers should be deployed to the PHC facilities for proper recording of

immunization and other health care activities.

Suggestions for further Studies

1. Ministry of Health should sponsor research to cover a study on availability of

CHS in the rural PHC in Enugu State.

2. Research to find out the cause of inconsistencies in vaccine provision and

utilization is advocated.

3. Research should also be conducted to find out mothers knowledge level of the

benefit of exclusive breast-feeding.

95

Limitations of the study

The study was affected by the following problems:

1. The situation of improper record of CHS activities was a problem. Some of the

records of immunization and other CHS activities in the PHC facilities were really

deficient.

2. In some of the PHC facilities, access to their record of CHS activities was

difficult despite the presentation of letter of introduction from the head of

department of Health and Physical Education, University of Nigeria. The health

workers were not willing to provide the needed information and records.

3. Most mothers were not really willing to respond to the questionnaire. A lot of

efforts had to be put in explaining and persuading them to respond to the

questionnaire stressing that their responses would be anonymous and used only

for the study.

96

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105

Appendix C

Questionnaire

106

Department of Health and Physical Education

University or Nigeria, Nsukka

Dear Respondent,

Provision, Utilization of Child Health Care Services in Primary Health

Centres in Enugu Urban (PUCHS)

I am a post-graduate student of University of Nigeria, Nsukka. Pursuing a

Master's degree programme in Public Health Education. The study is on provision

and utilization of child health services in primary health care centres in Enugu

Urban of Enugu State, Nigeria.

You are kindly requested to provide honest responses to the following

questions. Your responses will be treated in confidence and will be used solely for

the purpose of this study.

Please return this questionnaire back to the person who gave it to you.

Thank you for your kind co-operation.

Yours sincerely,

Onyenweze Augustina .C.

Section A: Personal Data

You are required to tick √ only one option as it relates to you, in any of the

given questions of this section.

107

1. To which of the following age bracket do you belong?

(a) 15-26 years (b) 27-38 years (c) 39 years and above

2. What is your highest educational attainment?

(a) No formal education (b) First School Leaving Certificate

(c) WASCE/NECO (d) NCE/ND (e) Bachelor Degrees

(f) Postgraduate

3. How many times have you given birth?

(a) Once (b) Two times (c) Three times (d) Four times

(e) Five times and above

4. What is your occupation?

(a) Farming (b) Trading (c) Manufacturing, e.g. soap making,

cloth weaving, dressmaking etc. (d) Civil Servant (e) Artisan e.g.

hairdressing, herbal practice, catering, nanny, etc. (f) Unemployed

(Full housewife)

Section B: Availability of Child Health Services

5. What arc the available child health services in the Primary Health Centre

you attend?

Please tick √ the available child health services in the PHC you attend.

(a) Ante-natal Services? (b) Maternity Services? Growth

Monitoring? (d) Baby Friendly Hospital Initiative (BFHI) (e)

Oral rehydration therapy? (f) Post-natal Services?

6. Which of the following immunization services are available in the Post-

natal Services you attend?

(a) BCG (b) Oral Polio Vaccine (c) DPT (d) Measles

Vaccine (e) Vitamin A Supplement (f) HBV (g) Yellow

Fever Vaccine (h) Ccrebro-spinal Meningitis Vaccines

108

Section C: Utilization of CHS

Please tick the option of your choice in each of item 7 (a) - (h).

To what extent do you utilize each of the following CHS

Very often Often Occasionally Rarely Never

a Antenatal services

b Maternity services

c Post- natal services

d Growth monitoring

services

e Oral re-hydration

therapy (ORT)

f Nutrition education

during ANC/PNC

g Exclusive breast

h Immunization services

Guide line

Not even once = never

1-2 = rarely

3-4 = occasionally

5-6 = often

6 times and above = very often

For immunization services

Question 7h

Not even once = never

1 – 3 times = rarely

4 – 6 times = occasionally

7 – 9 times = often

10 – 12 times = very often

Section D: Factors that may affect Utilization of Child Health Services

Please tick √ as it affects you.

8. Which of the following factors have prevented you from utilizing available

Child Health Services?

109

(a) Lack of money

(b) Ignorance of the need of CHS

(c) Bad attitude of health care providers

(d) Unavailability of child health services in the clinic

(e) Procrastination or postponing the days of going to the clinic or

Hospital

(f) Unco-operative attitude of my husband

(g) Availability of health personnel at home or in the neighborhood

(h) Non-availability of drugs in the clinic

(i) Non-availability of clinic equipment e.g. needles and

syringes thermometer etc.

(j) Non-availability of medical health personnel in the clinic

(k) High cost of drugs and services

(l) Difficulty in getting transport to the clinic

(m) Religious beliefs

(n) Cultural beliefs

(o) Superstitious e.g. immunization exposes child to HIV

(p) Taboos

(q) Lack of awareness of available CHS