Dorcas Idowu PHD Thesis..FINAL-July-2016

Improvement of Primary Health Care in Nigeria, Health System Analysis, Current Trends and Applicable Solutions

BY

IDOWU DORCAS MORADEKE BNSC, PGD, MSC, MPA, PHD.

For presentation to the Faculty of the Holy State University In Partial Fulfillment of the Requirements For the PHD Degree in Public Health

Holy State University Philadelphia, Pennsylvania.

1

TABLE OF CONTENTS CHAPTER ONE 1.1

INTRODUCTION

1.2

Statement of the Problem

1.3

Research Questions

1.4

Hypotheses

1.4

Justification of the Study

1.6

Scope of the Study

CHAPTER TWO 2.0

LITERATURE REVIEW

2.0.1 Stylized Fact about Health Issues in Nigeria. 2.0.1 Nigeria’s Health Statistics and Trends 2.1.1 HEALTH EDUCATION AND HEALTH PROMOTION 2.1.2

Biostatistics as a Part of Public Health Administration

2.1

Maternal Health in Nigeria: a statistical overview

2.1.1 Maternal Morbidity 2.1.2 Nigeria Data on Maternal Health 2.1.3

Health reforms in Nigeria

2.1.4

The relationship between health and human capital development

2.2

Trend in Health care expenditure, health status and national productivity in Nigeria 2

2.2.1 Country Profile 2.2.2 Geography 2.2.3 Population 2.2.4 Administration 2.2.5 Socio-demographic characteristics 2.3

Conceptual issue

2.4

National HIV Sero-prevalence Sentinel Survey

2.4.1 Epidemiology of HIV and AIDS CHAPTER THREE METHODOLOGY 3.1

Research Design

3.2

Variables in the study

3.3

Selection of Participants

3.4

Selection of Concepts

3.5

Instruments

3.5.1 Health Issues Knowledge Test (HTKT) 3.5.2 Health Issues Attitudinal Scale (HTAS) (3.5.3) Community Based Participatory Health Programmed Guides (CBPHPG). (3.5.4) Direct Teaching Method Guides (DTMG) (3.5.5) Focus Group Discussion Guides (FGDG)

3

(3.6)

Research Procedure

3.7

Recruitment and Training of Participating Teachers and Local Government Officers

3.7.1 Pre-test Administration 3.7.2 Experimental Centre 3.7.2.1 Steps in Community Based Participatory Health Program me 3.7.2.3 Direct Teaching Method- Control Groups 3.7.2.3 Post-Tests Administration 3. 8

Method of Data Analysis

CHAPTER FOUR ANALYSIS AND RESULTS 4.1

Qualitative Report

4.1.1 Answers to Research Questions 4.2

Descriptive Statistics

4.3

Hypotheses Testing

4.3.1 Treatments and Participants’ Knowledge and Attitude to Health Issues 4.3.2 Effects of gender on participants knowledge and attitude to Health Issues. 4.3.3. Effect of location on participants knowledge and attitude to Health Issues 4.3.5 4.3.6: Interaction effect of Gender and Location on Participant’s Knowledge and Attitude to Health Issues 4.3.7. Interaction effect of Treatment, Gender and Location on Participants Knowledge and Attitude to Health Issues. 4.4

Summary of Findings 4

5.1

Discussion of Findings

5.2

Participants Acquisition of Values and Skills through the Community based Participatory Education Program me

5.3

Treatment and Participants’ Knowledge of Health Issues

5.4

Treatment and Participants’ Attitude to Health Issues

5.5

Gender and Participants’ Knowledge of Health Issues

5.6

Gender and Participants’ Attitude to Health Issues

5.7

Location and Participants’ Knowledge of Health Issues

5.8

Location and Participants’ Attitude to Health Issues

5.9

Two-Way Interaction Effects of Treatment and Gender on Participants’ Knowledge and Attitude

5.10

Two – Way Interaction Effect of Treatment and Location on Participants Health Issues Knowledge and Attitude

5.11

Two – Way Interaction Effect of Gender and Location on Participants Health Issues Knowledge and Attitude

5.12

Three - Way Interaction Effects of Treatment, Gender and Location on Health Issues Knowledge and Attitude

5.13

Implications of Findings

5.14

Contributions to Knowledge

5.15

Conclusion

5.16

Recommendations 5

5.17

Limitations of the Study

5.18

Suggestion for Further Studies

CHAPTER ONE 1.1

INTRODUCTION

The effect of community based participatory health programs on health status and healthy living of individual has received generous enquiries in the literature. Outcomes from several studies seem to suggest that there is a positive association between health status and economic development. The wide acceptance of this nexus prompted the prominence of health outcome in the Millennium Development Goals (MDGs). In fact, three of the goals are health specific while the others can also be regarded as health enhancing. However, the channels that drive this relationship are fraught with disagreements. While high health expenditure is viewed as a channel of developing the health status of a nation, the results differ across countries and regions! Thus, the financing of Health Care Expenditure (HCE) becomes more important in many resource constraint countries (Olaniyan, 2013). Provision of health is seen as a key element of a policy to promote broad-based economic growth. The burden of diseases such as HIV/AIDS is known to slow the economic growth of developing countries. Therefore, every country devote huge public fund to health care provision believing this would improve the health of the citizenry so that they can contribute meaningfully to economic growth and development. While increase in budgetary allocation to social services is highly desirable in a developing country like Nigeria, this by itself is not sufficient to guarantee enhancement in service delivery. Bad budget management has been identified as one of the main reasons for ineffective public spending in many developing countries (World Bank, 1998).

6

In Nigeria, for example, despite the huge government expenditure on health provision, the health status of Nigerians is consistently ranked low. Nigeria ranked 74th out of 115 countries, based on the performance of some selected health indicators (World Bank, 1999). Nigerian overall health system performance was also ranked 187th among the 191 Member States by the World Health Organization (WHO) in 2000 (National Health Policy, 2004). The Nigeria’s rate of infant mortality (91 per 1000 live births) is among the highest in the world. It therefore becomes imperative to ask if governance has an impact on the effectiveness of health expenditure in Nigeria. The opportunity costs of spending on health is very high and thus the need for a justification on the increase or otherwise of health spending in such countries. Incidentally, SubSaharan Africa (SSA) is arguably the most underdeveloped region in the world with its attendant problems. Therefore, provision of adequate funding for health care either by the household or the government remains difficult. Some authors have argued that this might be the reasons for the bad health outcomes in the region. Bichaka and Gutema (2008), Kaseje (2006), Jaunky and Khadaroo (2006) cited by Onisanwa (2013). Communicable diseases and child mortality from preventable and treatable diseases are more prevalent in SSA than any other regions! (World Health Report 2010). It is thus necessary to improve the funding of the health sector in order to improve the health sector of the region. The question of what determines the quantity of resources a country devotes to medical care continues to get attention from researchers and policy makers (Christain and Reimer, 2005). This attention is based on the assumption that a rise in the share of income spent on health care expenditures is a direct, or at least a natural, consequence of the secular increase in living standards because health care is a luxury good. The health status of Nigerian is still considerably low and exists below that of most parts of the world. Low life expectancy at birth, high infant and maternal mortality rates, malaria and tuberculosis afflictions are some of the characteristics features of the Sub-Sahara African`s health status. Life expectancy at birth in the WHO African Region is the lowest in the world. This was estimated at only 52 years in 2007, compared with 76 years in the WHO Region of the

7

Americas. Leaving aside the high-income groups, the infant would have expected 46 years had it been from other low-income countries (WHO 2010). This is complemented by the fact that the region also has the highest numbers of women who die of complications during pregnancy or childbirth. Although the global maternal mortality ratio of 400 maternal deaths per 100 000 live births in 2005, the maternal mortality ratio for the African region is 900 per 100 000 live births, with no measureable improvement between 1990 and 2005 (WHO, 2010) Health care expenditure in the Nigeria varies substantially over time and across states. Health financing is important for the improvement of health status in any economy. At the macroeconomic level, the level and growth of health care expenditure has been attributed to the income level of such country. The performance of the health sector is therefore assumed to reflect the size of the income elasticity of health care. Earlier studies have focused on this with its attendant policy implications for the financing and distribution of health care resources. Two views arose out of this. The first is the view that health care is a luxury good and just like any other commodity should be left to market forces. The other view is that health care is a necessity which calls for more government intervention in the sector (see Culyer, 1988; and Di Matteo, 2003). Despite the existence of a limited number of studies, assessing health care expenditure and gross domestic product in Sub-Sahara Africa there exist a diversified opinion in regard to the income elasticity of health care expenditure. Using African data, Gbesemete and Gerdtham (1992) estimate the impact of per capita income on per capita health expenditure with 1984 data from 30 African countries and conclude that income elasticity of health expenditure is very close to unity while Vasudeva (2004) reports that health care income elasticity is greater than unit. Also Okunade (2005) reports large variances in both per-capita GDP and per capita health expenditure shares of national incomes among countries and within regions in Africa. The disparities, along with systematic differences in demographic and socio-political structures have also generated large variances in health status or outcomes among countries. Understanding the extent of the linkage between the share of health expenditure in GDP and change in standard of living is important for several reasons. First, it enables a proper accounting of the notable growth in the health care sector over the last half century. Second, it is 8

necessary for forecasting how health care spending is likely to evolve in the coming years. Finally, it is a crucial step towards an assessment of the optimality of the growth of the health care sector. In particular, if health spending is strongly increasing in income, so that rising income can explain most or the entire rising health share, it would be more likely that the increasing share of GDP allocated to health is socially optimal. Many of the studies find that there is a strong and positive correlation between the gross domestic product (GDP) of a country and the national expenditure on health care.

1.2 Statement of the Problem Better health care is a primary human need. According to the World Health Organization (WHO, 2005), fifty percent of economic growth differentials between developed and developing nation is attributable to ill-health and low life expectancy. Developed countries spend a high proportion of their Gross Domestic Product (GDP) on Health Care because they believe that their resident health can serve as a major driver for economic activities and development. To this end, governments in Nigeria over the years have been making frantic efforts at ensuring that there is an increase in the level of public expenditure on health. In 1970, recurrent expenditure on health was N12.48 million. This figure rose astronomically to N52.78 million and N132.02 million in 1980 and 1985 respectively. This trend continues as the expenditure rose steadily from N575.3million in 1989 to N68.20million in 1991 and further to N72290.07 million and N98.200 million in 2007 and 2008 respectively. The aforementioned scenario clearly underscores the fact that health care expenditure in Nigeria has been on the increase over the years. However, in spite of all these increase, much impact has not been made in the area of reduction of infant, under five and maternal mortalities since 1970. For instance, the Nigeria’s rate of infant mortality (91 per 1000 live births) is among the highest in the world, and the immunization coverage has dropped below thirty percent while the mortality rate for children under age five is 192 deaths per one thousand in 2005. By year 2007, it was reported that more than one hundred and thirty four thousand women died from pregnancy complications. In addition, the life expectancy ratio on the average has been on the decline over the study period. It should however be noted that despite the increase in government expenditure in health care in Nigeria, the contribution of this 9

to health is still marginally low whereas the magnitude of its impact on economic growth is undetermined. Provision of health is also seen as a key element of a policy to promote broad-based economic growth. The burden of diseases such as HIV/AIDS is known to slow the economic growth of developing countries. Therefore, every country devote huge public fund to health care provision believing this would improve the health of the citizenry so that they can contribute meaningfully to economic growth and development. While increase in budgetary allocation to social services is highly desirable in a developing country like Nigeria, this by itself is not sufficient to guarantee enhancement in service delivery. Bad budget management has been identified as one of the main reasons for ineffective public spending in many developing countries (World Bank, 1998). In Nigeria, for example, despite the huge government expenditure on health provision, the health status of Nigerians is consistently ranked low. Nigeria ranked 74th out of 115 countries, based on the performance of some selected health indicators (World Bank, 1999). Nigerian overall health system performance was also ranked 187th among the 191 Member States by the World Health Organization (WHO) in 2000 (National Health Policy, 2004). The Nigeria’s rate of infant mortality (91 per 1000 live births) is among the highest in the world. All these underscore the fact that health is yet to produce the desires results in accordance with its inability to improve the health status of the nation. Childhood immunization, maternal mortality, HIV/AIDS life-saving anti-retroviral drugs are regarded as some of the most effective public health interventions in modern history. However, recent statistics from the WHO regarding Nigeria’s health status is disturbing; the average life expectancy at 54 years is below the global average, maternal mortality is 608 per 100,000 live births, twice as high as South Africa’s 300 per 1,000 and almost 10 times Egypt’s 66 per 1,000. Besides, only 3% of HIV-positive mothers receive anti-retroviral treatment. According to Omeruan et al. (2009), the major challenges of Nigeria healthcare system have been largely due to the un-planned consequences of social policy. Consequently, health services in Nigeria have suffered from decades of neglect, endangering Nigeria health status and national productivity. The healthcare system management is in three tiers; tertiary healthcare- provided 10

by the Federal Government of Nigeria (FGN), mostly coordinated through the university teaching hospitals and federal medical centers. The secondary healthcare provision is by the state governments which manage the General Hospitals. The third tier is the Local Government (774 LGAs) which focuses on primary healthcare services administered in the dispensaries. It is the primary healthcare that suffers the most neglect. Women, children, and especially the core poor die from avoidable health problems such as infectious diseases, malnutrition, polio, guinea worm, measles, complications at pregnancy and childbirth. Government’s expenditure has not pro-vided adequate health infrastructure, especially in the rural areas of primary health care. The health sector suffers from the dearth of qualified healthcare personnel and regulations, as Nigeria’s promising doctors, pharmacists, nurses and other health professionals continue to leave Nigeria to apply their services more profitably in other countries. Nigerians are being denied quality healthcare services, especially those in the rural areas. Between 2005 and 2012, Nigeria’s HDI value increased from 0.434 to 0.471, an average annual increase of about 1.2% (HDR, 2013). However, health spending as a proportion of the federal government expenditures shrank from an average of 3.5% in the 1970s to less than 2% in the 1980s and 1990s (FMOH, 2004). Nigeria was ranked 187th among the 191 United Nations member states in 2000. That same year, Nigeria spent 4USD per capita on health, below WHO‟s minimum benchmark of 14USD per capita for developing countries (WHO, 2000). By 2002, total health expenditure was dismal l figure of 4.7% (WDR, 2005). In 2012, total health expenditure as percentage of GDP stood at 5.3%, ranked 153 out of 187th countries and territories. High profile individuals, especially the political class, continue to fly abroad on regular basis for medical treatment, further widening the inequality in accessing healthcare services. Increase in government expenditure and growth in per capita output in Nigeria do not speak for increase in social welfare and health status in particular. In studies by Laudau (1983), Baumol (1986) and Bhargava et al. (2001), productivity was found to be positively related to total investment in human and physical capital, political and international conditions. Deverajan et al. (1996), using a sample of 14 OECD countries, found that spending on health, transport and communication has positive impacts, whereas spending on 11

education and defense did not have positive impact on productivity. But all these variables are determinants of productivity. Nigeria’s fiscal scenario poses significant risks to sustainable development, given that oil boom has increased government’s expenditure from historical experiences of the 1970s. However, the size of government’s non-productive spending and corruption has always swollen deficit budget. This calls for serious concern by policy makers to check the growth of government wage bills. Political corruption is responsible for budgetary inflation in Nigeria. Hence, there is the need for redirection and reposition of this present status. This study, therefore examined the effects of community-based participatory health programmed on the knowledge and attitude of participants towards health status in Oyo and Osun populace. The moderating effects of gender and location were also examined. 1.3 Research Questions This is particularly worrisome as several questions have been raised on the situation. 1. What has been the trend of expenditure on health in Nigeria? 2. What is the status of Health care in Nigeria? 3. What is the spread level of HIV and other invented virus 4. What does Community Based Participated Health Programme entails? 5. What types of health activities involved in CBPHP? 6. Which category of people participates in CBPHP and Traditional birth Attendant? 7. In what ways are victims lured into traditional birth attendant?

1.4

Hypotheses The following null hypotheses were tested at 0.05 level of significance: Ho1. There is no significant main effect of treatment on participants’ a. Knowledge of their Health Issues. b. Attitude toward health Issues. Ho2. There is no significant main effect of gender on participants’ 12

a

Knowledge of Health Issues.

b

Attitude to health issues.

Ho3. There is no significant main effect of location on participants’ a

Knowledge of health Issues.

b

Attitude toward health Issues.

Ho4. There is no significant interaction effect of treatment and gender on participants’ a

Knowledge of health Issues.

b

Attitude towards health Issues.

Ho5. There is no significant interaction effect of treatment and residential type on participants’ a

Knowledge of health Issues.

b

Attitude towards health issues.

Ho6. There is no significant interaction effect of gender and location on participants’ a

Knowledge of health issues.

b

Attitude to health issues.

Ho7. There is no significant interaction effect of treatment, gender and location on participants’ a

Knowledge of health issues

b

Attitude to health issues.

1.4 Justification of the Study Investment in human capital plays an important role in increasing competitiveness, improving quality of life of the population and in generating economic growth and development of a country. Currently, Nigeria wishes to be among twenty most developed countries in the world by Year 2020. To give effect to this, one of the prerequisites is to ensure that capable manpower is available in various areas of social, political, institutional, technological and economic endeavors which drive the process of growth, development and industrialization. Consistent with the NEEDS programme of 2004, and the current Vision 20 2020 development programme agenda, 13

the country’s human resource development needs to be strengthened and stabilized in order to accelerate economic activities and trigger off higher productivity, income and economic growth and development. In order to achieve meaningful development, investment in human health is necessary because healthier workers are physically and mentally more energetic and robust, more productive, and earn higher wages. A healthy workforce is important when attracting foreign direct investment. Healthier workers are also less likely to be absent from work due to illness in their family. Illness and disability reduce hourly wages substantially, with the effect especially strong in developing countries where a higher proportion of the workforce is engaged in manual labor. Unhealthy workers may not be able to work, but reduce their productivity, shorten their working lives, and increase the numbers of days lost to illness (World Bank 1993). In Indonesia, for example, anaemic men were found to be 20% less productive than men who were not anaemic. When the anaemic men were treated with iron, their productivity increased nearly to the levels of the non-anaemic men (WHO, 1999). There is also a clear relationship between health and success in education. Healthy children are able to learn better and become bettereducated and higher-earning adults. In a healthy family, children’s education is less likely to be interrupted due to their ill health of their family. This study would reveal the desirability or otherwise of the use and effectiveness of community based participatory health programme as a means of enhancing knowledge of health issues and to increase positive attitude towards health issues also to solve the problem associated with traditional birth attendants. With this study, community people would appreciate that apart from the teaching and learning process in the class, there are still various strategies that could be adopted to tackle this menace of health issues with traditional birth attendant that has affected the fabrics of the country. The results of the findings of this study would expose the community people such as drivers, traders, artisans, farmers and community leaders to the statistical spread of various health diseases and the hazard effect of inadequate qualified personnel with adequate health equipment, causes and social, moral and economic effects of good health status on communities and national development.

14

This study would make people have more knowledge of health issues and they would become more than spectators but participants themselves in solving the problem of traditional birth attendant. It would also make the people realize that they have the opportunities to make a difference in reducing victim of various diseases in their communities regardless of their status. The study shall also advocate for the integration of the community based participatory health programme into school curriculum which would make the learners learn productively and make the society better. This approach of health education will promote citizenship ideals and prepare them to respect and live well in the community, thereby making them to work together and support the needs of the surrounding community. Moreover, this study will make the participants to be more aware of the negative impacts of those local made drug without adequate and scientific measurement and they would be well-equipped with the basic knowledge, skills, and the attitude required in fighting against traditional birth attendant in the selected communities. It is expected that the findings of the study will help to develop a participatory health education and health promotion package for people in the communities. This informal education package would serve as a good alternative to the traditional (rote) learning method in school. The import of the moderating effects of gender and location on the criterion measure in tackling various health problems in the society will be helpful in the application and success of the community-based participatory health programme.

1.6

Scope of the Study The study examined the effects of a Community-Based Participatory Health Programme on

knowledge and attitude of participants on various health issues in Oyo and Osun States, Nigeria. It examined the moderating effects of gender (Male and female) and location (urban and peri-urban) on community people’s knowledge and attitude towards solving various health problems. Thus, this study covered the community people in the informal sector such as drivers, traders, artisans, farmers and community leaders in four communities in Oyo and Osun States. These are: Saki (Urban) and Ago Amodu (Peri-urban) in Oyo State; Ejigbo (Urban) and Masifa (Peri-urban) in Osun State. Concepts selected for the study include concepts of inadequacy of health personnel, medical instrument, causes and consequences of traditional birth attendant on child health, community and nation and measures to prevent various diseases. The moderating effects of gender and location were also examined. All these are germane to health issues in Nigeria and the global community.

15

CHAPTER TWO 2.0 LITERATURE REVIEW

This chapter highlights some relevant theoretical, Conceptual and empirical studies on “Effects of Community-Based Participatory Health Programme on Knowledge and Attitude of Participants on Health Issues in Oyo and Osun States, Nigeria”. The review enlightens us on sources of fund to the health sector in Nigeria, trend in health issues, various health problem such as diseases, mental and other public health problem confronting the country, traditional birth attendant issues and the implementation of community based participatory health programme to solve various health problem. Also, it reviews the relationship that exists between the variables under consideration and provides theoretical and empirical background for the methodology adopted in chapter three. 2.0.1 Stylized Fact about Health Issues in Nigeria. ‘Nigeria still lags behind other African countries on various health indicators’ The country is remarkably diverse in social and economic development, but a poor healthcare system evidenced by high levels of morbidity and mortality continues to constrain the sustenance of a healthy population. The coverage of the national health system is limited while health education and enlightenment are weak due to high levels of illiteracy. In addition, childhood and

16

maternal mortality are relatively high and average life expectancy at birth is very low. (NBS, 2010) Table: 2.1 Federal Government Allocations to Health Sector (Billion Naira) Year

2006 2007 2008 2009 2010

Capital Expenditure

32.2

96.9

97.2

52.5

49.9

Recurrent Expenditure 62.3

81.9

98.2

90.2

111.9

Source: Central Bank of Nigeria (CBN) 2011 From the table we can deduce that Nigeria Capital allocation has been decreasing since 2007 to 2010 with number of the available year. Conversely, that of recurrent expenditure has been on the increase since2007 to 2010. We can deduce that Nigeria has change the directions of spending from capital spending to recurrent since population has been on the increase noting has changed about spending but we have experience tradeoff in the direction of spending. As recurrent expenditure is increasing capital expenditure is reducing simultaneously. Table2.2 Number of Doctors by Sex Year

Male

Female

2006

34244

15368

2007

40862

11546

2008

43301

12289

2009

45111

13214

2010

47161

14409

Source: Medical and Dental Council of Nigeria From the table above we can deduce that Nigerian male doctors increase from 2006 to 2010 while female doctors decrease from 2006 to 2007 but since 2008 it has growing steadily but not desirable when compared with the population of the country. An assessment of the health of the Nigerian population indicates that the state of healthcare in Nigeria remains poor although considerable efforts have been made to improve this over the years. Nigeria still lags behind many African countries on major health indicators. The average life expectancy declined rapidly over the years. In 2006 the life expectancy was 57.9 years for men and 56.4 years for women while in 2007 it dropped to 47.2 for men and

17

48.2 for women. This represents a percentage fall of 18.48 % for men and 14.54 % for women (WDI, 2011) The National HIV/AIDS prevalence rate dropped to 4.1 % in 2010 from 4.6% in 2007and 2009. The total figure of newly infected persons which stood at 351,600 in 2007 dropped to 281,180 in 2010.Median age at first sex which stood at 16.50 % in 2007 dropped to 16.05 % in 2008. This clearly shows that government policies on stigmatization in addressing the socioeconomic situation are effective. Table 5.6 shows that more people are aware of HIV/AIDS and are willing to subject themselves for test to ascertain their HIV/AIDS status. This shows that public policy and advocacy against stigmatization is having the desired impact on society. Better health care is a primary human need. According to the World Health Organization (WHO, 2005), fifty percent of economic growth differentials between developed and developing nation is attributable to ill-health and low life expectancy. Developed countries spend a high proportion of their Gross Domestic Product (GDP) on Health Care because they believe that their resident health can serve as a major driver for economic activities and development. To this end, Governments in Nigeria, over the years have been making frantic efforts at ensuring that there is an increase in the level of public expenditure on health. In 1970, recurrent expenditure on health was N12.48 million. This figure rose astronomically to N52.78 million and N132.02 million in 1980 and 1985 respectively. This trend continues as the expenditure rose steadily from 575.3 million in 1989 to N68.20millions 1991 and further to 72290.07 million and 98.200 million in 2007 and 2008 respectively. The aforementioned scenario clearly underscores the fact that health care expenditure in Nigeria has been on the increase over the years. However, in spite of all these increase, much impact has not been made in the area of reduction of infant, under five and maternal mortalities since 1970. For instance, the Nigeria’s rate of infant mortality (91 per 1000 live births) is among the highest in the world, and the immunization coverage has dropped below thirty percent while the mortality rate for children under age five is 192 deaths per one thousand. By year 2007, it was reported that more than one hundred and thirty four thousand women died from pregnancy complications. In addition, the life 18

expectancy ratio on the average has been on the decline over the study period. It should however be noted that despite the increase in government expenditure in health care in Nigeria, the contribution of this to health is still marginally low whereas the extent and magnitude of its impact on economic growth is undetermined. This is particularly worrisome as several questions have been raised on the situation. What has been the trend of expenditure on health in Nigeria? How has the expenditure profile impacted on health? 2.0.1 Nigeria’s Health Statistics and Trends Nigeria is a country on the West Coast of Africa; it is the most populous Black Country in the world, Nigeria has a young population 52% live in rural areas, Nigeria is rich in diversity: with substantial oil reserves over 70% poor. Significantly economic growth unimproved everyday livelihoods. Nigeria has some of the poorest health indicators in the world why? The Health System The Nigeria Health System is fashioned after the 3 tiers of Government, Players Government, and Non- Government Players: Donors – USG; DFID, Global Fund, PHC – adopted to provide health for all Nigerians. Very little community participation Table 2.3

Quality of care needs substantial improvement

Trend and Targets of Selected

2003

2008

2015 Target

Population

124 million

158 million*

Life expectancy at birth

46.5

47 years

TFR

5.7

5.7 children

Modern method CPR

8%

10%

36%

Unmet need for FP

17%

20%

0%

Health indicators Indicator

19

70 years

Maternal Mortality Ratio

800/100,000 LB

545/100,000 LB

Women with at least 4 antenatal

48%

45%

43%

39%

136/100,000 LB

care (ANC) visits Births delivered by a skilled

100%

provider Sources: 2003 NDHS; 2008 NDHS; UNDESA, 2010*; FMOH** Table 2.4

Trends and Targets of Selected Health Indicators

2003

2008

cont’d Indicator

2015 Target

Infant mortality rate (IMR)

100/1000LB 75/1,000 LB 30/1000 LB

Under-five MR

201/1000LB 157/1,000

75/1000

LB

LB

60%

41 %

95%

Children under 5 who are underweight for age

29%

23%

18%

Children under 5 who slept under an ITN the night

1.2%

23%

60 %

5.0%

4.1% **

1%

Proportion of 1 year old children immunized against Measles

before the survey HIV prevalence

Sources: 2003 NDHS; 2008 NDHS; UNDESA 2010*; FMOH**; MDG 2010 Report Figure 1: HIV Prevalence

20

Source: FMOH 2010

PUBLIC HEALTH ORGANIZATION IN NIGERIA Political will – country ownership Policies, Guidelines; Coordination bodies National Strategic Health Development Plan (NSHDP) 2010-2015 National Policy on Population for Sustainable Development (NPPSD) National Primary Health Care Development Agency (NPHCDA) MDG Office - Oversight of Public Expenditure in Nigeria (OPEN) NEEDS; NAPEP Health Bill Review by Zipporah (2012) 2.1.1 HEALTH EDUCATION AND HEALTH PROMOTION According to university of UTAH college of health promotion and education health promotion and education is a profession focusing on the behaviors, system, environment, and policies affecting health at a variety of levels the profession requires intensive specialize training encompassing the biological, environmental, psychological, social, physical and medical science. 21

It also involves the development of individual, group, institutional, community and systemic strategies to improve health knowledge, attitude, skills and behaviors which embowers people to take more control over their personal, community and environmental health and well being. Health promotion and education strategies include; individual and group education, training and counseling, audio-visual and computerized educational materials development, social action and planning, advocacy, and coalition building. There are various definitions of health education as applicable to community or public health practice. However, each of them has focused on learned behavior as contrasted from reflex or instinctive behavior. Sommer (1975), Moronkola (2003) and Gbefwi (2004) summarily defined health education as “a process of influencing voluntary behavior change which would lead to improved health status …” The World Health Organization (WHO, 1967) summed it up as “…the process of helping people to learn what to do and how to do it right in order to achieve improved health status.” Summarily therefore, health education is an on-going process and through it, the learner(s) is helped to acquire or improve on health practices and consequently, the health behavior being addressed. New skills may be learned through which the improved practices, hence behavior can be sustained. World Health Organization (WHO) defined health as “a state of complete physical, mental, and social well being and not the mere absence of disease or infirmity”. Physical health refers to anatomic integrity and physiological functioning of the body, mental health refers to the ability to think and learn while social health refers to the ability to interact with people. However, health can be viewed as an extremely based concept. Good health means different things to different people, communities and nations. A lot of people consider they are healthy once they are diseases free, however, people with disease or disabilities may see themselves as being in good health once they are able to manage their condition.

DEFINITION OF HEALTH EDUCATION

22

Health education is the process of transferring knowledge, attitude and skills that will bring about positive change towards healthy living. It is equally defined as a process of influencing people’s behaviors and attitudes using basic health information skills through carefully planned methods for positive health attitude to prevent diseases, promote and maintain health for quality life. It can also be a process of providing teaching and learning experiences and activities for the purpose of influencing health knowledge, attitudes, practices and conducts in respect of individual, family and community to promote healthy living. Health education is that discipline in public health in which planned activities are conducted to enable individuals and group of people to voluntarily adopt behaviors that promote health, prevent diseases facilitate recovery from illness and ensures rehabilitation. Health education is a process or activity for inducing behavioral changes. It can also be defined as combination of learning activities designed to facilitate voluntary behavior which are conducive to health in individuals, group or community. Any set of learning experiences that encourage changes in human behavior that will result in improved health status. According to WHO, “Health education, like general education, is concerned with changes in knowledge, feelings and behavior of people. In its most usual forms, it concentrates on developing such health practices as are believed to bring about the best possible state of well-being”. Lawrence Green defined health education as “a combination of learning experiences designed to facilitate voluntary actions conducive to health.” The ultimate goal of health education is to ensure voluntary behavioral change. The terms “combination, designed, facilitate and voluntary action” have significant implications in this definition. Combination: emphasizes the multiple determinants of behavior and learning experiences of educational interventions. Designed: health education is a systematically planned activity and not from incidental learning experiences Facilitate: create conducive atmosphere for action.

23

Voluntary action: Without the use of force, Health education is the empowerment of individuals through increased knowledge and understanding. Information

Knowledge

attitudinal change

behavioral change

health status

(individual & community).

Characteristics of Health Education It is a process (series of step) It is planned activity (based upon some set guidelines and objectives) The focus is behavior and the factors the influence it. Individuals and groups are the focus of all educational activities.

Health information vs. Health education Health education is different from health information. Health information refers to a fact, an idea that is scientifically correct based on well concerted research. Health education deals with the practice of the information as opposed to getting informed alone. Contents of health education: Hygiene, Family health care, human biology, Nutrition Control of communicable diseases, Prevention of accidents, Use of health services, mental health.

Aims of health education.

24

Motivating people to adopt health-promoting behaviors by providing appropriate knowledge and helping to develop positive attitude. Helping people to make decisions about their health and acquire the necessary confidence and skills to put their decisions into practice. To enable people to make their choices about health matters and provide experiences which develop insight and understanding and facilitate individual action. To encourage people to adopt and sustain healthful life patterns, to use judiciously and wisely the health services available to them and to make their own decisions both individually and collectively to improve their health status and environment. Setting for Health Education Knowledge of health education can be provided by anybody in various ways. These ways can be referred to as informal way of imparting knowledge. These are formal ways though which knowledge of health education can be made available to the people. These formal ways are referred to as formal setting. These formal settings met the criteria for accurate health instruction. They are: Home-based setting: This is the type of health education instruction provided by parents, guardians, brothers, sisters, uncles, aunties etc. to their children. The type of health instruction to these children include proper way of brushing teeth, washing of hands after visiting the toilet, regular bathing, cleaning the environment etc. School-based setting: These are health instructions imparted in the school environment. In this setting, health instructions are imparted so that healthy behaviors and lifestyles can be developed. When these are developed, desirable habits, attitudes, concepts and knowledge in individual learners will help them to improve their health and those of others. Community-based setting: These are health instructions to community members that enable them participate in the promotion of health among the community members. These participatory efforts include construction of bole-hole in order to provide portable 25

water for the community, enlighten talk on good hygiene in the community, cleaning and keeping the environment clean. Principle of health Ladoke Akintola University of technology public health reading manual 2014 identifies the following principles of health as follows; Interest Health education must be based on felt needs of the people otherwise they will not show may interest. Participation: people are able to learn actively when they participate in programme e.g. group discussion, workshop etc. Comprehension: language must be simple enough for people to understand, effective communication is a pre requisite to the success of health education. Reinforcement or repletion: an experience which is once and for all is easily forgotten. For people to remember, what is being taught must be repeated at interval? Motivation: Awakening a desire to learn, people are eager to have new knowledge only when stimulated. Communication: the educator must be a sympathetic listener and be able to establish he must understand whatever cultural pattern exists. Leadership: learning is best when given by someone we know e.g. local leader, school teacher, health workers must identify community leaders and work with them. Leaders must identify themselves with the people and be easily accessible. Flexible and fit in with people circumstance e.g. education about nutrition should be based locally available resources.

26

Approaches to health education The persuasion approach –deliberate attempt to influence the other persons to do what we want to do (DIRECTIVE APPROACH) The informed decision making approach - giving people information, problem solving and decision making skills to make decisions but leaving the actual choice to the people. Targets for health education Individuals such as clients of services, patients, healthy individuals Groups e.g. Groups of students in a class, youth club Community e.g. people living in a village Methods in health education The method depends on the objectives of the health education programme, the target group and circumstance under which the health education is to be carried out. There are basically 3 approaches depending on number of participants: Individual or personal approach Group approach Mass approach Individual or personal approach: This involves personal contact like in a consulting room or her facility. Other examples include home visit and personal letters. Advantages of individual approach include the fact that it provides opportunity to ask question and it provides room for discussion, arguments and persuasion. Disadvantages are that the number reached is small and health education given to those who come in contact with health workers alone.

27

Group approach: Group approach comes in form of: demonstration: practical way of showing how things are done. It gives a visual impression impact on the mind of the observer; return demonstration: trainee demonstrates to the trainer. Role play or social drama: A situation is dramatized by those who enact their roles as they have observed or experienced them, useful for giving health to children, it pays attention to what is going on and alternative solution to the problem and how the problem should be solved Lecture: usually one way method, group should not be more than 30. Group discussion: group learns by exchanging ideas, views and experiences. The group should not be less than 6 or more than 20 and there should be a leader to initiate the discussion. Better for participants to know each other before discussion starts. Workshops: It usually involves resource persons Panel discussion: 4-8 people who know about the subject will discuss in front of the group audience. Mass approach: The mass approach makes use of television, radio, newspaper, internet, poster and billboards.

FOUNDATION THEORIES AND PRINCIPLES OF HEALTH EDUCATION There are three main types of behavior which are observable in every human being. These are the Reflex, the Instinctive and the Learned Behaviors. Of these, learned behavior is the focus of health education. Basically, the family performs five functions on each individual from birth till the focus of such individual is established in the community where he lives. The functions are: Educational, Economic, Socialization and Stabilization, Sexuality Orientation and Pro-creational. 28

The question, however is, how the individual acquires the habits and behavior which eventually influences his life style.

Functions of the Family The key functions of the family to the individual are: Educational: teaching and learning new health concepts and skills through the application of perception and experience. Economic: provision of good health, feeding, clothing, shelter and other social facilities which would guarantee survival of the individual. Socialization and Stabilization: the individual imbibes the acceptable practices of developing and sustaining relationships within the cultural setting. However, when there is conflict or crisis, the individual is assisted to solve or resolve such through learned experiences. The tools for doing these endure several generations. Sexuality Orientation: development of orientation and required public practices through which the individual identifies and accepts responsibilities for his or her gender. At puberty, for example, a girl child comes to realize the relationship between the experience and child bearing or parenting. Pro-creation: the individual relates gender responsibilities to population growth and human development. The human society grows as a result of activities approved by the family and community. A couple assumes responsibilities for bringing on the next generation and there is succession rather than extinction. Note that, in each of the foregoing circumstances, the following takes place: Health habits or practices are learned and acquired by the child (the learner). These, eventually lead to a pattern of behavior. For the individual, family and groups, repetition of the 29

approved habits help to establish the belief that it is the correct way of doing things. This will only change if new (or better) ways are introduced to the child as he or she grows. The child (learner) will respond differently to new concepts about health and living and lifestyle at different stages. The environment will play a significant role in the process of learning new concepts about health. This is from the influence of socio-cultural practices over which the individual has no control and must adopt. Examples of areas where socio-cultural practices are firmly established for the child includes: birth and naming ceremony, child raising practices, marriage patterns and ceremonies as rites of passage to adulthood, death, dying and burial rites, beliefs about life events as anchored in the culture and influence of others, religion and concept of God and gods are often used to explain causes of disease, illness, faith and healing. Concept of prevention, control and cure.

Godfrey Hochbaum’s theory of Factors Which Influence Learning Process

Hochbaum postulates that …Human habits are associated with the priority needs for performing health actions. In this process, health habits emanate directly from the attitude formed as a result of what the learner’s belief. There is a sequence whereby Awareness relates to Knowledge, Understanding, Belief, Attitude and Habits (Practices). The six (6) major factors, according to Hochbaum, relate in this sequence, to analyze the process of learning new health concept or any concept for that matter, it is important to start with the level of awareness. In other words, the habits you have acquired and therefore exhibit (or practice) began with your awareness of them. Health habits are the building blocks of health behavior. A collection of habits produces a behavioral pattern. If for example, Juvenile

30

Delinquency (JD) is a behavioral pattern, what are the peculiar habits or practices associated with it? From all cross-cultural records, a JD does the following with known frequency: Stealing, Telling lies, Abusing drugs, Poor personal hygiene, Fighting, Truancy, etc. However, an adult who exhibits the same habits is called a criminal. Like JD, there are other behavioral patterns which are not necessarily bad or anti-social. For example, the following are pro-social behavioral patterns: A Good Community Leader (GCL), A Disciplined Student (DS), A Promising Politician (PP), A Youth Leader (YL). Abraham Maslow’s Theory of Motivational Needs There is a concept of Causal factors to the Functions of the family. This means that functions are performed where certain needs are established for them. The causal factors referred to are therefore types of needs required and found to be necessary for individuals; particularly at the point of entry into a family and the society.

MASLOW’S THEORY OF MOTIVATIONAL NEEDS Abraham Maslow (1954) was a social psychologist who provided explanations for the types of priority needs which the individual requires and are found necessary throughout life. They have been found to determine and compliment the functions of the family. Maslow identified five (5) types of motivational needs found to be common to all human beings irrespective of cultural background. In ascending order, the needs are: Physiological: required for nourishment, growth and development. These include good food, water, fresh air, and health care; Safety: required for protection and prevention from injury to the individual so that survival can be guaranteed. These include shelter and friendly relationships; Love & Belonging: required for sustainability of emotional state of the individual, hence mental health; Self Esteem required for repetition of desired and beneficial actions by and for the individual. 31

Required to keep the individual wanting to achieve greater things; even heights. As Alfred Adler, the great psycho-analyst would claim in his theory of Drum Major Instinct: “the desire to be up-front, to surpass others, to achieve distinction, to lead the parade”; Self Actualization: required to signify a level of satisfaction, hence the desired gratification from a pursuit and accomplishment. It is at the apex of all expectations and largely subjective.

Principles of Learning The following are the basic principles or rules of learning used in health education practice: It is an experience which occurs inside the learner, it is a behavioral change as a consequence of experiences, it is a cooperative and collaborative process between teacher and learner, it is sometimes a painful process for both teacher and learner, it is both emotional and intellectual. Learned behavior is the focus of health education practice in public health. This can be differentiated from two other types of human behavior: the reflex and the instinctive. There are theories which explain the path of learning and the factors which influence learning have been identified by Godfrey Hochbaum. The desire by the child to learn have also been identified by Abraham Maslow as motivational needs of the individual For the purpose of intervention, health education uses basic guiding principles of learning.

PRINCIPLES OF LEARNING IN HEALTH EDUCATION Learning is a systematic process of acquiring knowledge and skills for the purpose of becoming informed and familiar with the circumstances or issue. It includes the stage of memorizing, understanding and comprehending. This process must accompany change in behavior and it is the strategy often employed by health education. 32

Learned behavior rules the world of all living things. Most animal behavior is learned; that is, it is changed by experience. This can be seen, especially in the young of a species as they play and experiment in the environment that surround them. Various types of learned behavior are recognized: Learning is Unique to the Learner: Learning occurs inside the learner and it is activated by the learner. When a learner receives information, he interprets it into messages which are re-coded and stored for the purpose of recall. In actual sense, it is the individual who teaches himself anything of significance. People tend to forget most of the content taught to them and retain those which they consider relevant to their needs. The state of health of the learner is pre-requisite for effective learning. Behavioral Change Occurs As A Consequence of Experiences An individual receives several information, learns many skills and observes many demonstrations all in the process of learning. Both positive and negative experiences add up as the next state in which the individual is found. This is the state of behavioral change.

Learning Occurs Through Cooperation and Collaboration Learning occurs best through interactive and interdependent process. If the learner is able to interact freely with other sources of information and can compare valuable messages, he learns better and effectively.

Learning Can Be a Painful Process (for both the Teacher and Learner) Failure and success are the components of experience. The challenges faced by the learner and teacher sometimes result into frustration and crisis. The sway forward must involve both and sometimes enabling environment.

33

Learning Is Emotional and Intellectual The attitudinal predisposition of the learner influences or moderates what he comprehends in the process of learning. The most important attitudinal element which the learner relies on is his emotional state. Emotion can be described as a state of arousal which is duly expressed voluntarily or involuntarily in reaction to a set of information or messages. Hope and optimism are examples of positive expression of emotion. Despair and fear are examples of negative expressions of emotions. Effective learning under emotion can only occur when the learner applies intellectual skills particularly to analyze and synthesize information and messages. In other words, control of the learner’s emotions results in effective learning.

Conditions which facilitate learning for behavioral change In addition to the qualities of the teacher and learner, there must be an enabling environment. This helps to ensure adequate but sufficient intake of information and messages by the learner. It lowers all forms of externally induced stress which can affect learning in negative ways. It helps both learner and teacher to focus on the purposes of learning. Examples are: it must encourage the learner to be active and pro-active. Learner must be actively involved in the learning process. Must not be pushed but allowed to propel self from within; learner must be able to search and discover ideas through reasoning. It helps to reveal the expressed needs and what is unique about the learner. Differences in ideas must be accepted if differences in people are to be considered and accepted; it must recognize the rights of the learner to make mistakes Growth and change are facilitated when error is accepted as a natural part of the learning process; it must ensure that evaluation is done as a cooperative process with emphasis on self-evaluation; learning should be a personal process where the individual needs the opportunity to formulate the criteria to measure self progress. It anchors self-trust; the learner must feel and believe that he is respected throughout the process of learning. It affirms in the learner that he is accepted (as he or she is), cared for and value.

34

Relating Changes in behavior to learning and growth Recall that one of the conditions for learning is to ensure that evaluation is done as a cooperative process with emphasis on self-evaluation. Learning should be a personal process where the individual needs the opportunity to formulate the criteria to measure self progress. It anchors self-trust. Note the key phrases in this condition as follows: Cooperative process: For as long as there is cooperation between the teacher and learner, there will be effective learning and growth. Self-evaluation: The learner must develop an internal mechanism which must be expressed in the process of learner. Bench-marking must be both internal and external. Self-trust: is the key to dynamic growth and must come from the learner. It helps the learner to focus and check-mate distractions particularly in failed attempts to make progress. It helps the learner to “see the fork on the road”.

SCOPE OF INFORMATION, COMMUNICATION AND EDUCATION (IEC) Literally, IEC means "information, education and communication". The acronym IEC refers to a comprehensive programming intervention which is an integral part of a country development programme, aims at achieving or consolidating behavior or attitude changes in designated audiences, using a combination of communication technologies, approaches and processes in a flexible and participatory, though systematic and well researched manner. IEC is a communication tool which combines strategies, approaches and methods that enable individuals, families, groups and organizations to play active roles in achieving health seeking behavior to improve the quality of life of the communities. There are any types of IEC tools namely posters and pamphlets, flash cards, folk’s songs, street plays and puppetry. These

35

are the common source of IEC materials which are used for effective communication for social change. The term "population information, education and communication" (IEC) alludes to a large variety of activities that usually have a broad mandate and complex functions, involving many different audiences, messages and channels of communication. Nevertheless, IEC is normally used to refer to fostering interest in a particular subject, such as population, or the environment, for example. In the area of family planning, for example, the term could allude to a series of specific goals, such as: creating public awareness about the need for family planning; increasing knowledge about the use and risks of family planning methods, or where to obtain contraceptives; and motivating couples and individuals to visit family planning services.

The Concept of Information, Communication and Education (ICE) Information Information includes the generation and dissemination of general and technical information, facts and issues, to create awareness among policy makers, administrators, academics and the general public, of important developments in the population situation and policies of a country. It may involve public information activities to advocate necessary changes in policies, leadership and resource allocation. Communication Communication is a planned process aimed at motivating people to adopt new attitudes or behavior, or to utilize existing services. It is based on people's concerns, perceived needs, beliefs and current practices; it promotes dialogue (also called "two-way communication"), feedback and increased understanding among various actors. It is thus an integral component of all services and outreach activities. This process is most effective when it involves a strategic combination of mass media, and interpersonal (or "face-to-face") communication supported by print media and other audiovisual aids. Education 36

Education refers to the process of facilitating learning, to enable audiences to make rational and informed decisions, and to influence their behavior over the long term. Education can be carried out through the formal education sector, or through non-formal channels such as social networks, continuing education and literacy classes, cooperatives and workers' associations.

KEY ELEMENTS IN THE CONCEPT OF IEC Having defined the key word in this study unit, let us now examine the key elements of concept of IEC. Information, education and communication (IEC): aims to achieve measurable behavior and attitude changes among specific audiences, based on the needs of well-defined and well-researched audiences, requires planned and multicultural interventions, which combine information, educational and motivational processes, needs to be well synchronized and articulated with the provision of relevant products and/or services, requires multi-disciplinary skills and may borrow techniques and methods from various disciplines.

WHAT IEC CAN DO FOR A HEALTH PROGRAMME Having carefully considered the key elements in the concept of information, education and communication (IEC), let us now examine the benefits of IEC to health programmes: Provided that the service-delivery system or programme operations are well in place, IEC interventions can help achieve national population goals by: Increasing high-level political support for the programme, and placing high on the agenda of planners and policy makers the need for leadership, concrete policy changes, and/or a reallocation of resources; Gaining the public support and institutional response necessary for the programme;

37

Increasing programme planners' and managers' awareness and knowledge of the constraints faced by service users and service providers, and of resistance to change that providers may encounter. This may facilitate managerial decisions, and help planners design or revise national policies. Increasing the demand for services, particularly among the persons in greatest need, by providing necessary information and improving the services' image and visibility. Fostering the adoption by individuals or families of desired practices and behavior (e.g., the use of safe and effective family planning methods, and safe sexual practices). Countering negative attitudes based on misunderstandings and rumors (e.g., the incorrect belief that using the oral pill makes young women sterile). Teaching specific skills or knowledge (e.g., how to use a condom, what the modern methods of contraception are and their relative effectiveness, and where to buy contraceptives). Improving interpersonal communication or counseling skills of service providers in their interaction with service users.

VARIOUS MEDIA IN INFORMATION, COMMUNICATION AND EDUCATION (IEC) Health communication is a key strategy to inform the public about health concerns and to maintain important health issues on the public agenda. The use of the mass and multimedia and other technological innovations disseminate useful health information to the public as it increases awareness of specific aspects of an individual and collective health as well as important in health and development. Health communication is directed towards improving the health status of individuals and populations. Much of modern culture is transmitted by the mass and multimedia which has both positive and negative implications for health. Research shows that theory-driven mediated health promotion programming can put health on the public agenda, reinforce health messages, 38

stimulate people to seek further information, and in some instances, bring about sustained healthy lifestyles. Health communication encompasses several areas including edutainment or enters education, health journalism, interpersonal communication, media advocacy, organizational communication, risk communication, social communication and social marketing. It can take many forms from mass and multimedia communications to traditional and culture-specific communication such as storytelling, puppet shows and songs. It may take the form of discreet health messages or be incorporated into existing media for communication such as soap operas. Advances in communication media, especially in the multimedia and new information technology continue to improve access to health information. In this respect, health communication becomes an increasingly important element to achieving greater empowerment of individuals and communities. One of the most powerful aspects of the media is its ability to set the public's agenda. That is, media shapes what people view as important in the world, and it identifies and defines concerns, issues and problems. This is another form of building awareness. The mass media were not used widely in nutrition communication until the 1970s. Before then, nutrition communication relied almost entirely on face-to-face instruction in health clinics (Lediard, 1991).

TYPES OF MEDIA IN HEALTH COMMUNICATION There are three main types of tools or media in health communication. These are traditional media, small or print media and Mass media. We shall examine each of these media for purpose of establishing their usefulness in health education and communications. Printed and small media These include posters, billboards, leaflets, booklets, comics, flannel graphs, slides, photographs, bulletin boards, banners, displays, fairs and exhibitions. Materials are commonly 39

produced centrally and distributed, but where possible should be produced at state or local government level considering the special needs and context of the area. Women, schoolchildren and young people could be encouraged to develop and produce their own materials or at least be involved in developing concepts and illustrations. Drawings on popular walls, buildings, stores and meeting places can also be effective. Mass media The mass media is made up of channels such as radio, TV, video, films, and newspapers. Out of all these media, radio is one of the most popular and widely accessible and widely accessible communication media in Nigeria followed closely by Television. Mass media can reach many people quickly and at the same time. The use of interpersonal face-to-face communication to reach everyone may not be possible within a short time. Mass media are generally credible sources of information, can provide continuing reminders and reinforcement of messages to encourage maintenance of behavior change, and can be useful for raising awareness and bringing issues and new ideas to people’s attention. It can be used to build public opinion for behavior change by increasing knowledge or providing a forum for debate or creating debate, and to mobilize people. Some types of tools and media are more useful for some target groups than others. For example, television, radio, music and videos, cosmic and games may be more effective for young people than newspaper articles or leaflets. Similarly for rural women, it may be more appropriate to use radio, video or traditional media than leaflets or billboards. Over-emphasis on printed materials and media such as radio and television should be avoided as these will not reach rural or less literate audiences. Different materials and media are also useful at different stages of the behavior change process. For example, radio and leaflets may be useful to raise awareness and increase knowledge, but role play may be more appropriate for developing assertiveness skills.

GENERAL PRINCIPLES OF COMMUNICATION IN HEALTH 40

EDUCATION Communication is the transferring of a message from one person to another so that it can be understood and acted upon. Communication is a basic art of human interaction. Effective communication is developed by practice – a function of good coaching. For health practitioners to improve their communication skills so as to become effective educators, emphasis should be laid on principles of communication in health education. The ability to communicate effectively is the most essential skill of a health educator, especially as it relates to trying to change the behaviors of the listeners

Process of communication The process of communication involves two factors: the sender (communicate) and the receiver (communicate) who is linked by the message that is between them through the channel as indicated below: As soon as the communicator gathers the signs and symbols that he expects will call forth the attention and interest of the sender (communicate) with the desired objective of informing, educating, instructing, persuading or entertaining. He then encodes them in the brain choosing the appropriate channel for the transmission of the message and at the same time, determining who the receiver should be. The recipient (communicate) and then assumes that his attention has been attracted or engaged by the communicator decodes the information from the message. The receiver, for consistency, now responds by giving a feedback to the communicator, which could be negative or positive.

THE ELEMENTS OF COMMUNICATION We shall now consider the elements of communication which is the route through which the message is passed to the receiver. There are five elements whose interrelationship makes communication complete. It is presented in this form: 41

Who = the message (source, sender) What = the message Channel = the method of contact To whom = the message receiver (receiver) Effect = reply (feedback) We shall briefly discuss the various elements. Encoder The encoder is also known as the sender, the source, the transmitter or communicator. It is the first component or element and the one that initiates communication. The person receives the stimulus from self and responds to it, initiates the message, gets the message ready internally by selecting the codes or symbols which the receiver will understand and then puts it in a language which is shared by both of them (sender and receiver). Now let’s examine this practice of sending a message; if an encoder decides to put a message (health information) across in another language different from what the receiver understands, the sender (health practitioner) would have a great difficulty getting the message across. It is to be noted here, that the receiver – client, understand language of the sender because until the client does and act upon the message, communication has NOT taken place. To avoid communication gap, the sender and receiver must tuned together for the message. The encoder must be knowledgeable about the subject, have pleasant personality, a clear voice and ability to listen and inspire confidence. The source of the message can be an individual, a group of persons or a communication organization such as newspaper, magazines or motion picture studio.

Message This is the second component. It is a piece of information that is spoken, written or action performed by somebody. The information can be a stimulus or transmission of thoughts and 42

ideas, attitudes, intentions and needs which the encoder sends to the receiver. Every message sent must have objectives and quality. The quality of any message should include the following: clarity, conciseness, completeness, credibility and practicability.

Channel For any message sent, there must be a channel like: language, code, symbols, sound or any special signal capable of being understood and interpreted meaningfully by the receiver. There are three common channels open to the encoder – oral, written and non-verbal. Whenever the sender decides to speak, it means that the oral channel has been chosen; if the message is on paper, then it is the written channel that has been opted for and it is gestures and body language that are used in conveying the message, then it is a non-verbal channel that has been chosen. Whichever channel is used, singly or combined, it is essential for it to be capable of conveying the desired message efficiently. In health education, visual aids are particularly required to make the channel more effective. According to Unugo (1979), an oral channel involves face to face, radio, television, telephone, cinema, role-playing and computer, internet media of communication etc. A written channel refers to written discourse, drawing and graphs. A non-verbal channel includes body expressions, gestures and body and Para-language, actions, sharp colors, time and physical appearance. Channels are means of presenting messages so that the message can be seen through printed and visual forms, heard through the voice and the media and acted through demonstration and experiments.

Decoder The decoder is also expressed as the receiver. He or she is a listener or communicator. As soon as the receivers’ attention is drawn, interpretation takes place. It can be an individual, an 43

intended audience, a group or an organization that receives and responds to the message. The receiver therefore must be prepared to receive the message in the right mood, ready to listen without distraction and do so efficiently for correct response or feedback, and being ready to read and understand the written message. The higher the intellectual level of the receiver, the quicker and easier it is for them to understand scientific concepts.

Feedback This is the reply to every message that has been communicated. When the message gets to the decoder, the symbols are interpreted in the message sent. If the message is not properly coded, interpretation becomes difficult. The understanding of the message determines whether the feedback will be positive or negative. Feedback is a reaction to a message; it is a continuous process in communication. In health education, a friendly and relaxed personality would provide an ideal condition for effective feedback. Feedback confirms that the set objectives have been achieved, solution proffered for the identified problem while appropriate demonstration will follow for the expected change desired.

THE PRINCIPLES OF EFFECTIVE HEALTH COMMUNICATION PRACTICES Communication is a two-way process of giving and receiving information through any number of channels. The principles of effective health education practice which health practitioners must understand includes the following: Accuracy: the content is valid and without errors of fact, interpretation, or judgment. The content (whether targeted message or other information) is Availability: delivered or placed where the audience can access it.

44

Balance: where appropriate, the content presents the benefits and risks of potential actions or recognizes different and valid perspectives on the issue. Consistency: the content remains internally consistent over time and also inconsistent with information from other sources. Cultural competence: the design, implementation, and evaluation process that accounts for special issues for select population groups and also educational levels and disability. Evidence base: relevant scientific evidence that has undergone comprehensive review and rigorous analysis to formulate practice guidelines, performance measure, review criteria, and technology assessments. Reach: the content gets to or is available to the largest possible number of people in the target population. Reliability: the source of the content is credible, and the content itself is kept up to date. The delivery of/access to the content is continued or repeated over time, Repetition: both to reinforce the impact with a given audience and to reach new generations. Timeliness: the content is provided or available when the audience is most receptive to, or in need of, the specific information. Understandability: the reading or language level and format (including multimedia) are appropriate for the specific audience.

DESIGNING HEALTH PROMOTIONAL ACTIVITIES Having learnt the principles of effective communication, this unit introduces you to how to design health promotional activities. Health promotion is defined as ‘...the process of enabling people to increase control over, and to improve, their health’ (WHO, 1986). It represents a 45

comprehensive approach to bringing about social change in order to improve health and wellbeing. The previous focus and emphasis on individual health behavior was replaced by a significantly expanded model of health promotion which is reflected by the five elements of the Ottawa Charter as follows: building healthy public policy orienting the health services; creating supportive environments; strengthening community action; developing personal skills (Ottawa Charter for Health Promotion WHO, 1986)

Planning health promotional programme for the Community Planning is the process of determining in advance what one wishes to accomplish in a programme or activity. Planning allows for proper organization, implementation and evaluation of a health education programme. This is essential for health education. The four basic steps to effective planning of health promotional programme are: establishment of the main objective, collection of information required, development and implementation of the programme and evaluation. We shall discuss each of the steps one after the other.

Establishment of the main objective The health problem to be planned for is identified according to its community health importance and economic consequences. The objectives are clearly stated before undertaking the health education programme. These include the following: identification of the learning needs; setting learning (educational) objectives.

Identification of the learning needs Learning needs comprises of the knowledge, attitudes and skills required by an individual learner or the community to enable him or her or the community maintain or deal with the health problems. For example; to correct the ideas and perceptions of the people; what specific 46

information the community or individual should be given; what they feel and do about health problem; what specific attitude to be developed; and what actions of the people are desired either as individual family community group. The learning need of individual must be related to the disease or illness. There are two approaches to the learning needs of the community and that of the individual.

Learning needs of the community: Personal hygiene, adequate water supply, adequate immunization, especially for children, adequate breast feeding, proper diet, practice of family planning, and adequate environmental sanitation. Learning needs of the individual: The cause of the disease/infection, how to manage the disease, the dangers of self-medication, the dangers of traditional medicine, the prevention of the disease/illness. (Culled from Health Education and Communication Strategies: A Practical Approach) Setting learning (educational) objectives This is the statement of the outcome to be achieved by the learner at the end of the learning session. It guides the health practitioner to the content, the right methods to use and sets a standard for assessing the achievement during evaluation. The learner should be aware of what he/she should achieve at the beginning of the learning session. It directs the learner to focus on the exact knowledge, attitude and skills he/she is expected to acquire during the health promotion session. A properly written objective should be learner-oriented, observable, measurable, (behavior) attainable (achievable), within the available time and resources.

Collection of the information Required This include information about the health problem and the community 47

About the health problem All relevant information regarding the problem should be collected this is done through listening to their problems and complaints through history taking, physical examination, observation and laboratory investigations in the health facilities. Enquiry and collection of data on vital and social statistics of the disease (problem) age-groups involved or affected types of health facilities available and potential ones for the future and the level of acceptance of the health programme in the community. All these information are obtained and collected through situation analysis. These methods bring into focus the learning needs for planning an effective health education programme. About the community This includes information on the administrative and social structure of the community such as knowledge and understanding of the people about the problem, their misconception, beliefs and superstition, local customs, culture and habits that have a bearing on the problems, channels of communication, communication barriers and other social programmes operating in the area and the attitude of people towards these programmes and availability of resources. These determinants of health could be indentified through community diagnosis.

Development and implementation of the programme This includes the following: Topics for the health education session and master plan; Identifying contents of session plans; Selecting teaching methods for the health session; Selecting teaching aids for the health session.

48

Selecting topics for the health education session and master plan Health education topics are derived from the learning needs of the individual, family or community, the objective, the content to be covered during the health programme session and the resources available which include: personnel, fund and time. The health practitioner selects the topics relevant and useful in solving the health problem of the learners, and then prepares a master plan for the health education programme of that period.

Identifying contents of session plans The content of a health education session is the health information, instruction, and skills (message) to be communicated to the target group to meet the set objective(s). The health practitioner should study the objectives stated for the health session, identify and state the behavior (using action words) in the objective, determine the message in which the behavior is to take place and provide the details relevant to the content. The content could be obtained from resource materials like text-books, journals, research works, subject specialists and personal experience. These guide the health practitioner in developing the content of the topic.

Selecting teaching methods for the health session The following teaching education method is available for use: METHOD USES Group discussion when there is a need to change attitudes because people are better influenced by their peers; Interview: when information is directly related to the objective; Demonstration when a skill is introduced or reinforced;

49

Workshop: to promote active contribution and participation of the learners. Usually, real materials are used; Practice/exercise to allow every leaner to learn at his/her own pace; Projects to promote retention of what is learnt; Requires special skills to organize and execute; Counseling to regain the confidence in the client and allow for choice and coping skills.

Selecting teaching aids for the health session Teaching aids are instructional materials that use the five senses to assist in effective teaching. They also reinforce verbal messages and instructions. As instructional materials increase; the rate of learning stimulates learner’s interest, help to overcome the physical limitations of the health practitioners during health education and also encourage retention.

Types of teaching aids used for health promotional education Types of Examples: Mechanical Audio-visuals like films and television; projected aids like films, slides, transparencies and video; Audio like tape recorders, tape and radio; voice/music amplifiers like public address system, public address vans, etc; Mass communication media; Prints like newspaper, magazine, or nay reader material with wide circulation; Public address system – mobile or stationary like public address vans, hand hailer and microphone at a public gathering, etc; hand-made and hand operated aids Examples such as regalia, models, puppets, specimens, photographs, charts, flannel graphs, flip-charts, displays and exhibitions, chalkboards and chalk, bulletins and bulletin boards, notice boards, etc.

50

Identifying the health issues in the community In order to start planning you need to identify the health issues in the community. Your findings will help you to: Get more information to share with community members and help to explain why the project is needed; Get funding and other resources you will need to run your project; Find out more about the problem; Work out what you want to do to address the problem; When talking to people about health issues, remember; Tell people what will happen with the information they give you; Treat personal information as confidential unless you have the person’s written permission to share it; Don’t use names or other information that could identify people with a story or comment; If you take notes while talking to a person show them or read them back to check that they agree with what you have written. If they are not happy or want to change anything, let them do this; Have respect for what people say at all times.

IMPLENTATION OF HEALTH PROMOTIONAL ACTIVITIES Types of Health Teams 51

In the health team, there are many professionals each expected to play his/her role for the ultimate purpose of providing optimal health care. The team is made up of the following: medical doctors, nurses and midwives, pharmacists, community health practitioners, environmental health officers, laboratory technologist and technicians, radiologists and radiographers, health records. The role of each category of health worker is well explained by the nature of the work they do. The team members are also found in all the three levels of health care namely primary, secondary and tertiary. The expectation is that if the practitioners work as a team (whether at primary, secondary or tertiary level), the recipients of the health care across the three levels will be happily served. However, it is worth mentioning here that, the primary level provides preventive care; the secondary level provides curative care while the tertiary level engages in referral services from the primary and secondary levels, training of manpower and research.

Steps in community mobilization Community

mobilization

Identifying

key

nutrition

issues

and

analyzing

determinants of eating behavior The task of planning nutrition education interventions integrated into nutrition improvement programs requires that the various causes and effects of nutrition issues and problems be addressed in a concerted manner. Only through a systematic analysis of the nutrition and health-related needs of a community, can an effective nutrition education program be developed.

52

Any nutrition education intervention should consider the socio-cultural, economic, political, and technological environments which include food and nutrition issues. Thus, the first step is a situational analysis examining the factors that would draw out pertinent issues to be addressed through nutrition education. The step of identifying and analyzing key nutrition issues and behavior determinants is part of baseline or background research that involves three components (FAO/WHO, 1992): an epidemiological analysis of the specific nutrition issues; a policy analysis of national nutrition priorities and resources; and a behavioral analysis to identify the barriers for adopting the desired behaviors, as well as factors that favor change. The next step applies the first two A's in UNICEF's "Triple A" Approach, consisting of Assessment, Analysis and Action (UNICEF, 1992). An assessment determines the priority issues, problems, local power structures, supporting institutions, communication resources, as well as relevant policies, and the degree to which these affect the state of nutrition and health of the community. An analysis studies the underlying factors that impinge on the issues, problems, structures, resources and policies. Action, in terms of community out-reach strategies, includes: consultations with decision makers at different levels to find out their needs for information; planning and preparation of easily understood messages and materials; and social mobilization of the community as a way of motivating people to cooperate and share limited resources and of empowering community decision makers, be they the local leaders, teachers, mothers, or school children. In designing appropriate community out-reach strategies, nutrition education planners need two major types of information. These are: (i) information about people, and (ii) information about local resources (Stuart, 1991).

INFORMATION ABOUT PEOPLE

53

Information about people is sometimes referred to as audience predisposition in communication models (Gillespie, 1987). The information about people will help identify the nutritional needs of the community. It includes: Nutritional status: Four basic methods are employed to describe the nutritional status of "at risk" groups in the community: anthropometric studies, clinical studies, biochemical studies, and dietary intake studies.

Food consumption patterns: This describes what and how much people usually eat. It determines whether the amount and variety of food intake is adequate for the individual and the household. It also tells if there is food scarcity at certain times of the year.

Medical information: Morbidity and mortality rates and their causes are indicators of the interrelationships between nutrition and prevalent disease patterns, including infections and infestations.

Education: Literacy and educational levels are guides in designing appropriate messages adjusted according to the audience's level of comprehension and language facility. It also guides planners in choosing interpersonal and mediated approaches.

54

Media access and exposure: This indicates the extent to which the community has access and is exposed to certain mass media channels, while it determines the community's media habits, ownership, and preferences.

Economic status and education: Types of occupations, incomes and educational attainment of family members, and whether women work outside the home, indicate if money is regularly available to buy food. Food expenditures also provide an index of the percentage of family income spent on food and non-food items. Child care providers should also receive nutrition education.

Cultural information: Food habits, practices, superstitions, attitudes, social and religious customs, and breastfeeding and weaning practices are useful in determining and designing appropriate nutritional messages and activities.

Food and nutrition information networks: The structure and flow of nutritional information or misinformation among women and men in the community help to identify specific target participants for nutrition education interventions, e.g. sources of erroneous beliefs about breast-feeding and weaning, superstitions, etc.

Studies on functional classification: 55

These studies relate nutrient deficient patterns to spatial, ecological, socio-economic, and demographic characteristics of a population. For example, a study of upland dwellers can yield useful information for designing intervention programmes based on an "area level", integrating a development planning approach rather than a sectoral approach.

INFORMATION ABOUT LOCAL RESOURCES Information about local resources that will help identify problems related to food and nutrition in the community include: Water supply: This helps to identify possible sources of infection and whether enough water is used to maintain hygiene standards. It also indicates if it is possible to increase agricultural production.

Local food production: This identifies the kinds of foods that are locally available for consumption, including their seasonal availability.

Markets and foods: This gives an idea of what crops are sold locally, the process by which a quantity and quality of foods becomes available on the market, and the presence of street-food vendors, snack stands, and other outlets for prepared food.

56

Food storage: It should be determined whether food storage facilities are available, whether enough food can be stored properly for future needs, and whether lack of storage facilities causes specific losses and a shortage of supplies.

Housing: This indicates the adequacy of kitchen, toilet and other sanitation facilities. It is also used to measure space adequacy or crowding among family members.

Local institutions, policy, and support services: This shows whether the local government officials recognize the importance of nutrition in the overall development plans and programmes in their area of jurisdiction. It also determines if there are existing policies that guide local officials, organizations, extension agents, and nongovernment organizations so that they can participate and provide support services for interventions.

Transportation facilities: The availability of farm-to-market roads and public utility vehicles affects the flow of farm products to the market, the availability of food in the local market, and the mobility of individuals to visit health and educational facilities.

57

Educational and communication resources: The availability of these resources indicates the extent to which the members of the community have access to instrumental information and to formal, non-formal and informal education. A community diagnosis is carried out by collecting the information listed above, either from primary or secondary data. Whichever information-collection method is used, the people from the community are the focal participants in this initial planning step. Some techniques that have been used for drawing out needed primary information are the participatory rapid appraisal or PRA technique, focus group discussion or FGD, problem tree analysis, village /assembly, dialogue and consultation, communication network analysis, and community survey.

Selecting target groups The members of a community can be divided into specific groups, or segments of participants, for a community out-reach programme based on information made available. Audience segmentation is the term used for planning a nutrition education and communication intervention when a population is divided into fairly homogenous groups. Each group may then be selected for distinct nutrition education messages. The basic premise is that everyone in the population does not have the same need for a particular piece of information, resource or service. Hence the need to segment target groups. Target groups can be segmented according to the following characteristics:

Social demographic characteristics

58

These include age, sex, educational level, economic class, marital status, family size or number of children, race, religion, language/dialect, occupation, membership of organizations, media habits, geographic location (urban-rural; tropical-temperate), etc. Practices: food habits, breast-feeding and weaning practices, methods of food preparation, backyard gardening, cropping patterns, etc.

Psychographic characteristics These include common lifestyles, social role, the manner in which a person thinks, feels and responds towards a specific nutrition and health-related behavioral issue. They include customs, traditions, indigenous belief systems, values, and other social-psychological traits. Current marketing practices place a heavier emphasis on psychographics than they do on demographics. Examples of target groups for nutrition education are: the women in the community, school children, community health workers, teachers, political and religious leaders, and other fieldworkers, to name a few. These target groups may be further subdivided into more specific groups whose unique traits demand a particular message and strategy. For example, the women may be further segmented into groups of pregnant women, lactating mothers, and mothers of children from six months to six years of age. Other segments of women could be teenage daughters and mothers-in-law. Another important issue in audience segmentation is whether the central nutritional concern is under- or over-nutrition. Accordingly, the appropriate messages are designed and packaged. The target group, based on the priority issue to be addressed, may be classified according to primary, secondary, and tertiary target groups. For example, when promoting vitamin A-rich foods in the community, the primary participants are the child-care practitioners, such as mothers, grandmothers or mothers-in-law, teenage daughters, and other siblings. The secondary participants are the community nutrition/health workers, teachers, and local political and religious leaders who could teach, support, and reinforce desirable practices, values and beliefs in the primary target group. The tertiary participants are those whose expertise and official 59

positions, even if they are not from the community, could serve as valuable sources of information and support. This group could include provincial and district level development personnel in health, education, and agriculture, as well as university researchers, and marketing and communication/media specialists.

Establishing existing levels of nutrition knowledge, attitudes, and practices (KAP) The primary target groups of nutrition education in most cases are women, because they tend to make the decisions when it comes to food, nutrition, and health concerns of the family. Specifically, these women are the pregnant and nursing mothers, mothers of infants and preschoolers (up to six years of age), and mothers of elementary school children. In some cultures the men control the allocation of food resources within the household, determine the mode of infant feeding, food preparation, and use of medical services, etc. Therefore, they may need to be targeted as a primary audience for nutrition education as well. In all cases, formative research is necessary to find out existing levels of KAP in the target groups. This activity will identify the gaps or needs in KAP that could be addressed through nutrition education. Nutrition messages addressed to the target groups are concerned with eliciting specific behavior changes in what they know (knowledge of nutrition and health, food beliefs and superstitions, taboos and misconceptions); what they feel (attitudes, values, and preferences for certain foods and food preparation and child-feeding practices); and what they do (food habits, food preparation practices, customs and traditions, child-feeding practices, cropping system, etc.). Food beliefs, preferences, and habits of the whole family are passed on from generation to generation, and become customs and traditions. They dictate the homemaker's decisions on food selection and preparation. However, many food beliefs and preferences unknowingly lead to poor nutrition and health problems. Hence, a community out-reach programme on nutrition should also address the need to: (i) change the KAP of the homemakers and their families that 60

lead to, or aggravate nutritional problems; and (ii) reinforce behaviors that promote family nutrition and health.

Setting communication objectives Setting communication objectives is an important step in planning nutrition education and communication programmes. The foremost consideration is that the participants, the planners, and the message and media developers, define together the specific outcomes expected over a given period. There must be agreement among the participants on the problem to be addressed, the need for change, the need to take action to prevent or reduce the problem, the strategy by which the change can take place, and the indicators by which such change could be recognized (Valdecanas, 1991). Communication and educational objectives are stated in terms of the participants' desired behavioral outcomes, that is, in terms of the desired degree of change in what they know, feel, or can do. The results of the KAP study among the primary, secondary, or tertiary target group, as the case may be, provide the basis for setting the objectives. Clear and well-defined communication objectives guide message designers and media/materials developers in selecting content, developing appropriate communication strategies and media mixes, and planning monitoring and evaluation schemes. Some useful memory guides in formulating communication objectives are: A-B-C-D: Audience, Behavior, Condition, and Degree Example: "At the end of six months, 75 percent of the mothers with infants and preschool children in Barangay San Pedro will have adopted and prepared on a regular basis vitamin-A rich recipes learned from the Mothers Class." S-M-A-R-T: Specific, Measurable, Attainable, Realistic, and Time-bound

61

Example: "After one year, 95 percent of mothers with naught to six month-old infants in Los Baños will be breast-feeding their babies and for longer periods than observed a year before."

Developing and pre-testing messages and materials With adequate background information about the target groups and properly defined objectives, the next step is to develop a socially and culturally appropriate communication strategy, consisting of approaches, messages, and methods. Approaches chosen are those appropriate for each group. These could be a combination of any of the following: individual, group, or mass approaches using information, education/training, motivation, entertainment or advocacy. Messages vary according to the kinds of behavior-change specified in the objectives, the available resources and services, technologies, other relevant information, participant needs, and method of delivery. In order that each approach is used, activities must be defined according to the programme objectives. Appropriate messages, media, and methods should be designed and pre-tested according to the audience's abilities, resources, and preferences. Media and materials should ensure that target groups receive the message and act on it positively. Materials need not be expensive, for low-cost materials can be as effective. For example, a streamer can be made from used feed or flour bags, or a poster made from the back of old glossy calendars. Involving the community in making the materials is an effective way of getting the message across. For example, the feedbag streamer could announce the coming of health workers on immunization day. A poster may carry a motivational message, such as "Mother's milk is best" or "Use iodized salt". Pre-testing prototype materials, or formative research, are a very important step in message and media development. At the pre-testing stage, the message designer aims to discover any misunderstandings, misconceptions, or shortcomings in either the message or the medium that must be corrected and improved before the material is finalized, reproduced, and distributed. Pre-testing measures the reaction of a small but representative sample of the target audience to a

62

set of communicative materials. Materials may include posters, pamphlets, radio or video material, audio-visual materials for training support, and others. The developer designs two or three alternatives of a given material and tests them with representatives from the target audience. The materials should be found to be: attractive, easily understandable, credible, persuasive, culturally appropriate, memorable, and important to the audience (Bertrand, 1978).

Mobilizing social support and community participation Social mobilization serves as the strategy for motivating mothers, children, families, groups, and communities to become active participants in meeting their food, nutrition, and health needs. It provides the framework for action that links up various sectors at all levels in making available all possible means and resources toward improving the nutritional and health status of women and children (UNICEF, 1995). Five factors influence the nutrition and health situation of vulnerable groups in a community which may affect participation. These include: Socio-economic and political environment - e.g. the lack of political will among local government executives to improve the situation and the poverty and social problems besetting the community; local culture e.g. the traditions, customs, and superstitions which inhibit acceptance of correct practices; Access to programme services e.g. when there are few doctors, nurses, health workers, and community volunteers. Technologies and resources e.g. lack of qualified personnel and unavailability of facilities for service delivery, and home environment e.g. when the parents' level of knowledge and attitudes are constraints.

63

The five components of social mobilization can, in turn, enhance the positive contribution of the above five factors. These five components are: advocacy; Information, Education, Communication (IEC); community organizing; training; and monitoring and evaluation. Through advocacy, the social mobilizes seeks the support and commitment of these sectors to facilitate and accelerate the improvement of the situation of women, children and other vulnerable groups. The decision is in the hands of national and local officials, opinion leaders, the media, and civic, political and religious organizations, in other words, those who have the authority to enact laws or allocate much needed financial, physical, and manpower resources. Through IEC, all concerned sectors, including the target groups, are informed of the problems and motivated to participate in community activities. Community organizing allows the community to unify and collectively act to seek solutions to their problems. Training maintains the commitment of fieldworkers and implementers as it integrates new techniques to their work. Monitoring and evaluation provide feedback on how to improve strategies and measure goal attainment (UNICEF, 1995).

EVALUATION OF HEALTH PROMOTIONAL ACTIVITIES Evaluation can be regarded as a series of processes which entails a systematic processing of looking analytically into educational problems through the asking of appropriate questions, examining the answers correctly and using them as a basis for further decision-making. It is in built into every process of systematic development. The success or failure of any programme, in health, education or any other sphere of human endeavor, to achieve a particular set of objectives may be judged in many ways. These include; the amount of activity expended towards the accomplishment of the objectives and the magnitude of the outcome or the effect produced by the programme activity. Since evaluation is a process of determining programme performance for the purpose of improving service delivery, the process should be a continuous one (Adeyanju, 1987). The evaluation process must enable us to see whether our objectives are being met, help us to diagnose and give guidance at every stage of development, see the need for reform or change as well as promote further inquiries.

64

Types of Evaluation We can group the reasons for evaluating learners into two classes: first, those reasons which demand a continuous assessment (formative evaluation), and, second, those others that assist in decision-making at the end of the course (summative evaluation).

Formative evaluation Also called progressive evaluation, the primary purpose of formative evaluation is to provide feedback to the learner and/or teacher about the learner’s strengths and weaknesses. Formative evaluation follows small units of learning. The most significant advantage of this kind of evaluation is that it diagnoses learners’ problems early in the instructional process and allows corrective measures to be taken. It is done throughout the course of study.

Summative evaluation Summative evaluation is carried out at the end of the term, course or programme. It is also called “terminal evaluation”. It is used mainly for certification, licensing or for selection of learners for a further educational programme.

Process of Evaluation: Input, Output and Processor Input/output is the communication between information processing system (such as a computer) and the outside world, possibly a human or another information processing system. Inputs are the signals or data received by the system, and outputs are the signals or data sent from it. The term can also be used as part of an action; to "perform Input and Output” is to perform an input or output operation. Input and Output devices are used by a person (or other 65

system) to communicate with a computer. For instance, a keyboard or a mouse may be an input device for a computer, while monitors and printers are considered output devices for a computer.

Processors: The "Processor" performs the actions needed to produce a result from the process. If the Processor is automated, the actions may be prefigured, that is, designed in advanced. This is especially true of computer programs that carry out algorithmic processes such as automated insurance claims adjudication or automated loan application evaluations. This kind of knowledge is also embedded or, more precisely, "encoded" in the process. Then again the Processor may be a person. The actions, however, might still be prefigured, as is the case when a claims examiner, in accordance with clear-cut procedures handed down from on high, processes a claim that has been suspended from automated processing for manual resolution. Relevant knowledge is again captured in the procedure. Actions might also be configured by the performer that is, tailored to the situation at hand. For example, a sales representative for a pharmaceutical firm might call on a several physicians during a day's work. In discussions with the physicians, the representative will probably present some "canned" information but, in all likelihood, the representative will also customize his or her presentation to suit the interests and requirements of a particular physician during a particular call. In these situations, the knowledge, or capacity for action, clearly resides within the individual. All health education programmes require continuous evaluation in order to find out the success or failure of the programme. Evaluation should not be left till the end but should be made at regular intervals during the planning and implementation stages, to identify problems and make modifications. The baseline for effective evaluation is the objectives(s) set at the planning stage of the programme against which to measure results. Evaluation in health education should be made in practical line through specific objectives. Evaluation can be regarded as a series of processes which entails a systematic processing of looking analytically into educational problems through the asking of appropriate questions, examining the answers correctly and using them as a basis for further decision-making. It is built into every process of systematic development. The success or failure of any programme, in

66

health, education or any other sphere of human endeavor, to achieve a particular set of objectives may be judged in many ways. These include; the amount of activity expended towards the accomplishment of the objectives and the magnitude of the outcome or the effect produced by the programme activity. Since evaluation is a process of determining programme performance for the purpose of improving service delivery, the process should be a continuous one (Adeyanju, 1987). The evaluation process must enable us to see whether our objectives are being met, help us to diagnose and give guidance at every stage of development, see the need for reform or change as well as promote further inquiries.

Definition and importance of monitoring Monitoring is define as the day-to-day follow-up of activities during their implementation stage, to ensure that they are proceeding as planned and are on schedule. It is a continuous process of observing, recording, and reporting on the activities of the organization or project. Monitoring, thus, consists of keeping track of the course of activities and identifying deviations and taking corrective action if deviations occur. Monitoring is "the performance and analysis of routine measurements aimed at detecting changes in the environment or health status of population". Thus we have monitoring of an air pollution, water quality, growth and nutritional status of children etc. It also refers to the measurement of performance of an ongoing health service or a health professional, or of the extent to which patients comply with or adhere to advice from health professionals. Monitoring refers to the continuous overseeing of activities to ensure that they are proceeding according to plan. It keeps track of performance of health staff, utilization of supplies and equipments, and the money spent in relation to the resources available so that if anything goes wrong immediate corrective measures can be taken. 67

Evaluation of health promotional activities Evaluation is the process by which results are compared with the intended objectives, or more.

Elements of evaluation process Evaluation is perhaps the most difficult task in the whole area of health services. The components of the evaluation process are: Relevance: Relevance or requisiteness relates to the appropriateness of the Service, whether it is needed at all. If there is no need, the service can hardly be of any value. Example, vaccination against smallpox is now irrelevant because the disease no longer exists in the world. Adequacy: It implies that sufficient attention has been paid to certain previously determined courses of action. For example, the staff allocated to a certain programme may be described as inadequate if sufficient attention was not paid to the quantum of work-loan and targets to be achieved. Accessibility: It is the proportion of the given population that can be expected to use a specified, facility, service, etc. The barriers to accessibility may be physical (e.g. distance, travel, time): economic (e.g. travel cost, fee charged); or social and cultural (e.g. caste or language barrier). Acceptability: The service provided may be accessible, but not acceptable to all, e.g. male sterilization, screening for cervical or rectal cancer, insertion of copper T if the professional worker is male/female as the case may be. Effectiveness: It is the extent to which the underlying problem is prevented or alleviated. Thus it measures the degree of attainment of the predetermined objectives and targets of the programme, service or institution-expressed, if possible, in terms of health benefits, problem reduction or an improvement of an unsatisfactory health situation. The ultimate measures of the effectiveness will be the reduction in morbidity and mortality rates. 68

Efficiency: It is a measure of how well resources, money, men, material and time are utilized to achieve a given effectiveness. The following examples will illustrate: the number of immunizations provided in a year as compared with an accepted norm using cotton and gauze to clean the windows or chairs during personal work on project time, a medical officer who cannot speak the language of the client or a professional nurse who cannot insert a copper T or health personnel proceeding on long leave with no replacement. Impact: It is an expression of the overall effect of a programme service or institution, on health status and socioeconomic development. For example, as a result of malaria control in Nigeria, not only has the incidence of malaria dropped down, but all aspects of life agricultural, industrial and social-showed an improvement. If the target of 100 per cent immunization has been reached, it must also lead to reduction in the incidence or elimination of vaccine preventable diseases. If the target of village water supply has been reached, it must also lead to a reduction in the incidence of diarrhoea diseases. Monitoring and evaluation must be viewed as a continuous interactive process, leading to continual modification both of objectives and plans. Successful evaluation may also depend upon whether the means of evaluation were built into the design of the programme before it was implemented.

FEEDBACK MECHANISM IN HEALTH PROMOTIONAL ACTIVITIES

Types of feedback Feedback is commonly divided into two types—usually termed positive and negative. The terms can be applied in two contexts: The altering of the gap between reference and actual values of a parameter, based on whether the gap is widening (positive) or narrowing (negative).

69

The valence of the action or effect that alters the gap, based on whether it has a happy (positive) or unhappy (negative) emotional connotation to the recipient or observer. "Quantitative feedback tells us how much and how many. Qualitative feedback tells us how good, bad or indifferent. The terms "positive/negative" were first applied to feedback prior to World War II. The idea of positive feedback was already current in the 1920s with the introduction of the regenerative circuit. Friis and Jensen (1924) described regeneration in a set of electronic amplifiers as a case where the "feed-back" action is positive in contrast to negative feed-back action, which they mention only in passing. Harold Stephen Black's classic 1934 paper first details the use of negative feedback in electronic amplifiers. According to Black who stated "Positive feedback increases the gain of the amplifier thus negative feedback reduces it." According to Mindell (2002) confusion in the terms arose shortly after this: "... Friis and Jensen had made the same distinction Black used between 'positive feedback' and 'negative feedback', based not on the sign of the feedback itself but rather on its effect on the amplifier’s gain. In contrast, Nyquist and Bode, when they built on Black’s work, referred to negative feedback as that with the sign reversed. Black had trouble convincing others of the utility of his invention in part because confusion existed over basic matters of definition." Even prior to the terms being applied, James Clerk Maxwell had described several kinds of "component motions" associated with the centrifugal governors used in steam engines, distinguishing between those that lead to a continual increase in a disturbance or the amplitude of an oscillation, and those that lead to a decrease of the same.

The Non-governmental Organizations as Feedback Mechanism

70

Non-governmental organizations (NGOs), government-related organizations (GROs) or government peripheral organizations (GPOs) are "legally" constituted corporations created by natural or legal people that operate "independently" from any form of government, but in general with very good relationship with some specific governmental institutions. The term originated from the United Nations, and normally refers to organizations that are not a part of a government and are not conventional for-profit businesses. In the cases in which NGOs are funded totally or partially by governments, the NGO maintains its non-governmental status by excluding government representatives from membership in the organization. In the United States, NGOs are typically nonprofit organizations. The term is usually applied only to organizations that pursue wider social aims that have political aspects, but are not openly political organizations such as political parties. The number of NGOs operating in the United States is estimated at 1.5 million. Russia has 277,000 NGOs. India is estimated to have had around 3.3 million NGOs in 2009, just over one NGO per 400 Indians, and many times the number of primary schools and primary health centers in India. GRO/NGOs are difficult to define and classify, and the term 'GRO/NGO' is not used consistently. As a result, there are many different classifications in use. The most common NGOs use a framework that includes orientation and level of operation. A GRO/NGO's orientation refers to the type of activities it takes on. These activities might include human rights, environmental, or development work. A GRO/NGO's level of operation indicates the scale at which an organization works, such as local, regional, national or international. One of the earliest mentions of the term "NGO" was in 1945, when the United Nations (UN) was created. The UN, which is an inter-governmental organization, made it possible for certain approved specialized international non-state agencies - or non-governmental organizations - to be awarded observer status at its assemblies and some of its meetings. Later the term became used more widely. Today, according to the UN, any kind of private organization that is independent from government control can be termed a "GRO/NGO", provided it is not-for-profit, non-criminal and not simply an opposition political party. One characteristic these diverse organizations share is that their non-profit status means they are not hindered by short-term financial objectives. Accordingly, they are able to devote 71

themselves to issues which occur across longer time horizons, such as climate change, malaria prevention or a global ban on landmines. Public surveys reveal that NGOs often enjoy a high degree of public trust, which can make them a useful, but not always sufficient-proxy for the concerns of society and stakeholders. An effective feedback mechanism is very important in humanitarian settings. For one thing, they can help close the gaps between accountability rhetoric and practice. However, there is a need for evidence on what works, and doesn't in different contexts. This is the task every player in health promotional activities should know and work with it.

HEALTH INSTRUCTIONAL MATERIALS Types of instructional materials Communication and consequently teaching is more effective when more than one sense is used. The teacher who relies only on the spoken word to deliver the message is less effective than one who uses several senses (a multisensory approach). One sure means by which the teacher attempts making the contents and communication understandable to the learner is the use of instructional materials. Instructional materials are go-in-between channel through which information is disseminated from the teacher to the learner. They are classified in different manners. They come in a form of audio, visual, audiovisual, projected, non-projected, hardware, software, specimen, realia/real objects, etc. Attempts shall be made to explain some of them in details. A multisensory approach improves retention (the ability to remember), which is vital in education. The commonest instructional materials are audio-visual ones where the teacher combines the senses of seeing and hearing. These can be classified into projected and nonprojected aids.

Projected Aids

72

Projected aids include the overhead transparency (projector), kaleidoscopes, films, video cassettes and slides. They are powerful aids if you can obtain appropriate ones, but they are expensive and difficult to maintain. The overhead projector is relatively cheap and easy to maintain and is easily available. It will be described here in detail to enhance its use in training institutions.

The overhead projector The overhead projector (OHP) projects large transparencies from a horizontal table via a prism or mirror and lens. A bright image appears on a screen behind the teacher.

Setting up your projector screen The setting up of the screen depends on: the type of room; the size of the audience There are two possibilities of projection: project behind; project slightly to the side (better viewing) When lecturing, stand to right or left of the projector.

Advantages of using OHP The teacher faces the classroom and can point out features appearing on the screen by pointing to the material; Darkening of the room is not necessary; A wide variety of materials can be projected; Transparencies can be used as an illuminated blackboard during the class period or transparencies can be prepared beforehand; 73

A number of transparencies can be put on top of each other showing stages of development e.g. of an idea or structure; Tracing of diagrams and drawings is easy; Transparencies can be made in many colours, both permanent and non-permanent depending on the pens and ink used; The overhead projector has endless possibilities in the hands of a resourceful teacher and has applications at all levels of education.

Care and maintenance After finishing a demonstration do not remove the wire plug from the socket but switch off the lamp and keep the fan running until the bulb has cooled down (there is a thermostat fitted in most types of OHP); Keep lenses and mirrors free of dirt; Keep a spare bulb in stock; Store semi-permanent transparencies together with master copies of handouts in a file with the unit block or subject concerned, so it can be found easily when needed and used again the following year.

Non-Projected Aids These include the chalkboard, pictures/cartoons, flipcharts, posters, and “the real thing”, handouts and flannel boards.

74

The Chalkboard The chalkboard is the most convenient and most used teaching aid. However, it is often badly used. As with all teaching aids, it requires planning in order to achieve effective learning.

Some aids to chalkboard work Templates: Shapes cut out of card or plywood help to outline figures which are often needed, e.g. a triangle in mathematics. Bounce pattern: A sheet of thick rough paper in which a certain outline e.g. a map of a country with its region, is punched out along the outline. The paper is held against the chalkboard and a chalky duster flicked along the line of perforation. When the paper is taken away, lines of dots appear which can be joined by the teacher to produce the wanted drawing. Semi-permanent lines: Such lines can be produced by using soft chalk soaked in sugar solution. They can be wiped off with a damp cloth. Pictures Slides, photographs, picture-drawings, line-drawings, cartoons etc., are good teaching and appropriate pictures are difficult to obtain or prepare. Flipcharts/Cards Flip charts as an instructional medium is so called/named because of its potential feature of accommodating more than a chart. This is good to illustrate processes in a “flowing” form. These are cheap and easy aids to prepare. They can be made from butcher paper, old calendars, paper boxes, manila paper, etc. The diagrams can be drawn by somebody else or traced on. The pictures should be labeled in legible handwriting. When labeling, remember to: use thick felt pens; use different colors for emphasis; write in upper and lower (small) cases letters not capitals; do not write too much; when making a presentation using flipcharts, do not read the 75

chart as you talk. The secret is to make some notes at the back of the flipchart to guide your discussion; always face the audience. Posters Posters take longer time to prepare than flipcharts. They may consist of words only, pictures only, or a mixture of both. Unlike flipcharts, posters are usually single-leafed. Posters need a lot of planning and testing before use. They can be prepared for two types of viewers: For a mixed (heterogeneous) audience e.g. on a street for the general public; For a captive audience e.g. in a class. When a poster is being prepared for a heterogeneous audience, it should deliver the message at a glance. When preparing a poster, remember the following: Make it simple; Use simple language (avoid difficult words or slang); Put as little as possible on the poster.

The Real Thing (Realia) The best teaching aid is “the real thing”. For instance, it is much better to teach mothers how to wash a baby by using a real baby rather than a doll. A live baby cries and kicks, a doll does not. These characteristics have to be taken into account in teaching mothers how to wash a baby. So try as much as possible to use “the real thing” in your lessons. Your first thought should be: is it possible for me to demonstrate the real thing to my class in this lesson? Only when this is possible should you think of other teaching aids that are imitations to the real thing; the closer the imitation to the real thing, the better the teaching aid. This is an important consideration in helping the learner to transfer the impression he gets from the lesson to the real thing. Teaching

76

aids that are seen in the places where they belong are easier to understand and remember. A field trip is the general term for taking a class to the “real thing” in its context or normal surroundings.

The Flannel Board This is the device of choice for teaching in rural areas. All rural-health educators should know how to use it. The operation is based on the fact that materials with rough surfaces tend to adhere to each other. If flannel is not available, alternative materials can be found. The board is put in front of the class, sloping slightly backwards. Cards with a rough backing (e.g. sand paper) can now are placed on the board in any position. The cards can be moved or taken down at wills. Make cards from large print or written words, e.g. newspaper cuttings, photographs or dissected posters. Advantages It tells a story in which you can see things happen; It has strong colors that please the eye; The pictures are large enough to be seen from afar; It looks like things that people are familiar with; It arouses interest and questions.

Disadvantages Barazas are usually too big for flannel graph pictures to be seen from the back; When they are used outside, wind may blow the flannel graphs away;

77

The apparently miraculous way in which the picture sticks to the board is a distracting novelty.

MEDIA AND METHODS Conventional media and methods in public health

Individual method: This method involves person-to-person or faces-to –face communication, which provides maximum opportunity for two-way flow of ideas, knowledge and information. Adequate interaction between the health educator and his client help provide health education successfully resulting in attitude and expected behavioral change. The examples of individual methods of health education are interview and counseling. Interview Interview is to meet and talk each other and collect information and ideas. It is a kind of process or method of providing health education through the means of question and answer between the health educator and the learner. In this process, interviews, knowledge, attitude, feeling and health practices are studied and essential suggestions are given to bring about the positive change. Advantages of interview Helps to know knowledge, attitude and practice; Helps for intensive and systematic teaching with exchange of ideas and feelings; Help to reach a better conclusion for solution of a problem; Easy to conduct with less cost and limited facilities;

78

Even illiterate persons can be interviewed and taught; Easy to make follow-up; It is a two way communication; The expression and gestures can be observed.

Counseling Counseling is a process of encouraging and helping an individual in identifying his or her health problem, the cause of the problem, the ways of its solution and also encourages taking necessary actions to solve it. The decision of actions strategies is made on his own choice with least of advice from the counselor. A counselor will have to play a serious role of helping the client in identifying the actual problems and the appropriate method to solve it. So he must encourage for adequate interactions between him and his client. Opportunities for counseling are: at Hospital, at Home, at School Techniques of counseling: The following techniques which can help for effective and successful counseling. Building rapport: It is a process of developing relationship with the client and gaining faith. The counselor should show positive attitude towards client. He should first introduce himself and try to get clients introduction establishment of such relations will help to gen confidence, truth and mutual understanding which help to keep client at ease and help to exchange ideas, feelings, and experiences in maximum level.

Identifying clients need or problems.

79

Individuals have their own values, norms, beliefs and attitude all which influence decision. Counselor must try to understand the problem as the client sees himself. Counseling should conduct in a respectful way using a communication process that seeks to understand the client’s needs. Counselor must speak politely, cleanly, listen to, exchange ideas and help in identifying the health problems of the clients. The counselor should help the client in finding ways to solve the problems by encouraging in discussion and develop problem solving strategies based on his situation. Counselor should provide appropriate information and help to find resources. He can guide the client a sound decision and encourage implementing what he is planned.

Maintaining patience: A counselor should be patience while giving information, listening to the client’s ideas and guiding to help him, identifying the health problems and help to solve it by necessary actions. A counselor should be patient throughout the counseling period. He should do responsibility seriously.

Keeping secret: Counselor should maintain confidence on sensible personal matter is highly necessary during counseling. In ability on the part of counselor to maintain confidentiality will result in non cooperation and failure in counseling. Advantage of counseling It is helpful in dealing with individual clients and motivates him to take necessary action to solve his health problem; Provides maximum opportunity for feedback; 80

Helps to maintain two way communications; Illiterate people can be taught by this method; Easy to make follow up studies on the basis of counseling records.

Group method: An ideal group may consist of six to twelve members depending upon situation. This small group also can get some opportunity to ask questions and share ideas, information and experiences. In spite of the advantage of individual methods a health educator cannot be use because of time limitation and shortage of manpower. So it will be more practicable for him to provide health education in-group situations as well. Teaching in group can also be effective because it also provides ample opportunity for question answer and discussion. Examples of group method of health education are: group discussion, demonstration, mini-lecture, problem solving, brain storming, panel discussion, role play, field trip/educational tour, workshop/seminar. Demonstration Demonstration is the process of providing knowledge and skills as well as developing attitude of a small group of people through the manipulation of appropriate teaching devices or materials. Teaching by demonstration involves verbal and visual explanation. It is a mixture of theoretical and practical teaching. It is organized to teach about the specific topics and it takes 45 minutes to complete the demonstration but it slightly varies according to the topic. The numbers of learners in the group may be about 15 to the maximum. The learners are given opportunity to see and manipulate the device or materials used in demonstration and also give opportunity to practice the process and questions and answers to clarify doubts. Advantages of Demonstration It is the effective teaching method which involves varied learning experiences like seeing, hearing, feeling, testing and smelling depending upon the subject of demonstration;

81

It is interesting and draws attention of the learners because of the active learning process; It helps to develop not only knowledge and attitude but also skills for required work performance; Student’s achievement could be immediately assessed through verbal expression and skill practice; Provides concrete and realistic visual picture of what is being taught resulting in a more lasting impression; It is cheap, practicable, accessible and useful for different categories of learners. It needs only limited materials and object. It can be used at different teaching-learning situations at different places. Role Playing Role play is a socio drama which can be carried out by individual or a group of people taking different roles and acting out problem situation similar to that they encounter in their real life situation. They enact roles as they have observed or experienced and act or pretend to be a sick. Person, as a mother, child, health worker etc. In a role playing there will be about 5 to 6 characters and 15-20 audience but the number may be slightly vary according to situation . Advantages Give learners opportunity to express their ideas based on real life situation and can learn from each other; Enables the learners to see things through the eyes of others. Start learning how knowledge and attitude affect health behavior; Develops the power of quick thinking and expression .Helps the characters to explore their potentialities and come to a better decision. They can apply those skills in their real life situation while dealing with health problems; 82

Develop careful listening habit; Makes people think in a more constructive way; It interesting and provides active learning opportunity in a realistic way; It simple and inexperience and can easily be conducted at different situation; the best way to teach people about health in order to make them understand it.

Group Discussion The practice of meeting group of people and discuss to solve problem existed since the beginning of man's ability to communicate with verbal symbols. Today, group discussion is also used commonly in teaching a ' group of people about how to identify their health problem and find out ways and means to solve it. It is a method of teaching through the direct share of knowledge, ideas and experiences among small group of persons about a particular subject or problem within a limited period of time with a view to solve the problem. Any discussion should take only an hour or less to avoid boredom.

Field trip A study field is a planned visit to a place outside the classroom to provide practical knowledge in real situation. It is also called a study trip or an educational excursion or an educational tour. A study trip may be made to places within walking distance of the school taking few hours or even a day. A study trip may also be taken within the school complex to see and study the waste disposal system, latrines, water supply system, kitchen complex, cafeteria or canteen, and the food Store. Study trip can also be taken to a distant place for several days.

83

Mass method: This method is especially meant for a large number of heterogeneous people. Such group of people is commonly termed as mass. It can be inform of Lecture or Exhibition. The approaches for mass method can occur through any of the following methods:

Exhibition: Exhibition is the systematic and meaningful display of educational materials with an intention to educate large number of people within a limited period of time and at a particular place. Exhibition can sometimes be organized to provide health education to the community people. Exhibition consists of the use of different teaching materials and methods to illustrate and ex plain the points of teaching. They are posters, charts, graphs, models, real objects, cassette playing with some health message, demonstration, puppet show, videocassette, etc. Criteria of selecting appropriate method and media of health education Feasibility or practicability: There should be possibility of using the required methods at the place where we are giving health education, like we cannot use electrical devices where there is no electricity. Showing film, using overhead projector is impossible at such places.

Nature of the audience: Proper methods should be used and selected by considering the nature of audience; we cannot use panel discussion and symposium for children and news papers, pamphlets and other written document for uneducated persons.

Accessibility: The method should be effective enough to reach and influence each members of the total population, where we have to give message. It should not happen that one part of a community has well access to all sorts of methods and next part is avoided. These problems usually arise in hilly remote areas.

84

People's attitude and belief on the method or media: Usually people have more believe on radio, television and national magazines, but they have less believe on lecture, milking and palpating are more reliable and accepted more by people. So giving message through radio, television and magazines are more reliable and accepted more by people.

Subject or purpose of teachings: We have to select such sorts of methods which will help to fulfill the objective and needs of the people. It should be selected according to the interest of the people so that the audience will eagerly participate.

Health Education Media Media are the teaching aids by which knowledge, information and ideas are communicated with view of dissemination of messages. The teaching aids helps to health educator to impart knowledge to the audiences. The media or teaching aids are used to create awareness and in enforcing learning. They are used different ways and at different situations of individual, group and mass teaching.

Classification of health education Media Generally teaching aids or media can be broadly Categorized into 3 types:Audio Aids: learning occurs by hearing e.g. Radio, cassette player Visual Aids: People learn by seeing .e.g. Posters, pamphlets, flipchart, flannel graph, Butte tin board etc. Audio -visual aids: learning occurs by hearing and seeing.eg Television, film & sound, videotape, movie etc.

85

Retrieved

from

Hubley.co.uk

Interent

sources

FACTORS AFFECTING HEALTH Organizational factor affecting health: considering with organizational factors influence health is an important aspect of what nurses do when promoting the health of their parents. Think 86

about an organizational factor that affected the health of a patient you cared for during the last year. Did you encounter anyone who had to wait a long time for a healthcare appointment, schedule a health visit at a time that was really difficult for them, wait to get their medications refilled, or work to understand what a busy healthcare provider was actually saying? Consider the case of Ramon, who spoke very little English. When he came to the Urgent Care Clinic he had difficulty registering because he did not feel comfortable standing at the front counter, where everyone could hear, and saying that frequency urination brought him to the clinic. Once he met the nurse practitioner and a urine screen he had a urinary tract infection, he did not know how to tell the busy nurse he did not have money to get the antibiotic prescription filled for 5 more days , frustrated ,he left the clinic and went home .Discomfort ,burning and frequency prompted him to go to emergency room later that night ,where he had to wait 12 hours before being seen. Living with others: Individuals that are quarrelsome always constitute to health problems to other people. Diseases prevention: If diseases are prevented through keeping our environment clean and maintaining good hygiene, the people would be healthy. Intelligent use of food: people mostly eat food junks in eateries, children also eats chocolate and candy sweets which is not good for the body and cause health problems. Eating balanced diet, fruits, vegetables are good for the body. Mastering the environment: The environment is an important aspect of life. The environment one finds self has a lot to say about the person’s health. Choosing best health services: It is advisable to seek correct and adequate medical services when one is not feeling well. Always follow doctor’s prescription and avoid self medication. Economic factors affecting health: involves elderly clients on limited incomes, case of unemployment

87

Social factors affecting health: involves major impact on beliefs, health practices, health communication and trust that patient have in health care providers. Behavioral factors affecting health: variety of behavioral factors influences whether patients comply with their ordered and treatment. Some lack of compliance or adherence with ordered care is based on previous negative experiences with health care system. Population risk continuum for addressing health issues Primary prevention The target population is large, and it is not possible to say with certainty who will develop the problem of concern. Programmes focus on improving everyone’s interest in and capacity to maximize their own health and on environmental factors that enhance or impede health. Primary prevention decreases the number of new cases of a disorder, illness and premature death (reduces incidence).

Secondary prevention The target population is more narrowly defined as some identifiable subgroup known to be likely to develop a problem. Programmes focus on characterizing these at-risk subgroups and developing early detection and intervention methods. Again, programmes attend to both individual and environmental issues. Secondary prevention reduces incidence as well as the rate of established cases in the community (reduces prevalence).

Tertiary prevention Members of the target group are demonstrating clear pathology and require immediate intervention. Programmes focus on specific therapeutic interventions, factors that affect

88

treatment uptake and outcome and risks to the general population posed by the pathology or offending agent(s).

Primary prevention spans the health enhancement/risk avoidance portion of the continuum; secondary prevention the risk reduction/early intervention segments and tertiary prevention involves the treatment/rehabilitation segment of the continuum. Primary, secondary and tertiary prevention are not discrete, easily defined intervention points related to the development of a condition of concern, but rather simply denote a population continuum based on risk factors and conditions. Different kinds of intervention are necessary at definable times during the development of a preventable condition. Rather than suggesting that any one part of the continuum is more or less important than another, emphasis instead should be made that any intervention can be appropriate, “depending on the nature of the problem, the state of knowledge, the availability of resources, and the purposes served by the intervention”. Let’s examine how coronary heart disease might provide an example. Downstream, curative interventions include heart transplantation, thrombolytic therapy, coronary artery surgery, angioplasty, pre-hospital resuscitation and pharmaceuticals. Midstream secondary prevention efforts focus on smoking cessation, cholesterol lowering medications and weight and stress reduction. As the level of intervention moves upstream into primary prevention, it involves organizations (e.g. schools and worksites), entire communities and health and macro-social policies (legislating non-smoking areas, restricting the number and location of drinking outlets). No one intervention approach should be viewed as intrinsically more worthwhile than another; each makes important and complementary contributions toward improving public health.

Examining the relationships: health education, health promotion and health literacy

89

Much has been written over the years about the relationship, uniqueness and overlap between health education, health promotion and other concepts, such as health literacy, primary health care, community development and mobilization, and the role of empowerment. Attempting to describe these various relationships is not easy; findings and consensus will not fall neatly into place like the pieces of a jigsaw puzzle. Furthermore, discussion around these concepts can be intense since the professional affiliation associated with them is often strong and entrenched. Another hurdle is the frequent lack of consistency in the terminology used, which is because the concepts themselves are either still evolving or have evolved at different times from separate disciplines such as psychology, sociology, medicine and the field of social justice. Nonetheless, the purpose of this section is to build upon the definitions of health promotion, health education and health literacy given in the previous section and in Annex 1 and to review the ways in which these concepts relate to one another.

Health education and health promotion Health promotion is concerned with improving health by seeking to influence lifestyles, health services and, above all, environments (which are not limited to the physical environment but encompass as well the cultural and socioeconomic circumstances that substantially determine health status). There are several recognized definitions of health promotion, most of which embrace the tenets of health, community participation and individual empowerment. The most prominent, from the Ottawa Charter for Health Promotion, proposes a framework for action that sets out five priority areas: building healthy public policy; creating supportive environments; 90

strengthening community action; developing personal skills; and reorienting health services. Health promotion has its roots in many different disciplines. Over time it incorporated several previously separate components, one of which was health education. Some authorities hold the view that health promotion comprises three overlapping components: health education, health protection and prevention. These overlapping areas are potentially substantial: health education, for example, includes educational efforts to influence lifestyles that guard against ill-health as well as efforts to encourage participation in prevention services. Health protection addresses policies and regulations that are preventive in nature, such as fluoridation of water supplies to prevent dental caries. Health education aimed at health protection champion’s positive health protection measures among the public and policy-makers. The combined efforts of all three components stimulate a social environment that is conducive to the success of preventive health protection measures such as intensive lobbying for seat-belt legislation.

What is the Health Promotion Strategic Framework? The Health Promotion Strategic Framework (HPSF) is the first national strategic framework for health promotion in the HSE. It has been developed to support the HSE’s strategic objectives of promoting and improving the health of the population. The framework sets out clear, consistent, national objectives for the HSE in relation to its health promotion priorities. The framework will not only guide the activity of the Health Promotion workforce, but sets out a model for developing a health service that integrates health promotion into all aspects of HSE services in line with international best practice. This framework is guided by the HSE’s Corporate Plan (HSE, 2010) and identified National Priorities. International evidence recommends health promotion approaches that are focused on how and where people live, work, and play; these are known as settings for health promotion. This framework acknowledges the key role that health and social care services have in promoting the health of the population across these key settings, while recognizing the greater significance of

91

the social determinants of health and the unequal health status experienced by different population groups. The framework outlines a model of health promotion that addresses the broad determinants of health and health inequalities, through health services, community and education settings. It describes the approaches that are to be applied in each setting and sets out priority objectives and actions for national processes to support the implementation of the framework and for each of the three priority settings identified with appropriate investment, the long-term outcomes of these approaches have been demonstrated internationally to improve health and reduce inequalities, disease and costs on the health system.

Health promotion priorities in the health service setting In the health service setting, the framework outlines an approach that focuses on creating an appropriate balance between the promotion of health and the prevention and treatment of disease. The main objective for the health setting is the development of a Health Promoting Health Service (HPHS). Through implementation of this objective, the health service itself becomes health promoting, and not just a place in which health promotion activity takes place. This means that the environment, the staff-patient relationship, and the services, are designed to improve and sustain health and wellbeing. The framework will also be used to address health issues such as cardiovascular diseases and cancers using a ‘determinants of health’ approach. Developing as a HPHS builds on the HSE’s existing commitment to the Health Promoting Hospital initiative.

Health promotion priorities in the community setting Within the community setting, the priority objective is to develop and implement a model for health promoting communities that will enable and empower communities and individuals to

92

have greater influence over factors that affect their health. A strong focus on inter-sectoral collaboration is essential to achieve this objective. Health promotion priorities in the education setting Within the education setting, the priority objective is to implement a nationally agreed model for promoting health in preschool, primary, post-primary, third level and out-of-school settings based on existing Health Promoting School (HPS) approaches.

Health promotion and the settings approach The settings approach is an important development in health promotion theory and practice. The approach has its roots in the Ottawa Charter (WHO, 1986), which introduced the concept of ‘supportive environments for health’. This was further developed in the Sundsvall Statement on Supportive Environments for Health (WHO, 1991) which reiterated that: ‘Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love (WHO, 1986). The settings approach facilitates health promotion interventions to focus more on the broader determinants of health rather than simply addressing individual and/or population behavioral risk factors. Settings are ‘major social structures that provide channels and mechanisms of influence for reaching defined population groups (Mullen et al., 1995). The approach is underpinned by key health promotion values such as empowerment, public participation, equity and partnership. Key features of a settings approach include: developing personal competencies, implementing policies effectively, re-shaping environments, building partnerships for sustainable change, facilitating ownership of change throughout the setting (Whitelaw et al., 2001). There are definite links between the factors that influence health issues such as diabetes, obesity and cardiovascular disease, and health behaviors such as physical activity, smoking and healthy eating. Developing programmes that only address health issues at an individual patient 93

level are limited in their effectiveness. Such programmes require intensive support; fail to interface with the broader public health agenda.

Training and education ‘Training and supporting personnel to adopt and implement a ‘determinants of health’ approach through the development of new techniques and strategies’. A key priority for health promotion is to build the capacity of health care staff and others to promote health. This happens through training and education programmes as well as ongoing development and support. Training and education are delivered as part of a suite of interventions which address individual, group and population-based approaches for promoting health in addition to focusing on the broader determinants of health. The aim of these interventions is to improve knowledge, attitudes, self-efficacy and individuals’ own capacity to change (IUHPE, 2000). Furthermore, the education and training process, in itself, contributes to the personal and professional development of individuals, communities and organizations through their ongoing engagement over a period of days, weeks or months. Maximum impact from training, education and ongoing development is achieved when interventions are relevant, valued, participatory and achievable for all participants (IUHPE, 2000). Health promotion has a significant role to play in the development and delivery of specific training for health care staff and others in order to facilitate and support the implementation of the HPSF. In the design of this training three important elements need to be addressed: The HSE as a workplace taking account of the health promotion needs of staff. The HSE as a service provider whose employees have a health promoting function. The education, training and development needs of partners in community, voluntary and other statutory agencies. Each of these elements will require training needs analysis in order to inform the design of an appropriate training strategy for the HSE. Create supportive environments for health 94

The role of supportive environments is essential to achieving health gain. Supportive environments include the built and social aspects of where we live, work and play. Actions to create environments that support health have four main dimensions: physical, social, economic and political. A supportive environment for health includes the following outcomes: A planning process that is needs-based and incorporates evaluation and coordination between health care providers. Full engagement in collaborative partnerships which are adequately resourced and are regularly reviewed in terms of structure, function and effectiveness. The use of multi-strand approaches to promote and enhance health and include a combination of medical, lifestyle, behavioral and social-environmental approaches. The development of empowerment/engagement indicators, the allocation of adequate resources to effectively address the broader determinants of health and social inequities the development of evidence-based programmes and interventions, which include robust monitoring and evaluation measures. As part of implementing the HPSF, a standardized approach to programme development and implementation will be agreed and guidelines drafted for all new national health promotion programmes. All new programmes will begin with an assessment of health determinants at population level. This process will bring together intelligence from key stakeholders representing the settings and services in addition to available health data. The consultation process and partnership working will continue through all subsequent planning stages.

Reduce health inequalities Addressing health inequalities is critical if improvements in health and wellbeing are to be achieved across society and the gap in health outcomes is to be reduced. The HSE Health Inequalities Framework 2009-2012 (HSE, 2009) demonstrates the organization’s commitment to addressing the existing inequitable social class health gradient in Ireland.

95

The framework contains evidence-based, high-level actions which will guide HSE planning, monitoring and programme development and will also provide a clear direction for services, health care management, clinicians and professionals. Outcomes that can be expected from the implementation of the HSE Health Inequalities Framework include: Improved interagency cooperation to address the social determinants of health and health inequalities; Developments of partnerships for health which will result in integrated planning in areas such as housing, public spaces, transport, etc; Increased involvement and participation of individuals and communities in identifying and addressing health needs and health inequalities; The effective use of community development approaches to addressing lifestyle risk factors; Increased capacity of health and social care agencies to promote health and address health inequalities, and in particular, to support the development of primary care teams; Increased consideration of national and local health deprivation indicators and equality legislation within HSE service planning and delivery; Development and utilization of specific information, data systems, tools and key performance indicators which provide reliable evidence to support more effective decisionmaking; Monitoring and dissemination of evidence to support economic investment in health and the reduction of health inequalities; Actions to ensure that HSE services and health information meet national literacy standards and promote health literacy.

96

Improving health One of the most important goals of health services is to improve health. The concept of health improvement is based on the premise that health is something that can be created, and can, therefore, be improved. This concept is best understood through a comparison with disease-based approaches which focus on preventing illness. While disease prevention primarily addresses risk factors that cause people to become ill, health improvement seeks to promote wellbeing or health gain. For example, a cardiovascular disease prevention initiative may target those who are overweight through encouraging them to become more active, because reducing weight and increasing activity levels are known to reduce the incidence of heart disease. Conversely, health improvement approaches would predominantly focus on a positive sense of wellbeing, improved social interaction, and a greater sense of control over one’s health that might result from being active. In this way, health improvement places greater value on what Eriksson and Lindstrom (2008) call quality of life, rather than avoiding illness. Implementation of the HPSF will support the HSE to work towards achieving outcomes of improved health in the following areas: Increased awareness of the determinants of health and effective approaches used to address the determinants of health; Increased environments to support healthy choices in the priority settings of health services, communities and education; Increased capacity of individuals and groups to take action to improve health, for example, through the development of personal skills to address health issues and the determinants of health; Mechanisms to support improved health behavior and practices among individual population groups identified through particular settings, for example, children, adults, older people, special interest groups, etc.

97

Prevent and reduce disease Health promotion plays a critical role, not only in improving health, but also in maintaining and protecting health. An important element of this role is disease prevention. Traditionally, disease prevention is classified as:

Primary prevention: where efforts are made to prevent the occurrence of any disease. This ranges from the prevention of an acute illness, for example, by inoculation or vaccination, to the prevention of chronic conditions such as heart disease, cancers, sexual or mental illnesses.

Secondary prevention: where efforts are made to ameliorate and stop progression of the disease. This includes the use of surgical procedures and an array of other interventions such as smoking cessation, diet and physical activity programmes as well as one-to-one support.

Tertiary prevention: where all efforts are made to minimize the impact of disease on the affected individual and/or rehabilitate them. Evidence indicates clearly that primary prevention is the most efficient and effective tool for decreasing the burden of disease on societies and individuals alike. For example, this HPSF document (see next section on reducing costs to the healthcare system) highlights the valuable contribution of health promotion to the significant decline in cardiovascular disease between 1985 and 2000, identified in the 2007

on the

implementation of Building Healthier Hearts (HSE, 2007). Through the implementation of the HPSF, and ongoing investment in health promotion, significant progress can be made in the following areas to prevent and reduce disease:

98

Improvements in cardiovascular disease risk factors (for example, smoking, alcohol intake, salt consumption, etc.) and significant improvement in health-related behaviors (for example, healthier eating, greater participation in physical activity, etc.); Modifications in risk-taking behaviors and addressing risk factors for cancers; Reduction in factors that contribute to mental ill-health through creating supportive environments for health, reducing stressful circumstances and developing supportive personal relationships and social networks.

Health Service Executive Health Promotion Strategic Framework A significant reduction in sexually transmitted infections and negative outcomes in relation to unplanned and unwanted pregnancies. Contribution to a reduction in unintentional injuries in the home environment at work and on the road.

Reduce cost to the healthcare system It has been well documented that lifestyle and other determinants of health have a significant impact on health, leading to chronic illness and premature death. At least 80% of premature heart disease, stroke and Type 2 diabetes can be prevented through healthy diet, regular physical activity and avoidance of tobacco products (HSE, 2008). Chronic diseases are the leading cause of mortality in the world, representing 60% of all deaths (HSE, 2008). In Ireland, unhealthy lifestyles contribute to the five major causes of death. The prevalence of overweight and obesity in both adults and children continues to rise. 39% of adults are overweight and 23% are obese (Morgan et al, 2008). Overweight and obesity in children increases with age: at age five to twelve years, 11% of boys and 12% of girls are

99

overweight with 9% of boys and 13% of girls’ obese (Irish Universities Nutrition Alliance, 2008). In the coming years, increasing levels of overweight and obesity will pose significant challenges for the health and social services in terms of increases in chronic disease. The most successful strategies for prevention of chronic illness employ both individual-based approaches and population-wide approaches which address the determinants of health. (WHO, 2008). Throughout this framework document, a strong case has been made for the role of health promotion in planning and implementing such strategies. The role of health promotion is further reinforced by strong international evidence to show that health promotion works.

The International Union of Health Promotion and Education (IUHPE) Report for the European Commission on the Evidence of Health Promotion Effectiveness (2000) states that in the last 20 years ‘evidence has been collected and evaluated which gives strength to the case for increasing resources behind the discipline (of health promotion) and for it to become more central in producing a healthy society’. Furthermore, there is a strong economic case for investing in health promotion.

The role of health promotion in reducing the cost to the health care system Effective health promotion programmes, properly funded over sustained periods, can produce significant economic and health gains for individuals, the health service, Government and society. In the United Kingdom, estimates show that four out of five deaths of people fewer than 75 years could have been prevented and economic analysis shows that the total annual cost of preventable illness amounts to a minimum £187 billion - this equates to 19% of total GDP. These estimates suggest that for every 1% improvement in health outcomes from health promotion and prevention, public expenditure could be reduced by £190million, saving families £700m and 100

reducing employer costs by £110m as well as reducing the level of premature death and disability (National Social Marketing Centre, 2010). In Ireland, the 2007 audit of progress on the implementation of Building Healthier Hearts (HSE, 2007) demonstrates the major contribution that health promotion has made in the significant fall in cardiovascular health disease mortality (1985-2000). During this period, there were 3,763 fewer deaths; 51% of these were directly attributable to health promotion, while 43% were attributable to better treatments. Other examples of cost effectiveness in health promotion include the following:

Workplace health promotion programmes Systematic reviews of workplace programmes have established cost-benefit ratios from such programmes in the region of 1:41 to 1:61, that is, the savings obtained from improvements in employee health are around four to six times the costs of the programmes. Average reductions in cost are around 25% (Aldana, 2001). In Thameside Metropolitan Borough Council, the introduction of a wellbeing programme for employees, including a number of simple and low-cost interventions such as walking schemes and free fruit and water bottles, proved highly successful. The rate of absenteeism fell from 13.2 days per employee in 2001 to 8.9 days in 2007 (Calendar, 2007). The value of this reduction has been calculated as £1.5m over three years. There have also been measurable improvements in employees’ overall physical and mental health (Anon, 2006). A stress reduction programme for staff implemented by London Underground was estimated to have saved £455,000; this equates to approximately eight times the cost of the scheme. Interventions for the prevention of anxiety and depression among employees have also shown promising results in the reduction of sickness absenteeism (Washington, 2008).

101

Physical activity and obesity Implementation of the HPSF will support the HSE to work towards achieving outcomes of improved health in the following areas: Increased awareness of the determinants of health and effective approaches used to address the determinants of health; Increased environments to support healthy choices in the priority settings of health services, communities and education Increased capacity of individuals and groups to take action to improve health, for example, through the development of personal skills to address health issues and the determinants of health Mechanisms to support improved health behavior and practices among individual population groups identified through particular settings, for example, children, adults, and older people, special interest groups, etc. health promotion has developed and grown, with significant achievements in the areas of cardiovascular health, healthy public policies and healthy settings. This Health Promotion Strategic Framework provides the HSE with the means by which it can meet its commitments to protect and promote the health of the population. The framework is informed by the best available international and national evidence of health promotion effectiveness and includes a model to illustrate the main elements of health promotion in the HSE. This model outlines the process by which health promotion will address health inequalities and the determinants of health, as well as the health promotion outcomes it seeks to achieve through the three priority settings of health services, community and education. Protecting and promoting the health of the population requires inter-sectoral and interdisciplinary approaches to health promotion. These approaches include key specific roles for the Health Promotion workforce and for the broader health and social care workforce in addition to the non-Governmental organizations and 102

statutory and voluntary sectors. These commitments require the re-orientation of health and social care services in Ireland to include the development of organizational structures that support the promotion of health, and the development of the skills and capacity of those outside the Health Promotion workforce to adopt a stronger evidence-based health promoting role.

In conclusion to health promotion The techniques or ways in which series of activities are carried out to communicate ideas, information and develops necessary skills and attitude are constituents of various media and methods in health education. The use of any of the three main groups according to the number of people who are willing to get health education will enable the community health practitioner to provide the needed care.

INTRODUCTION TO OCCUPATIONAL HEALTH

Occupational health is an aspect of public health programme. It was established to ensure that the health status of everybody in an occupation is promoted. Occupational health and safety provides a comprehensive overview of the relationship of the occupation and human health. It also considers the physical, mental and social dimension of man in the work environment; it is believed that man is an embodiment of physical, spiritual, mental and social wellbeing interacting with his total environment. When all compartment of man are in a healthy relationship with each other adequately, employee performance in any occupation is assured and enhanced. Creating a healthy working place and a healthy environment in any occupational environment is the best way to position that occupation to better delivery of services. 103

ENVIRONMENTAL HARZARD This is a genetic term for any situation or state of events which has the potential to threaten the surrounding

natural environment

and adversely affect people’s health it

incorporates topics like pollutions, natural disasters such as and earthquakes. An environment hazard is also any substance, agent equipment, object, human behavior that is capable of causing injury, disability, disease or death in humans or has the potential for polluting or degrading the environment (Olaniran et al 1995)

MISCONCEPTION ABOUT THE MEANING OF HARZARD Some misconceptions about the meaning of hazard should be cleared. The word hazard is not synonyms with injury or disease. A hazard is only capable of causing injury if certain environmental conditions exist. Few examples are: a paned vehicle is a hazard but will not cause harm until it is recklessly driven by a drunk driver or there is a break failure; injury from sharp pointed object (a knife) misuse or carelessness; a big polythene bag appears harmless but becomes hazard to children if they are left unchecked. It can lead to suffocation and death; human feaces (excreta) a very hazardous waste can cause illness when ingested through water and food contaminated; exposure by individual to environmental health hazards is normally through a medium; exposure can be by inhalation through the nose, ingestion by mouth or absorption through the skin. From this pathway, human health is collectively known as environmental media, the environmental media are classified (Olaniran et al, 1995) into the environmental media as;The air we breathe, the food we eat, the soil which we cultivate, in animal objects in air environment, occupation and socio cultural event.

104

CLASSIFICATION OF ENVIRONMENTAL HEALTH HAZARD Environmental health hazard can be classified into 4 gimps depending on nature and type the groups are: - Physical, Biological, Chemical Socio-cultural and Psychosocial- Achalu E.1 (2000) occupational health and safety publishers. Most of the physical hazard are easily observable, detectable and measurable and are found in our immediate surroundings, but mainly in the occupational and home environment. Sure of the biological hazard are detectable techniques. Chemical hazard are the most numerous and complex. Most are found in the workplace and are measurable using sophisticated laboratory techniques. Socio- cultural hazard are the most difficult to detect and measure because they are usually defined attribute of man. Examples are; Physical environmental hazard are: Noise, dust, heat, cold, vibration, pressure, ionizing radiation, open fuse dump, motor vehicle. Biological are: pathogenesis (bacteria, virus, protozoa) sewage, disease vectors (mosquitoes, tsetse fly, black fly) venom snakes, bees, scorpions, man Chemicals are: pesticides, fungicide, herbicides and inorganic fertilizer, heavy metals (lead, mercy) acid, base, asbestos gas carbon monoxide, sulphurdioxide, ammonia. Examples of socio cultural/psychosocial are: poverty, cultural beliefs and places, religious beliefs and practices, education, occupation, life style, unhealthy habits (smoking, sexual promiscuity) drug abuse, stress, and marital problems.

In Nigeria today, the general awareness of hazards inherent in works and their consequences have not received much attention from government, trade union leaders and workers themselves. This attitude is borne out of the wrong notion that it is more beneficial spending money on the creation of jobs for money on the creation of jobs for many unemployed 105

persons in the society than promotion and protection of health and safety of workers. This view is however flawed as it overlooks the influence of a healthy workforce on productivity and efficiency and the benefit to enterprises and society. Therefore there is an urgent need to formulate and implement at national, the state and local levels, economic and social policies which will encourage and sustain the integration of health and safety into our national education system. However, some higher institutions are making efforts and Federal Ministry of Health and Ministries of Health in some state are organizing short courses in occupational health and safety. However Lagos State Government has gone further by inaugurating the Lagos State Safety Commission on the 5th of May, 2009 as an office under the Ministry of Special Duties, with the aim of “setting safety standard for all sectors involved in socio-economic activities in the state and issuance or withdrawal of overall safety compliance certificate at all levels.” At this period of technological advancement of adequate is no doubt that limited resources, both human and material, may at the initial stage hinder this requirement but pulling together all the available resources in private and government establishment and institution can help in meeting this goal.

The Principles and Objectives of Occupational Health The aims of Occupational Health as defined in the first session of the joint committee of the World Health Organization and International Labor Organization in 1990 are: The promotion and maintenance of the highest degree of physical, mental and social well being of workers in all occupations; The prevention among workers of departures from health caused by their working conditions; The protection of workers in their employment from risks resulting from factors adverse to health; The planning and maintenance of workers in an occupational environment is very important to ensure a good job performance.

In other words, occupational health bothers on health, safety and welfare of workers. It stresses the effect of the working environment on the general wellbeing of workers and the 106

influence of the workers’ state of health on their ability to perform the task before them. It is also an important means of achieving higher policy embracing the above aims. For better understanding, each aim will be explained in the following paragraphs. The encouragement and promotion of the highest degree of physical, mental and social wellbeing of workers are necessary for the success of an organization or a workforce. The importance of man’s diet in relation to the development and maintenance of his physical or mental well-being and the positive impacts it has on productivity cannot be over emphasized. A balanced diet should contain the proper proportion of carbohydrates, fats, proteins, minerals, trace elements, vitamins and water. Beside the supply of calories, a balanced diet is necessary for the renewal and maintenance of cell protoplasm, replacement of broken down tissues, synthesis of internal secretion of the body and the regulation of bodily processes. Therefore provision of well-equipped canteen should be sited in a very neat environment and the food handler should be medically certified before they are engage in food preparation and distribution in order to prevent food poisoning. Also, where we have less than 100 employees, the employer should provide certified food vendors into the work premises during break. At both levels, all local and international regulation relating to food hygiene should be enforced. The workers should be seen to be observing regular meal hours in order to discourage eating when performing a task. This will prevent accidental ingestion of hazardous agents, which may have negative influence on the health of the workers. Rest and relaxation are undoubtedly important factors in the maintenance of health and vitality both during and after work. It has been shown that accidents resulting from fatigue are common occurrence and that 15-minute rest period in mid-morning and mid-afternoon result in a reduction in the number of accidents. Thus, workers should be given breaks for at least 1hour in an 8-hour working day. This will give them opportunity to rest and relax and thereby restore the vitality for better performance for the day.

Man is a social animal and those responsible for the working environment must take serious note of this fact if maximum productivity is desired. Therefore it is essential that good

107

relationship, co-operation and understanding should exist between the employees and management personnel in the industries. Furthermore, it is essential that workers should have job satisfaction. This will not only motivate the workers to be more productive and efficient but will also create in them a sense of achievement and belonging.

Accommodation and transportation are essential for the social and physical wellbeing of workers. The location of accommodation in relation to the workplace has an effect not only on the social health but also on the physical health of workers. Therefore, it is more appropriate to develop industries and houses for workers together. The distance of houses from industries should however be influenced by the factories and what it releases into the immediate environment. For instance, a sugar or palm tree plantation can have houses of workers located some hundreds of meters away from plantation and processing plant. However, this cannot be said of chemical allied industries, which may release tons of hazardous fumes into the immediate environment. However, location of houses for workers should be within 2-10 kilometer radius from the factory. Transportation should be provided for the workers too. This is mainly because time and energy used by workers while waiting for public transport to convey them to their workplace could be conserved and best utilized at work if the workers are commute to work in company’s vehicles. The adaptation of vehicles such as trailers with mounted porter-cabins to convey workers to and from work as done by some construction companies in Nigeria should be discourage. Instead, the workers should be provided with air-conditioned buses with comfortable seating and leg space. The nature and condition of work dictate the type of occupational health problems prevalent in working environment. A common example in our community is a roadside mechanic who display in all his activities apathy towards safety and health and with little or no regard for the safety and health of others. His working environment is dirty and dominated by metal and plastic scraps covered with used engine oil. He rarely wears overall or any protective equipment such as gloves. If he has any, it is not properly maintained.

108

His working posture is a serious invitation to chronic musculoskeletal problems. Personal hygiene before and after work is not considered important. They are also potentially exposed to solvent (gasoline and diesel fuel), motor vehicles lubricants (engine oil, grease, and coolants). The indiscriminate use to petrol to clean their hands after work is very common among this automechanics. This often result in damage to the skin and nails as shown by arrow there have also been reported cases among mechanics of lead poisoning and death from ingestion and inhalation of gasoline resulting from manual sucking of fuel from tanks of vehicles they repaired.. Therefore there is a need to educate this group of workers and other artisans of hazards inherent in their works and the means of controlling them through seminars and workshop organized by experts in occupational health and safety with support and co-operation of their associations. These efforts can be combined with public awareness through electronic and print media. Additional efforts should be made to inform them regularly through the same organs of the importance of good housekeeping and personal hygiene. Personal protective equipment is necessary when a working environment is necessary when a working environment is created in such a way that process its products and by-products constitute health hazards to the neighborhood and it cannot be controlled through engineering processes such as enclosure and isolation. Thus, any form of personal protection is defined as a second line of defense against an unexpected condition. Personal protective equipment such as wearing of air purifying respirators is required during a short-term exposure to hazardous contaminants or when undertaking a task in a dusty work environment. The production activities should be organized in such a way that each worker is put in a job which he or she is capable of doing without constituting problem to him or her and other fellow workers. Thus, there is a need to carry out pre-employment medical examination and periodic medical examination before and when at work respectively. Pre-employment medical examinations involve physical examination of the persons and administration of a questionnaire followed by measurement of blood pressure, vision test, urinalysis and x-ray.

109

The medical examinations are carried out particulars job and one usually refers to as “fitness to work”. It is very essential for the establishment of baseline record of physical condition for the personal needs of both the employee and the employer. Another main reason for these tests is to assist in the assessment of the worker in a specific job. This is of vital use for legal information obtained through the questionnaire and results of tests obtained may be part of the management demands for the implantation of pension and personal insurance schemes. On the other hand, the purpose of health surveillance is to evaluate the health condition of the individual, with emphasis on specific “target organs” which may be affected by actual or potential exposure to industries hazards when at work. These examinations also include the physical examination of the body, chest radiography and spiromentry to determine the condition of the lungs. This is recommended for workers exposed to airborne particles during the course of their works. Blood tests can also be carried out for workers expose to ionizing radiation, lead, benzene and other specific chemicals. Atopy tests for allergens and immune status assessment working in noisy environments. Stool tests are mandatory for food handlers before and during their working circles in order to prevent food poisoning. The physical relationship between man-machine environments is very important for the general well being of workers and the organization. . In other words, employing suitable and well trained workers at every level of the organization, satisfactory design and maintenance of machinery, provisions of ventilation, lighting, atmospheric purity and allocation of adequate space for man and machine will no doubt prevent accident and ill- health at work.

The role of Occupational Health in Primary Health Care Primary health care as defined in Alma Ata “as the essential health based on practical, scientifically sound and social acceptable methods and technology made universally acceptable to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” It forms an integral part of the country’s health system of which it is the central function and main focus, and of the overall social and economic 110

development of the community. It is the first level of contacts of individuals, the family and the community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of continuing healthcare process.” Thus, the role of occupational health in primary health care includes the following: The participation and involvement of every individual and workplaces in all activities connected with promotion of health, safety and welfare of worker. This can be achieved through health education. The participation in all efforts connected with the improvement of workers’ wellbeing and the well of members of their families and the environment, in which they live and work. This can be in the form of collective and general cleaning of homes and factories, disposal of industrial and domestic waste and joint responsibility in the promotion and maintenance of social services where workers live and work; Accessibility to health care delivery by workers and members of their families. Home-visits should be encouraged to assess the health problems of every family; Encouragement of workers and members of their families to receive immunization against diseases association with their jobs.

The Practice and Administration of Occupation Health service The primary objective of an occupational health services is to plan, direct and co-ordinate all activities connected with the promotion and protection of health, safety and welfare of workers irrespective of their status or grade. But the practice of occupational health in government establishments and in most private establishments in Nigeria is more curative than preventive. More attention is focused on the curing of diseases. . The attitude of employers and the apathy shown by the governments and trade union also influence the present approach. For example a personnel manager of a factory in Nigeria was advised by the authority to send his workers for a workshop in industrial safety after observing the unsafe and unhealthy condition and poor work procedure in his factory. The manager did not only reject the idea but prefer to answer hundreds of applicants waiting at the gate of the factory who would be happier given opportunities to work in the same condition the author complained of. There is no doubt that the response of the manager is borne out of ignorance, unemployment, poverty, and apathy towards investment in improvement of the workers’ working condition. This manager and his kinds also 111

fail to understand that establishments that have no work-related illness such as waist pain, respiratory disorder and poor eye sight is at competitive advantage over one with suffering workers of general discomfort twenty-first century. They also fail to understand to a large extent that efficiency and productivity are products of comfort and high morale. There is therefore an urgent need to create an ideal national body to be responsible for the formulation and implementation of ideas and policies towards the promotion and protection of health and safety of the workforce. Thus, this chapter will give a direction towards this ideal situation.

An Occupational Health Service at the National Level The national authorities meet the health needs of the employees in the developed world. This reduces the workload on the service to be provided by the place of employment. This in contrast to the situation in most developing countries where there are no well-organized and equipped national medical services. Where it exists, it is not often within the reach of the common working population. However, in some multinational companies, the health of the workers and their dependants is taken care of in industrial based clinics or hospitals. Such hospitals are left with no choice than handling non-work related illness. There is therefore a qualitative workload with more emphasis on curative at the expense of preventive medicine. Thus, in respect of the present situation in Nigeria, there is a need for an ideal national policy on occupational health where efforts should be directed towards the development of health and safety standards and conducting research on hazard inherent in all activities in traditional trades, small workplaces and factories. The policy should include: Training of manpower in occupational health disciplines; Updating and enforcement of health and safety legislation at work; Provision of direct service in the recognition, evaluation and control of occupational health hazards; Promotion of occupational health and safety programmers and; Offering of technical assistance to state, local governments and industries.

112

Therefore an ideal national occupational health institution which is built on the above policy should be established and should comprise the following units: occupational medicine, occupational hygiene, occupational nursing, toxicology, ergonomic or human factor Engineering, occupational psychology, inspectorate, data Management

Let us spend some time to examine briefly the role of each of the units listed above except Occupational Health Nursing Unit, which because of its importance has the next chapter devoted to its role and responsibilities in the workplace.

Occupational Medicine Occupational Medicine is a branch of preventive with some dose of therapeutic function carried out by an Occupational Health Physician (OHP) and his team. The OHP’s main responsibility includes primary prevention of the occurrence of disease or disability arising from exposure to known agents in the work environment. In order to perform this function, the OHP must have the knowledge of the work environment, the product and by- products of processes. He or she must be in the best position to determine which level of any agent capable of damaging the health of exposed workers. On this phase he must be able to carry out preemployment, periodic and special medical examinations on workers. He or she must be able to determine the susceptibility of individual workers to exposure to certain occupational hazards, development of contact dermatitis as a result of exposure to a particular chemical for instance. He or she must have the deep knowledge of secondary prevention, which involves mostly control of aggravation of disease or disability by rightful placement of workers on a job which will not worsen an already established occupational disease. A typical example is prevention of worker with chronic bronchitis from working with pulmonary irritants or vapor. Other responsibilities of OHP include: medical examinations of personnel, health surveillance most especially on those that are at special risks, diagnosis and treatment of occupational diseases and injuries, emergency treatment, health education of personnel, first aid training, keeping of records of occupational diseases and injuries, and collaboration with interested person and parties within and outside the establishment. 113

Occupational Hygiene Occupational Hygiene is defined by British Occupational Hygiene Society as “the applies science concerned with the identification, measurement, appraisal of risk, and control to acceptable standard of physical, chemical and biological factors arising in or from workplace, which may affect the health or well-being of those at work or in community.” On the other hand, the American industry Hygiene Association (AIHA) describe an industrial hygienist (Occupation Hygienist) “as a person with college or university degree or degrees in engineering, chemistry, physics, medicine or related physical or biological science who, by virtue or special studies and training, has acquired competence in industrial hygiene. Such special studies and training must have been sufficient in all of the above cognate sciences to provide abilities to anticipate and recognize environmental factors and to understand their effects on humans and their well-being, to evaluate (on basis of experience and with the aid of quantitative measurement techniques) the magnitude of these stresses in terms of ability to impair human health and well-being, and to prescribe methods to eliminate, control, or reduce such stresses when necessary to alleviate their affects.” The definition and the description above summaries the responsibilities of an occupational hygienist, which are: Identification of health hazards in the workplace; Evaluation of the hazards, for example air analysis and evaluation of specimen such as urine, blood and expire air selection of suitable equipment and adaptation of appropriate measuring techniques; Interpretation of result obtained in term of concentration of the agent in the workplace, its ability to impair health, nature of health impairment, effect on efficiency and productivity and general effects on the community; Recommendation of appropriate control measures for instance, designing of ventilation system to extractor or dilute airborne contaminants; Presentation of specific conclusions to the management, health officials and workers’ representatives (trade unions); Present expert testimony before court of law, health and safety board or organization, compensation commission, regulatory agencies, and legally appointed investigation bodies;

114

Conduct programme with the main aim of creating awareness among workers on the need to prevent occupational diseases and injuries associated with their workers; Conduct epidemiological studies to ascertain the trend of occupational diseases and establish an improved standard for the measurement of health and efficiency; Conduct research to enhance the knowledge and the relationship between health and work and the occupational health impairment and community pollutant such as noise.

Toxicology This is “the science that studies the poisonous or toxic properties of substances or that which concerns the potential of chemical to produce toxic effect in the body”. Toxic effects are undesirable distributions of physiological function caused by overexposure to chemical agents. Toxics effect can also arise as a result of response to medication and vaccines. Many chemicals such as nickel and chromium are essential responsibility of a toxicologist to identify the line of demarcation between ‘safe’ and ‘unsafe’ quantities. This information will enhance the provision of adequate and appropriate remedial actions. Toxicologists are in the best position in the issuing of a handbook that contain information on the long term (chronic) and short-term (acute) effect of exposure to chemicals and the recommended standards of exposure. Toxicologists are also responsible for the preparation and interpretation of “Material Safety Data Sheet (MSDS)”, which provides the name of the manufacturer and the generic names of the substance. The chemical and the physical characteristics of the substance, fire and exposure hazards and health hazards inherit in the substances and safe handlings as well as the use of the substances are other relevant information provided by the MSDS.

Ergonomics Ergonomics or Human factors Engineering is the skill of designing equipment and tools in the most operable way with the special consideration to space, the comfort and adaptation to the users and vice versa. The main purpose is to ensure correct man-machine relationships with 115

emphasis on improved productivity, efficiency, safety and acceptable of the system by the users. The ergonomics unit needs contributions from other disciplines such as occupational psychology, engineering, anthropology and physiology.

Occupational Psychology Occupational psychology deals with the mental demands or the ability of an individual to perform his or her job. Job analysis, vocational guidance, study of physiological factors and their relationship with accidents and their causes are other aspects of the job of this discipline. Investigation of the prevalence of psychoneurosis and drug abuse at work is a case for study.

Occupational Psychology This covers the physiological aspect of working conditions and the health factors associated with environmental changes created by working condition such as heat or noise. Therefore special attention should be given to effect of heat stress on the health of outdoor workers in the tropic.

Inspectorate Unit The personnel in this unit should normally have training in occupational health and safety or safety engineering. Their primary duty is to enforce the law and regulations and to see that the objectives of the occupational health and safety body or the establishment are achieved. The personnel should be competent in interpreting health and safety issues and legislations and legislations and be able to provide valuable technical information on health and safety at work. They should also be skillful recognizing any potential health and safety risk inherit in processes and systems. For optimum utilization, there should be co-operation between these personnel and the employers to whom they will always point out their reasonable time without any advance 116

notice. They must also be allowed to carry out necessary investigations and to take samples or pictures of materials or workplaces and must also have access to records on occupation health and safety in the workplace.

Data Management The purpose of gathering of data in occupational health is to monitor the health condition of the workplace and also to act as a device for general preventive measures with special reference to work related illnesses and injuries. Persons with formal training in medical records should manage the data and should also be competent in the use of computer. Like other personnel in occupational health services, he or she should undergo periodic training in record keeping in order being abreast with the development outside his or her own domain. His or her duties should include: Record keeping on number of pre-employment and periodic examinations; Collation and dissemination to the appropriate authority monthly records of incident of both occupational and non-occupational illnesses and injuries; Keeping and analysis of attendance at work; Calculating of number of days lost due sickness, absence and working out the lost time injury.

The above data should be compiled at local and state levels and sent to the national body that will subject the data to further analysis. The outcome should be published along with other various aspects of occupational health problems following the same line of communication. This information will no doubt enhance planning toward better improvement on health and safety performance in workplace.

The Role of Other Workers

117

The private hospital and dispensaries that serve most workplace in Nigeria are mostly on a part time basis. They should encourage sending monthly data to the national body. It will be better if this duty made statutory because of its importance to planning and development. Trends of occupational diseases and injuries in our industries, hitherto wanting will become clearer. This will be valuable in the measurement of newly introduced practices and removal of the bad ones.

An Occupational Health Service Based in Industry A trained occupation health physical supporter by a team of competent Occupation Health Nurses should head an industrial based occupational health service. The number of occupation of health nurses employed depends on the population of workers in the organization. However, the personal should work together as a team with common objectives. Their day-today activity should include: Medical examinations of new employee and periodic examination of all established employees; The treatment of occupational and non-occupational diseases and work related injuries; Educational of worker against the spread of communicable diseases and prevention of occupational diseases and accident in workplace; Follow-up of treatment where appropriate and offering of advisory services to management and employee; When the situation demands it, an occupational hygiene consultant should be called to provide services in the area of monitoring of hazards such as noise, heat, dust and chemical.

The economic development of a nation depends on a health workforce. It is not only a right for every society to protect and promote the health of her citizen but an obvious need for socio-economic development. It is also obvious that occupational diseases and injuries an enormous burden to national economy and development. This is borne out of the cost of treating and rehabilitating workers who suffer from work-related illnesses. Therefore more attention should be focused on the development of technical and managerial capabilities of hazard control. With this arrangement the national body on occupational health and safety will be in the best position to focus her attention on development and implementation of a the national policy for

118

the prevention occupation diseases and injuries among workers and protection of the Federal Government in the Federal Executive Meeting Committee held in Abuja on 24th November 2006 approved to the National Policy and Occupational Safety and Health. The main aim of the policy as presented by the Minister of Labor and productivity is to improve the working conditions and environment in which workers operate, and at the same time prevent accidents and eliminate the development of ill health within factories and provide health service to the workplace Finally, collaboration with the national body on occupational health and safety should facilitate in well-organized conferences, workshops and seminars on current issues in occupational health and safety. In addition to the body should be able to offer advice and instructions to employers and employees in health and safety legislation. The provision of information on occupational health and safety should be given by means of lectures, radio, posters, pamphlets, video show, internet, exhibitions and instruction in workplaces, communities, primary, secondary and tertiary institutions.

The Role of the Occupational Health Nurse in a Workplace The close relationship an Occupation Health Nurse (OHN) has with the workers and the neutral position she occupies between employers and employees makes her role very unique in promotion of health and safety standard in an establishment. She is an independent professional but a very important member of an occupational health team. Her activities go beyond her basic knowledge in nursing but include practical involvement in the development of the programmers tailored to meet the need of workers in respect of improving their general well-being. Therefore, for effectively delivery, she must have the abilities and skills of these professions. In other word she must understand the principles of occupational hygiene and safety engineering and their application toward creating a conducive, safe and healthy working environment to the workers. In addition she must be able to communicate health and safety issues down the line and effectively handle other non-work related factor that can affect the general wellbeing of worker and to some extent their dependents.

As a result of these multi disciplinary activities, which can easily be described as ‘all-inone’ and cumbersome, occupational health nursing is often referred to as “the easiest job in the nursing professional to do badly and one of the hardest and most satisfying to do well.” However, occupational health nursing is defined by Brown M.L (1991) as “the application of nursing practice and public health procedures for the purpose of conserving, promoting and

119

restoring the health of individuals and groups through their places of employment.” Now lets us look briefly at the duties of an OHN in an occupational health service in a developing country:

Relationship with industrial community and its people The primary objective of the occupational health service in a workplace is to promote the well-being of workers. It is the responsibility of the OHN to meet this objective by making the management understand and appreciate the inter-relationship between health and work and the effect of good health of productivity and efficiency. Assisting the management to draw-up health and safety policy can enhance meeting this objective. She should also be able to understand, interpret and drive the health and safety regulation and statutory laws. The OHN is the first contact to the workforce. It is therefore essential that the OHN should have the knowledge of workers’ distribution according to age, sex and skills. She should, at the same time be able to identify and compile types of job and the associated tasks. The knowledge of the processes, materials, products and by products of these tasks and the hazards inherent in them are necessary information for the development of risk assessment of the workplace. This is achieve through a walk-through survey of the workplace and gathering information from workers, which enhance identification, and assessment, or evaluation of the risk inherent in every activity in the work place. The information obtained will provide detail knowledge of the health and safety issues, which required immediate remedial actions, or these for long term plans. In a workplace of smaller population, (of less than one hundred workers) where the OHN will likely be the only occupational health profession on ground, she has more opportunity to initiate, plan, evaluate and interpret a programme relating to health and safety. She should make the best use of this opportunity by organizing in-house health promotion lectures and training to remind both the workers and the employer of their responsibility toward occupational health and safety. The OHN needs to know and understand the management structure in the organization by studying the organogram. This will give her the picture of who is who in the organization at the same time highlight the organization’s reporting system and responsibilities of the incumbents.

120

This knowledge will encourage smooth communication through the line. It should be noted that in some organizations any issue concerning workers is usually decide with workers’ representatives (trade union leader) before implementation. However, in others, there may be an informal forum where problems can be discussed with little or no regards for the hierarchy of authority.

The Health Problems of Industrialization in Nigeria Industrialization is defined as “the process of social and economic change that transfers human group from an agrarian society to industrial one. It is part of a wider modernization process where social change and economic development are closely related with technological innovation particularly in the development of large-scale energy and metallurgy production. It is an extensive organization of economy for the purpose of manufacturing.” In other words, industrialization brings development with the improvement in the living standards of individuals in the society. As good as it sounds, processes, activities and operations associated with industrialization bring with them health, safety and environmental factors that are detrimental to human health and the environment. This chapter will, therefore, discuss briefly the major health problems associated with industrialization in Nigeria under the following sub-headings: social problems, environmental health problems, air pollution, water and land pollution, noise pollution

Social Problems Industrialization increases the mobility of unskilled workers from rural to urban areas. The movement from traditional farms in the villages and small towns to urban areas results in the disappearance of traditional ways of life, leading to overcrowding and mass unemployment. The population shift of the work force from the rural areas leave farmlands unattended to whilst urban areas become concentrated with a workforce relatively unskilled in search of “Golden Fleece”. The supply of manpower soon exceeds the demands and employers capitalize on this, offering workers the lowest possible wages and working environment that falls below universally 121

acceptable standard. These young men and women become trapped and are unable to return home ‘shame-faced’ and ‘empty-handed’. There is displacement of social supports and cultural values such as extended family structure, much appreciated by Africans, In other words, they are socially dislocated. There is confusion and conflict. The unemployment will eventually engage in illegal dealings such as fraud (419), prostitution, drug abuse, alcoholism, armed robbery and all other inhuman and violent behaviors. There are apparent traces of juvenile delinquency among the unemployed youths in cities, the so called ‘area-boys’, many of whom ended up in mental homes or prisons. Other negative vices associated with industrialization are increased in divorce rate and broken homes.

Environmental Health Problems An increase in the population of urban areas creates poor environmental sanitation and overcrowding. There is a rise in number of slums and poor sanitary dwellings. Malnutrition and poor housing are common phenomenon. The standard of food hygiene is reduced most especially in slums often occupied by unskilled laborers. Food borne disease such as typhoid and viral hepatitis become very common and often spread among the populace because of lack of access to health facilities. There is also possibility of the presence of communicable diseases such HIV/AIDs, tuberculosis, and cholera. Besides several occupational diseases such as asbestosis, silicosis and lead poisoning are introduced into the working-community. The present system of establishing factories near cities or in big towns, where workers are forced to live in crowded tenements and unsanitary conditions are harmful to the town dwellers and the workers themselves.

The health standard of workers in such industries

would be greatly improved of industrial establishments could be located in rural surroundings, thereby discouraging migration of workers to cities and big towns. Therefore, at this stage of Nigerian development, judicious regional and city planning is required. This should be carried out in such a way that workers and industries will settle down near vital resources such as raw materials mostly located in rural areas. However, before the establishment of any factory in rural area there should be proper layout and adequate provision of housing for workers.

122

In addition, the workers should be provided with regular electricity supply, effective transport arrangement and adequate and reliable sewage systems plus other essential amenities, which will make life comfortable for the workers and every member of the community.

INDUSTRILISATION INDUSTRILISATION

Urbanization Urbanization

New Machinery NewMachinery Processes New Hazardous Materials New Processes

Environmental Environmental Pollution Pollution

Hazardous Materials

Stress & Fatigue Overcrowding Poor Other work-related Housing Poverty illnesses infectious Malnutrition Diseases Industrial Unemployment Injuries Stress & Fatigue Other work-related Overcrowding Poor illnesses infectious Housing Poverty Diseases Industrial Broken Homes AreaMalnutrition boys’ syndrome Mental Injuries Unemployment Disorder Prostitution Drug Addition Armed Robbery 123

Water pollution Air pollution Land pollution

Water pollution Air pollution Land pollution Poor economic growth Poverty Social instability Social Disorder

Broken Homes Street boys’ syndrome Mental Disorder Prostitution Drug Addition Armed Robbery

Poor economic growth Poverty Social instability Social Disorder

Air Pollution Air pollution can be defined as contamination of the air beyond that which is natural. Chris Woodford September 14 2014 explain that air pollutants include sulfur dioxide and green house gas carbon dioxide it can be in gas or liquid or solid dispersed through air release in a big enough quantity to harm the people health or other plant or animals killing or stop them from growing properly and can cause unpleasant odor. Air pollution causes occupational health and public health problems affecting the community, and the entire ecosystem. There are local and global environmental changes related to the degradation of natural resources that can have longterm effects on the quality and quantity of food. For example, vegetables and plants in farmland located near cement industry are often covered with silica dusts. This hinders photosynthesis, which eventually disturbs the plants from manufacturing their own food for growth. This will eventually result in food scarcity with the ultimate consequence of famine. There have also been reported cases of silicosis resulting from the inhalations of silica dusts amongst the inhabitants living in proximity to these industries. The diseased lung is further prone to tuberculosis. Some of the major industry that introduces harmful agents into the atmosphere is petroleum (hydrocarbon), and battery making industries (lead). A considerable amount of pollutants is produced from exhaust of internal combustion of gasoline. One of these is organic lead, tetraethyl lead that is added to petro as an anti-knock agent (see lead poising for details). 124

Others effect of air pollution on man include irritation of the eyes and respiratory passages, damage to tissues, loss of visibility, and increase in the level of carcinogens in the air and absorption of toxic agents into food chain. In addition there is an accumulation of dust of fabrics, light fittings and buildings, which reduces their life span and beauty of the buildings. Reduction of smoke from vehicles can be modernized by efficient engine maintenance. Indiscriminate burning of industrial and domestic wastes in densely populated area can be reduced through recycling of wastes such as paper, rubber and plastic. Fugitive emission of gases and other pollutants into the neighborhood of a working environment can be controlled by the installation of appropriate and efficient filtering system at the sources. The community, employers and employees should be educated on the adverse effects of their activities on the environment. Legislation against indiscriminate burning of wastes should be achieved at every level of governing.

Water and Land Pollution There was once a story of a “prophet” in Lagos who ignorantly turned a colored stream near a textile mill into a worshipping site. The ‘prophet’ as reported to the extent of distributing the water to his followers as “holy water”. But in actual fact the stream was polluted by a direct discharge of chemical waste form the textile factory. Discharge of human waste into lagoon and streams in urban slums is a common experience in an unplanned industrial setting in Nigeria. Manufacturing and mining industries are huge sources of water and land pollution. They produce pollutants such as lead, mercury, nitrates, phosphates, sulphur, petrochemicals all of which are extremely harmful to people and the environment.

Noise Pollution

125

Sound is a form of energy transmitted through the air as waves of varying pressure while noise is define as ‘unwanted’ sound, which causes discomfort to listener. There are two main sources of noise; natural occurring (e.g. thunder) and manmade (e.g. traffic noise). There is no doubt that industrialization has increased ‘man-made-noise’ in Nigeria over the years. Typical sources of ‘man-made noise are aircraft, road traffic, manufacturing and construction industries, trains, musical instruments, radio, barking dogs, shouting, parties, workshops and last but not the least, the generating plant installed at various homes because of the epileptic power supply in Nigeria. There is serious indication of psychological effect of noise on man. According to WHO, some of the detriment effect of noise on health are annoyance, sleep disturbance, inference with communication and effect on performance and social behavior? Others are aggression, high stress level and tinnitus, on the other hand can lead to forgetfulness, severe depression and times can invoke panic attacks. Noise can also cause interruption, distraction and frustration thereby affecting safety and quality of products. As revealed in an article by a resident of New Delhi in Back to Asian Voice (2011), there is reported “increased number of headaches, greater susceptibility to minor accidents, increased reliance on sedatives and sleeping pills and increased mental hospital admission rates among those people exposed to high noise level in an industrial community. He went further by indicating that exposure to high noise has also been associated with range of physical effect including changes in blood pressure and other cardiovascular changes, increases hospital attendance, digestive disorder and general fatigue. Some of the above effect is supported by Donaldson & Donaldson (1983). According to them some studies around airport in Britain and elsewhere have shown a higher rate of mental illness than normal and also an increase in cardiovascular disease. Continuous exposure to noise of high intensity can cause permanent noise induced hearing loss, however this is uncommon with environmental or community noise. Education the people of the danger inherent in exposure to noise and most especially its effect on the mental wellbeing is in invaluable tool. This can be achieved through radio, television and newspapers. Location of workshops such as sawmills near residential areas in our cities and blaring of heavy music most especially in passenger buses should be made illegal.

126

Although industrialization has introduced many occupation and environmental health problems into our urban communities but it should be noted that there are some beneficial factors related to industrialization as shown by Europe and North America’s experience. The standard of life of the people is improved couple with buoyant economic growth. The reduction in prevalence of communicable diseases like cholera and typhoid in these continents has been attributed to technologically improved sanitation situation and provision of reliable sewage system. Therefore improvement of the wellbeing of Nigeria can come through improved environmental sanitation, and improvement in the scope and delivery of primary health care. It should be realized that the economic growth of Nigeria and her social stability depend not only on the skills of the workers but also on the general wellbeing of the workers and every individual in the community. The experience of the developed nations has shown that a healthy and happy working population with adequate health and welfare provision will produce genuine social stability and economic progress. Therefore, Nigeria needs a careful planning scheme of industrialization, one that will take the Nigeria’s environmental, health and safety problems into consideration.

OCCUPATIONAL HEALTH HAZARDS IN A WORK ENVIRONMENT A hazard is a condition with the potential of causing injury or damage. A hazard is not synonymous to accident or risk. This is simply because an accident can only occur as a result of exposures to a hazardous situation. Thus, an accident is defined as an undesired event and a consequence of exposure to a hazard, which result in injury to persons, damage to properties and interruption in business transaction. On the other hand, risk is the likelihood of an injury when exposed to a hazardous situation. An unprotected worker suffering from a disease such as epilepsy has a crisis when operating a machine and thereby knocks his head against the machine resulting in a serious head injury.

127

However we have been able to learn that: A hazard is a condition with the potential of causing injury or damage and it is inherent in every activity or situation. An accident occurs as result of exposure to a hazardous situation or condition. The condition created by an accident is an injury while the event elicited by it is death. A disease condition may occur as a result of exposure to a hazardous condition or situation an example is a person suffering from an infectious disease such as tuberculosis which may become a source of hazard to people who are in contact with the infected person.

Types of occupational health hazards At this juncture we should understand the difference between health hazards. Most health hazards have gradual effects on the body system as it will be observed in many cases in the next chapter but the effect of exposure to a safety hazard is instantaneous. For instance, asbestos particles can result in cancer of the lung two decades or more after inhalation whereas exposure to a live wire of high voltage can result in instant death through electrocution. The former is regarded as a health hazard because of its insidious nature whereas the latter is a safety hazard because the effect of exposure to hazard is instantaneous. Nevertheless, there is hardly any task or activity without one or more health hazards. For better understanding and appreciation, health hazards can be looked into under the following five sub-headings: physical hazards, chemical hazards, biological hazards, ergonomic hazards, psychosocial hazards

Physical Hazards Physical hazards include noise, vibration, ionizing and non-ionizing radiation, heat and cold. Some of these hazards can easily be perceived before damage is done. Another notable feature of these health hazards is the fact that they are all forms of energy. Their impacts can only be felt but they cannot be seen with the naked eye. For example, we can only perceived noise and vibration but they cannot be seen for instance, exposure to noise of high intensity over a considerable length of time that is more than 8 hour working day and 40-hour worker. Other are impairment of the circulation of the hand, which can result in deed finger’ due to repeated exposure of the hand to mechanical vibration of a machine.

128

Chemical Hazards Most of the chemical which constitute health hazards are in the form of vapour, gases, fumes, mists, dust and solid. The definitions of these terms are as follows: Vapor is the gaseous form of substances which are normally in the solid or liquid state at room temperature and pressure. The vapor can be changed back to the solid or liquid state either by increasing the pressure or decreasing the temperature; Gases are formless fluids in their natural state, which occupy space, or enclosure and which can be change to liquid or state only by the combined effect of increased pressure and decreased temperature; Fumes are solid particles generated by condensation from the gaseous state, generally after volatilization from molten metals. This is often accompanied by chemical reaction, such as oxide fume from are welding; Mists are suspended liquid droplets generated by condensation from the gaseous to the liquid state or by breaking up a liquid into a dispersed by state by splashing, foaming or atomizing; Dusts are airborne solid particles that range in size from 0.1 to 25 micros.

There are three main routes of entry of chemical hazards into the body before they can exert their toxic effects. These are inhalation, ingestion and absorption which are the effects of some of the chemicals commonly encountered in Nigerian industries.

Biological Hazards There include infectious agents such as bacteria, viruses, parasites, fungi and toxins associated with plants and animals. There also include pharmacoactive substances such as enzymes and hormones. The routes of entry of these agents are inhalation, ingestion, and penetration, through skin and contact with mucosal surface of the eye, mouth and nose. Health workers, clerical officers, cleaners and other personnel working in health care industries are at risk of infection with diseases such as tuberculosis, hepatitis B, cholera and AIDS (acquired 129

Immune Deficiency Syndrome). A number of occupational diseases caused by fungi infections prevalent among agricultural workers, for example grain handlers can suffer from farmer’s lung as a result of inhalation of contaminated grain dust. Workers working in wood processing facilities can be exposed to end toxins; allergenic fungi growing on timber and fungi that can cause mycoses. Workers in sewage and composite firms are exposed to enteric bacteria, hepatitis-A virus, parasitic protozoa and allergenic fungi.

Ergonomics Hazards There is a need to define the word ‘ergonomic’ because of those who are not familiar with the word. Ergonomics, also known as Human Factor Engineering, is define by International Labor Organization (ILO) as ‘the application of human biological science in conjunction with the engineering sciences to achieve the optimum mutual adjustment of man and his work, the benefits being measured in terms of human efficiency and well-being’. We should note, at this juncture that ergonomics is a unique field of its own, thus its coverage is beyond the scope of this book. The readers are therefore referred to books on ergonomics (see reference) for better appreciation of the subject. However, let us look into the scope and importance of ergonomics in the health and safety of workers, and the same time identify the relevant factors in ergonomics practice and the ill health caused by absence of these factors especially when they are not considered at the design stage of any project. The principal focus of ergonomics in any design is the user. Unsafe, unhealthy and uncomfortable conditions at work can be avoided when talking into consideration during stages the physical and psychological status and limitations of the user. Some of the factors to be considered at this stage are as follows: Space allocation, body posture and movement which involves or associated with sitting, standing, lifting, pulling and pushing; Environmental factors such as noise, vibration, illumination, temperature, chemical substances; Information and operation which include information gained visually or through other senses and the relationship between display and control, and tasks and jobs.

130

Some of the work-related illnesses, which can be developed if the above factors are not considered at the design stage of a project or facility, are waist pain and low back pain mostly resulting from poor posturing and inappropriate designed desks and chairs (office furniture). Other are irritation and inflammation at the tendon resulting from repetitive motions resulting in repetitive strain injuries(RSI) or work –related –upper-limb disorder (WRULD)

Psychosocial Hazards High job demands and low control of the job can cause stress. Other factors that can result in emotional strain are repetitive tasks, complex and highly demanding requirements, unreasonable targets, shift work and fear of termination of appointment. Others are interpersonal conflicts, role ambiguity, and low self esteem, underutilization of skills, discrimination, supervision, violence, and absence of social support both at home and at work.

Health Risk Assessment (HRA) As defined earlier, hazard is the potential cause to harm. But risk is the like hood of harm when exposed to hazard, thus HRA is the assessment of the like hood of harm when exposed to a known hazard. Application of HRA is the first step in preventing occupational health hazards in the workplace. It is a structured approach which is primarily concerned with using science and, where necessary, science policy judgments to estimate, either qualitatively or quantitatively the magnitude, like hood, and uncertainty of worker’s health risks that are caused by exposure to a known health hazard. It is made up of three main levels, which are identification, assessment and control.

Identification 131

Identification or recognition of potential health hazards requires through knowledge of the process and materials and the ability to identify the health hazards inherent in every activity or task associated with the entire job type.

Assessment This is the decision making process that evaluates the level of risk to workers from their exposure to health hazards. The assessment is based on combination of hazard rating HR and exposure rating ER expressed in a matrix. These are generated through a walk through survey of the workplace, interviewing the workers, monitoring or estimating the levels of the agents identified and studying the effectiveness of the control measures. HR is the severity of the effects of the agents, indicating and potentially of the agents to cause alarm while ER considers the duration and frequency of exposure to the agent. The health risk as obtained from the matrix is classified: ‘high’ medium and low”. This arrangement helps in the prioritization of the remedial actions or the control. In other words, the high risk must be attended to with immediate effect. Other factors that should be considered when assessing health risk are: assessing the quantity or level of the agent that the workers are exposed to, comparing the result obtained with the occupational exposure limits (OEL) or threshold limit value (TLV), recognizing the rate of generation of the agent and the amount and frequency of exposure of the agent, and knowing the route of entry of the agent into the body.

Control The type of control method adopted depends mostly on the type of health hazard. For an example control of biological hazards requires a special consideration. An outbreak of disease peculiar to a particular occupation needs immediate treatment and epidemiological studies to curtail its spread. However, the general methods of control are as follows: 132

The substitution or replacement if harmful processes or materials with one which is less dangerous to health; The alteration or change of process in order to reduce worker’s contact which includes isolation, enclosure and automation; Introduction of wet methods to reduce airborne dusts from operations such as mining and grinding; Installation of local exhaust ventilation at the source of generation of air contaminants; Provisions of general protective equipment such as protective clothing, earmuffs, masks, goggles and many others; Adequate supervision and good housekeeping which includes general cleaning of workplaces, segregation of waste from sources and their adequate disposal, maintenance of washing and catering facilities, provisions of potable water and control of pests in the environment; Special consideration of specific hazards, which require specific methods for instance reduction of exposure time for ionizing radiation and noise; Environmental monitoring of health hazards such as chemicals in order to assess the effectiveness of control in place; Periodic medical examination to detect the level of intake of chemicals into the body, this helps to determine when workers should be withdrawn from risky zone; Encouragement and promotion of health and safety education among workers and employers; Introduction of legislation to eliminate or minimize the exposure of workers to occupational hazards in the workplace.

Occupational Diseases Occupational diseases are one which occurs with characteristic frequency and regularity in an occupation where there is a specific hazard. In other words an occupational disease has a specific or strong relation to occupation, usually with only one casual agent. That casual agent usually has an effect on specific target organ in the body. For instance continuous exposure to noise of high intensity can cause permanent noise induced hearing loss. The effect produced by the agent in the body is recognized as a pathological change. However there is a distinction between an occupational disease and a work related disease. A work related disease is defined as that with multiple casual agents, where factors in the work environment may play in a role in the development of the disease, for example hypertension. This can be caused by other factors outside the work environment and at the same time be a product of a stressor such as quantitative overload.

133

The association of occupational diseases and works are easily noticeable or recognized by workers most especially in developing countries. Although they are not as frequent as other disabling diseases their impacts or health and social wellbeing of workers cannot be over emphasized. Occupational diseases often affect workers at the prime of their lives when they are more productive depriving them of their domestic and social activities, shortening even their lives and causing considerable losses to national economy. Therefore, the common occupational diseases associated with various workplaces in our communities. Are as follows;-, however, no distinction will be made between occupational diseases and work-related diseases. Anthrax: Anthrax is a worldwide disease. It is endemic in farm animal but found occasionally in man.

Exposure: It is found more frequent in male adult due to occupational exposure and particular in farm-workers, butchers, veterinary practitioners and employees handling bones fertilizers hide wool and animal fur. Causative Agent: The causative agent is Bacillus-anthraces. It can produce

spores

when faced with an unfavorable condition, thus becoming resistant to disinfecting processes. Incubation Period: The incubation period is between two and seven days. Modes of Infection: The organism enters the body through small abrasions when in direct contact with infected animal or indirectly through spores carried on varieties of materials. The spores can remain viable for years. Inhalation of spores may result in pulmonary anthrax (Wool- Sorter Disease) and the indigestion of contaminated meat result in gastro-intestinal anthrax. Clinical Feature: Most common form of disease is cutaneous anthrax (malignant pustule).It occurs on the exposed parts of the body e.g. face or arm and is characterized by pustule with rings of blisters and mark oedema; subsequently the area becomes hard and swollen. Pulmonary anthrax is rare and is characterized by fatal hemorrhagic edematous reaction of the lower respiratory passage. 134

Diagnosis: A history of occupational exposure and characteristic appearance of malignant pustule help diagnosis. Bacilli may be detected in the lesion. Preventive Measures: If anthrax is suspected, animals must be isolated until cured. If mortality occurs the animal must be cremated or buried in a deep lime-pit; The works that are occupationally exposed to this disease must be educated in the recognition of the lesion so that the treatment can commence as soon as it is recognized; The workers should be provided with protective clothing and they should be scrupulous impersonal hygiene; Dust control must be vigorous in wool industries; Occupationally exposed workers should be immunized materials are disinfected.

Brucellosis: Brucellosis is a world-wide disease.

Exposure: The disease is particular prevalent in young adults and also in children due to the consumption of infected milk or milk products. Farm-workers and butchers are especially exposed. Some laboratory workers are risk. Causative Agent: Brucella melitensis infect goats and found in goats milk. It causes Malta fever. Brucella abortus in the other hand infects cows (causing abortion) and it is found in cow’s milk. The last strain is Brucella Suis, which infect pig and is abortus related strain. Incubation Period: This is uncertain but is possibly between six days and six months. Modes of infection: The ingestion of infected raw milk or milk-products is a common cause of the disease and also contact with secretions from infected animals. Infected may be transmitted by dust and laboratory infections may be airborne. Clinical Feature: The disease commonly starts insidiously and is characterized by irregular fever associated with heavily sweats, marked malaise and

headache. Abnormal pain and constipation are

common. Diagnosis: History of tests occupational exposure will help in the diagnosis. Agglutination tests may aid diagnosis. Preventive Measure: Infected animals should be destroyed and buried in deep lime-pit. Farmworkers, butchers and laboratory workers should be educated on infection control of the disease and the

135

consequence need for great care in handling infected specimens. Milk should be pasteurized before consumption.

Tetanus: This is sporadic infection found typically in agricultural communities.

Exposure: There are more cases in males because of occupational exposure skin trauma is usually followed by contaminating the wound with manure, solid or dust which results in an infection. It is an occupation disease of farmers and cattle rearers. Causative Agent: The causative agent is a spore-producing organism called clostridium tetani .It is present in the intestine of cattle and other herbivores. Incubation Period: This is usually from 4 days to 28 days but sometimes may be much longer. The incubation period appears to depend on the site and character of the wound in which spores are deposited. Modes of Infection: Clostridium tetani, the causative agent, is an anaerobic organism. It survives best in deep, ragged and dirt-contaminated wounds rather than in clean superficial injuries. It possible to get the wound infected directly or indirectly from spores in earth, dust or animal manure. Poorly sterilized surgical gloves and unbleached cotton can be sources of infection in the hospital. Clinical Feature: The characteristics of the disease are intensely painful muscular contractions most especially in masseter muscles (lock-jaw) and neck. The contraction may resolve or the patient dies from exhaustion, infection, heart or respiratory failure. Preventive Measures Farmers and other occupational exposed workers should be immunized against the disease. Occupationally exposed workers most especially farmers should wear protective clothing and shoes while on the field. Hospital sterilization should be through to avoid infection after surgery. All wound should be carefully cleansed

and the patient should be given passive protection with an

injection of ant-toxin.

Tuberculosis: It is a disease of worldwide occurrence but endemic in most part of Africa.

Exposure: This is a disease prevalent among workers associate with occupation such as nursing, pathology, mining and cattle rearing.

136

Causative Agent: There are several types of Tubercle bacilli but the two which are important in the infection of man are Mycobacterium tuberculosis-human type

which is usually the cause of

pulmonary tuberculosis and Mycobacterium tuberculosis-bovine type which is more virulent in cattle in cattle than man. Incubation Period: This is between 4to 6 weeks for the primary lesion. However, infection may never spread beyond the primary stage or it may be reactivated after many years. Modes of Infection: Human Type: The primary infection is due to close contact with an infective case in hospitals nurses and doctors in close contact with infected pathology materials run an increased risk of infection. Bovine Type: the primary infection is due to ingestion of infected milk. It rarely occurs of the skin with thorough accidental inoculation of skin with Bovine Bacilli during slaughtering and butchering of cattle. Clinical Features: Primarily the patient will have chronic cough. This may be accompanied by loss of weight, fever, anemia and slight rise in temperature, generally toward s evening. Later the patient may develop haemoptysis (spitting blood). Preventive Measures: The occupationally exposed persons should be protected through vaccination of those who are matoux negative, among all health workers and other occupational group who have high risk of contracting the disease. There should be periodic medical examinations of exposed workers with the main objective of preventing the onset of the disease and curtailing further development and spread of the disease through early diagnosis. Workers handling infected patients or animals should wear appropriate personal protective equipment such as mouth mask and hand gloves. All workers should be educated of the mode of spread of tuberculosis. Good and well-ventilated workplace or accommodation should be provided for workers who away from home. Studies have shown that overcrowding and poor housing can enhance the spread of the disease.

Ankylostomiasis (Hookworm disease): This is a very common disease in tropical and subtropical regions of the world.

Exposure: This is a disease of far-workers, fishermen and miners. It is a significant cause of anemia in sub-Saharan Africa. Causative Agent: The causative agent is nematode called Ankylostma duodenal. Incubation Period: The incubation period depends greatly on the intensity of infection. Modes of Infection: The larvae, which normally harbor themselves in warm damp soils, infection penetrate unbroken skin and develop in few days. In endemic areas, infection usually occurs

137

through the protected foot. The larvae get into the lung through the blood vessels and later enter the alveoli they ascend the bronchial tract and then pass down through the esophagus to the duodenum. Where they are attached to the mucosa absorbing blood and thereby grow to maturity. Large numbers of larvae liberated from the female worm are found in faeces of the infected person. Diagnosis: Blood examination will reveal iron deficient anemia. Also, ova may be detected in feaces. Preventive Measure: Farmers, fishermen, and other occupational group liable to be infected by worm should protect their feet when engage in their respective work. Mines, farmland, streams and other likely sites should be prevented from being contaminated by infected faces. An adequate waste disposal toilet facility is required.

OCCUPATIONALY CONTACT DERMATITIS This is an occupational skin disease characterized by local inflammation of the skin resulting directly from, or aggravated by working environment. It occurs in workers of ages and in any working environment. It occurs in workers of all ages and in any work setting. It is the commonest occupational disease and responsible for enormous loss of working hours. It causes a great deal of illness, anxiety, personal misery and disease is reduced productivity and efficiency. The frequency of occupational contact dermatitis has been discovered to be directly proportional to the level of hygiene practice among workers and in the workplace and generally the disease is preventable.

Trends of occupational Disease by Compensation Claims PRINCIPAL DIAGNOSIS

COMPENSATION CLAIMS

Skin disease

2853

Musculoskeletal disorder

1640

Chemical Poisoning

278

Respiratory system disorder

791

Circular system disorder

320

Others

2078

(From Body of Evidence by Chris Peckham in Safety & Health Practitioner, January 2006;originally by Hacklier-Sarenson, C: Occupational skin disease-a case study from Denmark, published in contact Denstitis,1998,vol. 39,pp71-78.)

138

Exposure: The factors that influence the development of occupational disease are sensitivity, the attitude of the workers, duration and degree of exposure to the agent and the amount of sweating and friction of garments worn by the workers. Above table shows allergens encountered in some of the prominent occupations in our community. Causes: The causes of contact dermatitis are chemical, physical, mechanical and biological agents. Let us briefly look at each one of these factors Chemical Factors: The chemical factors are divided into two main types. These are primary skin irritants and secondary sensitizers. The primary skin irritant is substance that causes damage at the site of contact when there is direct contact between the chemical and the skin. These irritants include strong acid, alkali, aromatic amines, phosphorus, ethylene oxide and metallic salts that can produce observable effects within a few minutes after being in contact with the skin. The weak ones in contrast require days before manifestation of clinical changes. In the latter category are soap, detergent, solvents, and engine oil. As a result of the cumulative or insidious characteristic of these chemicals they are therefore responsible for major skin problems among workers. Secondary sensitizers are the causes of allergic contact dermatitis. Most sensitizers do not produce a skin reaction on the first contact, and the period of exposure before skin reactions occur may last a lifetime or only few days. The action of the allergen depends very much on its ability to change some properties of the outer layer of the skin. For instance, removal of fat oil and water from the outer layer of the skin will diminish the protective action of the skin and thereby creates an easier passage for substances to penetrate the skin. This may last from four days to twenty –one days during which there is no sign of skim damage. Once penetrate the allergen will combine with natural skin proteins, the continuation of which is (White blood cells are part of the immune system, which guard the body against germs or foreign agents.)

(Courtesy finish institute of occupational Health, African Newsletter on occupational Health Vol.14. Number 3 Dec. 2004.) The immune system has a memory to recognize and neutralize any substance or germ encountered more than once. Therefore, when exposure to the allergens is repeated, the workers become sensitized as result of the lymphocyte recognition of the allergen. The recognition is accompanied by the release of tissue and damaging chemicals called lymphocytes into the body. This results in a reaction that is characterized by swelling and of formation small blisters on the skin. This inflammation is usually restricted to the site of contact of allergen, but in severe cases it may spread over a considerable large area of the body. This feature usually commences twelve hours after exposure but becomes very severe after

139

three to four days. However it slowly improves after seven days without a treatment. The sensitizers may be permanent factors in the victim’s life but sensitivity may decline if there is no further exposure to the allergen. Some of the skin sensitizer are petroleum distiller ate coal tar derivate, chromate and nickel salts.

Physical Factor Physical factors such as heat, cold, ultra violet light from sunlight and ionizing radiation are capable of damaging the skin. For example, high temperature causes perspiration and softening of the outer layer of the skin resulting in heat rash. This is common among workers working outdoors in hot humid weather and in bakeries and steel rolling mills. Burns can result from exposure to ionizing radiation sources, molten metal’s and glass. It can cause frostbite among workers working in cold-rooms. Frequent handling of frozen food and other items can results impermanent damage to the blood vessels. Other parts of the body which are prone to damage when exposed are the ears, nose and fingers. Prolonged exposure to ultra violet light from sunlight can cause skin cancer, most especially African women who bleach their skins for beauty and who are often engaged in outdoor activities are highly susceptible to skin cancer. Other vulnerable groups are construction workers, forester and other workers engage in outdoor activities, which are carried out, for a considerable length of time. Sources of artificial ultra violet light such as molten metal’s and glass and welding operations can also damage the skin. Lasers beam widely used in medicine can damage the skin, eyes and other biological tissues.

Mechanical Factors Friction or pressure can produce some type of mechanical trauma. This may result in burns, abrasion or more commonly callosities produced by repetitive types of hand motions, for instance vibrations from a road digging machines. Other occupational groups in which callosities might be fond are carpenters, floor sweepers, farm workers and cobblers.

Biological Factors Bacteria, viruses, fungi and parasites attack that skin and sometime produce systemic disease of occupational origin. Among the occupational group who can develop this type disease are animal breeders, farm workers, bakers, carpenters, furniture maker sand laboratory technicians. Irritant contact dermatitis can also be caused when the body is in contact with leaves, stems, bark and seeds of some plants. For instance a skin rash is produced when in contact with Iroko wood. Also nasty itching resulting in multiple skins rashes is produced when the body is in contact with the sharpened airy seeds of devil-

140

beans (Iwerepe). This is often encountered by farm-laborers and farms during clearing of farmlands in preparation for a new planting season.

Clinical Features of Occupational Contact Dermatitis Several clinical variations of occupational contact dermatitis are known to occur; the lesions produced on the skin however depend on the type of agent in contact with the body

Some of the examples are: Acute contact dermatitis, which is generally caused by a primary irritant, a sensitizing chemical or poisonous plant; Acne-like skin disease, which is caused by contact with petroleum oils and grease; Pigment changes, which is caused by contact with some chemicals, such as petroleum oils, asphalt, pitch, and photo reactive materials. Sunlight can also produce changes in the pigmentation of the skin common among the albinos and Caucasians; Burns and other forceful injuries leading to ulceration of the skin can be caused by exposure to arsenic trioxide sodium chromate, potassium dichromate, lime and thermal burns; Skin tumors, which may become cancerous, can be produced through exposure to ultra violet light, x-ray, tar, arsenic trioxide, impure paraffin and certain shale fractions.

Common Causes of Occupational Contact Dermatitis

Agents

Reactions

Occupations

or

Activities

where

exposure may occur Acetic

Acid

Hydrochloric Ulceration

acid

irritation

of

the

skin Printing and Dying Bleachers, chemical

and ulceration of manufacturing.

the skin Sulphuric acid

Corrosive action on the skin, Chemical manufacturing. severe

inflammation

of

mucous membranes. Calcium Cyanamid

Irritation and Ulceration

Potassium hydroxide

Burns

and

Fertilizer makers, agricultural workers

Persistent Soap,

141

paper

and

electroplates

ulceration of the skin Sodium Silicate

manufacturers

Thickening of skins, ulcers Bleachers, on fingers

Sodium hydroxide

Loss

of

manufacturing

of

cardboard and boxes

finger

nails, Petroleum refiners and bleaching

persistent ulceration of skin

agent and dye manufacturing

Sodium/Potassium

Blisters, ulcers

Electroplaters and extraction of gold

Arsenic and its compounds

Darkening

of

skin, Artificial

leather

makers,

perforation of nasal septum, manufacturing of insecticides and eczema around mouth and glass industry nose, epithelioma Mercury

and

its Irritation of skin

Gold

compounds

extraction, manufacturing of

electrician appliances, manufacturing of bleach, soap, paper and glass

Barium and its compounds Irritation skin Dry skin

Dye and paint makers Spraying and

Acetone

painting, artificial silk and leather manufacturing, electrical equipment manufacturing, and acetylene workers

Carbon disulphide

Dry skin, skin irritation

Extraction

of

oil

and

fats.

Manufacturing rayon, rubber and cements.

142

Benzene,

Toluene

and Dry skin cleaning

Chemical rubber and artificial leather

Xylene

manufacturing and dry Petroleum distillate

(BTEX)

Acne, epithelioma

Petroleum

refiners,

machinists,

furniture

polishers

Petroleum Oils

Inflammation

of

hair Petroleum workers, machinist and

follicles, acne, skin ulcers mechanics malignant tumors

Eczema, acne, epithelioma Manufacturing of paints and cements, Pitch and asphalt

and inflammation of hair wood working, road building follicles

repairing

143

and

Occupation Diseases

Common Causes of Occupational Contact Dermatitis 2

Agent

Reactions

Occupations

or

Activities

where exposure may occur Tar(coal)

Acne, eczema and malignant Manufacturing of coal tar, tumors

Dichromate

Red

paper felt and pitches. skin,

blister-like Soap manufacturing,

eruption, Soap and soap powder

Cashew nut oils

dish

washers housewives

Eczema, blister-like eruption, Soap

manufacturing,

chronic abscesses

washers housewives

Severe dermatitis as blisters

Handlers

of

dish

unprocessed

cashew nuts Synthetic resins

Intensely red and itching skin

Plastic workers and vanish makers

Iroko wood

Rashes and facial oedema

Forestry workers and furniture makers

Factors that can influence the development of occupational contact dermatitisThe most common factors that can influence the development of this disease are: Pre-existing skin condition, irritant contact dermatitis for instance;

144

Cuts or scratches, which create easy passage for allergens into the skin; The chemical characteristics of the substance (acid, alkali or salt); The quantity and concentration of the substance that comes in contact with the skin; The duration and the frequency of exposure to the agent; Personal factors which include hereditary and tendencies and resistance of the skin, which increases with age; Environmental factors such as a hot workplace, which increases the rate of sweating and allows easy absorption of toxic soluble substances thereby increasing their toxicity to the skin.

Preventive Measures Operations should be conducted in entirely enclosed systems to reduce the level of exposures of wormers to allergens. Where possible substitution of harmful products should be considered; High degree of housekeeping and personal hygiene should be maintained. Toilets and washroom with showers should be conveniently located and supplied with adequate water, disposal towels and soap; Workers should be discouraged from using harsh substances and objects such as bleach and a hard brush to clean oily hands. This process, if not discouraged, will destroy the outer layers of the skin thereby making the body highly susceptible to dermatitis through absorption of chemical or any other agents into the body; All workers should be provided with adequate protective clothing such as aprons and gloves. However there should be careful selection of protective clothing because not all-protective clothing resists all chemicals; Periodic medical examination of every exposed worker is necessary. Sensitized workers discovered during this exercise should be transferred to areas where there will be no further exposure be protected from physical to the allergens. The affected skin should be protected from physical trauma, excessive sunlight, harsh wind and rapid temperature changes while the skin disease is active.

Cement Induced Skin Disease Eczema, a skin due to contact with cement is common among construction workers. This can be classified into two: toxic-irritant eczema and allergic eczema. In addition workers may sustain severe burn on any uncovered part of the body from contact with wet cement. Workers at risk are primarily masons and unskilled laborers. Those who fall into the latter category are block-molders and women employed to carry sharps sand mixed with cement during civil construction. Protective measures consist primarily creating a barrier between cement and the body. This can be achieved by wearing appropriate personal protective equipment. For instance cotton gloves with nitride

145

coating are to be preferred to leather gloves. Good personal hygiene such as washing the body after work should be encouraged consideration individual susceptibility and thereby put a skin protection plan in place in their organization.

OCCUPATIONAL DEAFNESS Occupation deafness is defined as reduction in the ability to hear caused by exposure to continuous or prolongs noise of high intensity at work. Quantitatively, continuous exposure to noise level of more than 85dB (A) working without hearing protection, for 8-hour working week can cause permanent hearing loss also referred to as permanent hearing Noise Include Hearing Loss (P-NIHL). This is referred to as sensor neural hearing loss since noise destroy the nerve cells in the brain. This is usually not reversible. The major occupational groups in our community who are exposed are grain-millers, tractor operators, civil construction worker, factory workers and musicians.

Clinical Features: The first evidence of permanent hearing loss is the reduction of hearing ability at the high frequency of sound most especially at KHz. The changes in the threshold of hearing in both ears are often the same. As the exposure continues the loss it spreads to the lower frequencies, the speech range. This insidious damage is accompanied by sensation or ringing in the ear most especially when the affected workers leave the noisy environment. Generally, there are four phases of development of PNIHL as appear below.

After continuous exposure to noise level greater than 85 Db (A) for a reasonable length of time the subject experiences ringing in both ears. This is often accompanied by non-specific sensation in the ear accompanied by headache, and feeling of tiredness and dizziness. These symptoms usually manifest after 10-20 days of exposure to noise. There is intermittent ringing in the ears with the absence of subjective symptoms. The experience may last from a few months to many years depending on the level of noise, the daily duration of exposure and the predisposition of individual to hearing damage. The subject is deprived of his normal hearing and can no longer hear the ticking off of the clock or contribute meaningfully to conversation most especially if there is a background noise. The affected individual raises the volume of the radio and television much to the annoyance of people around him. He also shouts when he talks.

146

This last phase is characterized by complete insufficiency in hearing. Conversation is compromised with severe consequence on social and general wellbeing of the subject. Any of these phases may be accompanied by persistent tinnitus indicating impairment of the nerve structure of the cochlea. This does not only aggravates the subject’s hearing but also has severe effects on his rest, sleep and general well being.

Diagnosis: Conducting an audiometric test will reveal the degree of deafness. The loss of hearing with maximum effects is localized between 3 and 6 kHz with a dip at 4 kHz as shown in Figure 8:3. In most cases the effect is bilateral, in other words both ears are affected. Preventive Measures: The affected worker should be removed from exposure to allow for a recovery when an initial shift in the hearing threshold is first observed. The industrial noise is reduced at source through installation of damping materials, enclosures and isolation of the noisy machines. If possible the machine should be replaced with a less noisy machine. Audiometric tests should be included as part of pre-employment medical examinations for workers intended to work on noisy machines in order to have the baseline information of the subject’s threshold of hearing. This will assist in earlier identification of hearing threshold shift most especially during subsequent periodic examinations. Audiometric tests also assist in monitoring compliance in respect of control pleasures that are put in place especially sometimes presence of a blue line in the gum. The classical symptom of the disease is wrist-drop but this is rarely seen nowadays). Inorganic lead also affects the synthesis of erythrocytes (red-blood-cells). There may be degree of hemolytic produced by chronic poisoning. This may result in mild anemia where the hemoglobin is normal or it may be severe anemia resulting in reduction of red blood cells

147

The effect on the kidney is based on the nephron. It causes extensive scarring and obliteration of the blood vessels and glomeruli. This is one of the causes of death from chronic poisoning of lead, particularly in children.

POISONING FROM ORGANIC LEAD Tetra-ethyl lead is an organic lead which is used as an anti-knock additive to petrol. It is readily absorbed through the unbroken skin and respiratory tract. It is a heavy liquid which is volatile at room temperature and has sweetish smell. Lead poisoning by organic lead is common among those who clean petrol storage tanks.

Effects on the body: Mild cases begin with insomnia, sleep disturbance, tremor, and loss of appetite and metallic taste. Mental excitement is marked during the day with severe headache and fatigue. Blurred vision and double vision may occur. In severe cases, the effect is on the nervous system. There is a brief spell of intermediate malaise followed by restlessness, talkativeness, excitement and delusions. This accompanied by a fall in the blood pressure and body temperatures. The illness may progress to mania with complete disorientation and development of delusions, hallucinations. In severe poisoning, death may be rapid.

Preventive Measures: Substation of lead with a less dangerous chemical should be considered where possible. Any process giving rise to lead dust or fumes should be enclosed. Provision of general ventilation in conjunction with local ventilation to remove lead dust and fumes from the source and at the same time to reduce its concentration in the working environment good housekeeping must be maintained through cleaning of workrooms and keeping of tools in order. Good personal hygiene must be encouraged through provision of washing facilities. There should be adequate supply of water, soap, towels and nail-brushes. Nail biting must be actively discouraged. In electric smelting processes and electric accumulator 148

works, damping or wetting of floors is required to prevent dust from becoming airborne workers cleaning and repairing petrol tanks should take precaution against lead poisoning by wearing appropriate or fit-for-purpose respirators and protective clothing. Women especially the pregnant ones should be employed to work in processes connected with lead manufacture or smelting because of reported cases of spontaneous abortion and stillbirth among pregnant women who are exposed. Health surveillance including blood tests should be carried out regularly as a means of identifying lead poisoning at the early stage of its development. This also helps in determining the effectiveness of all the control measures in place.

OCCUPATIONAL CANCER Cancer is a term by laymen and physicians alike to describe a multitude uncontrolled cell growths which by size, shape and relation to surrounding structures can displace, erode and later alter the functions of healthy organs. Since the discovery by Percival Pott in 1775 of the association between scrotal cancer and chimney sweeps several types of cancer of occupational origin have been discovered. Efforts will be made here to highlight the common ones with emphasis on the means of controlling the carcinogens or cancer causing agents.

Cancer of the Lung This is an occupational cancer of workers engage in mining or handling if radioactive materials, nickel, chromate and asbestos and iron-ore. Gas retort workers can also suffer from the disease. The disease occurs due to exposure to radioactive sources, inhalation of dust particles and inhalation of hydrocarbon fumes or vapor. Control Measures

149

The cancer-causing agent should be controlled at the sources, as an example, shielding of radioactive sources with lead plate. The working environment should be dust free and appropriate personal protective equipment such as respirators or noise/mouth masks should be worn when engaged in any task that is dusty. Periodic medical examinations of workers including the x-ray of the lungs should be mandatory. This will assist early detection of the development of the disease.

Cancer of the skin This is due to exposure to pitch tar, shale oil, radioactive materials and ultra violet light from the sun. There are various types of skin cancer depending on the location on the body. Scrotal cancer is observed among mule-spinners exposed to pitch, with arsenic. Pitch warts are found on the faces and arms of individuals who work with pitch and coal tar derivatives such as road workers. Rodent ulcer of the face is found among fishermen and agricultural workers as a result of exposure to ultra-violet light (UVL) from the sun. This is more likely to occur among Caucasians who are engaged in these occupations than Negroes. This is because Caucasians have lesser amount of melanin, (the pigment that protects the skin against UVL) than the Negroes. However, albinos who naturally do not have melanin in the skin and are outdoor workers in the tropic have potential of developing skin cancer. Control Measures The possibility of substituting a carcinogenic agent with the less harmful one should be considered. For instance mule-spinners-cancer in textile industry has been eliminated in Europe through substitution of an equally efficient vegetable oil for mineral oil. A general awareness of the health risk of handling carcinogenic agents should be highlighted among workers during storage, usage and disposal. The workers should be provided with appropriate protective clothing made from materials which are not pervious to the carcinogenic agent. The workers should be subjected to regular medical examinations to reveal skin lesions, which can be attended to at a stage when treatment is possible. 150

Cancer of the Bladder Cancer of the bladder occurs among workers engaged in the manufacturing of dyes, pharmaceuticals, rubber and plastic. The causative agents are aromatic amines used as intermediates in the manufacturing of these materials. Control Measures The disease can be eliminated by substituting the chemical with less risky ones. If this is not possible the chemicals can be curtailed through the installation of exhaust ventilation at the source of emission, enclosure of the process and meticulous supervision of the process through work procedure guide. The workers should be provided with appropriate personal protective clothing and cleansing facilities. The workers should also be informed of the possible health risk inherent in the handling of the chemicals through regular health promotion lectures. They should undergo regular periodic medical examinations for early diagnosis, which may improve prognosis.

Cancer of the Nasal Sinus This is due to inhalation of wood dust. It is an occupational disease of workers in furniture and shoe industries. The disease can also be contracted as a result of exposure to nickel dust. Control Measures The working environment should be well ventilated and processes giving rise to dust should be curtailed by enclosure. Periodic medical examination of the workers for an early detection of disease is essential.

151

Cancer of the Liver This has been observed among workers exposed to benzamine, vinyl chloride and arsenical insecticides. Control Measures Adequate precautions should be taken to safeguard the health of the workers through the provisions of safety equipment, periodic medical examinations and health education.

Cancer of the Bronchus This disease is noted among uranium miners. It is caused by alpha particles, which produces undifferentiated carcinoma that arises from the bronchial epithelium.

Control Measures Improvement in the ventilation in the mines will reduce in no small measure the risk of inhalation of uranium dusts.

DUST INDUCED OCCUPATIONAL LUNG DIORDERS The ill effects of inhalation of dust on the lungs can be classified into three main headings: pneumoconiosis, byssinosis, and extrinsic allergic alveoli. Pneumoconiosis This is a group of diseases which results from the effect of inhalation of various mineral dusts on the lungs. Each of the disease is characterized by a chronic fibrotic change. Some of this lung disease is described below. 152

Asbestosis This is an occupational lung disease that results from inhalation of fine asbestos fibers. Asbestosis is characterized by dyspnea and cough. Later, there is diminished movement of the lungs. Finger clubbing may be observed. Once the disease is established, it generally progresses to produce some degree of respiratory disability. There is no known cure for the disease. Asbestos, the cause of this disease, is the term used to describe a hydrated magnesium silicate in fibrous form. They are of two main groups, serpentine and amphibole. Chrysotile (white asbestos) belongs to the first group while amosite (brown asbestos) and crocidolite (blue asbestos) belong to the latter group.

Asbestos is used for various forms in industries because of its insulating properties and its ability to withstand heat of various degrees. The commonest use of asbestos in Nigeria is the manufacturing of roofing sheets and floor tiles and ceiling boards. Information obtained by the author from one of the manufacturers claimed that 10% of chrysotile with 90% cellulose and cement were used in the manufacturing of asbestos roofing sheets in his factory. It should also be noted that chrysotile, the less dangerous of the three accounts for over 90% of world use while amosite and crosidolite have limited use. Asbestos is also used for the manufacturing of brake pads and clutch plates. All workers exposed to asbestos fibers during the course of their works have the potential of suffering from asbestosis. It is a dose-related disease after a long exposure. The effects may not manifest until about 20-25 years after exposure. As a result of this insidious effect and its association with the development of mesothelomia, asbestos and its products have been banned in mostly developing countries.

Silicosis This results from inhalation of free silica, which is naturally present in flint and quartz. It is a disease common among grindstone cutters, quarry-workers, pottery workers and workers in cement making industries. The disease is characterized by dyspnoea, which affects the patient’s 153

ability to work. This may be followed by total incapacitation of the patients. It is the only pneumoconiosis which predisposes tuberculosis at significant degree.

Coal Miner’s Pneumoconiosis This occurs due to exposure of miners to coal dust. The development of the disease depends on the quality of dust deposited in the lung and the duration of exposure. There is no characteristic sign of the disease. However, wheezes may be heard throughout the lung field.

Mixed Dust Disease This results from inhalation of free silica and some other irritant dusts such as coal and iron dust. The disease occurs among foundry workers, welders, potters, boiler scalars and hematite miners.

Baratosis: This occurs as a result of inhalation of barium peroxide during mining. It also occurs during the manufacture of ink, glass and insecticides.

Stannosis The deposit of tin in the lung causes stannosis. The exposure occurs during the handling of tin ore or during crushing and charging process. It also occurs during exposure to tin fume in any process which involves molten metal.

154

Siderosis This is caused by inhalation of iron dust. It is a disease common among workers engaged in operation of iron and steel foundries, rolling mills, mining and crushing of iron ores, grinding and during oxy-acetylene welding. It may also occur among traditional blacksmiths.

Byssinosis This is a non-fibrotic occupational lung disease which results from inhalation of cotton dusts. The disease is common among textile workers, most especially in spinning and carding. The disease is easily confused with non-occupational bronchitis. After several years of exposure, the exposed workers may develop occasional tightness of the chest of the day of the working week. This symptom may later repeat itself at the same period but this time it will be accompanied by difficulty in breathing. The symptoms may later occur on every working day followed by permanent breathlessness with cough and sputum. The disease is often referred to as occupational asthma. But it is different from asthma. But it is different from asthma because the affected can recover during the week at the initial stage of development of the disease.

Extrinsic allergic alveolitis These are caused by inhalation of dusts which produces alveoli is that results in the reduction of gas transfer across the blood-lung barrier. The two typical examples are:

Bagassosis This is a pulmonary lung disorder, which results from inhalation of dusts from dry and moldy bagasse. (Bagasse is a fibrous residue, which is left over after juice has been extracted 155

from sugarcane stalks). This disease is characterized by fever, dyspnea and productive cough. It occurs among workers engaged in the manufacture of fiber-boards where bagasse is used as raw materials. It may also occur among workers responsible for the disposal of bagasse in sugar industry.

Farmer’s Lung It is an occupational lung disorder that occurs as a result of inhalation of spore laden dust. It occurs among agricultural workers exposed to dust from moldy hay and straw. It may also occur among local mattress makers who use dry straw in their trades. The acute stage of the disease is characterized by sudden onset of fever, dyspnea, productive cough and malaise, which resolves in few days. At sub-acute stage after repeated exposure over several months, attacks of breathlessness with dry cough and evening fever usually occur.

PREVENTIVE MEASURES AGAINST OCCUPATIONAL LUNG DISORDERS Substitution: harmless materials can replace harmful materials. For example artificial abrasives in grinding wheels have replaced silica. So also in lagging, manmade mineral fibers (MMMF) have replaced asbestos Ventilation: dust should be controlled at the source through the installation of exhaust ventilation. Wet method: this is the application of water to suppress dust with the main objective of preventing dusts from becoming airborne, for an example, wet drilling of coal or rock. Isolation of a dusty process: A special area can be dedicated to collection of dust produced during processes for example carding rooms in a textile mill.

156

Protection of Individual Worker: Workers engaged in any dusty work should be provided with appropriate and effective respirators and face masks, the masks should also be properly stored and maintained by the users. Medical Supervision: periodic medical examinations including chest radiography should be mandatory for every individual working in a dusty environment.

HEAT-ILLNESSES AND THEIR MANAGEMENT Heat Stroke Clinical Features: Core temperature of 40.5 degrees per Celsius, confusion, loss of appetite, convulsion and coma. Fatal if treatment is delayed. First Aid Treatment: Immediate and rapid cooling by immersion in chilled water with massage or wrapping in wet sheet and vigorous fanning with cool air. Casualty should be taken to hospital for medical attention Preventive Measures: Selection to work in hot industrial jobs should be based on health and physical fitness; gradual exposure of worker to heat for 8-14 days by controlling the amount of work done and degree of exposure.

Heat Cramps Clinical Features: This characterized by painful involuntary contraction of muscles of arms, legs and abdomen. First Aid Treatment: Administer salted fluid by mouth and should be taken to hospital for further treatment. 157

Preventive Measures: Salted fluid should be provided in industrial jobs; adequate salt intake with meals; first aid treatment; the affected worker should take a rest and later seek for medical attention.

Heat Exhaustion Clinical Features: These are fatigue, nausea, headache, and giddiness, clammy and moist skin, rapid pulse (tachycardia) and low blood pressure (hypotension). First Aid Application: Remove to cooler area; administrations of salted fluid by mouth and keep the casualty at rest and seek medical attention. Preventive Measures: Adequate intake of salt with meal plus adequate intake of potable water when at work should be encouraged. Every hypertensive worker should be discouraged from engaging in hot work such as working in bakery or furnace.

Heat Syncope Clinical Features: The casualty is unstable when standing erect with restricted movement leading to fainting First Aid Application: Recovery is rapid when the casualty is moved to a cooler environment. Preventive Measures: The exposed workers should be gradually exposed to heat using a break of specified period depending on the type of industrial jobs and physical fitness of the worker.

Heat Rash 158

Clinical Features: This is characterized by profuse tiny raised vessels (blister like) on affected areas. Pricking sensation is also experienced during exposure to heat. First Aid Treatment: Apply mild dry lotions to the affected areas of the skin and cleaning with sterilized cotton will prevent infection. Preventive Measures: Gradual exposure of worker to heat using a break of specified period depending on the type of work; good personal hygiene should be encouraged; well ventilated and cool sleeping quarters should be provided for workers.

2.1.2 BIOSTATISTICS AS A PART OF PUBLIC HEALTH ADMINISTRATION Biostatistics is the application of mathematical statistics to medical and biological data. The methods are based on hard mathematics but their principle can be easily understood. The paper gives a short overview of the generalized linear models and describes the possibility of their application in medicine. The methods are illustrated by two practical examples. The first medical problem is the effect of intravenous lactate infusion on cerebral blood flow in Alzheimer’s disease. Here a mixed model repeated-measurement ANOVA was used to examine the effect of Na-lactate infusion in time. Using mixed model, the variance-covariance structure of repeated measures can modeled, and missing values can be taken into consideration. The SAS software was applied for calculations. The other medical problem is the investigation of risk factors of respiratory complications in pediatric anesthesia using relative risk regression. Here, strong correlation was found between several independent variables. When the independent variables are correlated, there are problems in the estimation of the regression coefficients. To avoid multicollinearity, the structure of the correlation of the candidate variables used in the multivariate model was first examined by factor analysis; later new artificial variables were formed. The final multivariate model gave us the most important risks factors. Based on the model, children at high risk for preoperative respiratory adverse events could be systematically identified at the preanaesthetic assessment and thus can benefit from a specifically targeted anesthesia management.

159

Statistics may be defined as a body of methods for learning from experience – usually in the form of numbers from many separate measurements displaying individual variations. Due to the fact that many non-numeric concepts, such as male or female, improved or worse, etc. can be described as counts, rates or proportions. The scope of statistical reasoning and methods is surprisingly broad. Nearly all scientific investigators find that their work sometimes presents statistical problems that demand solutions; similarly, nearly all readers of research reports find that the understanding of the reported results of a study requires knowledge of statistical issues and of the way in which the investigators have addressed those issues. One characteristic of medical and biological research is that the examinations result in data generally described by numbers. Biostatistics provides methods that permit a description and summary of such so that consequences may be drawn from them. Biostatistics is an application of mathematical statistics to the evaluation of biological and medical experimental data. It is based on probability theory and mathematical statistics. Bio-statistical methods are widely used in medical research. A scientific paper without such an evaluation is currently almost inconceivable. Moreover, the number of medical papers is increasing very rapidly year by year, while the evaluation of the experiments reported requires increasingly more sensitive methods. Meanwhile, the spreading of up-to-date knowledge is rendered more difficult by the specialization at present going on throughout the medical profession.

Conclusion Medical experiments often result in repeated measures data. Using statistical software without knowing their main properties or using only their default parameters may lead to spurious results. Using only the default parameters simple models are supposed. Using carefully chosen statistical model may improve the quality of statistical evaluation of medical data. Investigation of risk factors of respiratory complications in pediatric anesthesia The medical experiment 160

Preoperative respiratory adverse events (PRAE) remain one of the greatest concerns for the anesthetist. Although some risk factors have been identified there is a lack of information about the relationship between the child’s/family history, the anesthesia management and the incidence of PRAE. We prospectively included 9297 children over a 12-month-period having general anesthesia. Data on the child’s/family medical history of asthma, atop, allergy, upper respiratory tract infection (URI) and passive smoking were collected. Anesthesia management and all PRAEs were recorded. Statistical models and methods Univariate statistics were performed using Mann-Whitney U test and Chi-squared test for continuous and categorical variables, respectively. Multivariate models were developed for preoperative bronchospasm, laryngospasm and all other complications as dependent variables. Having many possible independent candidate variables, model development required variable selection to avoid problems of redundancy and over-specification. The choice of the independent variables in the multivariate models was based on uncorrected p-values of the univariate tests (p0.05) Ho4 (b) There is no significant interaction effect of treatment and gender on the participants attitude to Health Issues. Table 16 shows that the was no significant interaction effects of treatment and gender on the post test attitude scores of participants: F (4,155=1.382; P>0.05)

260

70

60

61.4516 61.3265

50

49.7143

Mean Scores

49.0645 40

30

20

10

0 Experimental

Urban

Peri-Urban

Control

Fig 2: Line graph showing the interaction effects of Treatment and Location on Knowledge of Health Issues The graph in figure 2 was drawn to determine the differences in the mean knowledge scores of urban and peri- urban participants in the experimental and control groups. The graph clearly shows that there is no much difference in the interaction effect of treatment and location with respect to participants knowledge to Health Issues in the experimental and control groups as the graph revealed that urban participants performed slightly better than peri-urban participants in the experimental groups while the same urban participants perform better than the peri-urban samples in the control groups. It is clearly shown that the knowledge mean score of experimental urban participants is slightly higher than the knowledge mean score of the urban and peri-urban control groups. Looking at the figure the difference in the knowledge mean score of the urban experimental and the peri urban control groups is .126(61.452-61.326, this shows that the 261

experimental groups in the urban centers is slightly better by . 126 standard of the mean than the control groups in the peri-urban centers. This is a clear indication that the treatment contributed more to Health Issues knowledge in the peri-urban centers. Again from the graph, the experimental urban groups led by slight standard of mean. The margin seems to be little, however, it is significant. It could be deduced that the CBPHP gave better performance to the urban experimental groups compared to the effect of Direct Teaching Method on the control groups 4.3.5 Ho5: there is no significant interaction of treatment and location on participants (a) knowledge of Health Issues (b) Attitude to Health Issues Table 14 shows that there was no significant interaction effect of treatment and location on the post test knowledge scores of participants: F (4,155=0.20; P>0.05) Ho5 (b) There is no significant interaction effect of treatment and location on attitude of participants to Health Issues. Table 16 shows that there was a significant interaction effect of treatment and location on the post test attitude scores of respondents: (F (4,155(=11.661; P