UNIVERSITY OF IBADAN THIS THESIS SUBMITTED BY Mrs •..Jfoelyn. _OluKemi > _One rinade _ ADEDCYIN WAS ACCEPTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE d e g r e e o f MASTER OF PUBLIC HEALTH IN THE FACULTY OF CLINICAL SCIENCES AND DENTISTRY OF THIS UNIVERSITY THE EFFECTIVE DATE OF THE AWARD IS 28th JULY, 1986 - QL> DATE .”?s e ■pp&psr&t® (wrVERSlTY OF IB AD Ah. UNIVERSIT OF IBADAN LIBRARY AN ASSESSMENT OP THE TRAINING AND SERVICES OF COMMUNITY-BASED DISTRIBUTION (CBD) WORKERS IN OYO STATE BY EVELYN OLUKEMI OKORINADE ADEDOYIN S.R.N., S.C.M., B.Sc. HONS. (HEALTH STUDIES) KALAMAZOO A DISSERTATION PRESENTED IN PARTIAL FULFILMENT OF THE REQUIREMENT OF THE MASTER OF PUBLIC HEALTH (HEALTH EDUCATION) DEGREE OF THE UNIVERSITY OF IBADAN, IBADAN, NIGERIA AT THE DEPARTMENT OF PREVENTIVE AND SOCIAL MEDICINE COLLEGE OF MEDICINE UNIVERSITY OF IBADAN IBADAN, NIGERIA. AUGUST. 198H UNIVERSITY OF IBADAN LIBRARY ii. CERT LPlC/iTIO We certify that thin 'jcjrV was carried out by Mrs. Evelyn Olukemi OmorinadL .inedoyin of the African Regional Health Education Centre, Deportment of Preventive and Social Medicine, University of Ibadan, Superviaors ________~ ________ _________________ J.L. ADENIYI, D.A., H.P.Hf, ^.R.S.H., Dr. P.H. Senior Lecturer/Consult;nj; in Health Education African Regional Health Education Centre Department of Preventive[and Social Medicine College of Medicine- University of Ibadan Ibadan. ^ — — — - - ABE. OMIGHAKIN, mLp .W ., Pli.D. Lecturer ’' African Regional Health Education Centre Department of Preventive ;uid Social Medicine College of Medicine University of Ibadan Ibadan. UNIVERSITY OF IBADAN LIBRARY ill DEDICATION This work is dedicated; To God Almighty, who sustained me throughout the period of this degree programme. To my loving husband, Dr. Michael Adeleke Adedoyin whose encouragement made the successful completion of this programme become a reality and who combined hectic official work with domestic assignments and To my dear children, Toyin, Tayo, Tolu and Temi who endured my absence in the home with love and patience. UNIVERSITY OF IBADAN LIBRARY ABSTRACT The study attempted to assess the effectiveness of the Community Based Distribution (CBD) programme of low-cost Family Planning, Maternal and Child Health Services. This was established in 1979 by the Fertility Research Unit of the Department of Obstetric and Gynaecology, University College Hospital, Ibadan in collaboration with Oyo State Ministry of Healthj the Pathfinder Fund of Boston; and the Centre for Population and Family, Columbia University both in the United States of -America, The C.B.D., an innovative programme, consists of the training and utilization of Traditional Birth Attendants (TBAs) and Voluntary Health Workers (VHWs) to provide Primary Health Care to the door steps of the rural communities who live on the out-ekirts of the main stream of sophisticated health technology. The pilot project site was Akinyele Local Government, a rural area, North of Ibadan with a population of 89,900. It was found that the programme was successful because within two years of its implementation, the population served in­ creased from an initial 89,900 to 238,696 and the number of Zones from one to five. At the request of the Oyo State UNIVERSITY OF IBADAN LIBRARY V Ministry of Health officials, the project was extended t» other Health Zones in Oyo State: Oyo, Oshun, Ife/l'jesha Health Zones,. The study assessed the training of the CBD workers with particular emphasis on the educational components of the training curriculum and also the educational activities of the CBD workers and their impact on their client community. The CBD training curriculum findings indicate that as designed presently, has enough contents which are relevant to the training objectives. However, it will be more useful, if it is developed into a standard training manual with clearly stated objectives, training methodologies and an evaluation instrument which will set an acceptable level of attainment for a trainee to qualify as a CBD worker. In relation to the application of the training, most of the CBD workers to a large extent were found to perform well on what they were taught to do - knowledge *f educational tasks, performance of' educational task and effectiveness of educational task. The response and support of the community members especially the clients, to the educational activities of the CBD workers was found to be positive. UNIVERSITY OF IBADAN LIBRARY vi However, the CBD workers advocate that the government should re—introduce the monthly incentives because the CBD workers in carrying out their activities, incur tangible and intangible cost. UNIVERSITY OF IBADAN LIBRARY vii ACKMOV/LSDGEMEMT The product of this research would not have materialized without the explicit support and assistance of the following people. My foremost and heart-felt thanks go to my Supervisorss Dr. J.D. Adeniyi who initiated the study, whose unflagging assistance and supervision in the process of the research knew no measure and whose positive outlook to problems and ability to succeed in spite of all odds has been sources of inspiration to me. I an also indebted to my other Supervisor, Dr. M.A. Omishakin for his encouragement, guidance and critical review of this work. My gratitude is extended to all the entire members and staff of African Regional Health Education Centre and Department of Preventive and Social Medicine for their assistance. Many thanks go to Mr, W.R. Brieger who willingly loaned me his books for the course and research work. I am most indebted to Professor O.A. Ladipo, Head of Depart­ ment of Obstetric and Gynaecology and Mrs. G.E. Delano, Coordinator of Fertility Research Unit both of University College Hospital, Ibadan for inviting the two supervisors and the researcher to undergo the study of the CBD programme. I say a big thank you to all the staff of the Unit and Dr. E.M. Weiss (representative of the CBD UNIVERSITY OF IBADAN LIBRARY viii Funding Agencies) fcr the cooperation and the enthusiasim shown for the research. They were cf great help and supplied needed informa­ tion freely. My appreciation is extended to all the nursing staff of Community-Based Distribution (CBD) programme in Tonkere and Ifewara Health Centres (Oshun/ljesha Health Zones) fcr their cooperation during the evaluation of the training of CBD workers, that is, first stage of the study. The nursing sisters of CBD programme in Ilora Comprehensive Health Centre (Oyo Health Zone), Mrs. Famosinpe and Sister Ayinde were exceptionally helpful during the second and third stages of the research. They went with me willingly through the ragged roads and inclement weather even after official working hours, to locate all the scattered hamlets and villages where CBD agents lived. You are the pride of our nursing profession! I appreciate and acknowledge the cooperation of all the CBD agents, their clients and the community members interviewed for their cooperation and hospitality during the visits to their villages. I am also grateful to my employer, University of Ilorin Teaching Hospital for financial assistance and my Head of Depart­ ment, Professor 0. Alausa who recommended me for the M.P.H. degree programme UNIVERSITY OF IBADAN LIBRARY ix I ove a huge debt of gratitude to my beloved husband, Mike, whose unrelenting support and unfeigned love, even when the goings were rough, carried me through the period of my study. I appreciate and acknowledge the prayer support and domestic assistance of my Christian friends % Dr. and Mrs. M.A. Afolabi, Chief-Justice and Mrs. T. Oyeyipo, Dr. and Mrs. E.O. Odelowo, Professor and Mrs. Adeoye Adeniyi and a number of others too numerous to mention. To my relatives, church members and nursing colleagues, I say a big thank you for contributing to the successful completion of this degree programme. I give glory and honour to God for His sustaining grace and divine guidance throughout my period of study. Last but not in parenthesis my thanks go to my hardworking typist, Mrs. E.A. Bello UNIVERSITY OF IBADAN LIBRARY X TABLE OF CONTENTS Page TITLE PAGE ............... • • • • • • 0 0 0 i CERTIFICATION • • • • • • 0 0 ii DEDICATION • • • • • • 0 0 0 iii ABSTRACT .......... • • • • • • 0 0 0 iv ACKNOWLEDGEMENT .......... • • • V • • 0 0 0 vii TABLE OF CEMENTS ... v • • 0 0 0 X LIST OF TABLES ............... • • * • • • 0 0*0 xiii LIST OF DIAGRAM ............... • • • • • • 0 0 0 xiv LIST OF APPENDICES • • • • - • 0 0 0 XV CHAPTER ONE: INTRODUCTION • • • A • • 0 0 0 T Background to the Study- • • • • • # 0 0 0 3 Statement of the Problem • • • 0 0 0 0 0 0 11 Justification of the Study • • • 0 0 0 0 0 0 12 The Purpose of the Study • • • 0 0 0 0 0 0 13 The Scope of the Study • • • 0 0 0 0 0 0 13 CHAPTER TWO: LITERATURE REVIEW 0 0 0 0 0 0 15 A. Evaluation • • • 0 0 0 0 0 0 15 B. Training Process • • • 0 0 0 0 0 0 T5 C. Evolution of the Concept of Primary Health Care (PHC) Delivery 0 0 0 23 UNIVERSITY OF IBADAN LIBRARY xi TABLE OF CONTENTS (Continued) Page CHAPTER THREE; THE STUDY 36 Objectives of the Study ... 36 Theoretical and Conceptua.1 Framework 36 Selection of Study Areas ... 38 Study Period ... 39 Study Design ... ... Uo Methodology ... h3 Data Collection Methods ... 1+7 Method of Analysis ... ... 1+9 Limitation of the Study ... 50 CHAPTER FOUR; FINDINGS 53 Stance 1 ; Assessment of the Training of the CBD Workers 53 Stage 2; Assessment of the Educational Activities of the CBD Workers and their Impact on the Client Community 63 Stage 3s Information on Selected Organizational Aspects of CBD Project ... ... 100 CHAPTER FITE; DISCUSSION ON FINDINGS 1Cl Stage 1; Assessment of the Training of the CBD Workers ... ... ... 108 Stage 2; Application of the Training of CBD Workers ... ... ... 116 Stage 3s Information Collected on Organiza­ tional Aspects of CBD Project ... 121 UNIVERSITY OF IBADAN LIBRARY TABLE OF CONTENTS (Continued) Page CHAPTER SIX; CONCLUSIONS AND RECOMMENDATION ... 123 Conclusions ... ... ... ... ... 123 Recommendation ... ... ... ... 125 BIBLIOGRAPHY ... ... ... ... ... 130 APPENDICES ... ............................ 135 UNIVERSITY OF IBADAN LIBRARY xiii._ LIST OF TABLES Page 1. Number of Trained. CBD Workers Per Population in Each Health Zone ... • • • 10 2. Educational Status by Age ... ,,, • • • 59 2a. Age and Sex Distribution of Trainees 60 3. Age Distribution of TBAs and VHWs in Relation to Family Planning Practices 81 k. TBAs’ Methods and Duration of Family 82 Planning Practices ... ... « • • 82 1+a. VHWs’ Methods and Duration of Family Planning Practices ... f.„ t t • 83 5. Types of Services Ever Received by 2l+ Clients Interviewed ... f#, ... 86 6. Family Planning Clients Showing their Ages, Sex, Types Used, Duration of Use and Obstetric History J5 UNIVERSITY OF IBADAN LIBRARY xiv. LIST OP DIAGRAM Page Assessing the Transferahility of Knowledge and okills © o ••• UNIVERSITY OF IBADAN LIBRARY XV, LIST OF APPENDICES Page Community-Based Distribution of Maternal, Child Health and Family Planning Curriculum for Training Programme of Traditional Birth Attendants/Voluntary Health Workers ... ». i Description of Educational Tasks for Each of the Four Areas of Study ... ... .. vi Participation of Trainees at Tonkere During Training Sessions by Sex ... ... .. x Standing irders for Treatments by TBAs/VHWs .. xii Questionnaires for CBD Workers ... .. xiv Questionnaires for CBD Clients ... .. xviii Questionnaires for Supervisor’s ... xix Questionnaires for Community Leaders XX Questionnaires for Director of CBD Project — U.C.H. ... ... ... xxi Questionnaires for Coordinator of CBD Project in State Health Council ... ... xxii UNIVERSITY OF IBADAN LIBRARY CHAPTER ONE INTRODUCTION Nigeria with a population of over 80 million of which 75 per cent live in the rural and suburban areas, is the most popu­ lous black nation in Africa. One of the most significant health care problems in Nigeria, as in other parts of the developing countries is the fact that the provision of health services is in reverse proportion to the population, that is, about 75 per *ant of health services are situated in cities and towns and therefore utilized by about 25 per cent of the populace (Williams and Omishakin, 1983)• Consequently, mobility is continuing in the direction of major cities in search for jobs and better lives. Compounded with these are the serious endemic problems of malaria, regarded as the nation's number one killer, and other major preventable communicable diseases. According to Williams and Omishakin (1983)» the poor rural dwellers face disparities un a number of social and demographic measures as compared to the rest of the population. These disparities, together with poor road conditions and other communication systems, play a major role in determining the health status of the pocr/rural population and their accessibility to existing health services. UNIVERSITY OF IBADAN LIBRARY 2 It is disheartening to note that in Nigeria, like many other developing countries, maternal and infant mortality rates are higher than those in technologically advanced countries. These rates are often considered indices of public health status (Williams and Omishakin, 1983). In developing countries like Nigeria, Gambia and Kenya, infant and maternal mortality as high as 200 per 1,000 live births and 300 per 100,000 births respectively have been recorded (Gamble 1952, Grounds 196U, WHO 1971 * Oduntan and Odunlami 197U). Unfor­ tunately, these children and the women are the most vulnerable groups of the world's population (Ademuwagun et al 1977, Ladipo, O.A., 1985). In view of all these, the World Health Assembly in 1977 decided that the main social target of governments and WHO should be the Attainment by all the peop]e of the world by the year 2000, a level of health that will permit them to lead a socially and economically produc­ tive life. At the International Conference on Primary Health Care (PHC) held in Alma Ata, in 1978, various governments, ('WHO member States) were urged to develop strategies f«r attaining the goal of health for all by the year 2000 A.D. through a health system based on Primary Health Care (PHC). UNIVERSITY OF IBADAN LIBRARY 3 Of the major components of PHC, perhaps one of the most important is the improvement of reproductive health care through a well articulated system that ensures integration of maternal and child health and family planning services (Ladipo, O.A. 1985)• Health programmes that focus on maternal and child health will go a long way to make Health for All by the Year 2000 A.D. a reality. BACKGROUND TO THE STUDY Community-Based Distribution (CBD) Programme Progress towards the goal of "Health for All by the Year 2000" requires new approaches. One of such approaches is the establishment of Community-Based Distribution (CBD) programme of low-cost family planning, maternal and child health services established by the Oyo State Government of Nigeria. The CBD, an innovative programme, consists of the training and utilization of Traditional Birth Attendants (TBAs) and Voluntary Health Workers (VBWs) co provide PHC with minimal day to day reliance on clinics, professional medical personnel, or complex diagnostic screening and record keeping procedures (Population Reports, 1982), UNIVERSITY OF IBADAN LIBRARY 4 This programme ensures active participation and involvement of consumers in the.;delivery of its health services thus implying that health systems arc not regarded as "baskets to accommodate consumer demands." The Oyo State CBD Programme was established in 1979 as one of the strategies to bring health care to the door steps of the rural communities. In 1979» "the Fertility Research Unit of the Department of Obstetric and Gynaecology, Univer­ sity College Hospital (UCJl), Ibadan, under the direction of Professor O.A. Ladipo, in collaboration with Oyo State Ministry of Health; the Pathfinder Fund; and"the Centre for Population and Family Health, Columbia University both in United States of America (U.S.A.) emliacked on the CBD programme. Tne main objective was to demonstrate that village level workers including TBAs could be organized and trained to effectively provide simple health care services. The importance of the CBD programme cannot be over­ emphasized in the sense that the programme acts as a stop­ gap between the urban people who enjoy 75 per cent of the health services .and the disadvantaged rural communities. The programme is also advantageous in the sense that it is easily accessible to them because the services are rendered UNIVERSITY OF IBADAN LIBRARY - 5 - by the community members who live among the people. Moreover, the programme is low cost, the poor/rural community could afford the health services. The CUD programme thus helps to increase the health manpower and provide health care at little or reasonably affordable cost to both health providers and consumers. The pilot project site for the Oyo State CBD programme was Akinyele Local Government, a rural area North of Ibadan with a population of .about 85,900 (Figure 1). There is a clear evidence from preliminary results of the CBD operations research project that the project is expanding and gaining a lot of popularity (Community Based Distribution Project Summary, January, 1981+, Reyes and Jinadu, April 19814-). The project is providing five types of services, namely? - illness treatments (malaria, diarrhoea, cough, worms, anaemia, and wounds) contraceptive disbursements - deliveries - health talks - pre-natal pill disbursement i.e. care of pregnant women UNIVERSITY OF IBADAN LIBRARY frAflp o- ̂ (XjQ A 'tk<2x :̂Cfx!H') '7-jQr\t-S-> ft' Irjt fV c^ , C’ftjb H P ^cly g ^ r (Xx\6 ^fcu.ck-1 AyPA? lf£WMA Aki^YEte (pilot l\v>ê I I ONi^E^ C-&£> H Saclcyucĉ texj CSH £ H CrM R £ . ~ ) UNIVERSITY OF IBADAN LIBRARY ~ X E 6 In Akinyele pilot area alone where 158 CBD workers were trained, a total of 100,730 of such services: illness treatment, family planning, ante-natal care and delivery were rendered between 1982 and 1983 with each CBD worker averaging 27 services per month. Within two years of its operation, the population served has increased from an initial 85,900 to 238,696 and the number of zones from one to five (Table 1). Because the pilot project was very successive in the first two years of its implementation, an expanded programme was initiated at the request of the Ministry of Health officials to satelite sites in 0yo, Oshun, Ife/ljesha Health Zones (Figure l). The number of trained CBD workers per health zone is highlighted in Table 1, Certain unique aspects of the project call for special atten­ tion because just as they constitute its strength, they are also potential sources of weakness. Some aspects which must be considered are that: 1. It is designed to serve already underserved rural communities and to supplement government efforts| 2. It is low-cost5 3. It is served by trained locally recruited volunteers5 i|. It involves community participation? 5. It focuses on some pre-determined priorities such as Oral Rehydration Therapy (ORT), Family Planning and activities of TBAS, UNIVERSITY OF IBADAN LIBRARY 7 6. It enjoys State Government Support; 7. It involves the use of Local/State Government health personnel in supervisory roles over informal traditional health care providers and volunteers. Theoretically a number of issues and problems are posed by a project of this nature. Some of the Issues that need to be addressed includes 1. balancing between cost and quality in a low-cost programme; 2. filling the gap between knowledge and skills acquired by volunteers during training and their actual performance in the field; 3. reconciling project priorities and community needs; i|. ensuring that the training curriculum meets the needs and characteristics of the trainees; 5, sharing of time between routine daily cares -and occupations of volunteers and the CBD duties assigned to them; 6. resolving conflicts between daily routine activi­ ties of volunteers and project demands; UNIVERSITY OF IBADAN LIBRARY 8 7. identifying the most appropriate areas of competence of volunteers; 8. determining the socio-cultural relevance of CBD services and the level of acceptance. Prom these issues, a number of hypothetical assumptions can >e made and tested. For example, it can be hypothesized thats 1. the characteristics of the volunteers (education, age, sex, etc) who are being trained will have implications for the type and quality of services they will bo able to provide in their respective communities; and 2. that the level of acceptance of C.B.D. services Tiy community members will depend to a large degree on the extent to which CBD project priorities are in line with community health priorities and methods are consistent or compatible with their socio-cultural norms and values. Therefore the study was set out to assess the effec­ tiveness of the CBD programme in a number of dimensions in three stages as listed below. UNIVERSITY OF IBADAN LIBRARY 9 Stage 1 Assessing the training of the CBD volunteers in •rd.er to find outj (i) the adequacy of the curriculum contents in relation to training objectives; (2) the appropriateness of the training methods, and (3) the knowledge/skills acquired during training. Stage 2 Assessing the effectiveness of the training that is, to find outs (1) whether the CBD volunteers are performing according to the expectations of the coordinators of the programme; (2) what could hinder effective performance of their educational tasks, and (3) the impact of educational activities in the community being served. Stage 3 To assess the part played, by the Government, the community and the Agency in the management of CBD Project UNIVERSITY OF IBADAN LIBRARY 10 Table 1 Number of Trained CBD Workers Per Population in Bach Health Zone Health Zone Population Trained CBD Workers likinyele 85,900 158 Qyo 25,500 101 Oshan 28,296 100 Ife/ljesha 99,000 101+ Total 238,696 1+63 UNIVERSITY OF IBADAN LIBRARY 11 Statement of the Problem In developing countries, there is lack of awareness of the tremendous benefits derived from evaluation/assessment and particularly assessment of training and its application. In the health sector in particular, because of a number of factors, assessment/evaluation has not been a regular feature of important programmes. These factors include poor record keeping; poor patient compliance; inadequate trained staff; material and facilities that c m facilitate assessment. Also many a time clients are suspicious of the purpose for which information are being collected with the result that either the answers are false or incomplete. The fear of using such information for taxation purposes is also common. This tends to make it difficult to know what impact the programme is making in the community. Whether the programme is useful to justify its continuation or there is a need to modify it or even cancel it usually remains unknown. The afore-mentioned factors could be overcome by a careful planning and determination to make the best of the prevailing circumstances UNIVERSITY OF IBADAN LIBRARY 12 Justification of the Study All programmes in health sectox* need one foxro of evaluation or another because such evaluation will give the authorities an idea of their - 1 of success. Without evaluation/assessment, the continuation of a nrogramme cannot be justified since these programmes consume money, and/or affect the health oi the people. The study is there­ fore justified. The stud:; will help to answer such questions as "Is the programme cost effective? Is the level of training adequate to perform the desired functions? Is there any need to modify the training method and/ox the content of the training? Has the programme influenced +he community? It is only through a careful assessment that these questions can be answered. The answers to these questions and many more, are so crucial to the decision to continue, modify or cancel the programme. H-.-uce, the study is justified. In addition, the sxudy is imperative as a fulfilment of the requirement of the modified sub-contact 1982 of the CBD project between the AT: and. funding agencies. It was spelt out in the contract that there should be a number of special studies focusin . or; the qualitative characteristics of the programme that could answer questions likes UNIVERSITY OF IBADAN LIBRARY 13 "What are the field workers doing1-: How well are they performing thsir roles? W^iat problems do they have? etc* The feedback from such studies, (this study being one of them) will result in corrective actions in programme services.. To this and, the Fertility Research Unit of the Department of Obstetric and Gynaecology, UGH, Ibadan requested two Health Education Specialists and a post-graduate student, the writer, from African Regional Health Education Centre, Department of Preventive and Social Medicine to assess the educational effort of the project. The Purpose of the Stud;y The purpose of this study is: (1) To assess the training activities "of the CBD workers., (2) To assess the .f. nacy of the workers in relation to tin skills acquired and their impact on their client community. The Scene of the Stuciy The study will critically examine and assess the curriculum and the trainin,-. of the CBD volunteers with regard to five areas of services: malaria treatment, diarrhoea/ORT, Family Planning, Pregnancy and Delivery, UNIVERSITY OF IBADAN LIBRARY Ill The study will also assess the CBD workers in relation to: (a) Knowledge cf educational tasks § (b) Performance of educational tasks, and (c) Effectiveness of educational tasks. In addiction, the study will assess the part played by the management, supervisory staff and the community leaders in the implementation of the CBD programme. UNIVERSITY OF IBADAN LIBRARY CHAPTER TWO LITERATURE REVIEW The literature review covers three areas? (a) Evaluation (b) Training \c) Evolution of the Concept of Primary- Health Care (PHC) Delivery Evaluati^n Evaluation and information feedback should be an integral part of any programme be it health or otherwise. Unfor­ tunately. evaluation is an exercise that is rarely carried out in the developing countries or is non existence (Kleczkwoski and Nilsson, 198I4).. This neglect means that little, if any, time or resources are set aside to find out how facilities, staff or personnel, etc. are actually functioning. The lack of suitable siaff, financial and material resources may reduce or prevent evaluation of any programme. This means that mistakes that might have been revealed during evaluation process remains undiscovered, resulting in added expense or wasted resources„ Although it might be impossible to determine the cost of a particular evaluation process, but it might be possible that savings resulting from the.recommendations of the UNIVERSITY OF IBADAN LIBRARY 16 evaluation teams might out-weigh the training operational costs of the teams. The benefit derived from evaluation studies cannot be over emphasized. For example, the result of one evaluation study could affect the legislation and policies at all levels of government administration (Kleczkwoski and Nilsson, I98I4). Therefore evaluation is not an end in itself but a tool whose purpose is to measure the success or other wise of a programme and thereby enable the administrator to do a better job. According to American Medical Association 1961: Evaluation is merely a stepping stone to improvement - a starting point for continued or redirected effort. However, Daniel Stufflebeam* (1973) in relation to evaluation advocated a system analytic view of evaluating a programatic activity at four stages s 1„ The Context Stage which is supposed to answer the question whether there is a need for the training programme; 2. The Input St age which is to answer the question as to the feasibility of the training programme in terms of availability of adequate resources for planning, design, implementation and evaluation5 UNIVERSITY OF IBADAN LIBRARY 17 3. Process Stage which involves a day to day monitoring and analysis of the training activities in order to deter­ mine whether the training programme proceeded as planned. I4. Product Stage which analysis the impact of the training on the trainees (intermediate outcome) as well as the community client system (final outcome). In other words, the product stage is interested in finding out the result of the training programme or its achievements. Green et al (1980) on the other hand see and define evalua­ tion as the comparison of an object of interest against a standard of acceptability. For example, the object of interest in health education, according to Green et al (1980) include the long range goals of improved quality of life or health and social benefit; the activities, methods, materials and programme of health education. They advocated three levels for evaluating a health education programme. These levels ares 1. Process Level: At this level, the standards of acceptability are defined, both professionally and administratively and are derived chiefly by means of concensus among the health education specialists. UNIVERSITY OF IBADAN LIBRARY 1 8 2. Impact Evaluations This refers to the evaluation of the immediate effect of the health programme on knowledge, attitude and behaviour of the client. 3. Outcome Evaluations This deals with the assessment of health practices or behaviours that have been hypothesized to show up over the long term. . Training Process History of Training Training is an age long process. According to Steinmetz (1976), as man invented tools, weapons, clothing, shelter and language, the need for training- became an important ingredient in the match of civilization. The early nan, Steinmetz ascerted, was able to pass to others the knowledge and skills gained in mastering circumstances. The ability to pass on this knowledge end skill was done either by deliberate example, by signs and by words. Through these dex'ices, the development process called training was admi­ nistered and when the message was received by another successfully, we say that learning took place and knowledge or skill was transferred. Training process has improved over decades from the ancient method of deliberate examples to formalized system of training. Trainings that existed and probably still exist include: craft training, factory schools, industrial training association, the UNIVERSITY OF IBADAN LIBRARY 19 job instruction training, management training, etc. Training is not carried out in vaccum. It functions in an environment of policies, procedures, standards and institutional objectives and has intimate relationship to ether strategies of management,, (A Handbook of Health Care Institution, 1970j» For example, establishing performances standards is a prerequisite to any successive training effort. Laying emphasis on how skill and knowledge are transferred in order to prepare the trainee to master a set of job function, five essential processess were identified by Bloom (1956)* 1* Knowledge: This is the simplest class of learning which requires that the trainee should acquire and recall information, ideas, facts and terminology* The primary behaviour required involve memorising and being able to recall information* 2, Comprehension: is the grasping of meaning by relating the new information to prior knowledge or experience* This requires the trainee to re-phrase information in his own words, to provide examples or analogy to interprete the meaning of information,, 3. Analysis and Synthesis are processes of organising or re-organising materials to.achieve a particular pur­ poses Such as simplifying a problem into meaningful UNIVERSITY OF IBADAN LIBRARY 20 p o in ts fo r c la r i t y and examine r e la t io n s h ip betw een them, or p u tt in g p o in ts to g e th e r to form a m eaningful w h »le. These p r o c e sse s req u ire rea so n in g , d is c r im i­ n a t io n , concept form ation , problem s o lv in g and crea ­ t i v e th in k ing# J4. A p p lic a tio n which in p l i e s th e p o ss e s s io n o f knowledge and s k i l l and c o n s i s t s o f th e a b i l i t y to ap p ly them to new s i t u a t io n or to th e s o lu t io n o f a problem . This r eq u ires some a n a ly s is o f th e new problem , s u f f i c i e n t com prehension to id e n t i f y th e knowledge and s k i l l ap p rop ria te to s o lv e th e problem and a ls o a b i l i t y to implement them in a p r a c t ic a l way, 5 . E v a lu a tio n s This p r o c ess r e fe r s to a p p ra is in g th e e x te n t to which a good or d e s ir e d outcome i s b e in g achieved # I t could a ls o r e fe r tc ju dging w hether th e method used i s th e b e s t one a v a i la b le . I t i s a t th e com pletion o f th e se p r o c e s se s , Bloom (1956) con clu d ed , th a t assessm en t fu n c t io n s o f th e system can take over to e v a lu a te th e e f f e c t iv e n e s s o f th e tr a in in g in th e c o n tex t o f th e needs o f th e la r g e r h e a lth sy stem . UNIVERSITY OF IBADAN LIBRARY - 21 Havelock and Havelock 1973 describe a training programme as a system with goals, a division of labour (trainer~trainee), a temporal sequence and a definable set of training activities or experiences, etc. They identified at least nine indicators of a good training design which are described below: 1• Structure: This indicator include consultation with sponsoring communities, setting criteria for selection of trainee, timing, training the trainers and training design. Others are definition of objectives in behavioural terms and sequencing training activities to logically lead to the accomplishment of training objectives.- 2. Relevance: This could be measured in terms of: (a) relevance of training objectives to felt needs of the trainee. (b) relevance of training to the social needs of the communities represented by the trainees. UNIVERSITY OF IBADAN LIBRARY 22 3* Specificity end Generality: Specificity refers to the extent to which different elements of the training which have similar behavioural or operational specifics were identified and discussed together so as avoid misunderstanding. But generality refers to the opportunities afforded the learners to think through as to how a newly acquired skill or experience can be adopted for use in different localities and under different situations. U- Reinforcements This refers to the extent to which the trainer was able to present the new knowledge and skills as beneficial to the trainees* 5. In-Process Evaluation: This is the extent to which the structuring of training activities allow evaluation of programme elements while the training is still going on* 6. Synergy: Refers to the extent to which different inputs or stimuli from different sources converge on one point of discussion during training. I- UNIVERSITY OF IBADAN LIBRARY 23 The sources may be different individualst different media sources such as films, newsprint, folklores demonstrations or actual life experiences when appropriate and feasible. “. Presentation: This refers to how the subject being taught is presented to the trainees to aid assimillation, whether the environment where the training is done in­ appropriate and necessary facilities are adequate. . linkage and Involvement: This is the extent to which opportunities were provided for inter-personal contact both outside and within the training period. 9«- Incentives: This refers to a type of stimulus given te boost the trainees' ego. While Have? rck and Havelock 1973 provided indicators to look for _r order to determine whether a training design is good or bad, Bloom * -5-) provided a framework of how skills and knowledge are trans­ ferred in order to prepare a trainee to master a set of job function. In order to evaluate a training programme, a combination of Bloom's :no opts and those cf Havelock and Havelock will complement each other.- The goal of training is to increase educational knowledge and -Is as well as influence attitudes about educational process Technical Beport Series, 1973). evolution of the Concept of Prim ary realth Care fPHC) Delivery About 80% of the developing world live in the rural areas and it is alarming to find that 75% of these rural dwellers have little UNIVERSITY OF IBADAN LIBRARY 2b or no contact with health technology that relieve their health burden (Newell, 1975)• Health has become an expensive luxury to them! A number of reasons could be attributed to the neglect of the rural dwellers as far as health service coverage is cfncerne^.; (1) Health resources tend to be concentrated in the urban areas which accommodates only 2Q?o of the tftal popula­ tion (Bannernman, 1983)* These facilities are even sf expensive that only the elite and wealthy pe#ple in the cities can afford the specialized services. Furthermore, whereas, the urban masses are easily noticed by health planners, the rural population continue to remain in the shadow because of distance. Thus the planning process continues to be centred in the urban sector with its ease of access to labour, capital, commerce, power supply, and industry not to talk of political pressure. These health facilities absorb a major part of the total health budget. (2) The so called orthodox and conventional health care services devised for the third world population remain culturally unacceptable and economically unobtainable. (3) The number «f professionally trained medical personnel are so few that they could not provide total health coverage t# the populace, for example the ratio physician per person is 1s22,000 (Qjnzruga, 198o)« UNIVERSITY OF IBADAN LIBRARY 25 Put this is a ratio falling short of WHO stated goal for developing countries - 1s 10,000 (Ojaxruga, 1980)-. The shor'age of medical doctors is further aggravated by the poor geographical distribution of the physicians. Most of them flock to urban areas and prefer to practice there. Having recognised this disparity in health service coverage and with less than 15 years to reach the goal of Health For All by the Year 2000 (WEO/UNICMF Alma Ata Declaration, 1978)» positive efforts and measures have been taken to ensure total population coverage of health services. A number of positive measures to ensure total population coverage include the use of Bax- foot doctors in China, Village Medical Helpers in Tanzania and the system of Community Based Distribution of Family Planning with ox without Maternal and Child Health Services (Newell, 1975)* At the Alma Ata Conference, it was stated that Primary Health Care (PHC) is the key to attaining the target of Health For All (SPA) by the year 2000 A.D. Primary Health Care (PHC) is essential health care made universally accessible and affordable to the people or family through community participation. (Alma Ata Declaration, 1978). In practice, however, the application of PHC differ from country to country. In developed country, the approach may be to promote an alternative to the present high cost system of care through programmes such as self-care and in developing UNIVERSITY OF IBADAN LIBRARY 2 6 c o u n tr ie s , th e approach w i l l be concerned w ith the development of a lt e r n a t iv e to the inadequate or none e x is t e n t o f conven tional h e a lth s e r v ic e s a t 'he fro n t l in e l e v e l (WHO 1977)* Newell (1975) id e n t i f ie d th ree a lt e r n a t iv e approaches in which PHC has been s u c c e s s fu lly implemented in develop ing countries s (a ) N ation a l Change (China, Cuba, Tanzania). In th is ca se , th e s ta r t in g p o in t was a n a tio n a l p o l i t i c a l d e c is io n to change the o v e r a ll h e a lth care d e liv e r y system as p art o f the medium and lon g term n a tio n a l g o a l. (b) Ext en sion of the e x is t in g s?/stem (Iran , N iger, Venezuela) a ccep tin g th a t th ere were a la r g e group o f underserved peop le and th at a n a tio n a l e f f o r t was required to provide them with health serv ices-. Key persons in each country considered some o f the a lte r n a t iv e methods used in other co u n tr ies and then evolved a n a t io n a l, in d iv id u a l s o lu t io n . (c ) Local community development approach (Guatemala, In d ia , In d o n esia ). In th is group, there was not only d iffe r e n c e in s c a le but a ls o a d iffe r e n c e in o b je c t iv e . Each lea d er entered h is community w ith UNIVERSITY OF IBADAN LIBRARY 27 the intention of providing a direct health service» No decision were re- at the political or adminis­ trative level to civnge either goal or the social order of the society. Inspite of the differences, weaknesses and strengths, Newell (1975) pointed out that all have shown some degree of success with an indication that health development as part of rural development is possible if one goes about it an acceptable manner. However, Newell concludes that it cannot be an exaggeration to say that countries that started the process of national change by a political process have a clear advan­ tage in speed and coherence. In relation to policy and planning, the translation of PHC concept into action depends on establishment of government policies, preparation of national plan .and the setting of targets and priorities including the establishment of levels of service. The concept of PHC, alining at the improvement of the state of health and the quality of' life, calls for the formation of a comprehensive policy which considers health in UNIVERSITY OF IBADAN LIBRARY 28 in all its dimensions, "philosophical, cultural, cconomic, nutritional, environmental, educational, preventive and curative" (report of a study group, India, 1981). Such policy should encourage the participation of all relevant government ministries, including health ministries. It also implies that such a policy should respond to the needs »f people. The full implementation of this policy into action and the realization *f the goal "Health for All by the Year 2000" would call for the preparation of time-limited programmes, the creation of the needed administrative personnel and provi­ sion of the needed funds on the basis #f priority (Study Group, India, 1981). From the point of view of planning, •bjectives have to be set in a measurable and defined terms, the needs the population determined and the tasks the members the health team defined (Bryant, 1969). In general, policies and plans should ensure that provision is made for health and other agencies to be staffed at various levels so that they are supportive to community-based activities. It should not be imposed on the communities but provide for their improvement in the planning and implementation of activities (King, 1966). UNIVERSITY OF IBADAN LIBRARY 29 Included in the concept of Primary Health Care (PHC) is the community involvement and participation in health care delivery. Mahler (1981) defines community involvement as a process in which health and social awareness go hand in hand and each reinforcing one another. He further states that such involvement requires communities to assume greater responsibilities defining their needs, identifying solution, mobilizing local resources and defining necessary local organisation. This involve­ ment and participation was stressed at the World Assembly so as to provide the needed base for PHC. Newell (1975) agreed with other researchers that a large number of illnesses such as malaria, gastro-enteritis (and distribution of contraceptives, etc.) can either be prevented or remedied by simple measures that can be provided by the community health workers if given proper guidance and training. Moreover, there is a need for community participation in the recruitment, training of community health workers, and for the establishment and maintenance of an effective health care service at the peripheral level (Levin, 1981). The system of community-Based Disxribution (CBD) of health services was reported in Brazil as early as 1973 (Gorosh et al, 1979)* The CBD programme in Brazil was developed by BEMFAM project to extend Family Planning (oral contraceptives) to Brazil rural UNIVERSITY OF IBADAN LIBRARY 30 areas. Brazil has an estimated population of over 100 million (Encyclopedia Britannica 1978)* CBD is a system which utilizes indigenous non medical hut locally trained personnel to render health care. CBD programmes have been implemented in more than 30 developing countries (Bertrand et al, 19814-). CBD of Family Planning has been the commonest health service delivered in most countries. Only a few of the countries have included maternal and child health services ~o their programme (Population Report Series, 1978). Countries with well established CBD programme include Bhailand, Colombia, Sri Lanka, India, the Philippines, Brazil and Egypt (Kleinman, 19fi0). In some countries like Zaire (Bertrant et al, I98I4), CBD programme of Family Planning was integrated with other health services. In the rural areas of the Republic of Zaire (with an estimated population of 36 millron Encyclopedia Britannica, 1978), the programme was combined with the delivery of drugs to combact malaria, intestinal parasites and dehydration from diarrhoea*. It was discovered in Zaire that the integration of the programme with child health services and the promotion of contraceptives as a method of child spacing were believed to be prerequisites to the acceptance of family planning in a society where infant mortality is high and pronatalist attitudes prevail (Bertrand et al 1982+)* UNIVERSITY OF IBADAN LIBRARY 31 Kleinraan (1980) asserted that the usefulness of CBD is not limited by lack of professional skill or lack of physical facili­ ties. I n other words, though the CBD agents are not trained professionally nor are there physical facilities like modern hospitals from where they can operate, they bring health care to the door steps of the rural people. Moreover, CBD programme is cost effective, easy to replicate and in some cases moves towards partial or substantial financial self-sufficiency. Other countries have employed the services of locally trained indigenous people for PHC. In Tanzania with a current estimated population of 21 million (Encyclopaedia Britannioa, 1978) "Village Medical Helpers," gave broad range of preventive and curative services including nutrition and health education. These people were given 3-6 months of training in basi preventive and curative health care. Mobile clinics were supported by rural health centre (Gish, 1975)* In isolated villages of Afghanistan with estimated population of 23 million (Encyclopaedia Britannica, 1978) "Friend of Health" provide health services. The worker is not salaried but lives by selling the pre-packaged drugs for small profit. The effective­ ness of this approach can be questionned but is shown here only to indicate the existence of such possibilities for promoting commu­ nity participation within PHC (Miazad, 1978). UNIVERSITY OF IBADAN LIBRARY - 32 A community centre built by the people in Senegal (a rela­ tively small population estimated at U million, Encyclopaedia Britannica, 1978) "Matrine Rural" was run on a cooperative basis to provide pre and post natal care services to 36 villages within a radious of six kilometres (Ling, 1978). Bhe health centre is staffed by 25 traditional birth attendants called "Matroness." In China with an estimated population of one billion (Encyclopaedia Britannica, 1978) a large part of PHC is given by the "Barefoot doctors" (Harrison, 1980). Here modern and tradi­ tional medicine co—exist in the medical school at national, regional and social levels. With the above examples, it is obvious that requirements for sound PHC can be fulfilled by different approaches depending on variables such as population densities. -• small cr . rge popu­ lation and resources such as human and material. However, according to Stephens (1981). PHC programmes should be characte­ rized by availability, accessibility, acceptability and continuity with adequate facility. His studies in Sweden. U.S.A., U.K. and U.S.S.R. also show that the use of auxiliaries could be successful without any fall in standaird. Because the CBD training is performance-oriented, the trainees were supposed to apply or practice their skills among the community members under conditions an similar as possible UNIVERSITY OF IBADAN LIBRARY 33 to the predetermined job situation. The practice on the field enables the trainees (CBD workers) to relate conceptual knowledge to real practical problem to help develop work skills and to test their own competence and gain self confidence. According to W.H.O. Technical Report 1973? the impact that training has made on programme effectiveness has rarely been eva­ luated, This is partly because it is extremely difficult to measure performance effects that can be attributed solely t* training apart from other variables. Moreover, the report continue, it is also because of a tendency to assess training (learning) merely during and at the end of training without pursuing evalua­ tion beyond that. This study fulfils the conditions laid down by Daniel Stufflebeanfe concepts of evaluating a programatic activity at four stages. Although the answers relating to the context and input stages had been provided by the coordinators of the CBD trainers, the impact and outcome evaluations are the foci on which the assessment of the CBD programme is based. The process stage could be applied to the assessment of the training sessions where there was participant observation by the researcher as to the adequacy of the curriculum contents, appropriateness of training methods and evaluation of knlwledge/ skills acquired during training. UNIVERSITY OF IBADAN LIBRARY 3h The intermediate outcome of the product stage would be related to the post training activities of the CBD workers and their impact on the client community. However, since the existence of CBD programme is of short duration (18 months) the assessment of the final outcome of the product stage would not be relevant for the present study. Green et al, 1980 seem to be concerned with a defined or pre-set standard of acceptability on which the result of an evalua­ tion will be based and compared. But unfortunately, because the CBD programme is innovative, there are no pre-set standard on which the result will be compared. Howbeit, both Green et al 1980 and Stufflebeam et al 1973 are concerned on the impact of the programme on the consumer. However, Daniel Stufflebean's concepts of evaluation was employed in this study. The CBD programme of Oyo State, Nigeria could be said to ful­ fil Stephens' concept of PHC that is characterized by availability, accessibility and acceptability. The health services of the CBD programme are easily available, accessible and acceptable to the community members by the fact that the services are being rendered by CBD volunteers who reside within the community and whose nomina­ tion involved the community members themselves. UNIVERSITY OF IBADAN LIBRARY 35 Although the CBD volunteers in the straight sense may not serve as auxiliaries because of the level of their education and training but in the same way, the proponent of CBD programme envi­ sage that these people could render a number of health services which traditionally belong to the professionals without any fall in standard. UNIVERSITY OF IBADAN LIBRARY CHAPTER THREE THE STUDY The study which is mostly descriptive in nature, is concerned with the assessment of the educational efforts of the Oyo State CBD programme established to augement the inadequacy of the existing health services in the rural areas. 3.1. The Objectives of the Study For the purpose of this study, the following objectives were formulated% 3.1.1. To assess the training of the CBD workers with respect to the adequacy ef the curriculum content, the appropriateness of the methods used, the know­ ledge and skills they acquired during the training. 3.1.2. To assess the performances of the trainees that is, assess how the trainees applied the knowledge and skills acquired during the training %n their client community. 3*1»3* To assess the impact of the trainees that is, their effectiveness on the communities that have bene- fitted from the services of the CBD programme. 3.1.U. To/assess the part played by the officials that is, the agency/community leaders/goverfcment in the management of the CBD programme. 3.2. Theoretical and Conceptual Framework j ....... The assessment of a training programme done as an outsider is, in the opinion of experts be-set with a number of problems. Experts believe that the task of evaluation is made difficult if UNIVERSITY OF IBADAN LIBRARY 37 evaluators were not originally involved in the definition of programme goals and objectives. The evaluator is also at a greater disadvantage if the programme is innovative, in that there may not be a basis or acceptable standard to be used for comparison. In the absence of well developed programme to be used as a standard of acceptability, the evaluator will have to contend wiuh using theoretically derived standards in carrying out his evaluation. Unfortunately, the CBD programme is being evaluated by _n outsider and the above mentioned problems can be expected, Daniel Stufflebeam and in his associates (1973) advocated a system analytic view of evaluating a programmatic activity at 'four stages as described in the literature review. According to the reports of previous research! -s (Wray J, 1985, and Ladipo, O.A., 1985) the answers to the context and input stages had been satisfactorily provided by the coordinators of the training programme prior to its commencement. Joe Wray, 1985 in his study confirmed that the existing health services were accessible to only a small proportion of people in need, therefore a better way of getting services out to the people was needed - through the services of the CBD volunteers established in Oyo State, Nigeria and 120 other countries. The Pathfinder Fund of Boston and Centre for Population and Family Health in Columbia University have ..provided financial assistance in ma.king the training of the CBD volunteers--.a - 37 - UNIVERSITY OF IBADAN LIBRARY 38 reality. Therefore, the evaluation of these two stages were considered outside the scope of this study. In other words, the rationale, •bjectives and the design *f the training were taken as "given-" The logical question which one should ask in a situation like this is - "is this a good training design?" The first condition to be met in answering the questions is to determine what constitutes "a good training design" or what are the indicators «f a good training design. Once again, theoretical standards were resorted to by choosing indicators of a good training design from those indicators enumerated by Havel»ck and Havelock, 1973* 3.3. Selection «f Study Areas Ifewara and TWikere villages in Ijesha and Oshun Local Governmsnt Health Zones of Oyo State were selected for stage one of the study, that is, assessment of the training of CBD workers, because these were the training sites that fell within the study period. For stage 2, six centres, that is, Il«ra, Awe, Akinmorin, Fiditi, Federal and State Farm Settlements in Oyo L«cal Government Health Zones were used for the assessment of the educational activities of the CBD workers and their impact on the client community. Progress of the project in this health zone was necessary because it is an expanded area of the project. UNIVERSITY OF IBADAN LIBRARY 39 Moreover, it is to. only zcr-.c, apart from Akinyele, the pilot project area, that hah completed the three phases of the training .of CSD workers and had commenced health services. Oyo Zone, the stage two study area and Ibadan, the headquarter cf the C3D programme, were used for stage three which involved the interview of Senior Project/Ministry of Health responsible staff, supervisors and community leaders involved in selecting the CED volunteers. 3• h * Study Purled The study was undertaken between May 1̂ 81+ - August, 158$, made up ofs May - July, 198hs - Review of training curriculum and manuals. - Assessment of the training of CED volunteers at Osun and Ljesha Health Zftnes. - Interim Report. - Design of questionnaires. August 1981* - March 1 s - Assessment of the educational activities of the CBD workers and their impact on the client community. In te r im R eport UNIVERSITY OF IBADAN LIBRARY ko A p r il - Hay, 1 985s - I n te r v ie w o f S e n io r P r o je o t /M in is tr y o f H ea lth r e s p o n s ib le s t a f f , sam ple o f s u p e r v iso r s and commu­ n i t y le a d e r s in v o lv e d in s e l e c t i n g th e CBD v o lu n te e r s . - In te r im R ep ort. June - August. 1985s - A n a ly s is o f d a ta - P re lim in a r y r e p o r t . 3*5* Study Resign The CBD programme r e c o g n ise d th e im portant r o le o f h e a lth ed u ca tio n s t r a te g y in g a in in g community accep ta n ce as w e ll as en su r in g a c t iv e p a r t ic ip a t io n and in vo lvem en t on con ­ sumers in th e d e liv e r y o f i t s h e a lth s e r v i c e s . T h e r e fo r e , a number o f e d u c a tio n a l ta s k s were id e n t i f i e d f o r th e CBD w orkers a lo n g s id e th e m ed ica l ( c u r a t iv e and p r e v e n t iv e ) ta s k s in r e s p e c t o f each o f th e f i v e ty p e s o f s e r v ic e s (d ia r r h o e a management, m a la r ia tr e a tm e n t, trea tm en t o f m inor a ilm e n ts , fa m ily p la n n in g , a n te n a ta l and d e l i v e r i e s ) covered in th e CBD programme. F o llo w in g a. rev iew o f th e t r a in in g cu rricu lum (A ppendix A ), th e e d u c a tio n a l a c t i v i t i e s to be perform ed by th e CBD w orkers under each typ e o f s e r v ic e was e x tr a c te d from th e cu rricu lu m and are d e sc r ib e d in (A ppendix D ). * UNIVERSITY OF IBADAN LIBRARY According to the programme plan, the CBD trainees were expected to? (i) Receive training in the performance of their educational tasks, (ii) Acquire proper and adequate knowledge and skills during the training? and (iii) Apply the acquired knowledge and skills in their respective village communities covered by the CBD programme (Diagram 1) .. These three objectives of the training programme provided three main stages for assessing the effectiveness of educational efforts of the CBD workers. These weres Stage 1 An assessment of the educational component of the CBD training programme with particular reference tos (i) the adequacy and relevance of educational content or specific educational tasks to the needs of the CBD trainees. (ii) the adequacy of the preparation of the trainers to effectively transfer needed knowledge and skills to the CBD trainees for an effective performance of their educational task. UNIVERSITY OF IBADAN LIBRARY 1+2 - Stage 2 An assessment of how appropriate and efficiently the CBD workers have utilized the knowledge and skills acquired during their training and how these were being reflected in the types educational activities which they carried out in their respective communities. And als% assessing the behavioural •utcome of educational activities of the trainees fr#m the level of impact on the client community (Diagram 1). These involveds (i) describing how the trainees perceived «r defined their educational tasks and r*les; (ii) identifying the points of educational contact between CBD workers and their client communities that is, What. When, How, and t* Whom health education was given5 (iii) assessing the significant characteristics of the CBD workers (TBAs versus VHWs status, age, sex, literacy, relative community status) and their relationship to the educational effectiveness, (iv) finding out if previously treated jr served clients have learned anything new related to the management of health problems covered under each of the five services provided by the CBD workers; UNIVERSITY OF IBADAN LIBRARY 1+3 (v) finding the extent to which newly acquired health knowledge and practices of clients have resulted from the educational efforts of the CBD workers -•r from other sources. Stage 3 This part of the study was to find the part played by the management, supervisory staff and community leaders (involved in selecting the volunteer workers) on selected organizational and implementation aspects of CbD project. 3.6. Methodology Stage 1i The CBD training programme was carried 5#ut in three phases. Phase 1 is a basic training in simple anatomy and physiology with emphasis <#n the female reproductive system, personal hygiene, care^f the haby and treatment of common diseases and minor ailments. After the training, participants were given a kit containing drugs including syrups; tablets such as anti—malarials, anti-histamines5 dressing, g^ntracep— tivesj (oral pills, condoms, foam tablets and delivery equipment given only to TBAs). In phases II and III - trainees received instructions.in family planning, immunization, registration of vital data, control of endemic communicable diseases (especially those that are associated with poor standard jf personal hygiene UNIVERSITY OF IBADAN LIBRARY and en viron m en ta l s a n i t a t io n ) , f i r s t a id , p r e v e n tio n o f home a c c id e n ts , record k e ep in g and th e u se o f r e f e r r a l s . Phase I l a s t e d th r e e weeks w h ile phases I I and I I I combined la s t e d one w eek. E v a lu a tio n o f p h ases I I and I I I was done in T'onkere - a v i l l a g e lo c a t e d ‘JO km. South e a s t o f Ibadan betw een ipth and 8 th * o f June, 198U w h ile th a t o f phase I was c a r r ie d out in Ifew ara (a n o th er v i l l a g e lo c a t e d abdut 130 km. S ou th - e a s t o f Ibadan) but w ith a n o th er group from June 18th t o J u ly 6th , 1 9 8 U. Twenty (2 0 ) t r a in e e s (10 TBAs and 10 VHWs) and two t r a in e r s p a r t ic ip a t e d in th e Tonkere p h ases I I and I I I t r a in in g , tw en ty s i x t r a in e e s ( 1 7 TBAs and 9 VHWs) and th r e e t r a in e r s p a r t ic ip a t e d in th e Ifew ara phase I t r a in in g . A l l th e t r a in e r s had r e c e iv e d t r a in in g prifcr to t h e ir p a r t ic ip a t io n in th e t r a in in g o f CBD w ork ers. S tag e 2: The a ssessm en t o f tr a in e e s ' perform ance and im pact on t h e ir c l i e n t community was c a r r ie d out in Oyo Zone one o f th e expanded a rea s o f th e CBD programme. Oyo Zone c o n s i s t s o f s i x c e n tr e s s Awe, Akxnmorin, I lo r a , F i d i t i , S ta te and F ed era l Farm S e t t le m e n ts . The CBD su p e r v iso r s based in I lo r a were in v i t e d to h e lp th e in v e s t ig a t o r lo c a t e th e random ly s e le c t e d CBD w orkers f o r in te r v ie w in t h e ir s c a t t e r e d h am lets and UNIVERSITY OF IBADAN LIBRARY villages belonging to the catchment areas of the six centres. Selection of the CBD \TOrkers was designed to ascertain knowledge of educational tasks, educational performance, effectiveness of educational tasks; "strengths" and "weaknesses" of TEAs and VHWs in performing their educational tasks. To assess the impact of the workers' educational activities some community members who benefitted from the services of the CBD volunteers were also selected for interview. Stage 3 j The methodology used here involves collecting information in relation to: (a) Selection of CED workers and supervisors. (b) Organizational aspects of the project. (c) Perceived strengths and weaknesses of the project (d) Suggestions for improvement. Eight officials representing various interest groups of the programme were to be interviewed to collect informa­ tions on the above mentioned aspects of the project. UNIVERSITY OF IBADAN LIBRARY Diagram 1 Assessing the Transferability of Knowledge and Skills Evaluation Flow of Techniques Levels Interface Communication . , TBAs --TEA 1. Training the Impacting Trainers Trainer trainers i VHWs --- VHW TEA TBA- 2. Curriculum Acquiring Trainers Trainer VHW VHW - nant water around, it was observed that most of the community members who process "gari" had stagnant water from their cassava fermentation* Even though only five of the workers mentioned that the use of mosquito nets, mosquito proof windows and doors would prevent mosquito bites (among other methods of prevention) UNIVERSITY OF IBADAN LIBRARY 76 in the house, the high cost of these items will not allow the community members including the CBD workers themselves to subscribe to any of the above items. 3. Family Planning Of the 2h CBD workers interviewed, 22 (91*6%) of them are promoting family planning actively (discussing and dispensing its drugs). The other two, a VEW and a TBA because of their secondary infertility are silent about it unless closs relatives inquire about .it as prospective acceptors. Story telling and discussion are common methods that most workers employ to introduce family planning to prospec­ tive acceptors on individual basis and usually during treatment or home visit. An example of stories used by CBD workers to introduce family planning is illustrated belows "Two couples, A and B got married about the same time. Couple A spaced their children and had few - 3» They were able to feed them well and educate them to Universitj'- level. The three children eventually became important and responsible people in their neighbourhood. Couple B, who did not space their children had many - seven. Because they are many, their parents could not educate all of them. Moreso, because of inflation and dwindling Nigerian's economic situation, UNIVERSITY OF IBADAN LIBRARY 77 the most echicated among the children only had three years of secondary education before withdrawal because of funds. Couple B subsequently learnt of the achieve­ ments of couple A's children and felt very unhappy about their own plight, so be wise friend!" A TBA confessed that she only discussed the topic if and when clients see any of the contraceptive methods in her kit during her rounds and inquire about it out of curimosity. The VHWs find it easier to talk about family planning to their male clients first, on the ground that it is unethical in Yoruba culture to approach another man's wife on the issue (people might think he is trying to start a sexual relation with her or trying to make her promiscuous). The TBAs too prefer to talk about family planning to their female counterparts. It was observed that out of the 12 VHW workers inter­ viewed, ten (83.3%) have used or presently -using one form of contraceptive devices, one is practising abstinence and the other one is "silent" (Table 3) because of secondary inferti­ lity. All of the 10 acceptors are using modern family methods (i.e. "pills," foam tablets and condom) Table 1*. UNIVERSITY OF IBADAN LIBRARY 78 Of the 12 TBAs interviewed, half of them have used or presently using family planning devices, four are practising abstinence while two are non acceptors because of secondary infertility (Table 3)* Abstinence as a method of family planning is more common among the females than the male (Table 3)« CBD services commenced in Oyo Zone about 18 months ago, so all the acceptors within this time are "new acceptors." Fifteen of the CBD workers (5 TBAs and 10VHWs) are modern family planning acceptors (Tables U and I), a). Ten of them accepted after receiving the CBD training while the other five accepted before the CBD services commenced. Three of the acceptors stopped for various reasons; one of the CBD (VEW) family planning acceptors stopped because the method employed (foam tablets) failed - that is wife became pregnant (Table !|a). Another one (TBA) stopped because she lost her 2 year old (last) child and would want another child right away. (Table 4). The third lady had her I.U.D. removed (which she had before the CBD training) because she lost her husband and would not want to re-marry or have any other sexual partner (Table I4). It was of interest to note that half of the VHWs (family planning acceptors) use condoms on their girl friends UNIVERSITY OF IBADAN LIBRARY 79 irrespective of whether their wives are family planning acceptors or non-acceptors (Table lj.a). Even though one of the meanings of family planning is helping infertile people to he fertile (as taught during the CBD training) none of the three CBD workers (2 TBAs and 1VHW) detected to have secondary infertility sought for help from the trainers in Oyo Zone. One would wonder why the trainees concerned did not avail themselves of the opportunity. It was found that two of these sub-fertile workers - (A TBA and VHW) are using native medicine for their infertility while another TBA, though has a living child is receiving treatment in Ogbomosho Baptist Hospital about 50 km. away. The two CBD workers in question confessed that it is rather difficult for them to promote family planning education since they have not got any living issue of theirs. Moreover, people will blame their unfortunate condition on the promotion of family planning. k» Ante-natal Care and Delivery This aspect of the training concerns only the TBAs even though both the TBAs and VHWs received the lectures together. Howbeit, it was gathered that if there is a labour case where there is no TBA, the VIM will remain with the labour case for observation until the TBA (usually from the near by area) UNIVERSITY OF IBADAN LIBRARY 80 arrives. Of the 12 TBAs interviewed, only 5> of them (about l\2%) have taken at least one delivery,, However, most of them said that the mothers usually call on them (TBAs) only after the babies had been delivered unassisted. Even though they did not take such deliveries, they usually give post-natal cares such as bathing the babies, cleaning the mother up, and making sure that both the babies and the mothers are comfortable before departure. Follow-up visits are usually carried out too. One of the "practising" TBAs recollected that she had taken over 20 deliveries since she has had the training. One was not sure whether she had been taking deliveries before she went for CBD training. Among the CBD workers interviewed, she was the only TBA who confessed that CBD work takes too much of her time. She said that at times she had to be with a labour case throughout the night and had to check cases up regularly at her own expense irrespective of distance. If she has had so many deliveries, no wonder she is complaining of coo much time being spent on CBD work and wanting to be remunerated. She commented, "I hardly have time to do my own thing." UNIVERSITY OF IBADAN LIBRARY 81 TABLE 3 Age Distribution of TBAs o,nd VBWs in Relation to Family Planning Practices Acceptors Abstinence Non-Acceptor ̂ 0 (Secondary Infertility) Aange Total TBA VHW TBA VHW TBA VHW 25 - 29 1 1 2 - - - k 30 - 34 - - 1 - - - 1 35 - 39 2 2 1 - 2 1 8 2 3 - - - - 5 bS - b9 1 1 1 3 50 - $b - - - - - - - 55 - 59 - 1 - - - - 1 60 and above Total 6 10 h 1 2 1 2b UN 0IV 1ER £SITY OF IBADAN LIBRARY 82 TABLE li T3a s 1 Methods and juration Family Planning; Practices Age Types Duration 1+0 Traditional Ring 5 years 1+5 1. U. D. 10 years 35 I. U. D. (removed after spouses death) 3 years 35 I. U. Do 3 years 1+5 I. TJ. D, 6 years 25 Pills (stopped after child's death) 1 month 25 Abstinence ill months 32 Abstinence 18 months 25 Abstinence 1 year 38 ++bstinencp 2 years ______ ___ i UNIVERSITY OF IBADAN LIBRARY 83 TABLE Ua YHWs1 Methods and Duration of Family Planning Practices Age Types Duration h2 Condom (on girl friends) 6 months Li 1 Condom (on girl friends) 6 months 55 Pills (by wife) 1 year 6u Condom on girl friends 8 months bo Pills (by wife) 6 months 35 Condom (on girl friends) 1 year 35 Foam Tablets (by wife) - failed 8 months U6 Condom on girl friends 6 months 6o Pills by wife 2 months 28 Condom on girl friends 5 months U5 Abstinence 2 years 36 Non acceptor secondary infertility 5 years UNIVERSITY OF IBADAN LIBRARY Effectiveness of Educational Task of CBD Workers This aspect of the report deals with how effective the CBD workers applied the acquired knowledge and skills to their client communities. Of the 2k clients that were interviewed, 11-of them were for family planning, 7 for malaria, 3 for delivery and 3 for diarrhoea/ORT cases (Table 5). During the earlier part of the study, there were no family planning acceptors interviewed as clients, ^ince the CBD workers selected their clients (by themselves) to be interviewed, it was difficult to say whether the family planning acceptors refused to be selected for interview (for fear of being "detected openly") or it was just by chance that they were not presented for interview. Subsequently, the CBD workers were persuaded to "search'lfor and select for interviews cases of family planning (both acceptors and non acceptors). As a result, more cases cf family pi arming than maternal and child health cases were interviewed as recorded in Table It was observed that the CBD workers are well accepted by the villagers Randall and Adekola (April, 15*83)« UNIVERSITY OF IBADAN LIBRARY 85 They are better equiped to render PEG to the community members than health personnel in static clinics because the former are part and parcel of their client community. Due to their invol­ vement and participation in the health care services, the CBD workers were found to be commited to the consumers' requests. Since they live in the community, they could identify with the community members freely, attend to their health problems promptly and ensure confidentiality where need be. As one client put it, "their presence here has saved us from running round to find transport to take sick people to the cities for treatment especially during the night." They were found to be respected individuals and perceived as nurses, doctors or health workers. At the same time, both the villagers and the workers have high regard for the supervisors and the University College Hospital (UCH) Family Planning staff. They regard them as "our people from the centre or UCH." Sven though none of the workers or villagers had seen the investigator before, warm reception was given as soon as they learnt (from the health sister who accompanied the investigator) that she is from UCH. UNIVERSITY OF IBADAN LIBRARY 86 liB L E 6 Types of Services ever Received By 2ii Clients Interviewed Services Received No. of Clients 1. Family Planning : 11 (10 acceptors. 1 non-acceptor) 2. Malaria treatment 7 3. Diarrhoea treatment 3 k . Delivery 3 Total 21+ UNIVERSITY OF IBADAN LIBRARY 87 They appreciated the investigator's visit and were very generous and hospitable in all the villages visited* This type of gesture is usually bestored to people they know are connected with CBD programme. This is not unconnected with the appreciation of citing the project in their area for everybody's advantage* All the seven patients treated for malaria remem­ bered that they were treated with medications called "aporo iba" and "tonic" that is Nivaquine and iron tablets. The minimum number of days (remembered by the clients) for taking the anti-malaria regimen was two days. Three of the clients confessed that they never completed the anti-malaria regimen once they felt better. The left­ over medications were usually kept for future use especially when there is a shortage of such drugs from the workers. The other four clients agreed that they completed the medication even if they got better because they wore instructed to do so by the workers so that the malaria would not recur within a short time. Most of the clients interviewed agreed that there were medicine hawkers around but very few have bought UNIVERSITY OF IBADAN LIBRARY 88 medications from them since the existence of the CBD workers especially because the latter is low-cost and affordable by most people. Of the seven patients treated for malaria, five of them were adults, one school child and an infant. The parents of the school child and the infants were inter­ viewed on behalf of their children. Five of the patients (7 1.U3%) treated for malaria remembered being health educated on environmental sanitation to prevent and reduce the incidence of malaria attack. Examples given includes cutting bushes around, disallowing stagnant water around, making the gutters clean thus allowing free flowing of water, etc. One of the patients was advised on improve­ ment of agricultural production to boost food production and three were advised to consider family planning. One of the clients whose child was treated for malaria and who was advised to consider the use of family planning confessed that she would not buy the idea because, according to her, she does not get pregnant "easily”. There is usually a gap of about three years or four years before another pregnancy would come. This particular woman from Ekewa village is 38 years old with three UNIVERSITY OF IBADAN LIBRARY 89 children. It would appear that the CBD workers do not inform their clients that family planning could help people with infertility ar well and this might Tie true of this client. The CBD worker could have referred that client *?■ UCH family planning unit for further investi­ gation although it could not be ascertained whether the client presented her problem seriously t» the CBD worker. ?h*>ably the CED workers were n#t taught how t# handle such a case - secondary infertility# The three mothers whose deliveries were taken agreed that they could have delivered their babies in the centre if their labour had started during the day. . • All o£ them had their babies between 3*0#-' a.m. and Ss#p a.m. Although all of these mothers agreed that they were advised on personal and environmental hygiene and also op che care of the babies and their feeding utensils, this advice was not taken to as observed during the visit to the clients homes. One particular client who is semi-illiterate and a civil servant (gov£*nment poultry attendant) was observed tc be dirty environmentally. She was visited at abofft 10.00 a.m. ft and by then her surrounding had n rt W e n swei^. UNIVERSITY OF IBADAN LIBRARY 90 Another mother from Aba Elesu was observed to be dirty both personally and environmentally. She was visited at about 12.50 noon and none ox her tw«-■children had had a bath including the mother herself. Her apartment to*.had n*t been swept at the time of visit. N* wonder the baby had septic spats all over his head. She agreed that she was advised to boil her baby's drinking water but because her custom forbids th use of hot water, she did not take to the advice rather, she adds allum to the water. The same woman confessed that she was advised to consider family planning but because she is ycung (25 years) and has only had two children, she c*uld not buy the idea yet,. The clients (one adult and two infants) whe--were treated for diarrhoea remembered that they were treated with a powdered form of medication mixed with boiled water and called !,ogun idag'be" (anti-diarrhoea). They were all advised on personal and environmental sanitati*n- t*>prevent further attach of diarrhoea. None of them was taught to prepare the ORT but were visited daily in order t* -prepa,re a fresh ORT. The oralyte was said teobe effective as all the cases treated recovered within three days of use UNIVERSITY OF IBADAN LIBRARY 91 Family planning education is likely to be accepted through the CBD workers because the prospective acceptors are likely to trust and confide in people they are familiar with (ensuring not being exposed) than go to trained health professionals. Some of the acceptors interviewed confessed that they had heard about family planning through the mass media but hesitated to buy the idea because they could not undergo the rigors and protocols of hospital system. Others said that they could be "detected" by relatives in the clinics or health centres. But, then availability of the workers at their door steps has motivated them to subscribe to family planning. Moreover, the family planning acceptors could have their contraceptives reimbursed at anytime without having to wait for family planning clinic days in the hospital setting. Peoples' attitudes towards family planning is rather negative among the fairly young (30 years and under, and who have had less than five children. For example, one of the delivered mothers interviewed confessed that she was advised on family planning but because she is "young" (25 years old) and has only two children, she I UNIVERSITY OF IBADAN LIBRARY 92 could not buy the idea yet. Another client from Jobele although has had $ children but young (25 years) objected to family planning on the ground that because she is the only surviving child of the parents, there was pressure on her to have more children as the mother is prepared to take care of them. It was noticed that she had the five (5) children within the space of 5 years that she was married but none of the children, except the one delivered at the time of the visit, live with her. Since the mother has taken the burden of child rearing from her, she is left to Just "donate" them to be reared by somebody else. No wonder her negative attitude towards family planning. The older clients, 35 years and above and who have had more than 5 children did not seem to object ̂ family planning. Most of the male clients interviewed would subscribe to family planning to prevent pregnancies arising from extra-marital relations and also as a protection from contacting sexually transmitted diseases (STD). Contacting such a disease will not augur well to them if their wives got to know about it. Moreover, most of the men will not allow their own wives to use contraception for fear that they may became promiscuous. UNIVERSITY OF IBADAN LIBRARY 93 The older women 35 years and above would use contraception to postpone the birth of their next child. It was observed that a few of the women have the superstitious belief that if women stop the procration of children purposely, what is left unborn will cause such a woman to be obese! God who gives and allows the children to be born will provide the means to cater for them! Of the eleven prospective family planning clients, ten of them were acceptors and one, a non-acceptor is the wife of a VilW. She was interviewed as a non-acceptor because she had earlier turned down her husband's advice on the use of a con­ traceptive. She did not go to the CBD worker for "service" but the CBD agent went to advertise family planning service to her. She refused on the ground that she is too young (30 years old) and that her child who is 2 years old is still breadt feeding. It was observed that she has had six deli­ veries but five children alive. At this point, the investi­ gator explained to her other advantages and use of family planning at the end of which she agreed that she would consider the issue but would prefer to go through the TBA in her village. The TBA in question was hinted about this issue before the investigator's departure. Seven of the ten family planning acceptors (clients interviewed) were on pills UNIVERSITY OF IBADAN LIBRARY 9k (representing about 70%), one on foam tablets and the other two on condoms (See Table 6). The minimum length of time of usage was I4 months and the maximum one year. This shows that acceptance of family planning took off about six months after the CBD training. The training was conducted about eighteen months ago. The minimum number of pregnancies each family planning acceptor had, was six and the maximum eleven. The number of children alive of any of them is four while the maximum seven. The age distribution of the acceptors was 30 - 60 years (see Table 6). These findings seemed to confirm the peoples' saying that family planning should be directed to and encouraged among those with many children and middle age. Wo wonder the woman from Aba Elesu who was delivered by a TEA refused to consider because she has only had two children and besides she was "young" 25 years old. Another woman (a VHW’s wife) discussed earlier refuse accepx.'ng family planning because she is young, 3^ years though she has had five children alive*. It was observed that the youngest of the family planning acceptors interviewed was about 30 years old who has had six deliveries? five children alive and one dead* UNIVERSITY OF IBADAN LIBRARY 95 TABLE 6 Family Planning Clients Showing their Ages. Sex. 'IVpes Used. Duration of Use and Obstetric History Age Sex Obstetric History Type Duration F Gravida 7> Parity 6, 1 abortion, 1+5 2 died, n alive Pill 5 months 35 F Gravida 8, Parity 8, 1 died, 7 alive Pill 5 months F Gravida 8, Parity 8, 3 died, 35 5 alive Pill 8 montlfe l+o F Gravida 9> Parity r{9 2 abor«* tions, 1 died, 6 alive Pill n months F Gravida 6, Parity 6, 1 died 33 5 alive Pill 1 year 50 M Not Applicable Condom 9 months 6o M Not Applicable Condom 1 year no F Gravida 8, Parity 8, 2 died, Foam 6 alive Tablets 1 year no F Gravida 11, Parity 9, 2 abor­ tions, 3 died, 6 alive Pill n months l+o F Gravida 8, Parity 6, 2 abor­ tions, 6 alive I.U.D. 6 months 30 F Gravida 6, Parity 6, 1 died, 5 alive Non Acceptor UNIVERSITY OF IBADAN LIBRARY 96 TEA Versus VHW Most family planning- acceptors employ modern contracep­ tives instead of the traditional methods. Family planning is not a topic easily talked about in this area. Its communication between a TEA and a male client on one hand c.nd a VHW with a female client on the other hand is very difficult. However, TEA communicates very well with female c?ients and also VHW relates well to male clients. Most of the men interviewed (80%) said that they use contraception to prevent pregnancies from arising out of their extra-marital relations. All the male clients inter­ viewed confirmed the earlier report that an important reason for husbands objecting to their wives' use of contraception is the fear of their wives becoming "promiscuous." The VHws are among the early acceptors of family planning, while one third of the TEAs are non-users. Pill tablets were popular among female acceptors and condom among the male acceptors. This corresponds with Reyes and Jinadu * s Finding (198I4)» UNIVERSITY OF IBADAN LIBRARY 9 7 Promoting Family Planning Acceptance It is obvious that the TBAs and VHWs are conscientiously and successfully fulfiling a need in cne Oyo Zone by providing family planning education services. These services have been useful to the CBD workers themselves as 15 out of 2b CBD workers (62.5%)are modern family planning acceptors,(Tables Ij. and ija). Of these 15 acceptors, 10 of rhem are new acceptors (66.7%) that is acceptance since the inception of CBD services, Tne active CBD worker, as far as promotion of family planning is concerned, can create enough awareness and motivation among his or her immediate contacts or peer groups to recruit individuals or couples into family planning. His influence on friends and neigh­ bourhood groups will have a "multiplying effect," thus bringing more people into family planning. TEA workers can also dispel incorrect notions about family planning such as wrong belief chat people who have used the "pill" might find it difficult to become preginnt subsequently (Kleinman, R.L., 1980). Nevertheless, it is imperative to be cognizant of the fact that a family planning education or any health information may not necessarily lead to a desired action. In most cases, the consumer receives and interpretes the health information according to his needs and desires (Knutson 19^5)• This was the situation observed UNIVERSITY OF IBADAN LIBRARY 98 during the study among some CBD workers/clients. The limitations identified against family planning acceptance are highlighted below and the case studies illustrate examples of the limitations; (1) Parental Pressure on an only child Case Is Woman. Age 25. with 9 children At Jobele village in Fiditi centre, a TBA took the writer to one of her clients who had just delivered a baby. The said delivery was taken by this TBA# The new mother confirmed that she has had five children, she is 25 years and has been married for five years. Asked why she is not prac­ tising family planning, she said that she is the only daughter and child of her parents and consequently, she is under constant pressure to have more children. One might hypothesize that family planning education may not achieve the desired goal in the case of this woman. (2) Personal experience of childlessness by the TBA resulting in lack of motivation to promote family planning Case II: Woman (CBD Worker) 38 years, no children Family planning is integrated into the CBD services and is promoted by the CBD workers (Tills and VHWs), often through their own use or by members of their families. One of the TBAs has been married for 17 years but no living issue of her UNIVERSITY OF IBADAN LIBRARY 99 own. She said that it is rather difficult for her to promote family planning since she has not got an issue of hers. She suspects that people think she is using one of the family planning devices and this may he responsible for her problem. (3) Competition among wives for the greatest number of children (especially male children in a polygamous setting Case Ills Man CEP Worker. )-i3 Years. 27 Children A VHtf with 5 wives and 27 children was interviewed.. His first 3 wives are family planning acceptors (oral contra­ ceptives). However, the other two junior wives bluntly refused to subscribe to any form of family planning because they want to have their own children like the VEW's senior wives UNIVERSITY OF IBADAN LIBRARY 100 Stage 3s Information on Selected Organizational Aspects of CBD Project from Management, Supervisory Staff and Community Leaders The findings described hero pertain only to the selected organizational and implementation aspects of CBD programme. (a) Selection of CBD Agents and Supervisors This involves the criteria used in the selection of the TBAs, VHWs, and supervisors including their job description.- The criteria used for the selection of the TBAs and VBWs with their job description were jointly discussed and agreed by the funding agencies, the UCH staff from Fertility Research Unit, the supervisors and the community leaders of the village involved^ Following are the criteria used: (i) The trainees should reside in the area they are to operate in. (ii) The personal qualities should include honesty, willingness and interest to do volunteer work and respected member of the community. (iii) Those chosen need not be literate since Yoruba, the local language was to be the medium of instruction for the training* (iv) Equal geographic representation is needed to ensure adequate population coverage* UNIVERSITY OF IBADAN LIBRARY 101 (v) Two-thirds of the trainees were to he female TBAs while the other cne-third were to be male VHWs. The CBD agents were to render primary health care with particular emphasis on malaria treatment, Diarrhoea/Oral Rehydration Therapy, Pregnancy, Delivery and Family Planning to members of the community according to their standing orders in the areas assigned to them. The criteria used in selecting the local and State government field supervisors including their job description were agreed upon by the Ministry of Health staff, the funding agencies and the staff of the Fertility Research Unit. They are as followss (i) Most of the health workers selected were already in the Health Centres as government employees. However, a few hardworking health staff were deployed from their primary working places to the CBD programme. (ii) Irrespective of where such people were working before selection, they were to be responsible and trustworthy people with interest in rural health services. UNIVERSITY OF IBADAN LIBRARY 1 0 2 (iii) Howbeit, the Local Government Authorities were imployed not to transfer their employees working as supervisors for continuity and stability pur­ poses. The field supervisors are to dispense drugs to the CBD workers, conduct monthly meetings, give refresher courses and supervise their work on the field by conducting home visits with the workers, (b) Organisational Aspects of the Pro.iect This involves the selection of the pilot project area and the integration of the project into the existing health services at the Local and State levels. The Oyo State Health Council was said not to be involved in the selection of the pilot area so the staff interviewed were unaware of the criteria used. However, from the UCH point of view (funding agencies and staff of Fertility Research Unit), the criteria used include: (i) Akinyele Local Government was said to be a virgin territory where no related research had been carried out before. (ii) Its proximity to Ibadan, the Headquarter of the project will ensure easy supervision. UNIVERSITY OF IBADAN LIBRARY 103 ( m ) The Deputy Director of the project from U.C.H. being Secretary to the Midwives1 Association (Oyo State Branch) was able to detect the midwives interest in Family Planning, which is an aspect of CBD. According to the State Health Council staff, the project has been integrated into the existing health services both at the Local and State levels by incorporating all the four health zones in the project. At least, one Local Government in the health zones has the CBD project. In addition, the existing health centres manned by the Local Government staff form referral centres for the CBD agents thus making use of the staff and the facilities of the Local Government. (c) Perceived Benefits ani Shortcomings of the Project This relates to the strengths and weaknesses of the project. In relation to the strengths, the following were highlighted as beneficial both to individuals and to the group or community as a whole, (i) To the senior officials, the programme is both unique and the only option for extending health services to the grass root. UNIVERSITY OF IBADAN LIBRARY 101+ (ii) To the supervisors, the programme has been parti­ cularly useful in that they felt that the programme has brought them closer to the rural people more than ever before and has made them feel proud to participate and get involved in extending health care to the less priviledged rural community who live outside the main stream of sophisticated health technology. A supervisor felt that the efforts of the workers in the community has reduced the number of minor ailments being brought to the health centre. (iii) Although, the supervisors gained nothing in cash but, some of them consider it a privilege to receive gifts from the community farm products. (iv) Modem family planning is gradually being embraced by the rural community since the inception of the ,BD programme as evidenced by "new" acceptors. (v) To confirm the primary objective of the CBD programme, the community leader ascerted that the programme has been able to extend health care to the remote areas that normally would not have enjoyed the services of static clinics because of distance. He believed that the agents' UNIVERSITY OF IBADAN LIBRARY 105 prompt attention to the sick people has reduced a number of serious illnessess that would have occurred had there not been such services*,. (vi) Some people felt that the obstetric care given and early referral to the health or maternity centres has reduced obstetric emergencies* Others felt that because it is low cost and affordable,, most people patronize the CBD workers' health services better than the private clinics or buy drugs at expensive prices from the medicine hawkers around the villages. The Problems. Identified by CBD Agents and Supervisors These includes (i) Inadequacy of Drugs § Shortage of essential drugs impeded the smooth running of the programme. Availability of drugs is an important motivating factor for community participation as observed in this study. It was observed that the drugs used are being supplied from U.S.A. Augmentation of this as promised by the Oyo State Government would have reduced shortage UNIVERSITY OF IBADAN LIBRARY 106 (ii) Finances Since there is no separate account for CBD programme in the State Health Council, emergency situation that requires monetary expenditure tends to suffer e,g, petrol into CBD vehicles or vehicle repair, The supervisors have incurred some finan­ cial cost on themselves, the refund of which will pass through "bottle neck of bureaucratic protocol. The Ministry of Health only supports the programme in principle but not capable financially] (iii) Transport Difficulties; The Local Government staff supervisor who does not have CBD vehicle for supervision has to share with the State Health Council supervisor. Moreover, poor road condition, made worse during the rainy season, make commercial vehicles to the villages less frequent and difficult to come by. All these tends to retard supervision, (iv) Lack of Adequate Incentives/Remunerations Some of those interviewed felt that there should be incen­ tives given to the workers, though not monetary. UNIVERSITY OF IBADAN LIBRARY 107 Some suggested self-help projects. Others felt that incentives should not have been introduced at all as is the case with Akinyele pilot project area which was eventually cancelled. The incentives were said to have accounted for about 50% of the expenditure. UNIVERSITY OF IBADAN LIBRARY CHYPTIH. FIVI? rascussiOL ci bindings Stags 1: j.- :.nt -f 1..- _ •'.■fining of the C3D Workers Havelock and Havelock 1973 suggested four ways of”' - analyzing'a training programme# These are: (a) Breadth of goals| (h) relationship of training to the on going life history of the trainees; (c) psychological wholeness; and (d) transferability, (a) Breadth of Goals Before evaluating any training activity the issue of goals of training is of paramount importance. It is necessary to answer the question WHY of the training before one moves to M O and HOW. The question of WHY of the training has been answered. next question is who? and "hew? ’The pertinent question is whether the CBD training programme was intended to create a cadre of professionals with a new set of knowledge and skills or ’whether it was to improve on the one already possessedly t-’ a. Here it may be true to say that while the training of village health workers amounted mainly to creating a new cadre of professionals the training of traditional birth attendants amounted to improving their already possessed skills. Therefore the UNIVERSITY OF IBADAN LIBRARY 109 use of the same training design for both groups was hardly justifiable. The knowledge and skills to be acquired should w clearly defined in behavior terms. These functions could be specified singly or in sets of related functions. Those to be performed in the short run or in the long run and where they are expected to be performed must he stated. It is equally important to organize the functions in a way that they can fit into old roles of the trainee. For example, the new skills might demand a new set of behaviours which conflict with the existing ones. As useful as role plays might be (which were used to highlight practical issues) one feels that a single role play might not be sufficient to explain all the issues and problems which a CBD worker would have to face in actual practice. Training a VHW may be far more difficult than training a TBA. There is the need to develop a new identity within his or her community prior to training. If a training is to serve a useful purpose, it must he asser- tained that the trainee is subsequently accepted and able to function in his new role. In introducing the topic of family planning, the trainers started by showing that the practice was not alien to tradi­ tional communities. Examples of such devices were shown but the trainees were not opportune! to discuss the need to change from traditional to modem methods. It would have been more effective UNIVERSITY OF IBADAN LIBRARY 1 1 0 to spend sometime reinforcing the old practice and then introduce modern family planning devices as better replacements to traditional ones which were dangerous and unreliable. The VIM might face more difficulty than the TEA because he is returning to communities with long established traditions of role relationships such as traditional doctors, traditional birth atten— r dants, religious priests, etc. Therefore, careful and extensive planning and preparation are necessary both in recruiting the trainees and in preparing their community work settings. This has led some theorists to say that the training in individual skills may not pro­ duce desired results without changing at the same time the total social organizational context in which the trainees will operate. r They therefore advocated a "whole-system" training. It can be postu­ lated here that the approach to the C3D programme approximates a continuum beginning with specific skill learning and ending with a whole system development. In the short run, the training curriculum of the CBD programme which provided individual skills on pre-deter- ► mined priorities in understaffed rural communities might be adequate; in the long run sustaining it would depend on the successful re­ orientation of the attitudes of rural communities to a low-cost service provided by locally recruited volunteers, and of the health personnel to a programme that supplements their own efforts. The , training included record keeping and referral and. assumed that Local and State Governments health staff would give the necessary UNIVERSITY OF IBADAN LIBRARY 111 supervision* Periodic monitoring of the performance of the CBD workers is initially justifiable as a way of collecting data for an improved training curriculum. The CBD workers would also benefit from periodic short in-service training programme while the popularisation of the CBD programme in the rural areas can be pursued through the mass media and other traditional channels of communication, (b) Relationship of Training to the On-going Life History of Trainees According to Havelock and Havelock (1973)> there are three points that should be considered in formulating training goals that would relate to what already exists in the trainee. The first might be to provide entirely new attitudes, knowledge or skills - inputs that are largely unique and original as far as the trainee is concerned^ the second might be to provide rein­ forcement or additional support to existing attitudes, knowledge and skills of the trainee while the third might be to eradicate or redirect already existing attitudes, knowledge and skills which are deemed to be inimical to the desired change. The first dimension is usually referred to as de-nove learning. It is usually believed that it is easier on the part of the trainer to conceptualize «nd - explain a new role or function than to present it as an adaptation or alteration of something already existing. On the part of trainee it is said that a trainee is likely to be enthu— UNIVERSITY OF IBADAN LIBRARY 1 1 2 siastic in learning something new particularly if it is seen as an add-on items which does not challenge his existing state of knowledge, skill or concept. In practice and as in the case of the CBD training programme it is unlikely to find a de-novo learner. Any trainee recruit would inevitably have come for training with some past experiences and attitudes which might stand in the way of learning anything new. As to the second dimension of reinforcing existing attitudes, knowledge and skills in the trainee, behavioural learning theory has shown that the most promising approach to training is positive reinforcement whereby a person is rewarded for doing what he is doing "right" but it has been noted that this approach is very difficult to plan or orga­ nize because of the difficulty in determining v iat individual trainee is already doing right and when he is likely to exhibit such behaviours. Such a training requires the provision of adequate opportunities during the training sessions that will allow every trainee to respond freely and participate in the process of training, ^hen trainer on the other hand might be able to observe the trainees and reward the behaviours that are consistent with the goals of the training. This approach no doubt requires that the UNIVERSITY OF IBADAN LIBRARY trainers are very skillful and alert. As to the third dimension of eradicating existing attitudes, knowledge and behaviours in the training, this has been considered to be the most difficult sort of training to undertake. It is highly threatening to the trainee because it might make certain negative assumption about him and the pastt* The trainee might be defensive thus impeding subsequent learning of new attitudes, knowledge and skills particularly if they are offered by the same trainer. This difficulty, notwithstanding, many training programmes prefer to start with this approach. Examples „ :cL. _^atronaensit Jvi'tydraining which involves exposing and clearing of behaviours which might inhibit the development of an ideal group relationship. It was detected that although these three dimensions were present in the process of training, there was little sensitivity on the part of trainers as to how each dimension affected the progress of the trainings (c) Psychological Wholeness- This refers to the problem f reconciling what trainees do (behavioural outcomes of training) with what they say. In other words, verbalizable thoughts which are associated with behaviours (phycho-motor) and actions (cognition) must be reconciled with what people feel (affect). UNIVERSITY OF IBADAN LIBRARY In simpler terms it means the consistency between words ana deeds.. It is believed that training is most effective or satisfactory when all these three psychological elements are present in the trainee in some degree. A trainee who adopts a new behaviour should also be able to articulate and justify it. When this condition is met,, the trainee will be able to fully integrate the new skills in this everyday life and most importantly he will Ire committed to imparting the new skills to others* The trainee will also be able to develop positive attitudes towards the skills and thereby maintain them. Although a trailer may want to emphasise one or more of these three psychological elements it is usually suggested that it may be more rewarding to work on all the three levels. It was observed that trainers were devoting more time to what and when to do than why they are done especially in the management of malaria, diarrhoea anr1 wounds. Probably in adult group in which most behaviours are already fixed explaining why should receive more emphasis, (d) Transferability At the level of the trainee the goal of a training programme may be defined an the growth or self-fulfilment UNIVERSITY OF IBADAN LIBRARY 115 of the trainee while at community-client level where training is applied the goal may be defined as the re-making of the social order. Training therefore involves two types of transfer (i) the transfer from the trainer to the trainee; and (ii) the transfer from the trainee to the society as a whole (Diagram 1). Assessing transferability in the CBD training programme - means whether the training made ..a difference to the VHWs a and the TBA's and whether their return made a difference when they got back to their respective communities ' In order words, the trainee should be able to retain and use what he learned for a significant period of time in his community. The first type of transfer can be measured through concurrent and terminal evaluation at the end of training. The second type of transfer can be measured only after the trainees have practised for a reasonable period of time. This shows that transferability involves a more elaborate analysis of the contractual arrangements that exist between the trainee and as community. UNIVERSITY OF IBADAN LIBRARY 116 Stage 2s Application of the Training of CBD Workers Community Based Distribution programmes have been established in more than thirty developing countries (Bertrand et al, 198U)• Most of the programmes are family planning oriented except in a few countries like Zaire and Nigeria (in Oyo State) which combined illness treatment, maternal and child health services with family planning. The Oyo State CBD programme utilizes trained volunteers to render family planning, maternal and child health services to the remotest part of the State, It has minimized services delivery cost and eliminated some of the barriers controlling potential clients under the clinic-based systems - barriers such as distance, cost and administrative problems e.g. waiting lines, red tape. The findings showed the educational activities of the CBD workers and the impact on their client community. The discussion will focus on selected illness treatment practices, family planning, pregnancy and delivery and also community response to Community Based Distribution (CBD) programme, (a) Selected Illness Treatment Practices The CBD workers were found to be competent in employing the standardized treatments according UNIVERSITY OF IBADAN LIBRARY 1 1 7 to their standing orders. Diagnosing and treatment of malaria Especially adult malaria) by the workers did not seem to be a problem. Because it is the commonest ill­ ness in the rural communities and likely to be treated more frequently, mastery of diagnosing and treatment is possible. Age, sex and educational background did not play a role in the knowledge of the workers’ educational tasks. One may speculate that one does not need to be educated to carry out health services of this nature that is, CBL. Diarrhoea was not identified by the CBD workers as a health problem in the rural areas especially among young children and infants. This finding is contrary to that of Ademuwagun et al (1977)• The workerJ supply of Oralyte was mainly used to treat school children and adults and its preparation was done by the CBD workers themselves. It would have been ideal if the workers taught their clients how to mix Oralyte during their first encounter with a diarrhoea case. Time needed to prepare subsequent daily Oralyte mixture would have been directed to other important health matters. Besides, treatment would be unbroken since the time of UNIVERSITY OF IBADAN LIBRARY 118 waiting for fresh Oralyte to be prepared would have been eliminated. Since regular supply of Oralyte could not be guaranteed, the CBD workers might not be willing to leave the Oralyte sachets with the clients. (b) Family Planning The CBD workers' knowledge of educational tasks in relation to family planning did not appear doubtful. However, the measurement of blood pressure for a prospective pill user which most of the workers did not mention during interview could be interpreted thuss since this procedure would not be carried out by the workers on the field, there is possibility of forgetting to mention it during the interview. To confirm that this was just an omission, the clients interviewed (pill users) confessed that their blood pressures were measured at the clinic before the use of the pill. Howbeit, further screening in relation to contra-indications for prospective % pill users were observed. Family planning education remains a sensitive matter to be discussed 'bpenly" in Nigerian setting (Reyes and Jinadu, March 198U)• Its communication between the opposite sex is rather difficult. Although, it is accepted that men may seek sexual relationship outside of marriage, women on the contrary do not want others to know that they are practising family UNIVERSITY OF IBADAN LIBRARY 119 planning (Randall and Adekola, April, 19835 Reyes and Jinadu, March, 1981+). In addition, an infertile or sub-fertile individual should not and would not be willing to propagate family planning. For instance, two of the three CBD workers with secondary infertility felt reluctant to propagate family planning. 0ne would advocate that such people would not be selected for future CBD programme. Despite the negative attitude of the fairly young people (with fewer children) towards family planning, the use of contraceptives is gradua­ lly being embraced by some community members through the CBD * programme. The use of modern contraceptives by most of the CBD workers themselves have created enough awareness and motivation among the community members thus recruiting more people into family planning. For instance, most of the modern contraceptors among the clients are "new" acceptors, that is, accepted contraceptive use shortly after the CBD services commenced. (c) Ante-natal -3S£e- and Delivery All the TBAs interviewed performed well in recalling how to care for pregnant women and delivery process. However, appropriate action in real situation cannot be guaranteed in the sense that those who could recite the process involved in deli­ very will actually perform well especially when only a few of UNIVERSITY OF IBADAN LIBRARY 120 them are actually taking deliveries. This implies that periodic refresher courses will base necessary tc help those who.are :not active TBAs. (d) Community Response to CBD Work The community members appear to embrace the CBD programme. They feel priviledged that they are able to enjoy health services at their door steps with mini­ mal cost to them. However, they appreciate regular supply of drugs. This finding shews that the CBD programme is providing valuable services to the communities at reasonably low cost. This corresponds to the findings of Reyes and Jinadu (198U). The CBD workers themselves complained that the work is taking a lot of their time off their source of livelihood and advocate some form of incentives to offset the cost incurred on themselves especially the cost of travelling to and from monthly meetings and cost of transporting their clients to the clinics or hospitals. This implies that a form of incentive is required to ensure continuous commitment to the CBD work UNIVERSITY OF IBADAN LIBRARY 121 Stage 3 s Information Collected on Selected Organizational Aspects of CEP Project The findings from the study showed the involvement of the agency, community and government (Oyo State Ministry of Health) in selected organizational and implementation aspects of the CBD programme as listed under (research purpose and methodology)« The discussion will therefore focus on the three categories of people: (a) the agency - the staff of the U.C.H. Fertility fiesearch Unit, (b) the government - Oyo State Ministry of Health through the State Health Council; (c) the community members enjoying the services., (a) The Agency It was discovered that the agency in collaboration with the government and the community members including the funding Agencies (Pathfinder Fund of Boston and Centre for Population and Family Health, Columbia University, New York, U.S.A.) jointly decided on the criteria needed for the selection of the CBD volunteers., And because the project was based on the health needs of the people, hence the UNIVERSITY OF IBADAN LIBRARY 122 cooperative attitudes of all the people involved in the running of the CBD programme. The supportive and supervisory role of the TJ.C.H. staff in the expanded areas of the project has motivated the dedicated hardworking attitudes of the State and local Government supervisors which was discovered during the study. (b) The Government - State Health Council Although the CBD programme has been officially transferred to the Oyo State Government, TJ.C.H. staff still assist in the supervision of the CBD programme. It could be postulated that this system encourages the government bureaucracy of "clogging the wheel of progress" of the programme. It would have been ideal if the govern­ ment had been involved in the initial planning especially at the siting of the pilot project. The government was found to have supported the programme only in principle but responsibility of augmenting the supply of drugs has not been fully supported. (c) The Community Members It was discovered that the community members were fully involved in the planning, implementation and evaluation of the programme. Hence the acceptability of the programme and the appreciative attitudes experienced from the villagers during the study. UNIVERSITY OF IBADAN LIBRARY CHAPTAR SIX COLLUSION AIIP RECCIIMEKDATIOSS C»nclusi»n The CBD programme which involves the training and utilization of Veluntary Health Workers (VHWs) including Traditional Birth Attendants (TBAs) to render family planning, maternal and child health and also selected illness treatment was found to be valuable and useful to the rural community. The training curriculum as designed presently was found to contain enough contents which are relevant to the training objectives. The trainers were found to be competent in their subject matter but the absence of a clear definition of training objectives in behavioural terms for each topic did not augur well for a uniformity of style among the trainers. In the application of the training, most *f the CBD •Jr it workers were found to perform well on what they were taught to do in relation to family planning, maternal and child health and illness treatment. Although family planning education remains a sensitive topic to be discussed in the public but its services were found to be promoted by the UNIVERSITY OF IBADAN LIBRARY 12b CBD workers through personal use and by influencing other members of the community. The response and support of the community especially the clients to the educational activities of the CBD workers is very positive. This is not unrelated to the ways and manners the workers carry out their assignments. All the CBD workers interviewed said that they want the government to re-introduce the monthly incentives because the CBD activities take too much of their time. However, Reyes and Jinadu (198I4.), concluded in their study that monthly incentives are not needed to promote effective volunteer CBD work . One might postulate that the change in their atti­ tude is not unconnected to the fact that they have come to realize their level of commitment, and would like to be compensated in reciprocate. Moreover, the high cost of living coupled with dwindling economic situation in Nigeria might "push1* them to desire some incentivesc In the management of the CBD programme, the field supervisors in the expanded areas were found to be devoted and hardworking in their supervisory role, This finding corresponds to that of Randalls and Adekola (1983)* UNIVERSITY OF IBADAN LIBRARY 12$ The programme was found to be beneficial both to individuals, management staff and the community as a whole. Apart from the participation of the management staff in extending health services to the grassroot, the programme also brought them closer to the rural community more than ever before. Hfwever, some short comings in the CBD programme were discovered to be: insufficient drugs, financial constraints inadequate transport facilities and lack of clear cut decision as to whether an incentive will or will not be given to the CBD volunteers. The services of the CBD programme could be improved by solving the problems or short-coming's highlighted above. Rec ommendat ions The following recommendations are made on the basis of the findings of this study to enable improvement of the services of CBD programme. Training's For future CBD training, the authority and community concerned should agree on a centrally •lfcated training site that will be easily accessible .-te all the trainees. For instance, some of the trainees from Ifewara had to travel ^.#ng distances UNIVERSITY OF IBADAN LIBRARY - - and. start off as early as 5*00 a.m. in order to get to the training site by 8:30 a.m.. Despite this inconvenience, the trainees still turned up for the training sessions as they were highly interested in the programme. In cases where future training site will ¥e * too far from the trainers and where public acc«mm*-> * dations are scarce, arrangement sh#uld be made with the community members to provide living accommoda­ tions for trainers to prevent lateness.- . As there were many topics to be covered for phases two and three of the trainingj the time allowed for these phases did not seem to be sufficient (five working days for b*ih) as evident by the haste with which so many of the topics were taught. Therefore, for future training adv*-c cates an extension of training days for phases two and three of the CBD training programme. • It is advocated that the training curriculum should be developed into a standard training manual with clearly stated educational ofrjotetdves for the trainers and behaviours! objectives f*r * UNIVERSITY OF IBADAN LIBRARY 1 2 7 The trainees, training methodologies and also an evalua­ tion instrument which will set an acceptable level of attainment for a trainee to qualify as a CBD worker. Visual Aids: Appropriate visual aids and teaching materials should be provided for use where necessary to assist the -understanding of the topics. Adequate space to accommodate the trainees and trainers during the training sessions should be available. In Tonkere, for example, space was rather small for the group and the writing board, which was of poor quality, and inadequate was remotely located. During the discussion on food science, variety of food items should have been shown or a visit to the market place to see the variety of food items recommended would have been ideal, For the Workers (TBAs and VHWs): To ensure continuous oommitment of the workers to the CBD work, a "self-help" agricultural project should be established in the expanded areas of the project just as it operates in the pilot area. This might be able to offset the expenses incurred on the CBD workers. For example, the CBD agents tend to bear the cost of transporting their clients UNIVERSITY OF IBADAN LIBRARY 128 In the selection of potential CBD volunteers for future training, their family history among other criteria should he considered so that those with any form of inferti­ lity - primary or secondary should not qualify to he selected. Such people were found not to he good promoters of family planning. For family planning education to achieve its desired goal it may he necessary to effect prior diagnosis of potential and prospective acceptors, because a family planning education programme may not he applicable to all concern. For instance, the woman from Jobele (discussed earlier) who is 25> years old, had five children within five years of marriage. She confessed that she could not subs­ cribe to family planning yet because there is constant pressure from her mother to have many children as he is the only surviving child of her parents,. For the Government; Since the CBD programme is now being managed by the Ministry of Health and only supported by the staff of University College Hospital Fertility Research Unit, the State Government should embrace it whole heartedly, that is both in principles and financially. Therefore, adequate budget and separate account should be provided for the smooth and continuing running of the programme. UNIVERSITY OF IBADAN LIBRARY 129 The government should recruit personnel capable of sustaining and expanding the programme. The fees collected from the services rendered by the CBD workers should be used to service the project. There should be a cut down on the bureaucracy of the civil service which is a major impediment to the smooth running of the project. The government should device means by generating money that can be internalized into the project rather than be diverted to the government pool. This also will help to sustain the project. However, regular evaluation of the programme to justify its cost effectiveness is advocated. The CBD programme is fulfilling an important role in the rural community. It is a unique and laudable programme and its replication is highly recommended for other States of the Federation, UNIVERSITY OF IBADAN LIBRARY 130 BIBLIOGRAPHY Abiona, J.J., Oyedeji, E.O., Lana, B.s Training in the CBD Project, Oyo State, Paper presented at the Conference of the Oyo State CBD Project, Ibadan, Nigeria. January, 1985* Unpublished. Ademuwagun, Z.A., Oduntan, S.O., Familusi, J.B.: Mother and Child Health in Africa: The Role of Health Education. Israel Journal of Medical Sciences. 13 (5), 508-13, May 1977• American Medical Association, "Report of the 8th National Confe­ rence on Physicians and Schools." Chicago, p. 76, 1961. Anonymous: Community-Based Health and Family Planning. Popula­ tion Report. Series L, Number 3, November - December, 1982. Anonymous: Community-Based Distribution Project Summary, Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria, January, I98I4. Unpublished* Anonymous: Family Plann, ing Programmes. Population Report.Series J., No, 19 March, 1978. Anonymous: Training and Continuing Education: A Handbook for Health Care Institution Hospital Research and Educational Trust, Chicago, p.2, 1970. Anonymous: Project Design and Budget Modification for the Period October 1, 1982 - September 1 , I98I4. Modification No. 9 to Sub-contract No. 2 Under Cooperative Agreement No. AID/ DSPE-CA— 003• September !+, 1982 Exhibit A. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria. Bannermann, R.H.: The Role of Traditional Medicine in PHC. In Traditional Medicine and Health Care Coverage: A Reader for Health Administrators and Practitioners by R.H. Banner­ mann et al, WHO, Geneva, 1983* Bertrand, J.T., Mangani, N., Mansilu,- M,: The Acceptability of Household Distribution of Contraceptives in Zaire. International Family Planning Perspectives. Vol. 10, No. 1 , March, 19814. Bloom, B.S. ed.: Taxonomy of Educational Objective, Handbook I: Cognitive Domain. New York, 1956. UNIVERSITY OF IBADAN LIBRARY 131 Bryant, J.H.s Health and the Developing World. Cornell University Press, U.S.A., 19^9* Delano, G.E.: Organizing the Community for Community-Based Health Services; The Oyo State Project. Paper presented at the Conference of the Oyo State CBD Project, Ibadan, Nigeria. January, 1985* Unpublished. Encyclopaedia Britannica, 1978. Gamble, D.P.s Infant Mortality Rates in Rural Areas in Gambia Protectorate. Journal of Tropical Medical Hygiene. 35s 1U5, 1932. Gish, O.s Tanzania - The Way Forward. World Health, pp. 8—13» April, 1973. Gorosh, M.E., Ross, J.A., Rodrisues, W. and Arruda, J.M.; Brazils Community-Based Distribution in Rio Grande do Norte. International Family Planning Perspectives. Vol. 3, No. I4, December, 1979- Green, L.W., Kreuter, M.W., Deeds, S.G., Patridge, K.B.s Health Education Plannings A Diagnostic Approach. 1st ed. Mayfield Publishing Company, California, pp, 132 ■ 136, 1980. Grounds, I.G.s Mortality and Wastage Rates for African Children in Kenya. East African Medical Journal, 1+1 s 333? 1961+. Harrison, P. Cuba’s Health Care Revolution. World Health. WHO. pp. 2-7, December, 1980. Havelock, R.G. and Havelock, M.C.s Training for Change Agencts, Institute for Social Research, Michigan; University of Michigan. 1973• King, M.s Medical Care in Developing Countries, Oxford University Press, Nairobi, 1966, Kleczkwoski, B.M. and Nilsson, N.O.s Health Care Facility Projects in Developing Areas? Planning, Implementation and Operation. Public Health Papers. No. 79? W.H.O*, Geneva, 1982+. UNIVERSITY OF IBADAN LIBRARY 132 Kleinman, R.L.s Community-Based Distribution of Contraceptives. Family Planning Handbook for Doctors. $th Edition Interna­ tional Planned Parenthood Federation. England, 1980. Knutson, Andies The Individual, Society and Health Behaviour Russel Sage Foundation, New York, 1965. Ladipo, O.A. History and Overview of Oyo State Community-Based Delivery Programmes The pilot project. Paper presented at the Conference of the Oyo State CBD project, Ibadan, Nigeria, January, 1985* Unpublished. Ladipo, O.A., Weiss, E.M., Delano, G.E. and Revson, J.s Community-Based Delivery of Low-Cost Family Planning and Maternal and Child Health Services in Rural Nigeria. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria, 1982. Unpublished. Levin, L.S.s Self-Care in Health - Potentials and Pitfalls, World Health Forum. Vol. 2 , No. 2 , pp. 177— 98iu, 1981. Ling, J.C.S.s Sage Femme. World Health, pp. 22 - 25, May, 1978. Mahler, H.s The Meaning of Health for All by the Year 2000. World Health Forum. Vol. 2 , No. 1 , Geneva, 1981. Miazad, R.s Afghanistan - Friend of Health. World Health pp. 2 0 - 2 1 , May, 1978. Newell, K.W. (Editor) Health by the People. World Health Organization, Geneva, 1975* Oduntan, S.O. and Odunlatni, V.B.s Maternal Mortality in Western Nigeria. Tropical and Geographical Medicine. Vol. 27, pp. 313 - 316, 1975. Ojanuga, D.N.s Attitudes of Medical and Traditional Doctors Towards Integration of the Government Health Services in the Western State of Nigeria. Journal of Tropical Medicine and Hygiene. Vol. 83, No. 2, pp. 85 - 9®. April, 1980. UNIVERSITY OF IBADAN LIBRARY Randall, P. and Adekola, A.O.s Ikereku Mini Study - Family Planning Issues. Department of Obstetric and Gynaecology, University College Hospital, Ibadan, Nigeria. 1983. Unpublished. Reyes, P. and Jinadu, O.s A Feild Study of the Performance of the Oyo State Community-Based Health/Family Planning Workers. Department of Obstetric and Gynaecology, University College Hospital, Ibadan, Nigeria, April, I98I4. Unpublished. Steiametz, Cloyd S.s The History of Training - In Training and Development Handbook by Craig Robert L. Second Edition, McGraw-Hill Inc., U.S.A., 1976. Stephen, W.J.s Primary Medical Care and the Future of the Medical Profession. World Health Forum. Vol. 2, No. 3, pp. 315 - 321+9 1981. Study Group, Indian Council of Social Science Research and Indian Council of Medical Research - Health For Alls An Alternative Strategy. Indian Institute of Education, Pune, 1981. Stufflebeam, Daniel et al.s In Havelock, R.G. and Havelock, M.C. Training for Change Agents. Insti­ tute of Social Research, Michigan: University of Michigan, P. 80, 1973* Weiss, E.s Operations Research in health and family planning services £ Lessons Learned in the Oyo State Project.. Paper presented at the Conference of the Oyo State CBD project, Ibadan, Nigeria, January, 1985. Unpublished. Williams, P.B. end Omishakin, ?1.A.s Major Barriers to Effective Delivery of Health Services in Nigeria, International Quarterly of Community Health Education Vol. U, No. 1, 1983-85. World Health Assembly, Formulating Strategies for Health For All (HFA) by the Year 2000, W.H.O., 1977* UNIVERSITY OF IBADAN LIBRARY r 13b - World Health Organization Statistics, 1971 WHO/UNICEF - From Primary Health Care - A Joint Report by the Director General of WHO and the Executive Director of UNICEF, WHO, Geneva, 1978. ■WHO Training Guide. Primary Health Worker: Working Guide. Guide for Training, Guidelines for Adaptation Experimental edition. WHO. Geneva, 1977. WHO Technical Report Series. Training and PreparatidB of Teachers for Schools of Medicine and of Allied Health Services, No. 521, 1973* Wray, Joe: Community-based delivery of primary health care and family planning services: An historical and global overview. Paper presented at the Conference of the Oy.o State CBD project, Ibadan, Nigeria, 1985» Unpublished. UNIVERSITY OF IBADAN LIBRARY APPENDIX A C Q m W I T Y - B A S E D DISTRIBUTION OF MATERNAL CHILD HEALTH AND FAMILY PLANNING CURRICULIM FOR TRAINING PROGRAMME OF TRADITIONAL BIRTH ATTEDmiiNTS/vOLUNTARY HEALTH WORKERS 1st Week F" ? PHASE 1 Ley Lectures Monday Introduction a) Welcome address b) Warm-up Exercise ĉ Introduction of CBD Project d̂ Aims and objectives of CBL e) Criteria for selecting TBA/VHW f) Job description of TBA/VHW Tuesday Elements of Anatomy and Physiology Female Reproductive System. i ] Male Reproductive System, Wednesday Pregnancy a) Menstrual Cycle b) Conception Thursday Ante-Natal Care a) Growth of the baby. b) Examination of the pregnant woman. c) Diet in Pregnancy. d) Common discomfort during pregnancy e) Danger signs during pregnancy. f) Patients at risk. g) Advice to the pregnant women. Friday Intrapartum Care a) Content of Kit. b) Management of Labour. c) Signs of impending labour d) Normal changes in the women in Labour. e) Preparation of women in Labour UNIVERSITY OF IBADAN LIBRARY PHASE 1 2nd Week Day - Lectures Monday Normal Delivery a) Labour - First, Second & Third stages A) Management of separation and expul­ sion of the placenta, c) Examination of the placenta. Tuesday a) Identify deviations from the normal during labour and emergency treatment. li) Control of bleeding. Wednesday Care of the new-born a} Resuscitation Procedure A) Cyanotic baby Care of the umbilical cord. A) Care of the eyes, e) High risk baby. Thursday Care in the Puerperium a) Breast feeding A) Proper feeding practices c) Engorged breast i) Minor discomfort of mother and management e.g. sere nipples, after pain, etc. <*) Complications e.g. Puerperal infection, delayed bleeding, retention of urine, etc. Friday Infant Care a) Normal child growth. b) Needs of Infant. c) Childhood Ailments anfl Management e.g. Convulsion, fever, etcf UNIVERSITY OF IBADAN LIBRARY 3rd Week PHASE 1 Day 1 : .' 3 Lectures Monday Management of Minor Ailments a) Malaria - Role play h) Cough - Role play c) Parasites - Role play Tuesday a) Diarrhoea - Role play 1») How to use and mix Oralyte Wednesday a) Anaemia - Role play h) Standing Order for Treatment Thursday C.B.D. Kit (Management) a) TBA/VHW - Content of the Kit T») Drug supply/re supply c) Tally sheet - Role play Friday a) Record keeping 1») Referral Card c) Home Visit UNIVERSITY OF IBADAN LIBRARY IV, COMMUNITY-EASED DISTRIBUTION OF MATERNAL CHILD HEATrT1H AND FAMILY PLANNING CURRICULUM FOR TRAINING PROGRAMME TRADITIONAL BIRTH ATTK.JAICTS7VOLUNTARY HEALTH WORKERS 2ND PHASE 1 Week Day, - Lectures Monday Family Planning a) What is Family Planning (f/p )? h) Advantages of F/P. c) Traditional Methods of Birth Control (b/c ) Tuesday a) Modern Methods of B/C Methods h) Advantages of each B/C Methods(B/CM) ° Side effect of B/CM) d. Complication of B/CM. Wednesday Contra-indication of B/CM a) Motivation, Counselling, In Interviewing of clients. How, where and when to get B/CM. c) Referral System Thursday Health Education a) Personal Hygiene h) Nutrition c) Immunization Programmes and Needs Friday i Birth Registration >a!i Importance of well-bahy clinic UNIVERSITY OF IBADAN LIBRARY V, COjytMUUITY—BASED DISTRI3UTI0H OF PATERHAL CHILD HEALTH AM) FAMILY P L A C I N G CUgRIClILUM FOR TRAINING PROGRAMME OF TRADITIONAL BIRTH ATT^M ^ T S / V O L U M ' A R Y HEALTH WORKERS 3PM PHASE 3 - DAYS Say/ Laie:. Lectures Monday Prevention of Infection a) Prevention of communicable diseases. b) Environmental Sanitation. o) Parasite, <0 Prevention of House Accident. e) First Aid Treatment (Wound Jressing) f) Home Economics Tuesday Management of C.B.D. Programme a) Identification of Problem/Solution *) Evaluation. c) General Discussion. d) Per-Diem Payment. Wednesday Graduation a) Group Presentation - Role ijlay. >) Award of Certificates/Kits. c) Party. UNIVERSITY OF IBADAN LIBRARY I VI APPENDIX E Description If Educational Tasks for Each Of the Four Areas of Study Educatienal Tasks of CBD Workers In Family Planning 1. They are to educate families ti accept family planning. 2. To educate families on choice and correct use if contra­ ceptives methods and contra-indication of each method. 3. To educate families on the meaning of family planning andaits advantages to the family, community and the nation in general. Methodology CBD Workers TBAVHW Interview Families Accepto*rs No*n -accepto*r s Eiucaticnal Tasks of CBD Workeds on Pregnancy and Delivery 1. CBD (TBA Workers to educate pregnant mothers fin personal and environmental hygiene before, during and after child Virth, 2, They should educate pregnant mothers to send fjfr the CBD workers in cases of emergency for ore, intra and UNIVERSITY OF IBADAN LIBRARY vii ~o~". post-natal periods by teaching them the signs and symptoms of imminent dangers - dizziness, swollen legs, anaemia, etc. 3. They should educate families on care and appropriate feeding of mother and baby, particularly 'breast feeding, types of weaning£- dpireetparation of baby«?food, balanced die* » for the pregnant mother, exercise and rest. 1|. CBD workers should educate on the importance of, protecting pregnant mothers against malaria, e.g. association between malaria and stillbirth. 5. They should organize and mobilize'community efforts and V: resources for increased food production - gardening, poultry, fishery, etce Methodology TBA&t C3D Workers VHWs A. Interview Pregnant Mothers (Sample) Married Men (Sample) 3 . Look for evidence of acceptance of Family Planning (Users). UNIVERSITY OF IBADAN LIBRARY viii. Educational Tasks of CBD Workers on Malaria 1. The CBD workers should health educate the community on environmental sanitation - disposal of refuse and empty receptacles, filling of pot holes, covering of empty pots, clearing of weeds, clearing of drains, etc. . They should educate the community on the use of appropriate protective items; mosquito nets, use of mosquito proof windows and doors and use of insecticides and repellents (traditional and modem). 3* They should educate the community on the causes, signs and symptoms of malaria. I4. Educate the community on the acceptance and use of anti-malaria drugs and on the known harmful effect of traditional drugs and herbs. 5. Educate the community on the management of high temperatures and convulsions, danger of traditional drugs like cowsurine. 6. Organise and mobilize community efforts and resources for malaria control. Methodology TBAs CBD Workers VHWfe A. Interview Sample of Male community members Female UNIVERSITY OF IBADAN LIBRARY TEA and VHW in action in the community B. Observation Environmental Sanitation Check list ox selected (Sample of) households Family Drug Kit Educational Tasks of CBD Workers on Diarrhoea/ORT 1. They should educate tho community onthe causes diarrhoea and measures of prevention and treatment. # 2. Educate mothers on how to prepare ORT. 3. Educate mothers on how to recognize the signs and symptoms o'f dehydration and when to give Oral Rehydration Therapy (ORT). Methodology TBAfS CBD Workers VHWs A. Interview Mothers whose children had had diarrhoea Nurses/Midwives fn clinics Patent Medicine Sellers B* Observations New cases of diarrhoea o' Evidence of hygiene measures - boiling of water - refuse disposal infant feeding practices UNIVERSITY OF IBADAN LIBRARY X APPENDIX C Participation of 'Trainees at Tpnkere during Training Sessions by Sex Participation Variables Pate Sex NQ Q AB CF G U/6/8U M 5 2 3 0 0 ' F 6 0 k 0 J 5/6/8U M 9 1 0 0 0F 6 b 0 0 0 6/6/81* M 2 3 0 8 0F 2 0 0 7 0 7/6/8U M 7 3 0 1 0F 7 1 J 3 e 8/6/81+ M 0 1 0 0 10F 0 0 0 0 1C T O T A L bb 15 7 19 ...20 Participation Variables NQ = No Question Q = Question AB = Absent CF = Correct Feedback G = Graduation UNIVERSITY OF IBADAN LIBRARY x i Topic Tate Sample Quost^.-ns •Contraceptive Devices Q/6/8I4. - Can unmarried, female students use contraceptives? - What age groups use the "pill?" Contraceptive Devices 5/6/81| - Do condoms come in sizes or how will it fit every user? - Will the shield expand just like condom during applica­ tion. Obtaining Birth 6/6/31). - How will children not b o m in Certificate hospital obtain a birth certificate? Communicable Diseases ~ How should Yellow Fever b© treated? General Questions - How should sore mouth be treated? - Is family planning services free? General Questions 8/6/85 - Is it necessary totally the contraceptive devices dispensed? UNIVERSITY OF IBADAN LIBRARY x i x . APPENDIX D STANDING ORDERS I W TREATMENTS BY E-^s/vif'a DRUG ADULT AGS OF PATIENT s ILLNESS SCHOOL CHILL UNDER 5 1• Fever/ Nivaquine i+ start 2 start 1 startMalaria 2 bd x 2/7 1 bd x 2/7 h M x 2/7 Under 3 yearss Nivaquine Syrup 2 tsn start1 bd x2/7 Pahadr-1 2 TDS 1 TDS £ TDS x 3/7 x 3/7 x 3/7 Multivite 1 bd 1 daily xr 7/7 x 7/7 Multivite 1 tsp daily Syrur x 7/7 Folic Acid 1 daily 1 daily 2 daily T n :.r • I x 7/7 x 7/7 x 7/7 Antihis- timines 1 start Bene dry]. Phenergan Syrup 2 tsp start 1 tsp start 2. Cough Benylin 1 tsp 2 tsp i tsp Syrup TDSDs 3/7 TDS x 3/7 TDS x 3/7 3. Diarr- Oralyte 2 packets needed for all agess hoea 1 packet per day mixed with 3 small stout bottles (1 liter) of water; 1 cup (6oz.) - given after every stooling. UNIVERSITY OF IBADAN LIBRARY xiii 1 bd x 3/7 Worms Mabendezcl 1 bd x 3/7 1 bd x 3/7 IJ*t' £*r children Not for preg­ under 2 years nant women $. Anaemia F«lic Acid 1 TD3 1 b* £ TDS x 7/7 x 7/7 x 7/7 Multivite 1 TDS 1 b* i TDS x 7/7 x 7/7 x 7/7 6. Prenatal Ferr«cal Plus 1 daily (per treatment) (er Filib«n) 1 i+ days 7. Delivery Ergftmetrine 1 immediately post-partum UNIVERSITY OF IBADAN LIBRARY APPENDIX E QUESTIONNAIRES FOR CEP WORKERS Diarrhoea/ORT - CBD Worker 1 . Name ______________ _ ________ 2. Address: _____ _______ ____________________________ 3. Age: . ___ . U. Sex: _____ ___________ 5. Married/Single/Divorce/Widowt _____________________ 6. What are the causes of diarrhoea? 7. How can you treat diarrhoea? 8. How can you prevent diarrhoea? 5. Do you teach the mothers how to prepare ORT? 10. Apart from ORT, what other anti-diarrhoea da’'you give? 11. What are the signs and symptoms cf dehydration? 12, a* Whm-should you start to give ORT to somebody with diarrhoea? b. What is ORT (Orhl Rehydration Therapy)? 13, Observation: Ask for new cases of diarrhoea. Evidence of hygiene measures such as boiling of HgO, refuse disposal, infant feeding practices, QUESTIONNAIRES FOR PREGNANCY 1U. What type of care would you give to a pregnant wjman? UNIVERSITY OF IBADAN LIBRARY X V . 1£. What advice do you give to them concerning (a) diet, 00 personal, and §c) environmental hygiene during pregnancy 16. What advice do you give concerning their preparation for labour, delivery and post-natal? 17. What advice do you give to pregnant women in case they have signs and symptoms ox imminent danger such as dizziness, swollen legs or eyes, ants crawling round their urine? Q.UESTIOMIAIRSS FOR DELIVERY 18. How would you recognise that a pregnant woman is in labour? 1«. How do you prepare for taking delivery? 20. How do you take delivery? 21. What kind of post-natal care do you give tc mothers? 22. When do you seek for medical assistance during (a) Labour (b) Delivery (0) Post-natal 23. How many deliveries have you taken since you have been trained? QDESTI0MAIH5S FOR K J.IL Y FLAMING 2U. What advice do you give to pregnant women concerning family planning? UNIVERSITY OF IBADAN LIBRARY x v i . 2^. (a) Whom did you introduce the topic - Family Planning to first, husband or wife? (b) How d® you ':troduce the topic? 26. Who buys the idea first, husband or wife? 27. What advice do you give in making appropriate family planning choice/method? 28. Which of the family planning methods are m*re in demand? 29. (a) What types of problems have the acceptors enc®un- - tered concerning the use ®f the chosen method? • (b) H«w dijj. you solve them, if any? 30. (a) D# you^use any of the family planning methods yourself? (>) i£ so, how long have you had it and what method? | 31• What type #f problems have you encountered concerning the disbursement of family planning methods? QjUESTIOHHAIKES FOR MALARIA 32. What do y®u think can cause malaria? 33. H»w w®qld x*u know that some »ne is suffering fr#m ' malaria? 3I4, How would you treat malaria? 35. (a) What steps should one take t» reduce the incidence ef malaria in the community? 00 What efforts and resources are required f^r malaria control in the community? 36, What df you do to prevent mosquitj bites in homes? UNIVERSITY OF IBADAN LIBRARY xvii. 37. (a) Is there a differ once between the use of anti­ malaria drugs given by you and the traditional ones? (b) If yes, what is it? (c) What are the harmful effects of traditional drugs such as herbs and cowurine? 38. What should you do to somebody with (a) temperature (b) convulsion 39* What have you done to encourage people t* improve in agricultural food production? i+O. Observe environment for sanitation. Check family Drug Kit UNIVERSITY OF IBADAN LIBRARY xviii APPENDIX P question '• Tpg fok patients 1. Name; 2. Address! 3. How old are you? 1+. Sex: 5. Married/Single/Divorce/Widow 6. (a) What is your understanding (.f CBD workers (b) How long ago h we they existed in the village? 7. Have you ever been a&tended to by CBD worker for anything? If so, for what were you treated? 8. (a) Are there medicine dealers around the village? (b) If so, what type of medicine did you buy from them since the CBD workers were trained? 9. Do you remember the name of the drug you we're given when last you were treated by CBD worker? (b) If so, name some. 10. For how many days did you use the drugs that you were given? 11. If you get better before you complete the course of treatment given, what do you do to the rest *>f the drugs? 12. How much did you pay for a course of treatment? 13. What advice were you given concerning! fa) r Environmental Sanitation (h^ Improvement in agricultural production to boost food production, (c) Family Planning. UNIVERSITY OF IBADAN LIBRARY xix APPENDIX G- QUESTIONNAIRES FOR SUPERVISORS Name s Address; Ages Sexs Married/Single/Divorce/Widow; What are the criteria used in selecting the CBN workers? (a) Prom your own point of view, what are the short­ comings of the project? 00 How can you improve on the shortcomings? What should the government do to promote the CBD Programme? How have you integrated the CBD project into the existing local health services? As a CBD worker, what have you gained since this project commenced in cash or kind? (a) As a Supervisor, a„re you enjoying the responsibility given to you? (t) If No, why not? (c) If yes, what aspects appeal to you most? (d) And what aspects do you dislike most? UNIVERSITY OF IBADAN LIBRARY X X APPENDIX H QUESTIONNAIRES FOR COfliUNITY LEADER Name: Address: Age: Mcarried/ Single/Divorc e/W idow: Status: e.g. Chief/opinion leader, etc. What are the criteria used in selecting the CBD worker? (a) Prom your own*poinx of view, what are the short­ comings #f the project? (h) How can you improve on the shortcomings? What should the government do to promote the CBD programme? (a) Have the CBD workers Been useful to this community? (h) If yes, explain. UNIVERSITY OF IBADAN LIBRARY xxi a p p m d i x i Q.TJHSTIONIhJKSS FOR DIFOCTOB OF CBD PROJECT - U.C.H. 1 . Same: 2. Addresss 3. Ages 1+. Sex: 5. Married/Single/Divorce/Widows 6. ’Vhy was Akinyele Local Government selected as the pilct project area and not any ether* local* government in Oyo State? 7. What were the criteria used in selecting the CBD workers? (TBAs and VTIWs) 8. How were the supervisors selected and what were the criteria used in their selection? 9. Were the selected supervisors working in the project sites before they were -iven this responsibility? 10. (a) Prom your own point of view, what are the shortcomings of the project^ (b) How can you improve on the shortcomings? 11. What should the government do to promote the CBD programme? UNIVERSITY OF IBADAN LIBRARY __ ___ _t J- 1 ]. QUESTIONNAIRES FOR COORDINATOR OF CEP PROJECT IN s t a t e h e a r t h c o u n c i l Name: Address: Age: Sex: Married/Single/Divorce/WidoW: Why was Akinyele Local Government selected as the pilot project and not any other local. government in Oyo State? Hpw were the supervisors selected ani whac were the criteria used in their selection? Were the selected supervisors working in these areas i.e. the project sites before they were given the responsibility of supervisors? (a) Since the take over of the CBD project by the Oyo State Government, what are some of the problems encountered in relation to: (1) transports!ion (2) f inane ial (3) personnel (b) drugs ($) equipment (*) How ’were they solved? (a) From your own point of view, what are the short' comings of the project? UNIVERSITY OF IBADAN LIBRARY xxiii (b) How can you improve on the short comings? 11o How have you integrated the CBD project into the existing local health services? 12. What contributions has this programme made to the Health Care system in Oyo State. # UNIVERSITY OF IBADAN LIBRARY