Month: June 2019

UMBILICAL CORD CARE AND MANAGEMENT OUTCOME AMONG MOTHERS IN CALABAR SOUTH LOCAL GOVERNMENT AREA, CROSS RIVER STATE, NIGERIA

ABSTRACT

Umbilical cord remains the major means for the transmission of infection after birth and constitutes 33% of neonatal mortality in Nigeria. Most of the cord care in Nigeria is home based as two third of the delivery takes place at home. The purpose of this study was to determine the umbilical cord care and management outcome among mothers in Calabar South Local Government Area of Cross River State, Nigeria. The research method was a cross – sectional descriptive survey design. Four hundred and fifty (450) respondents were selected using a snow ball (networking) method. Data were collected using a researcher developed questionnaire. The instrument was validated by the supervisor, two lecturers in the Department of Nursing Sciences who are experts in child health and three neonatologists. The reliability was established using a test re-test method at interval of two weeks. The scores obtained were correlated using Pearson product correlation coefficient to obtain coefficient reliability of 0.993 – 0.99 at 0.05 level of significance. Data collected were analyzed using mean, simple percentage and standard deviation to answer the research questions. Findings revealed that 201 (44.7%) of the respondents had good knowledge of standard cord care and their major sources of information was from mothers / mothers-in-laws. Three hundred and fourteen (69.8%) used unhygienic and harmful materials for cord care. The major reason for choice of materials was mainly to wade away evil spirit which the respondents belief causes neonatal deaths. The technique for cord care was poor as only 92 (20.4%) cleaned the base of the cord before cleaning the surrounding skins. The management outcome was poor as 338 (75.1%) of respondents reported signs of umbilical infections in their neonates and only 5 (4.1%) reported the problem to the health facilities within 24hours of onset of problem. There was a significant association between age, educational level, income and cord management (p=<0.05). In conclusion, there was poor knowledge of standard cord care among the respondents in this study. Unhygienic materials were used in the care of umbilical cord by most of the respondents. Based on the findings, the study recommends that there should be increased home visits and education of the mothers by the health personnel to reduce the consequences of poor cord management after delivery.

 

CHAPTER ONE /INTRODUCTION

Background to the Study                                                                                                    

In developing countries umbilical cord infections constitute a major cause of neonatal morbidity and pose significant risk for mortality (WHO, 2009). Cord management introduced to mothers in both developed and developing countries to reduce exposure of the cord to infectious pathogens include clean cord cutting, hygienic cleaning and washing of hands before and after cord care (Garner, 2008; Basil, Kayode, Mark & Mbe, 2009).

 

The umbilical cord is a unique tissue consisting of two arteries and one vein which at term is about 56cm in length and extends normally from the centre of the placenta to the umbilicus of the unborn baby (Abba, 2008). During pregnancy, the umbilical cord connects the fetus to the mother through the placenta. The blood flowing through the cord brings nutrients and oxygen from the mother to the fetus and carries away carbon dioxide and other metabolites from the fetus (World Health Organisation, 2009; Bello & Omotara, 2010; Ezenduka & Eze, 2002).

 

After the delivery of the baby, the cord should be clamped firmly and cut with sterile instrument to separate the baby from the placenta attached to the mother’s uterus leaving about 6cm with the baby. The instrument used in cutting the cord cuts across the living tissues and the blood vessels which are still connected to the baby. In view of the fact that this time the umbilical cord is wet with an open surface wound and blood vessels still patent, they provide a nutritive culture medium for bacterial growth. These require that some degree of hygiene practices must be adopted to prevent infection, which may present as yellow discharge from the cord, foul smelling, red skin around the base of the cord, pain when touched the skin around the stump and excessive crying.  These strengthen the need for standard cord management among mothers (Bemor & Uta, 2011).

 

Methods of caring for the umbilical cord vary greatly between communities depending on their cultural and religious beliefs, level of education and resources. In the developing countries most deliveries occur at home where health care services may not be available. Sometimes materials used to tie the cord include strings, thread and strips of cloth, scissors and sharp stone (Obuekwe & Obuekwe, 2008). The risk of cord infection is increased by unhygienic cutting of the cord and application of unclean substances such substances sand from door post mixed with saliva, herbal preparations and lantern wax. Even babies delivered in hospitals may be affected by traditional practices after discharge which most times lead to umbilical cord infection and dead among the neonates (Sreeramaraddy, Josh, Sreekumaran & Giri, 2006).

 

The use of alcohol daily and as often as each diaper is changed has been recommended by the World Health Organisation (WHO) as standard care. With standard care the cord usually falls off between five to fifteen days after birth (WHO, 2007). Where clean cord care is not practiced, the cord is readily colonized and infected by pathogenic organisms (Bennet & Adetunde, 2010; WHO, 2007). Therefore, mothers who adopt clean cord management will by implication contribute to the survival of the neonates and prevent neonatal death from infections such as omphalitis, neonatal tetanus and septicaemia (Bemor &Uta, 2011; Bennet &Adetunde, 2010; WHO,2007).

 

Globally, neonatal tetanus accounts for 7% of neonatal deaths, but accounts for more than 48% in Africa (Peter & Johnson 2010).   Nigeria has one of the highest infant mortality rates of 94 deaths/1,000 live births (WHO, 2009). According to the report, 26% was due to umbilical infection (Peter & Johnson 2010; WHO, 2009). In Calabar South Local Government Area of Cross River State, umbilical infection is responsible for 49% of neonatal deaths (Antai & Effiong, 2009). This study therefore addressed umbilical cord care and management outcome among mothers in Calabar South Local Government Area of Cross River State, Nigeria.

 

 

Statement of Problem

Globally, about 130million babies are delivered annually, 4million (3.1%) die within the first 4 weeks of life (Peter & Johnson, 2010). Twenty- five percent (25%) of these deaths are as a result of umbilical infection (Peter & Johnson, 2010). In developing countries, most of the cord care is home based since two third of births take place at home (WHO, 2009). Peter and Johnson (2010) reported that, globally, about 150,000 neonates die annually from omphalitis. Each year some 600,000 infants die of neonatal tetanus in Africa; in untreated cases, case fatality rate approach 100% and a further 460,000 die as a consequence of other severe bacterial infections (Peter & Johnson, 2010).

 

In Nigeria, several hospital-based studies have reported cases of umbilical cord infections. For instance, in Port Harcourt, umbilical cord infection accounted for 10% of neonatal admissions and 30% of neonatal deaths (Antai & Effiong, 2009).  A review of umbilical infection in Ibadan showed that it accounts for 18% of neonatal deaths (Bennet & Adetunde, 2010). In Calabar South Local Government of Cross River State, 49% of neonatal deaths were due to umbilical cord infection while the condition was responsible for 19% of all newborn admissions (Antai & Effiong, 2009). Many of the neonatal deaths occur at home and therefore unseen and unaccounted for in official statistics (Ambe, Bello, Yahaya &  Omotara, 2010; Green, Udoh & Peters, 2006; Garner, 2008). According to the reports, many of these neonates are brought in for admission in very bad state, consequently resulting in neonatal deaths. Unfortunately, these statistics reflect the hospital facility situation, little or no information is available for cases of home neonatal deaths from umbilical cord infection.

 

From the researcher’s experience as a practicing pediatric nurse, several cases of umbilical infections have been rushed to neonatal units often too late to be helped. It is not unusual at primary health facilities to witness several cases of umbilical cord infections. The question that comes to mind which is the problem is – how do mothers manage the umbilical cord since two third of births take place at home in developing countries and cord care is home based? It is therefore desirable to determine the Umbilical cord care and management outcome among mothers in Calabar South Local Government Area of Cross River State, Nigeria.

 

Purpose of the Study

The aim of this study was to examine umbilical cord care and management outcome among mothers in Calabar South Local Government Area of Cross River State – Nigeria.

 

Objectives of the Study

Specifically, the objectives of the study include to:

1. determine the level of knowledge of standard cord management and sources of information  among mothers in Calabar South Local Government Area.
2.  identify the various materials used by mothers for umbilical cord management.

 

1. identify the reasons for the choice of materials used in umbilical cord management.
2. determine the techniques for cord management among mothers in Calabar South Local Government Area.
3. determine outcome of cord management in relation to materials used.

 

1. determine the association between the demographic characteristics of mothers and cord management.

 

Research Questions  

1. What level of knowledge do mothers have regarding standard cord management and from which source of information?
2. What materials do mothers use in the management of umbilical cord?
3. What are the reasons for the choice of materials for umbilical cord management?
4.  What are the techniques used by mothers in umbilical cord management?
5. What are the outcomes of cord management in relation to materials used?
6. What is the association between demographic characteristics of mothers and cord management?

 

Significance of the Study

Findings from this study will provide information to the health personnel on the various materials used by mothers for umbilical cord care, reasons for the choice of materials, the basis on which health decision are made by mothers in relation to cord management. These will  provide specific intervention(s) in form of health education to mothers to reinforce evidence – based strategies for effective cord management for better neonatal outcome.

 

It is also hoped that findings will serve as source of knowledge to mothers on standard cord management, thereby resulting in reduction in umbilical cord infections and neonatal deaths. The findings will also serve as source of knowledge to the community on standard cord management, thereby reducing umbilical infection and neonatal mortality in the community and society at large.

Academically, this work will serve as reference to other researchers in related fields.

         

Scope of the Study

The study focused on mothers in Calabar South Local Government Area of Cross River State, Nigeria. It was delimited to umbilical cord care and management outcome among mothers in Calabar South Local Government area of Cross River State. It was also delimited to the knowledge of standard cord management and sources of information, materials used by mothers, reasons for choice of materials, techniques of cord care, and the association between the demographic characteristics of mothers and cord management.

 

Operational Definition of Terms:

Umbilical Cord Care: the various materials used in cord care, the reason for the choice

of materials by mothers and the techniques used for cord care.

Knowledge of Standard Cord Management: implies awareness of the recommended methods

of cord care which are:  tying the cord with cord clamp, cutting with clean object, cleaning with

methylated spirit and keeping it clean; the range of cord separation time which is between 15days and knowledge of advantages of cord care which is to prevent cord infection.

Materials used:  tools for cutting and solutions/substances used for cleaning or applying on the

umbilical cord such as sterile scissors, surgical blade, sharp stones, alcohol (methylated spirit),

salty water, breast milk, herbal preparations, “Ndodop” lantern wax, salt, saliva and sand, triple

dye, strips of cloths and tree bark fiber.

Techniques Used by Mothers:  method of cleaning the umbilical cord, the frequency, wet or

dry care, closed or open wound care.

                                                     

Wet Care: use of liquid materials in cleaning the cord at the time of delivery and care is repeated daily until the umbilicus heals.                                              

Dry care: no cleaning nor application of liquid / substances to the cord after birth till it heals

naturally.

Closed wound care:  the use of umbilical binders or bandage after cleaning the cord.

Open wound care: the umbilical cord is left uncovered after cleaning to promote drying, cord

separation and healing.

Reason for choice of substances: why mothers choosed the various materials for cord care. The

reasons may include cultural and religious beliefs, influence of health workers and significant

others (mothers/mother in-law, Traditional Birth Attendants, church members).

Management outcome: entails cord separation time and healing in relation to material used for

cord care. If there was any infection (red skin around the base of the cord, yellow discharge from

the cord, foul smelling cord, pain when touched the skin around the cord, unable to open

mouth/suck or twitching) and how it was managed.

Demographic characteristics: used in this study were age, educational attainment and income of

the mothers.

TEACHERS PERCEPTIONS OF THE USE OF OBJECTIVE STRUCTURED CLINICAL EXAMINATION TOOL TO EVALUATE STUDENTS CLINICAL COMPETENCE IN  MIDWIFERY SCHOOLS SOUTH EAST NIGERIA

 

CHAPTER ONE

INTRODUCTION

Background to the Study

Evaluation of learning outcomes is an important and inevitable part of the education process that has been carried out in institutions of learning for ages. This is because; it is through academic evaluation that one infers whether the learner has learned and how far educational learning objectives have been achieved.   Tyler in Basavanthappa (2009) defined evaluation as a process of determining to what extent educational objectives is being realized. Scriven in Mahara (2002) stated that evaluation is both a process and a product. A process of systematically and objectively determining the merit, worth and value of things and also denotes the product of that process. Evaluation is done using evaluation tools, which are instruments used in determining whether or not learning has taken place. A major focus of evaluation in Midwifery education is to determine those students who have acquired the knowledge and skills needed to practice Midwifery based on set standards (already agreed upon by educators). This thus involves class room and clinical evaluation.  Clinical evaluation in Midwifery Education is aimed at appraising the quality and standard of clinical competence of students following training in order to produce graduates who can perform competently in real life situation.

 

Clinical competence is said to be what the students should be able to do at an expected level of achievement such as at graduation. It is also the synthesis of all attributes necessary to do that task for which one is being trained.  College of registered nurses of Mamtoba (2012), defined clinical competences as the mastering of relevant knowledge and acquisition of a range of relevant skills at a satisfactory level including interpersonal, clinical and technical competences and the integration and application of the knowledge, skills, judgment and attitudes required to carry out the role and work for which one is being trained. Competencies can be cognitive or performance based.  The cognitive measures of competence is more efficiently measured psychometrically (e.g. self assessment test) while performance based measures are better evaluated using performance based assessment example OSCE.

 

Traditionally evaluation in clinical setting in Schools of Midwifery was done using oral/practical examination, where a number of students were examined in different clinical areas of practice. According to Barman (2005), questions asked were not consistent. The traditional method was very subjective, had poor-inter-rater reliability and was subject to halo effect (Shaw, 2006).  Both teachers and students were dissatisfied with this method of evaluation because of these deficiencies. This made evaluators to search for a more appropriate objective and standardized alternatives to improve the evaluation process.  A standardized form of examination to be used as tool for assessing clinical competence was deemed necessary to help educators obtain accurate and objective information about students understanding of what has been taught and so helps in determining whether or not learning has taken place (Benner; Friedman; & Menin in Mahara, 2002). This led to the introduction of objective structured clinical examination (OSCE) in Schools of Midwifery in Nigeria, as a tool for assessing clinical competence of Midwifery students.

 

According to Medinfo (2009), Objective structured clinical examination (OSCE) is a form of performance based assessment used to measure candidates’ clinical competences.  OSCE is a more objective, comprehensive consistent and standardized tool for assessing students’ clinical skills and competence (Igbal, Khizar and Ziadi 2009) than the traditional oral practical method of evaluation. According to Hala and Hanna(2012) OSCE is one of the most valid, reliable and effective test to measure synthesis of knowledge and clinical skills.  OSCE stations provides the mechanism for assessing the students application of knowledge as well as his or her psychomotor and interpersonal skills, problem solving abilities, teaching and assessment skills.  OSCE is also perceived as an excellent teaching and learning mechanism.  However it is expensive and labour intensive.

It was introduced in 1975 by Dr. Ronald Harden and his colleagues at University of Dundee in Scotland for clinical assessment of medical students. OSCE was gradually adopted widely first in the United States of America (USA), followed by United Kingdom (UK). OSCE is now used in over 50 countries of the world (Praveen and Suman 2012). It has been accepted as the main tool for clinical assessment in medical schools and licensure bodies across USA, Canada, UK, Australia, New Zealand and other countries of the world, due to the perceived benefit and merit of OSCE over other evaluation tools like oral/practical exams, multiple choice questions, viva voce etc. It is now being used in both health and non-health disciplines like dentistry, nursing, midwifery, engineering and law (Praveen and Suman  2012).

 

The acceptance of OSCE as a standardized tool for evaluation of clinical competence was based on teacher’s knowledge and their perception of the benefits derived from using OSCE over a period of time.

The Nursing and Midwifery Council of Nigeria (N&MCN) adopted the use of OSCE as an evaluation tool for assessing clinical skills and competencies of student midwives since 1992. However since the introduction of OSCE in school of midwifery in Nigeria it has not been assessed.  The current study is therefore intended to investigate the perception of teachers on the use of OSCE for measuring students’ clinical competence in order to provide evidence about the feasibility of its use as an evaluation tool.

 

Statement of Problem

Evaluation of clinical competence is an important activity with a lot of consequences on the welfare of the patients and community at large. Faulty method of evaluation will yield wrong data that can lead to graduation of incompetent students whose practice can have detrimental effects on the clients and thus increased morbidity and mortality rates. In addition, graduation of students who do not merit pass based on faulty evaluation tools may produce incompetent practitioners whose practice can expose them to litigations and this also affect their self esteem and their means of livelihood (Orchard in Mahara 2007). OSCE appears to be generally accepted as a gold standard for assessing clinical skills in developed   countries of the world but it has not been used extensively in some schools in underdeveloped and resource constrained locations.  In some schools the use of OSCE was introduced but was later replaced with traditional methods of clinical evaluation (Ernesto, 2004).  This is because they perceived such methods to be better than OSCE due to problems peculiar to OSCE which ranges from human resources, material resource and organizational problems (Trocon, 2003). Schools of midwifery in Nigeria being a low resource area may not be left out.  It is a known fact that resources invested into both health and educational systems in Nigeria is not enough. This may have affected the evaluation process in schools of midwifery in Nigeria as well.  The N&MCN recently mandated educators in schools of nursing and other post basic schools to plan for the introduction of OSCE in their schools.  If OSCE is to be introduced successfully, there is need to find out the perception of educators in schools of midwifery about OSCE. This is important in order to identify the weaknesses of the already existing OSCE.  When these weaknesses are taken care of they will in no doubt lead to successful introduction of a reliable, objective and valid OSCE.

 

Purpose of Study

The purpose of this study is to investigate teachers’ perception of OSCE as a tool for assessing student’s clinical competencies in Schools of Midwifery.

 

Research objectives

The specific objectives of the study are to:

• Determine teachers’ opinion about the appropriateness of OSCE tool for midwifery examination.
• Determine the teachers’ view about the task involved in preparing for an OSCE examination.
• Determine teachers view about administration of OSCE as a tool for clinical evaluation.
• Identify perceived benefits of using OSCE for clinical evaluation from teachers.
• Find out problems associated with OSCE as a tool for assessing clinical competence as perceived by teachers.

 

Research questions

• What are the opinions of teachers about the appropriateness of OSCE for Midwifery examination?
• How do teachers in school of Midwifery view the task of preparing for an OSCE?
• How do teachers in school of Midwifery view the process of administering OSCE?
• What do teachers perceive as benefits derived from using OSCE for clinical assessment of students?
• What do teachers in school of Midwifery perceive as the problems associated with the use of OSCE?

 

Hypotheses

1. There would be no significant difference in the perception of teachers with 1 – 10 years experience and those with above 10 years experience about OSCE.
2. There would be no significant difference in the perception of teachers about OSCE among teachers with degree and those with diploma.

 

Significance of the study

The findings of the study have revealed perceptions of teachers in schools of Midwifery about the use of OSCE as an evaluation tool with regards to its strengths and weaknesses. The findings will serve as a useful guide to Educators in the field of nursing and midwifery to forestall obvious or anticipated problems and benefits. The problems when taken care off will enhance successful construction, implementation and execution of the new evaluation tool/technique. It will also encourage teachers’ to either revise or improve the already existing OSCE in schools of midwifery or use other methods together with OSCE to enhance adequate evaluation of clinical competence in basic and post basic schools of nursing. This will go a long way to reduce morbidity and mortality rates among mothers and children.

 

 

Scope of Study

This study was delimited to studying perceptions of teachers in accredited schools of Midwifery in South East Nigeria who are involved in OSCE with regards to appropriateness of OSCE, the task involved in preparing OSCE, the process of administering OSCE and the benefits and problems associated with OSCE.

 

 

Operational Definition

Teachers’ perception of OSCE

This refers to the views and opinions of teachers about OSCE as a tool for clinical evaluation as measured by the Teachers Perceptions of OSCE Questionnaire.

Teachers

In this study  teachers refers to both midwifery tutors and clinical instructors who make direct use of OSCE tool during clinical assessment in schools of midwifery.  They develop, administer and score OSCE.

Clinical competence

This refers to what a student midwife is able to perform in terms of practice, based on set standards by N&MCN at the time of graduation, such as taking care of mothers during pregnancy, labour and pueperium and their babies.

Evaluation of Clinical skills and competence

Refers to assessment of student midwives clinical learning outcome (in terms of skills and competences) using OSCE as a tool.

 

SOCIOECONOMIC FACTORS AS DETERMINANTS OF QUALITY OF LIFE OF DIABETIC PATIENTS IN NNAMDI AZIKIWE UNIVERSITY TEACHING HOSPITAL NNEWI ANAMBRA STATE

CHAPTER ONE

INTRODUCTION

Background of the study

Diabetes Mellitus (DM) describes a group of metabolic diseases in which the person has high blood glucose (blood sugar), either because insulin production is inadequate, or because the body’s cells do not respond properly to insulin, or both (Nordqvist, 2013). Globally, the number of patients with diabetes is expected to increase from 285 million to 439 million by 2030 (Shaw, Sicree, & Zimmet, 2009). Currently, DM affects 246 million people worldwide (Levitt, 2008). According to Nwankwo, Nandy and Nwankwo (2010), the major part of this numerical increase will occur in developing countries. There will be an increase from 51-72 million in the developed countries and 84-228 million in the developing countries. Thus by the year 2025, greater than 75% of people with DM with will reside in developing countries.

The disease was previously thought to be rare in Africa, the population regarded as low and middle income; however, as a result of changes in the lifestyle, feeding patterns, and levels of physical activity among other factors, the prevalence has increased in many African countries over the past few decades. For example, the diabetic population in Uganda, estimated at about 98,000 in 2000, increased more than fifteen times (1.5 million) in a decade. Based on the country’s estimated population of 30 million people in 2010 (Nyanzi, Wamala & Atuhaire, 2014), the figure implies that about five percent of the country’s population was diabetic.

Nwankwo,et al (2010), posited that while it is estimated that 92% of Nigerians live under $2 a day, studies have shown that there has been a progressive increase in the prevalence of diabetes in Nigeria and the burden is expected to increase even further. According to World Health Organization, there are 1.71 million People living with diabetes in Nigeria and this figure is projected to reach 4.84 million by the year 2030 (WHO, 2009). Current prevalence rate estimates of diabetes in Nigeria have been tagged at 2.5% compared to its 2.2% rate in 2003, ( Nwankwo,et al,2010) .

Diabetes is associated with long-term complications that affect almost every part of the body (National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), 2014). The disease often leads to blindness, heart and blood vessel disease, stroke, kidney failure, amputations, and nerve damage. Uncontrolled diabetes can complicate pregnancy, and birth defects are more common in babies born to women with diabetes. According to Nwankwo, et al (2010), diabetes and its complications impose significant economic consequences on individuals, families, health systems and countries.

The threat is growing. The number of people, families and communities afflicted are increasing. This growing threat is an under-appreciated cause of poverty and hinders the economic development of many countries (WHO, 2009) and the economic burden is heavy. The upward trend in the number of diabetic patients points to the need for improved treatment and care for the disease. The fact that treatment for the disease and its associated complications are highly complex, a considerable patient education and medical monitoring are required. Thus, the patient is required to regulate blood sugars amidst required changes in lifestyle factors and the unpleasant medication that usually accompanies the disease in order to maintain a correct degree of metabolic control. The fact that these changes make the patients vulnerable to stress, their quality of life is highly bound to be affected.

Quality of life is a scientifically proven indicator of the quality of health experienced by a patient (Eckert, 2012). Due to insufficiency of traditional end points (which are mainly focused on the biologic and physiologic outcomes) in capturing the effects of interventions on patients’ health-related quality of life (HRQoL), a growing interest has emerged during the past decades for assessing determinant factors of patients HRQoL, especially in chronic diseases. Six studies, which examined the effect of diabetes on HRQoL, compared HRQoL in people with and without diabetes and reported negative effects of both type 1 and type 2 diabetes on HRQoL (Aliasghar, Baharak, & Mirmalek-Sani, 2013)

According to Nyanzi, et al (2014)  the predictors of quality of life of diabetic patients are identified by Imayama et al (2011)’s study as personal, medical, and lifestyle factors. Particularly, the study noted that old age, higher income, higher score on activity (personality) trait, not using insulin, having fewer comorbidities, lower body mass index (BMI), being a nonsmoker, and a higher physical activity level were significantly associated with better health related quality of life in adults with type 2 diabetes. . The findings of Aliasghar et al (2013) showed that people with diabetes had a lower HRQoL than healthy people. The findings also indicated that better socioeconomic status and better control of cardiovascular risk factors were associated with better HRQoL among patients with diabetes.

In line with these studies, there has been a resurgence of interest in the relation between health and socioeconomic position (SEP). SEP encompasses two important notions: the influence of the structural location of individuals and groups in a society and the cumulative effects of time. It addresses the context in which health-damaging exposures and health-protective resources act at different stages of the life course to influence adult health. Such an approach provides a broad framework in which to think about and understand how both recent and remote socioeconomic factors interact to affect adult health. A substantial body of literature demonstrates that in the general population, material and social deprivation are directly related to disease incidence and prevalence and inversely related to health status. According to Brown, (2014) various studies have addressed the relationship between lower SEP and mortality or the development of chronic conditions such as diabetes mellitus, cardiovascular disease, and cancer. Research on the relationship between SEP and health has often focused on individual characteristics such as income, wealth, education, and occupation. However, SEP encompasses not only current individual socioeconomic status but also social relationships and community-level characteristics (Brown, 2014).

Brown, (2014) further stated that although effective therapies are available for managing diabetes and preventing or treating its complications, these therapies are underutilized, particularly among persons of low socioeconomic status. For someone with diabetes, socioeconomic status such as educational level, income and culture may influence access to and quality of care, social support, and community resources. It may also influence diabetes-related knowledge, communication with providers, ability to adhere to recommended medication, exercise, and dietary regimens, and treatment choices. Socio-economic  factors  such  as income, education and neighborhood culture determine  how  people  are  born,  live grow  and progress  in life .They determine how people maintain good health. When  an individual is  poor  and ignorant  it  creates  barrier  in accessing  health  care  because  the individual  cannot  afford  the  cost . Besides  an  ignorant person  would  not  be  aware of the  ill health  and   would  not  seek  for  help  at the proper  time and place  when  the  need  arises.

The social status of persons with diabetes and the characteristics of their communities or culture may determine their risk of mortality and diabetes-related complications as well as their quality of life. Lower individual SEP, as measured by individual or household income, education, employment, occupation, or living in an underprivileged area, has been associated with poorer physical or emotional health, all-cause mortality or poor quality of life. In order words, poor socioeconomic factors affect the quality of life of an individual because   he may not be able to meet up with required need. At the same time with good socioeconomic status there is the need to use it properly as it may positively or negatively affect the quality of life of an individual.

In the light of the foregoing, the following question was posited: What role does socioeconomic status such as education, occupation; culture and income play in the quality of life of diabetic patients? This study is aimed at assessing how socioeconomic factors are determinant of the quality of life of diabetic patients in Nnamdi Azikiwe University Teaching Hospital.

Statement of the problem

DM is a serious disease and a cause for a growing public health concern in both developed and developing countries. This is because DM is an incurable chronic disease that patients live with their whole life; its complications are usually serious and problematic. There is also rapid increase in prevalence of DM globally and especially in developing countries. Current prevalence rate estimates of diabetes in Nigeria have been tagged at 2.5% compared to its 2.2% rate in 2003 (Nwankwo, et al, 2010). In NAUTH the prevalence of diabetes is noted to be increasing from the records of the endocrinology department (2013 = 780, 2014 = 811).

The prevalence of complications of DM such as nephropathy, diabetic foot ulcer and cardiovascular diseases in this population is high. Most of the patients only report to the hospital when complication has set in. In some cases the patients either sign against medical advice or they do not procure the prescribed drugs. All these may impact on the quality of life of individual. One wonders if socioeconomic factors such as education, income, occupation and culture are contributory. According to Majed (2013), several studies have demonstrated that DM has a strong negative impact on the HRQOL, especially in the presence of complications, though from literature there is paucity of information on quality of life of DM patients in Anambra state. Most of health care interventions are only concerned with eradication of symptoms and attempts to delay complications as much as possible. Health care is essentially a humanistic transaction where the patient’s well-being is a primary aim, therefore attention should be focused on QOL aspect of health from the need for commitment to the continued promotion of a holistic approach to health and health care, as emphasized in the WHO definition of health as “A state of physical, mental and social well-being, not merely the absence of disease and infirmity”. This study focused in assessing socioeconomic factors as determinants of quality of life of diabetic patients.

Purpose of study

The study is conducted to assess socioeconomic factors as determinant of the Quality of life (QoL) of diabetic patients in Nnamdi Azikiwe University Teaching hospital Nnewi, Anambra state.

Specifically, the study determined the QoL of the diabetic patients by domain and the educational, economic, occupational, religio-cultural and social / family factors as they relate to their QoL.

Research questions

• What is the QoL of diabetic patients in NAUTH by domain?
• What association is there between diabetic patient’s educational levels and their quality of life?
• How is diabetic patient’s economic status associated with their quality of life?
• What is the association between diabetic patient’s occupation and their quality of life?
• How are diabetic patient’s religio-cultural practices in the management of DM associated with their quality of life?
• What is the association between diabetic patients social / family supports and there quality of life.

Research Hypotheses

1. There is significant association between diabetic patient’s educational levels and their quality of life.
2. There is significant association between diabetic patient’s economic status and their quality of life.
3. There is significant association between diabetic patient’s occupation and their quality of life.
4. There is significant association between diabetic patient’s religio-cultural practices in the management of DM and their quality of life.
5. There is significant association between diabetic patient’s social /family supports and their quality of life.

Significance of the study

This study will provide much needed information about the socioeconomic factors that affect the life of diabetic patients. Knowledge of this will be of great benefit to the diabetic patients, health care providers, the general public, other future researchers, and the country as a whole.

Knowledge of this will assist health care providers to know areas to focus on during health care education, and it will help them to plan and provide effective and efficient health education for the patients. When patients are adequately educated and empowered, they are able to take care of themselves better, thereby reducing complications and fostering improved quality of life free of disabilities.

It will inform those tasked with health rationing or anyone involved in the decision making process. The outcome may be economic and social security policies that have positive impact on the lives of people with diabetes, thereby improving their quality of life.

The general public will also benefit as there will be reduction in health care cost, improved quality of life of diabetic patients, and improved economic productivity of the country and reduction in morbidity and mortality rate due to diabetes complications. It will also be of help to other researchers who may wish to work in this field in future.

Scope of the study

The study is delimited to diabetic patients, who are receiving treatment at the diabetic clinic at NAUTH .It is also delimited to the association between socioeconomic factors such as education, income, occupation, religious-cultural practices, family/social support and the quality of life of diabetic patients in NAUTH.

Operational Definition of Terms

Quality of life

In this study the researcher has adapted the WHO’s definition of QOL which identifies it as a multidimensional concept and defines it as “individuals’ perceptions of their position in life in the context of the culture and value system in which they live and in relation to their goals, standards, and concerns” (WHO 1993). The definition includes six broad domains: physical health, psychological state, level of independence, social relationships, environmental features, and spiritual concerns.    It will be assessed using adapted WHO-SRPB field test instrument, covering overall quality of life and aspects related to spirituality, religiousness and personal beliefs. Each item is scored on a point likert scale 1(low) -5(high) and a mean score calculated for each domain. Respondents with scores below 3 are rated with low QoL and those with scores above 3 are rated with high QoL. The mean score of items within each domain is used to calculate the domain score.

Diabetic patients

ABSTRACT

The study investigated the relative influence of note taking and group discussion method through experimental manipulations. The main objective of this study is to verify the relative influence of two study methods (note-taking and group discussion) on performance of student nurses on a test. A 3 x 2 x 2 factorial design was adopted for the study. The sample consisted of 96 students who were randomly selected from three experimental conditions (of 32 students from each school). Two of the groups were subjected to experimental manipulation while the third served as control group for the study. Training on note taking skill and group discussion study skill were given to the two experimental groups. The two experimental groups were again subjected to learning and using either of the two study methods exclusively for preparation for an examination that took place one week after the lectures and trainings. An examination on personal and environmental hygiene test was conducted to assess performance changes brought about by experimental manipulation. Analysis of covariance (ANCOVA) and student’s t-test was used in order to test the eight hypotheses formulated for the study. Based on the principal findings that: The two study skills had influences on the students performance and that note taking group performance was significantly better than the discussion group recommendations were given. It was recommended that the teaching of study methods be included in the primary and secondary school curriculum to capture student during their formative years.

 

 

 

CHAPTER ONE

INTRODUCTION

Background of the Study

Academic performance is the index used to determine how well educational objectives have been achieved. Education has been seen as the process of helping an individual to discover, develop and make use of his inner abilities, potentials and capabilities for successful living in the society. In this process, it is academic performance of individual that is used to infer academic success or failure (Seidler, 2007).

 

According to Dewey (2005), learning is intelligent development of all the possibilities inherent in experience. The ability to acquire and utilize these experiences he termed learning. The ability for effective learning can be improved upon through different ways and anything that can improve learning can improve academic performance.

 

Recent findings as presented by Nwabuisi (2004) and Selye (2004) have shown that there is only a thin line between learning outcome and study habits or methods. Good study method they said is a prerequisite for achieving academic excellence. Different people use different approaches during studying to achieve academic excellence. Dewey (2005) identified and outlined different study methods to include note taking while reading, organization of discussions groups or reading buddies, memorising, reading through and reciting.

 

These study methods have been used by students over decades. Several researchers (Ash and Carlton, 2003, Fisher, 2006, Udayton, 2008,) carried out surveys to determine the different study habits of students. From each of these surveys, 50% of the respondents prefer group discussion and 40% uses note taking while studying, and 10% do not have definite styles of studying .This goes to show group discussion and note taking as mostly used study styles.

The prime place of good study habit on academic performance among students cannot be under-estimated. Note is the students’ closest companion. It is the most readily available cue to the memory in the educational enterprise. Note taking is very much an integral part of the learning process; it converts the art of reading to the art of studying. It has been identified by many authors including Rimum and Master (2006); Coleman (2003); and Nweze (2004), as a means of achieving recall, reconstruction and utilization of learnt materials.

 

Group discussion method is a very helpful study style for some students. It is a round table tutorial class in which ideas, views and impressions are shared among the group. This also creates an avenue for problems on a particular subject to be solved collectively within the group.

 

Teachers, parents and counsellors over the years have been advising students to engage in one or two of these study styles in a bid to help them pass their examinations without sound basis. This work therefore seeks to ascertain the relative influence of the two study methods on academic performance of student nurses.

 

There is scanty of literature in nursing education in nursing students’ study habit and influence in their academic performance.  The present study will fill the gap in knowledge.

 

Statement of Problem

The level of academic failure among student nurses within our environment is high. Over the years, it is observed that the percentage of students that fail in the nursing and midwifery council examination is on the increase. For instance, over the past decades, the council has continually recorded a high percentage of failure among students who were presented for examinations throughout the federation with only few exceptions of schools where students performed well. Many schools of nursing for example school of nursing ESUTH have recorded mass failure of PTS examination since its inception. Also the result of council examination from the department of nursing sciences Ebonyi State University Abakaliki in 2009 showed 25% pass recording up to 75% failure. Other basic schools of nursing also recorded similar results where greater percentages of students failed. This situation is upsetting and worrisome to any nurse educator and parents. The trend does not augur well with the nursing profession.

 

Apart from students’ poor performances, other factors contributed to the interest for the present study. In the course of her interaction with the students, the researcher observed that many students who performed poorly at institutional examinations complained of certain problems that led to their poor performances to which they seek counselling. For instance, some students  who came for counselling complained of problems like poor concentration while studying, lack of understanding, others complained of understanding while studying , but when  given question papers during examinations, their brain will suddenly go blank thereby forgetting everything they have read and so on. These and other problems complained by students’ point to problems associated with poor study habits.

 

Findings from previous studies, (Dewey, 2005, Carebridge, 2007) have shown that poor study habit often lead to inadequate learning which subsequently lead to poor academic performance. The foregoing has prompted the interest for the study. This study therefore is designed to determine whether note taking and group discussion methods of studying have any influence on students’ performance on a test. As far as the researcher is concerned; no study in nursing has investigated the effects of these two study methods on student’s performance in Nigeria. The present study will therefore close the gap thereby providing baseline information.

 

 

 

 

 

 

 

 

 

 

 

 

Purpose of the Study

The need to improve learning, foster good academic performance and combat massive academic failure among our students stimulated the interest for the present study. The purpose of this study is to ascertain the relative influence of two study methods – note taking and group discussion – on performance of student nurses in School of Nursing, University of Nigeria Teaching Hospital Enugu, School of Nursing, Enugu State University Teaching Hospital Park Lane and School of Nursing, Mater Mesiricodea hospital Afikpo Ebonyi State.

Thus, the study is specifically geared toward achieving the following objectives:

• To ascertain the influences of note taking and group discussion methods of learning on performance of students on a test.
• To identify which of the studying methods – note taking or group discussion – is more effective in improving performance of students on a test.

 

 

Significance of Study

Contemporary societies worldwide placed ultimate priorities on the education of students. Parents in both developed and developing nations of the world are pushing their children to achieve academically as much as they can, earlier than ever before (Sarafin, 2003, Ellis, 2002).

 

The paramount aim of education in Nigeria is “the development of the intellectual capacity of individuals to understand and appreciate their environment, the acquisition of both physical and intellectual skill that will enable individual to develop into useful members of the community (NRC, 1999). This aim can hardly be achieved in the absence of effective learning strategies.

In the light of all these considerations, the findings from this study would be useful in the overall teaching/learning process both at Schools of Nursing and universities where nursing is being studied. It will therefore provide a very firm empirical basis for maximizing home and lecture room teaching and learning. It will add to the existing body of knowledge in education.

 

The finding will equally add to the scanty literature on study habit or skill; and sharing of knowledge from this study may contribute to reduce to the barest minimum students’ involvement in examination malpractice.

 

Scope of the Study

The study covered two study methods – note taking and group discussion; the influences of these two study methods on performance of nursing students in three schools- School of Nursing, University of Nigeria Teaching Hospital Enugu, School of Nursing, Enugu State university of science technology and School of Nursing, Mater Mesiricodea Hospital Afikpo, Ebonyi State.

 

Research Questions

• Is there any significant difference in the performance of students who are exposed to note taking and group discussion methods and those of the control group?
• Is there any significant difference in the performance of students who are exposed to note taking study method and those in the control group?
• Is there any significant difference in the performance of students exposed to group discussion study method and those in the control group?

(4)        Is there any significant difference in the performance of students exposed to note taking study method and those exposed to group discussion study method?

(5)        Is there any significant difference in the performance of male and female students exposed to note taking study method?

(6)        Is there any significant difference in the performance of male and female students exposed to group discussion study method?

(7)        Is there any significant difference in performance of students with high and low mental ability exposed to note taking study method?

(8)        Is there any significant difference in the performance of students with high and low mental ability exposed to group discussion study method?

 

Hypotheses

The following null hypotheses were tested at 0.05 level of significance:

• There is no significant difference in the performance of students who are exposed to note taking and group discussion methods on one hand and those of the control group on the other hand.
• There is no significant difference in the performance of students who are exposed to note taking study method and those in the control group.
• There is no significant difference in the performance of students exposed group discussion study method and those in the control group.

(4)        There is no significant difference in the performance of students exposed to note taking study method and those exposed to group discussion study methods.

(5)       There is no significant difference in the performance of male and female students exposed to note taking study method.

• There is no significant difference in the performance of male and female students exposed to group discussion study method.
• There is no significant difference in performance of students with high and low mental ability exposed to note taking study method.
• There is no significant difference in the performance of students with high and low mental ability exposed to group discussion study method.

 

Operational Definition of Terms                                                        

Students Performance: In this study means the students’ grade or score on personal and environmental hygiene test. Such that 70-100 means excellent performance 50-69 means borderline performance while  0-49    means poor performance.

 

Note Taking: is the study method or style in which the students will read individually, taking down notes while reading in order to gain full understanding of the content of the learnt material.

 

Group Discussion: is a study method whereby the students engage themselves in small group of 4 – 5 in order to discuss a study material.

 

Study Habits: These are methods or styles, students use when reading for their examination.

 

Mental Ability: In this study means the ability of the students as measured by the students grades (scores) in the examination. Those that scored 60 and above were regarded as with high mental ability. Those that scored 49 and below were regarded as with low mental ability. Those that scored 50 – 59 were not included to provide reasonable demarcation between the high and low mental ability students.

CHAPTER ONE

                                                 INTRODUCTION

Background to the Study

Test and testing are part of all educational programmes. In basic nursing school classroom content is complex, the scope is broad and the pace is accelerated. Frequent testing of students is necessary throughout the programme for evaluation of progress in mastering content.  Also at the end of planned instruction, preliminary training stage (PTS), junior block, intermediate block, students are given examinations.  Their performance in such examinations is used to make decisions that impact on the students. Examination performance thus is an important issue for the students. Students finishing their PTS verbalize and exhibit a great deal of anxiety regarding PTS examinations.

 

Anxiety is one of those emotional components of human life; it is a basic human emotion consisting of fear and uncertainty that typically appears when an individual perceives an event as being a threat to the ego or self-esteem (Sarason, 1988 in Eric Digests 2005). When students develop serious fear of performing poorly in an examination it is termed test anxiety. According to Zeidner (1998), test anxiety is a multidimensional sign that can be described as a group of phenomenological, physiological, and behavioral reactions that occur with possible negative consequences or failure in an examination or similar evaluative situation.  Test anxiety especially worry has impact on academic performance and working memory (Eysenk, 2001).  There are two major tasks for students who find themselves under test condition. One is to be able to cope positively with that feeling of unpleasantness and uncertainty brought about by test and similar situations.  The other is to live up to expectation of the test by performing well.  Most students might study hard to pass tests but might not be able to overcome or resolve the conditions they find themselves in during examinations such as test anxiety.

 

Examination performance is the grade point average or score obtained following an examination. This is often expressed in percentage e.g. (50%) or in letters e.g. A, B etc. There are many factors that affect examination performance; one of these is test anxiety.  Researchers estimate  that 20 to 30 percent of American students experience test anxiety (Strauss, 2012).

 

Some research works carried out in Nigeria have shown that our students in primary, secondary and higher institution experience test anxiety (Ebigbo, 1982 in Akubuiroh, 1990).  Although Kalu (1980) and Akubuiroh (1990) did some work on the relationship between test anxiety and examination performance, it has been long.  No recent major work has been done to show whether the level of test anxiety (high, moderate or low) relate significantly to examination performance (high, moderate or low score levels).  The focus of this study therefore is to determine the relationship between test anxiety and examination performance.

 

Statement of Problem

The prevalence of poor academic performance among secondary and tertiary students has been high in Nigeria (Ekundayo, 2010). For the past three years both the senior secondary school certificate (SSCE) results and joint admission and matriculation board results have been poor. For instance in the 2013 SSCE GCE only 29.17% of candidates obtained credits and above in five subjects including English and Mathematics which showed 8% decline over 2012 GCE results. The likely factors were stated to include qualification and experience of teachers, poverty, method of conducting the examination and test anxiety of the students.

 

In the case of Basic Nursing School, the PTS examination is believed to induce a great deal of anxiety because out of the four papers taken in the examination if a student fails three or four papers he/she will have to discontinue the nursing programme whereas failing two papers will give him/her opportunity to repeat the PTS class for six months and this also means waiting for the next PTS class to come in thus losing one year in the course of study.  In the same vein failing one paper will subject the student to re-sitting for that one paper.  Only the students who pass all four papers and oral/practical will happily move to the next level.

Also in the Basic Nursing Schools there are cases of nursing students who come in with good ordinary level grades, participate actively in class work, do their assignments, prepare for examinations and think they have a grip of the course material but on the day of examination some of them blank out and feel so nervous that they cannot respond to those questions they knew the answers the night before (Lyness, 2010).

 

 

Most studies focusing on examination performance centred outside the personality construct of the students such as test anxiety.  Factors such as teaching methods, experience of the teachers, school and classroom  environment and the like have been studied and recommendations made and there is no evidence of improvement.  The researcher wondered  whether the problem may be associated with test anxiety and that gave impetus to the study.

 

 

In addition, contradicting findings in this area have been reported in other countries.  Hence the need to investigate the level of test anxiety of students prior to and during examination and see if the test anxiety has any relationship with students’ examination performance in basic nursing schools.

 

 

 

Purpose of the Study

This study intends to find out if there is any relationship between test anxiety and examination performance of basic nursing students.

 

 

Objective of the Study

Based on the purpose of study the following objectives were set for the study.

1. To determine the test anxiety levels of basic nursing students during examination.
2. To determine the relationship between test anxiety scores and examination performance of nursing students.

 

3. To determine if there is a significant difference in the test anxiety levels of students in the two schools.

                                                                                              

Research Hypothesis

Ho1:                There is no significant relationship between test anxiety scores and examination performance/scores of basic nursing students.

Ho2:                There is no significant difference in test anxiety levels of nursing students from UNTH and those of ESUTH.

 

Significance of the Study

It is hoped that findings from this research will show the levels of test anxiety of nursing students during examination and the relationship between the test anxiety and examination performance.

 

These findings will help students who have severe anxiety to seek counseling and/or strategies for coping with test anxiety before taking examinations.

 

Also findings from this research will help nursing educators to understand why many able students fail examinations and exist Nursing programmes.  This will enable them implement methods aimed at reducing test anxiety among students.

 

In addition findings from this work will help Nursing and Midwifery Council of Nigeria inculcate techniques and strategies for coping with test anxiety in the curriculum of basic nursing schools to ensure good examination performance.

 

Scope of the Study

This study will cover two basic schools of nursing in Enugu urban namely, school of nursing University of Nigeria Teaching Hospital (UNTH) and school of nursing Enugu State University Teaching Hospital (ESUTH) both in Enugu urban. The variables concerned in the present study are Test Anxiety, Examination performance and the relationships between the two.

 

This study is also delimited to determining the test anxiety scores of the students, whether there is a relationship between test anxiety score and examination performance and whether there is a difference in the tests anxiety levels of students in the two schools.

 

The study will also be delimited to the PTS nursing students in the two schools.  PTS nursing students were chosen because of the PTS examination which is very anxiety inducing as a certain level of failure will lead to discontinuing the nursing programme.

 

Operational Definitions

For the purpose of this study, the terms listed below are defined as follows:

Test Anxiety: feeling of distress or nervousness and other emotional symptoms during a test or examination as measured by Sarason Test Anxiety inventory used for the present study. There are three categories of test anxiety.

Mild Test Anxiety: This is test anxiety scores from 40 – 79.

Moderate Test Anxiety: This is test anxiety scores from 80 – 119.

High/Severe Test Anxiety: This covers scores from 120 – 160.

Examination Performance: End of PTS examination scores as published by UNTH and ESUTH.

Nursing Students: PTS students in the school of nursing UNTH and school of nursing ESUTH.

PTS Examination: This is the first examination taken after six months of preliminary nursing training.

Sarason Test Anxiety Scale: Also known as reactions to tests anxiety scale will be used to measure test anxiety in this study.

PSYCHOSOCIAL CHALLENGES EXPERIENCE BY PATIENTS AT TERMINAL STAGE OF ILLNESS AND THEIR PERCEPTION OF PALLIATIVE NURSING CARE IN TERTIARY HOSPITALS

 

ABSTRACT

Terminal illness is the term used to describe disease conditions which progressively deteriorate and lead to the death of the patient. Such conditions include cancer and full blown AIDS, among others.  The diagnosis of terminal illness in a person evokes lot of both physical and psychosocial challenges. The physical challenges are easily observable by healthcare-providers while subjective psychological challenges are scarcely unexplored. There is a dearth of research about the psychosocial challenges experienced by these patients. This study investigated the psychosocial challenges experienced by hospitalized cancer patients (stage III & IV) and their perception of palliative nursing care received in tertiary hospitals in Enugu State. The understanding of these psychosocial challenges experienced and expressed by these patients is crucial in effecting timely and appropriate palliative nursing care intervention.  Descriptive phenomenological qualitative design was used which provided opportunity for the participants to express experiences in narrative form freely. Eighteen participants purposively participated and data were collected using researcher developed interview guide and their responses tape recorded. Data were analysed thematically, using Tesch & Giorgi’s approach. The findings revealed that the psychological challenges experienced by the participants included devastation, anger, loss of control, loneliness, withdrawal from relationships and an overwhelming sense of powerlessness to function independently, anxiety, worry, sadness/depression and fear about the disease outcome. Social challenges experienced included limitations in performing their activities of daily living (ADL); dependency on others for care; difficulty in communicating with healthcare-providers, some family members and friends; financial difficulties; lack/poor encouragement from family members/friends as well as irregular visitation.  Majority of the participants did not experience spiritual challenges; instead, the illness moved them closer to their God.  The psychosocial challenge mostly experienced by the participants was worry about the outcome of the illness and their family welfare.  The participants’ perception of palliative nursing care revealed that nurses did not understand the depth of their psychological needs and care; nurses knew the disease outcome but don’t know what to tell them; nurse-patient relationship was isolating and not close; nurses were too busy with their office work, and did not answer their calls promptly but served their medication promptly; nurses did not attend to their ADL needs regularly; and that nurses prayed for them only at night.  The participants most valued care were treating them with love, respect and concern through making time to talk with them and listen, for them to unburden their minds; and attending promptly to their ADL needs.  In conclusion, the participants had lots of psychosocial challenges and perceived that the palliative nursing care received to help them cope with the challenges were not satisfactory.  In recommendation, there is need for knowledge update of palliative nursing care in tertiary hospitals to ensure that these patients receive holistic care from experts.

 

 

                                                   CHAPTER ONE

                                                 INTRODUCTION

Background to the Study

A stage of disease/illness may be described as early, late or terminal. A terminal disease condition is an infection or illness which is considered ultimately fatal or incurable (Baylor, 2006). It is more commonly used for illnesses which are progressive such as cancer or advanced heart disease, including the end stage diseases like acquired immunodeficiency syndrome (AIDS) (Adenipekun, Onibokun, Elumelu, and Soyannwo, 2005).  In Nigeria, Cancer and HIV/AIDS are two important terminal illnesses associated with severe distress before eventual death.  Cancer is a leading health problem that affects millions of people every year and is the leading cause of death both in developed and developing countries (Chou, Dodd, Abrams and Padilla, 2007). The diagnosis of terminal illness presents people with lots of challenges. A challenge in this context is the feelings, needs, difficulties, pain or distress experienced by people at terminal stage of illness. The potential sources of distress experienced by patients with terminal illness are not limited to pain and physical symptoms but with such challenges as emotional, mental, social, economic or even spiritual. The physical challenges experienced by terminally ill patients are undeniable and easily observable by healthcare providers but the psychological (emotional and mental) challenges are subjective (McAndrew, 2004).  Individuals diagnosed with incurable diseases that are aware of impending death are likely to be emotionally disturbed in their mind than can be perceived by others from their appearance.

 

The psychological sequelae of the patients may include depression, anxiety about one’s body image, fear of invasive treatments, self-pity, and a pre-occupation with death (John and Ndebbio, 2002). Previously independent patients may fear that they will now need to rely on others for their daily needs, losing the ability to choose for themselves how their lives progress and this promotes low self esteem.  Thus, social functioning may be impaired resulting in withdrawal from relationships, and consequently social isolation. Also, many people experience a crisis of faith as the end draws near, either craving comfort from their religious beliefs or shunning them altogether. All these psychosocial issues which can affect a patient’s quality of life need to be appropriately identified from patients’ point of view.  Therefore this study focused on the psychosocial challenges experienced by these patients, as this is vital in ensuring social adjustment and improvement in the quality of their lives.

The professional inputs of nurses will enable such patients and the relatives to face the dying process with strength and hope. Palliative care then remains the only option for the management of terminally ill patients (e.g. advanced cancer) whom medical effort has turned away from active therapy and becomes concentrated on the relief of symptoms and support for both the patient and family members (Meremikwu, 1998). According to Paice (2002), some patients perceive the palliative care as services for those who have given up but palliative nursing care concerns are symptom relief, promotion of general well being, spiritual, psychological and social comfort.

There are three important aspects of palliative nursing care of patients at terminal stage of illness namely: supporting the patient; fostering communication

 

with the patient so that he/she does not face the illness in increasing isolation from others; talking with family members and with others who care for the patient, such as the physicians and clergymen among others.  Palliative care optimizes quality of life throughout the course of the illness through meticulous attention to the physical, spiritual and psychosocial challenges of these patients and their families. Understanding of these peculiar psychosocial challenges experienced by these patients is crucial in effecting timely and appropriate interventions. Despite the multitude of research studies related to terminal illness, studies on challenges expereinced by these patients  (especially advanced cancer patients) and their perception of palliative nursing care received from the nurses in tertiary hospitals in Enugu, have not been studied, thus the need for this study.

 

Problem Statement

Psychosocial challenges are common experiences for cancer patients.  Mckenzie and Crouch 2004 (in Lockwood-Rayermann, 2006); and Kataoka, Portillo, Henry, Holzemer, 2008) commented that psychosocial distress is prevalent in people with cancer because the diagnosis causes disruption in all aspects of patients’ daily lives, yet there is dearth of published literature in our locality that examined the psychosocial challenges experienced by these patients and their perception of the palliative nursing care received from the nurses. Majority of the work done in Nigeria are on physical challenges such as pain yet psychosocial challenges are said to be more devastating to the terminally ill patients.

 

Purpose of the Study

The purpose of the study is to determine (using descriptive phenomenology) the psychosocial challenges experienced by hospitalized cancer patients (stages III & IV) and

how they perceive palliative nursing care received from nurses in tertiary hospitals in Enugu State, Nigeria.

 

Research Questions

1. What are the psychosocial challenges experienced by hospitalized cancer patients (stages III & IV)?
2. What is the most distressing psychosocial challenge?
3. How do these patients perceive the palliative nursing care received from the nurses towards helping them cope with the experienced challenges?
4. What aspect of palliative nursing care do these patients perceive as most valuable?

 

Significance of the Study

Results from the study will be useful in understanding psychosocial challenges experienced by cancer patients (stages III & IV).

The data collected will be used to design appropriate intervention to handle these challenges experienced by these type of patients.

The result will also expose the weaknesses and strengths of nurses in providing these specialized type of care so as to enhance their quality of care and then increase these patients’ satisfaction with care received.

 

Scope of the Study

This study is limited to adult patients at terminal stage of illness such as those with cancer of any part of the body (stages III & IV) in the three tertiary hospitals (University of Nigeria Teaching Hospital, Enugu State University Teaching Hospital, and National Orthopaedic Hospital) in Enugu State. Unconscious patients are excluded from the study because they cannot communicate neither can they perceive anything.  The study is delimited to psychological, social and spiritual challenges of these patients and the challenge they considered most distressing. It also includes their perception to palliative nursing care received and the care they considered most valuable.

 

Operational Definitions

1. Patients at terminal stage of illness, in this study, are those with advanced stage of cancer of any part of the body (stages III & IV).
2. Psychosocial in this study include psychological (emotional feelings), social (functioning in usual roles, maintaining relationships, receiving support), and spiritual (frequency in praying and use of spiritual books as well as need of the Priest/Pastor and spiritual support).
3. 3 Challenges refer to difficulties/problems/needs experienced by patients at terminal stage of illness in respect to their emotional feelings, performance of activities of daily living (ADL), performance of social and spiritual activities.
4. Perception in this study connotes various ways patients at terminal stage of illness describe and rank the palliative nursing care they received.

 

5. Palliative nursing care in this study refers to the tasks performed by the nurses in the tertiary hospitals Enugu in helping the patients at terminal stage of illness cope with their psychological, social and spiritual challenges experienced.

CHAPTER ONE

INTRODUCTION

 Background to the Study

Psychoactive Substance use and dependence cause a significant burden to the individuals and societies throughout the world. The World Health Report (2010) indicated that 8.9% of the total burden of disease comes from the use of psychoactive substances. The report showed that tobacco accounted for 4.1%, alcohol 4%, and illicit drugs 0.8% of the burden of disease in 2010. Much of the burden attributable to substance use and dependence is the result of a wide variety of health and social problems. Data from the (World Health Organization, 2011) show large-scale seizures of cocaine, heroin, cannabis and amphetamine-type stimulants in different parts of the world. Availability of cocaine, heroin and cannabis depends on the level of cultivation in source countries and on the success or failure of trafficking organizations. However, even with increased levels of law enforcement activities, there always seems to be enough available to users. According to (UNODC, 2011) estimates show that about 200 million people make illicit use of one type of illicit substance or another.

 

Psychoactive substance use is a social problem that has spread and increased rapidly in  educational institutions especially among secondary school students (Neeraja, 2011).  This social problem is considered an issue of serious concern as it adversely affects the lives and performance of students involved as well as the harmonious functioning of the entire structure of the society. Use of psychoactive drugs and other associated problems are inimical to the survival and effective functioning of human societies. A significant number of untimely deaths and accidents have been linked to the activities of persons under the influence of one psychoactive drug or the other (Shelly, 2010).

Drug abuse is viewed by different authorities in various forms. Neeraja (2011) defined substance abuse as the dependence on a drug or other chemical substances leading to the effect that are detrimental to the individual’s physical and mental health or the welfare of others. According to Smelzer, Bare, Hinkle, and Cheever (2008) substance abuse is a maladaptive pattern of drug use that causes physical and emotional harm with the potential for disruption of daily life. From these definitions, it can be deduced that substance abuse is the misuse of one or more drugs which could be prescribed by a health practitioner with the intention to alter the way one feels, thinks or behaves and it is associated with consequences which include physical and emotional harm to the person.

 

The African Symposium (2010) viewed substance abuse as the improper use or application of drugs by a person without proper knowledge of the drugs and without due prescription from a qualified medical practitioner. This definition focuses on psychoactive drugs. All drugs can be abused to an extent that it turns into addiction when the drug user is unable to stop the use of the drugs despite the harmful effects on the user’s social, personal and economic lives. The problem of substance abuse is so grave that though it was originally conceived as the problem of a ‘select few’, it has extended beyond the usual characteristics of abusers being males, adults and urban based people, to now include females, youngsters and rural dwellers (Rocha, 2009). These abusers erroneously believe that drugs enhance their performance, put them in good mood etc. The accompanying problems of this act constitute a major threat to the well-being of the society (Ajala, 2009).

The youths in Nigeria like many countries of the world are increasingly developing addiction to psychoactive substances. The National Drug Law Enforcement Agency (NDLEA, 2011) collected drugs use and abuse data from schools, records of patients admitted at mental health institutions for drug problems and interview of persons arrested for drug offences. The result showed that youths constitute the high risk group for drug trafficking and abuse. Friends and school mates account for about 90% of the source of influence of the use and abuse of various psychoactive substances. In Nigeria, alcohol and cigarette are legal substances but, the two have been discovered to cause physical damage to human bodies. It has been reported that smoking tobacco causes 90.0% of lung cancer, 30.0% of all cancers, and 80.0% of other chronic lung diseases (Sale 2008). Apart from these health implications, according to Stephen (2010), alcohol and cigarette are said to be “gateway drugs” to other more potent psychoactive drugs like marijuana, heroin and cocaine.

 

The future of any community, society, state or nation is tied to the character of the adolescent in that particular place, area or locality. It is also said that “The youth are the leaders of tomorrow”. Therefore responsible youth in the society indicates responsible and brighter future of that society and also the reverse is the case.

 

In our society people are known to have had problems that had made them to adopt various measures to cope with such problems and live successfully within the confines of societal normative values. While some people take solace in lawful ways others resort to unlawful and unhealthy measures such as the use of drugs or psychoactive substances to the extent of abusing them, hence resulting in addiction. According to Edum (2006) the adolescent in our society are not left out in this, as they are either influenced by peer group while others do so because of the easy availability of the abused substances, others also watch on television and films and some read in books and so try to experiment to experience the effects. The effects of specific psychoactive substance vary depending on their mechanism of action, the amount consumed and the history of the user among other factors.

 

An ugly fact that is with us in the recent time is road traffic accident related to psychoactive substance use as well as increased crime rate in Nigeria, though a number of measures are put in place to check this menace. This includes the establishment of the National Drug Law Enforcement Agency (NDLEA) through Degree 48 of 1989 and 33 of 1990. However, in spite of these measures people especially the adolescents continue to use psychoactive drugs illicitly with its attendant problems.

 

Kano state is the most populated state in Northern Nigeria (NPC, 2006). The use of psychoactive Substance in this state is the order of the day, evidence by increase in crimes of different nature, failure at examination, abandoning school and poor performance in all aspects of life etc.

 

Dala local government is the largest, most populated local government Area of Kano State. One myth about the youth and adolescents in Dala local government is drug and substance use evidently shown by increase in crime, abandoning and inconsistencies in school, as well as failure in examination. These reasons encouraged and motivated the desire to investigate the prevalence and pattern of psychoactive substance use among the senior government secondary school students of the largest local government area in the middle of Kano City, Dala Local Government Area of Kano State, Nigeria.

 

Statement of the Problem

Substance use is not a strange phenomenon; the global, regional and national dimension of it are documented. It is in recognition of the complexity of the problem that 26th June of every year has been declared as the International Day Against Abuse and illicit trafficking by United Nations. In its June, 2003 report, the United Nations Children and Education Fund (UNICEF) stated that the problem of HIV/AIDS is inextricably connected to a range of problems, among which is drug abuse among children and young people. Similarly, the United Nations Office on Drugs and Crime (UNODC) pointed out that drug abuse among “area boys” in Nigeria has been reported as the cause of delinquent behaviours and crime.

 

The World Health Organization (WHO, 2010) believes that young people are more vulnerable to suffering physical, emotional and social harm from their own or other people’s drug use. It also identifies strong links between the high rate of drinking, violent sexual behaviour, traffic and other accidents and drug use. In relation to tobacco, World Health Organization also estimates that about 250 million children and adolescents who live in developing countries like Nigeria are likely to be killed by tobacco (Stephen, 2010).

 

The United Nations office on Drug and Crime (UNODC) partly attributes the prevalence of drug use in Nigeria to street hawking of drugs and pharmaceutical preparation. The prevalence rate of adolescent’s substance and drug abuse in our society poses a great concern to health care providers as some end up as addicts. This is quite substantial in Kano state. According to NDLEA (2010) reports, Kano State is the highest in terms of people arrested with the case of drug trafficking’ and suspected drug addicts (638 arrested suspects) followed by Katsina (411) and Rivers (347) etc.

 

According to NDLEA (2010) most of the people arrested in Kano state for drug addicts and trafficking are from Dala local government and neighboring communities and majority constitutes secondary school drop outs. Therefore based on the foregoing reasons, the researcher deemed it necessary to determine the prevalence and patterns of psychoactive substance use among the senior secondary school students in Dala LGA, Kano State Nigeria.

Purpose of the Study

The main purpose of the study is to determine the prevalence and pattern of psychoactive substance use among Government senior secondary school students in Dala LGA of Kano State, Nigeria.

 

Objectives.

The Specific Objectives are to

1.  Identify the characteristics of students who use identified substances
2. Establish the prevalence of substance use among the senior secondary school students in Dala Local Government.
3. Identify the patterns of substance use among the senior secondary students.
4. Identify the substances commonly used by the Senior Secondary students
5. Identify the sources of influence of drug use among secondary school Students
6. Determine the age of onset of substance use among secondary school student
7. Identify the reasons why senior secondary school students use drugs

 

Research Questions

1.  What are the characteristics of students who abuse drugs?

 

2. What is the prevalence rate of psychoactive substance use among the senior secondary school students in Dala Local Government, Kano State?
3. What are the patterns of substance use among senior secondary school students?
4.  What are the substances commonly used by the senior secondary school students?
5.  What are the sources of influence of drug use among senior secondary school in Dala?
6. What is the age of onset of substance use among secondary school student in Dala   local government?
7. What are the reasons senior secondary school students used drugs?

Hypothesis

1. There is no significant difference between Male and Female in secondary school in drug abuse.
2. There is no significant difference in pattern of drug abuse in days per month based on Psychoactive Substances
3. There is no significant relationship of respondents age range at the first use based on life time use of psychoactive

 Significance of the Study

The present study will reveal the prevalence, pattern, types and sources of psychoactive substances used by secondary school children. It will also reveal the characteristics of the students who use drugs and the problems students encounter as a result of drug use. These findings are essential as they will help in understanding the overall social, academic and drug problems of the students and youth in Kano state.

This finding would  be useful to the parents, teachers, police and the drug law enforcement agency (NDLEA) as well as other bodies concerned with checking drug abuse problems in Dala LGA of Kano state and Nigeria at large. The findings will provide a source of reference for intervention programmes in Kano state.

It is also hoped that the findings of this study will be useful for social monitoring and alerting people to the signs of Substance use so as to enable early diagnosis and treatment of affected persons. It will also assist in planning of preventive strategies for substance use in our secondary schools across the country.

The finding of this study will be useful to future researchers on the topic, as they will build on the strength and limitations of the study. And the finding of the study may spur them to form anti-psychoactive substance use clubs and associations. The activities of these groups can reach the wider society and will assist in curbing the menace of substance abuse in Dala LGA, Kano State and the country at large. The present study wills no doubt, spur interest for further studies.

 Scope of the Study

The scope of this study is delimited to on Government Senior Secondary School Students in Dala LGA of Kano State. The study will be delimited to prevalence and pattern of psychoactive substance use among Government Senior secondary school student in Dala LGA, Kano state.

Operational Definition of Terms

• Psychoactive Substance: This refers to any substance which may be a drug or not but has the property of altering the mood in form of stimulation or distortion of perception.
• Psychoactive substance use refers to the use of any substance which may be drugs or not that has the property of altering the mood in form of stimulation or distortion of perception
• Drug Abuse- refers to the illegal or excessive drug use; deliberate use of an illegal drug or of too much of a prescribed drugs
• Prevalence of psychoactive substance use: refers to the proportion of a population found to have used a psychoactive substance or drugs.
• Pattern of psychoactive substance use: Is the process addicts use which include Modes of Taking, frequencies and Style of psychoactive substance abuse etc
• Source of influence: Those factors that introduce student to the drugs or substance use e.g peer group, family etc.
• Secondary school students: Are students in the second phase of secondary education of 6-3-3-4 education system in Nigeria who finishes primary school.
• Senior Secondary School Students refers to the students in SSI, SSII and SSIII of secondary school education system in Nigeria.

CHAPTER ONE

INTRODUCTION

Background to the study

Cancer is a group of diseases that cause cells in the body to change and grow out of control. Most types of cancer cells eventually form a lump or mass called a tumour, and are named after the part of the body where the tumour originates (American Cancer Society (ACS), 2012). Breast cancer begins in the breast tissue.

Breast cancer is the most common cancer in women worldwide, with nearly 1.7 million new cases diagnosed in 2012 (World Cancer Research Fund (WCRF) International, 2013). In United States, breast cancer accounts for 29% of newly diagnosed cancers (ACS, 2013). One in 8 women in the United States will develop breast cancer in her life time (ACS, 2013). Also, ACS (2011), stated that breast cancer incidence death rates increase with age. In their opinion, 95% of new cases and 97% of breast cancer deaths occurred in women 40years of age and older.

In Africa, breast cancer is second (after lung cancer) leading cause of death among African women (Courage to Dare Foundation, 2013). By the year 2020, one million cases of breast cancer are expected yearly in African countries (Courage to Dare Foundation, 2013).In a Ghanaian Teaching Hospital in 2012, breast cancer accounted for 29.3% of all cancers (Tagoe, Yarney, Kenu, Amanhyia, Enchill & Obeng, 2014).

Studies from Nigeria indicate that breast cancer has been the most common female malignancy in areas of western and Eastern Nigeria (Anyanwu, 2008), Breast cancer incidence had risen at least four times over the decade and accounted for 40% of women cancers in 2010 (Adepoju, 2012 ). In the South-Western geopolitical zone of Nigeria, cancer of the breast was the leading malignancy among women (Ogunbiyi, Fabowale & Ladipo, 2010). In North central geopolitical zone (Ilorin),breast cancer  constituted  22.41%  of  new  cancer cases registered in 5 years and accounted for 35.41% of all cancers in women (Afolayan, Ibrahim & Ayilara, 2012).

It is disheartening that breast cancer is responsible for about 450,000 females deaths per annum worldwide (WCRF, 2014). Whereas the deaths could be avoided or reduced if people accept they   are at risk, believe that screening is an effective tool against breast cancer, and utilize the available opportunities of breast screening, stay free from breast cancer, be healthy and alive.

Unlike other cancers, breast cancer lends itself to earlier diagnosis and subsequently more successful treatment. Early detection of breast cancer is a major determinant of reduction of its morbidity and mortality. A 95% survival could be achieved if breast cancer is detected early (Tavafian, Hasani, Teamur & Zare, 2009). According to WHO (2009) two components of early detection have been shown to reduce cancer mortality viz: education to help women recognize early signs of cancer and seek prompt medical attention; then screening to identify early cancer or pre-cancerous lesions before signs are recognizable.ACS (2012), is of the opinion that women should be familiar with how their breasts normally feel, and report any breast changes promptly to their health care providers, because 95% of breast cancers in advanced stages and 65% of breast cancers in primary stages are detected by  women through Breast Self Examination (BSE). ACS (2013) recommends that women receive an annual mammogram beginning at age 40. Women in their 20s and 30s should have a CBE by a health professional every 3 years. Women who are at high risk for breast cancer should have magnetic resonance imaging (MRI) and a mammogram every year beginning at 30 years of age. BSE practice is a gateway to health promotion behaviour that provides women with knowledge and attitude that set the stage for clinical breast examination and mammography screening later in life (Avei, 2008). Furthermore, early detection of breast cancer has been facilitated by several technological innovations. Magnetic resonance imaging (MRI) has been reported to detect almost all cancers at an early stage when used along with mammography (ACS, 2012). Acknowledging the importance of early detection, several countries have adopted breast cancer screening programmes as part of their cancer control strategies (Farid, Sadat & Dahlui, 2014).

In Nigeria, there is yet to be a national organized early detection programme but mammography has become more available in more centres in the last two years (Oluwatosin, 2010). Even at that, most persons utilizing mammography are referred cases with breast lesions and symptoms. Again in Nigeria late presentation has been reported over decades till date. Egwuonwu, Anyanwu, Nwofor and Ame (2012) reported that Nigerian women                                                                                          with breast cancer are still diagnosed at advanced stages of the disease when little or no benefit can be derived from any therapy. Odemwingie (2014) stated that 30 Nigerian women die every day from breast cancer. Adisa (2013), reported that 52% of Nigerian women presented with stage iv breast cancer between 1991-2005.  This is indeed a worrisome trend that demands evidence based attention to reduce the burden of breast cancer in Nigeria. Identifying and understanding factors that predict the breast cancer screening behaviours are primary to instituting measures to increase screening thereby enhancing early detection of the disease and reducing mortality from breast cancer.

Predictive factors of breast cancer screening behaviour are those factors that are more likely to motivate the women to engage in the screening exercise and adhere to the practice throughout one’s life time, in order to detect cancer early if it starts developing. Such factors include level of education, knowledge of signs and symptoms of breast cancer and risk factors, parity of the women, age, family history of breast cancer, place of residence, association with health worker and benefits derived from breast screening, all these are the focus of the study.

 

Statement of Problem

Globally, the devastation that befalls women diagnosed of breast cancer remains inestimable (Olowokere, Onibokun & Oluwatosin, 2012). Early detection remains a major effective approach to combat the disease (Olowokere, Onibokun & Oluwatosin, 2012). Several studies have indicated that community-based breast cancer screening, executed for an appropriate age range at appropriate intervals and with quality assurance in every step, has decreased breast cancer mortality in women by 30% (Dunder, Ozyurt & Erdurak, 2011).

Bello, Olugbenga, Oguntola, Adeoti and Ojemakinde (2011), reported that good knowledge of breast cancer screening among female nurses does not imply better screening rates in South-western Nigeria. In their study, only 55.6% of female nurses practiced BSE and 22.9% had undergone mammography. Again, early diagnosis is only possible when the women avail themselves voluntarily to the screening services before symptoms are noticed.

Despite health education efforts to enlighten women on breast health awareness including the awareness of different screening methods available, the increasing incidence of breast cancer and presentation at an advanced stage are still challenges to healthcare professionals in Nnewi, North Local Government Area. Previous records (2009-2012) from cancer registry Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi showed that one thousand, two hundred and eleven (1,211) women were affected by breast cancer. Information from the mammography unit in NAUTH, Nnewi revealed that in 2012 only 45 women presented themselves for mammography ,  and only 6 out of this number voluntarily came for screening, 39 were referred cases. In 2013, 92 women were screened. The increase was as a result of awareness sponsored programme. Even at that only 40 of the women came for routine screening, others were referred cases. Also, in 2014, limited number of women (30) availed themselves for mammography and only 3 women actually came for routine screening. The low rate at which women in Nnewi North L.GA. respond  to breast cancer screening  mammography stimulated the researcher to ponder on  the possible reasons; by asking what are the factors that predict their behaviour to the breast cancer screening tests?

 

Purpose of the Study

The purpose of this study was to investigate the predictive factors of breast cancer screening behaviours of women in Nnewi North L.G.A of Anambra State.

Specific objectives were to:

1. Ascertain the level of knowledge of breast cancer screening methods among women in Nnewi North L.G.A.
2. Ascertain the level of knowledge of risk factors and early indications of breast cancer among women in Nnewi North L.G.A.
3. Determine breast cancer screening practices/behaviour among women in Nnewi North L.G.A.
4. Determine the factors that predict breast self examination (BSE) screening behaviour among women in Nnewi North L.G.A.
5. Determine the factors that predict clinical breast examination (CBE) screening behaviour among women in Nnewi North L.G.A.
6. Determine the factors that predict mammography screening behaviour of women in Nnewi North L.G.A.