Millions of Nets : But are they being used?

The year 2010 was targetted at the 2000 Abuja Malaria Summit as the time when 80of vulnerable groups (pregnant women; children below 5 years of age) would be sleeping under insecticide-treated nets (ITNs).1 Subsequently the US President's Malaria Initiative (PMI) raised the bar to 85in its 15 focus countries.2 Most recently; the United Nations3 broadened the scope of ITN use and stressed that 2010 would be the year of Universal Coverage (UC). UC is variously interpreted in each endemic country and can mean one net distributed for each two people in the population to two nets per household. Ultimately it has been recognised that in order to reduce the burden of malariadisease; everyone should sleep under an ITN; or as now being used; a long-lasting insecticide-treated net (LLIN)

Willingness to seek HIV testing and counseling among pregnant women attending antenatal clinics in Ogun State, Nigeria.

HIV counseling and testing (CT) is slowly being introduced as one of several key components of the comprehensive package of HIV/AIDS prevention and care in Nigeria, particularly in the prevention of mother-to-child transmission of HIV (PMTCT). A cross-sectional survey of 804 women attending antenatal clinics (ANC) in Ogun State, Nigeria was done using questionnaires to assess their willingness to seek and undergo CT and know the determinants. Focus group discussions were also held in the general community: 84.3% of respondents believed in AIDS reality, while 24.3% thought they were at risk of HIV infection. Only 27% knew about MTCT, while 69.7% of 723 who had heard of HIV/AIDS did not know about CT. Only 71 (8.8%) had thought about CT and 33 (4.5%) mentioned HIV testing as one of antenatal tests. After health education on CT, 89% of the women expressed willingness to be tested. Their willingness for CT was positively associated with education (p < 0.05), ranging from 77% (no education) to 93% (post-secondary). More of those with self-perceived risk expressed willingness to test for HIV (p < 0.05). Those willing to be tested had a higher knowledge score on how HIV spreads than those not willing. Multiple regressions identified four key factors that were associated with willingness for CT: increasing educational level; not fearing a blood test; perception that the clinic offered privacy; and perceptions of higher levels of social support from relatives and peers. Those unwilling or undecided about CT expressed strong fear of social stigma/rejection if tested positive. The results provided insights for planning promotional programs and showed that not only are IEC efforts needed to boost knowledge about HIV/AIDS, but that change in clinic setting and community are imperative in creating supportive environment to encourage uptake of CT services.

Mother-father concordance on treatment choices in the care of sick children under five years of age in Osun state, Nigeria.

Communication and agreement between spouses has been found to be an important factor in terms of acceptance and use of family planning services and supplies. Therefore, it is likely that agreement between spouses may play an important role in other aspects of family health, including care of childhood illness. This study, based in a rural and an urban community in Osun State, Nigeria, set out to determine the agreement between mothers and fathers on the illness experience and care provided to their preschool age children. Among the 550 couples studied, most mothers (98%) and fathers (94%) reported that they "did something" to help during their child's recent illness. The illness was recognized first by the mothers according to 83% of respondents. Overall, 81% of couples concurred that the mother was the first to discover the illness. Concurrence was greater in urban areas and where fathers read a newspaper frequently. Only 45% concurred on who took the decision for first action to address the illness, which again was greater in the urban area and in families where the father read a newspaper frequently. Parents also were not in full agreement about the name of the child's illness, but concurrence was greater in the case of malaria/fever. Finally, concurrence on the actual first form of treatment care reached only 36%. Most concurrent couples and non-concurrent mothers mentioned drug shops/chemists as the first source of care, while non-concurrent fathers placed government clinics first. While mothers are likely to be the main caregivers, fathers do have decision making and financial roles. Not only should health education for appropriate and prompt care of child illnesses be aimed equally are both parents, it should also recognize that fathers may have different perceptions from mothers. Education should also encourage better couple communication.

Management of childhood febrile illness prior to clinic attendance in urban Nigeria.

Parents and caregivers often try various treatment modalities for their sick children before bringing them to clinic. Many community-based studies have documented home and self-treatment practices, often with the aid of patent medicine vendors, but less is known about prior treatment behaviour of caregivers who actually reach a government clinic. This study, therefore, aimed at documenting the treatment provided by caregivers prior to their attendance at a public hospital. Beginning in April 1996, a year-long study was conducted among 1,943 sick children and their caregivers who attended the largest government-owned paediatric hospital in Lagos, Nigeria. The major complaints mentioned by the caregivers included fever, cough, and diarrhoea. Most (89%) caregivers had administered some form of medicine to the child prior to the clinic visit, and on average, 2.5 medications had been given. Associations were found between major complaint and type of medicine given: fevers were associated with antimalarial drugs and analgesics (antipyretics), cough was associated with cough syrup and analgesics, while diarrhoea was associated with antidiarrhoeal drugs. Although one-fifth of the children had received an antibiotic, provision of antibiotics was not associated with a particular complaint/illness. Since caregivers appeared to use perceived complaints/illnesses as a treatment guide, this can form the basis of safer and more appropriate recognition of illness and home management. In addition, the information obtained in this study can be used for training clinicians to inquire about home management and, thus, for making more informed decisions about their own treatment and prescribing practices.

The challenges of community-directed treatment with ivermectin (CDTI) within the African Programme for Onchocerciasis Control (APOC).

The principal strategy adopted by the African Programme for Onchocerciasis Control (APOC), for the control of onchocerciasis in the 19 countries of Africa that now fall within the programme's remit, is that of community-directed treatment with ivermectin (CDTI). Halfway through its 12-year mandate, APOC has gathered enough information on the main challenges to guide its activities in Phase 2. An analysis of reports and other documents, emanating from consultants, scientists, monitors and national and project-level implementers, indicates that there are three broad categories of challenge: managerial; technical; and socio-political. Under these three categories, this review identifies the most pertinent concerns that APOC must address, during Phase 2, to enhance the prospects of establishing sustainable systems for ivermectin distribution. The major challenges include: (1) maintaining timely drug-collection mechanisms; (2) integrating CDTI with existing primary-healthcare services; (3) strengthening local health infrastructure; (4) achieving and maintaining an optimal treatment coverage; (5) establishing and up-scaling community self-monitoring; (6) designing and implementing operations research locally; (7) ensuring the adequacy of community-directed distributors; (8) increasing the involvement of local non-govemmental develop organizations in the programme; (9) achieving financial sustainability; (10) implementing equitable cost-recovery systems; and (11) engaging in effective advocacy. The implications of the challenges and suggestions about how they are being (or could be) addressed are also highlighted in this brief review, which should be of value to other programmes and agencies that may be contemplating the adoption of this unique strategy.

The feasibility of implementing a dietary sodium reduction intervention among free-living normotensive individuals in south west Nigeria.

High sodium intake is associated with high levels of blood pressure, both among and within populations. However, there have been few intervention studies from Africa reporting blood pressure changes with dietary reduction of sodium. In this study, we tested the feasibility of achieving a reduction in dietary sodium intake in free-living individuals using a dietary intervention among 82 free-living normotensive adults in southwest Nigeria. The participants, 49 men (mean age 47.2 years) and 33 women (mean age 43.6 years), received dietary advice to reduce sodium intake and maintained the reduced sodium diet for a 2-week period. Blood pressure and 24-hour urinary excretion of sodium were measured at baseline and after two weeks on the reduced sodium diet. Baseline 24-hour urinary sodium excretion was 140.5 (SD 53.4) mmol/24 hours among men and 132.6 (SD 48.0) mmol/24 hours among women. Twenty-four hour urinary sodium excretion fell by 76.9 (95% Cl 59.7, 94.1) mmol/24 hours among men, and by 79.4 (95% Cl 59.4, 99.1) mmol/24 hours among women. On the low sodium diet, systolic blood pressure fell by 4.7 (95% CI 1.9, 7.4) mm Hg among men, and by 7.0 (95% CI 2.6, 11.4) mm Hg among women while diastolic blood pressure fell by 1.9 (95% CI -0.3, 4.1) mm Hg among men and by 1.6 (95% CI -1.8, 5.0) mm Hg among women. It is concluded that a significant reduction in sodium intake may be achievable in free-living individuals in this setting using a simple dietary intervention. The findings of this pilot study should encourage more sophisticated intervention studies (such as cross-over trials and double blind randomized clinical trials) in Africans for the elucidation of mechanisms and consequences of hypertension in Blacks.

West African Youth Initiative: outcome of a reproductive health education program.

PURPOSE: To describe the implementation and evaluation of an adolescent reproductive health peer education program in West Africa. The program, known as the West African Youth Initiative (WAYI), was developed to improve knowledge of sexuality and reproductive health, and promote safer sex behaviors and contraceptive use among sexually active adolescents in Nigeria and Ghana. METHODS: Between November 1994 and April 1997, two organizations, the Association for Reproductive and Family Health (ARFH), based in Nigeria, and Advocates for Youth, based in Washington D.C., supported community-based youth-serving organizations in the two countries to implement peer education projects. Consultants from the African Regional Health Education Centre (ARHEC) in Nigeria provided technical assistance in designing and conducting a quasi-experimental process and outcome evaluation of the projects. RESULTS: There were significant differences over time and between intervention and control groups concerning reproductive health knowledge, use of contraceptives in the previous 3 months, willingness to buy contraceptives, and self-efficacy in contraceptive use. CONCLUSIONS: Overall, the project provides evidence that peer education is most effective at improving knowledge and promoting attitudinal and behavior change among young people in school settings.

Treatment of childhood fevers and other illnesses in three rural Nigerian communities.

The seeking of healthcare for childhood illnesses was studied in three rural Nigerian communities of approximately 10,000 population each. The aim was to provide a baseline understanding of illness behaviour on which to build a programme for the promotion of prepackaged chloroquine and cotrimoxazole for early and appropriate treatment of childhood fevers at the community level. A total of 3117 parents of children who had been ill during the 2 weeks prior to interview responded to questions about the nature of the illness and the actions taken. Local illness terms were elicited, and the most prevalent recent illness and the actions taken. Local illness terms were elicited, and the most prevalent recent illnesses were 'hot body' (43.9 per cent), malaria, known as iba (17.7 per cent), and cough (7.4 per cent). The most common form of first-line treatment was drugs from a patent medicine vendor or drug hawker (49.6 per cent). Only 3.6 per cent did nothing. Most who sought care (77.5 per cent) were satisfied with their first line of action, and did not seek further treatment. The average cost of an illness episode was less than US$2.00 with a median of US$1.00. Specifically, chloroquine tablets cost an average of US 29 cents per course. Analysis found a configuration of signs and symptoms associated with chloroquine use, to include perception of the child having malaria, high temperature and loss of appetite. The configuration positively associated with antibiotic use consisted of cough and difficult breathing. The ability of the child's care-givers, both parental and professional, to make these distinctions in medication use will provide the foundation for health education in the promotion of appropriate early treatment of childhood fevers in the three study sites.

Development of reactive onchocercal skin lesions during a placebo-controlled trial with ivermectin among persons without lesions at baseline.

Clinical trials of the effects of ivermectin on onchocercal skin disease have documented reduction in itching, but a less than clear benefit on reactive skin lesions. It has been suggested that one of the positive effects might be the prevention of new lesions. A study among a rural adult farming population in southwestern Nigeria provided ivermectin in three treatment groups and a placebo to community members who were examined and treated at 3-monthly intervals over a 15-month period. Among the 1206 people recruited for the study, 627 (52%) had no lesions at baseline examination. Atotal of 291 participants without baseline lesions attended all five follow-up examinations, and only their results were analysed. Members of all four groups developed new lesions, but those receiving ivermectin had a consistently lower proportion of lesions than the placebo group. This difference reached statistical significance at the 5% level in three of the five periods and was below the 10% level at the other two periods. These findings are suggestive of an inhibiting effect of ivermectin among those without lesions at the beginning of a community treatment programme, and justify community treatment as a way of limiting morbidity and social stigma associated with these lesions.

Psycho-educational therapy among Nigerian adult patients with epilepsy: a controlled outcome study.

Psychological interventions in relation to epilepsy are worthy of empirical investigation since there is broad agreement that the psycho-social problems of epilepsy are often more disabling than the seizure attacks. The present study using a controlled outcome design evaluated the efficacy of a 2-day psycho-educational program among patients with epilepsy in Nigeria. The psycho-educational program is the consequence of a two-stage study design, which set out to identify and evaluate psycho-social factors that determine interictal psychopathology in people with epilepsy. Thirty out-patients matched according to seizure type and frequency of seizures were randomly assigned to treatment (n = 15) or waiting-list control (n = 15) groups. The major outcome measures used were knowledge about illness schedule, the Becks depression inventory and the Crown-Crisp experiential index. Significant differences between the two groups were found on the three major scales used. The treatment group by within-group analyses, showed a substantial significant decrease in level of depression, a significant increase in the knowledge about epilepsy as well as a significant decrease in all measures of neurotic disorders except for hysterical sub-scale.

Urban malaria treatment behaviour in the context of low levels of malaria transmission in Lagos, Nigeria.

Urban malaria in West Africa is not well documented. While rapid urbanisation may create environmental conditions that favour mosquito breeding, urban pollution may inhibit the growth of Anopheles species. In 1996, the Basic Support for Institutionalizing Child Survival (BASICS) Project of the U.S. Agency for International Development (USAID) started building urban community health coalitions in Lagos, Nigeria, to empower communities to provide prompt treatment and appropriate prevention for major causes of childhood morbidity and mortality, including malaria, diarrhoeal disease, acute respiratory infections and vaccine preventable diseases. Intervention against malaria was predicated on national policies that assumed Nigeria was holo-endemic for malaria and that prompt treatment of febrile illness with anti-malarial drugs was an appropriate action. At the suggestion and with the assistance of another USAID programme, the Environmental Health Project (EHP), BASICS embarked on a rapid assessment of the epidemiological, entomological and sociological situation of malaria transmission and case management in three Lagos communities. During April and May 1998, blood film investigation of 916 children between the ages of 6 months and 5 years yielded a parasite prevalence rate of 0.9%. Night knockdown collections of mosquitoes in rooms yielded only C. quinquefasciatus and A. aegypti. The same results were obtained for night landing collections on human bait. Very low densities of A. gambiae larvae were found in breeding sites in Lagos Island (0.7) and Ajegunle (0.3). In contrast, community members, during focus group discussion identified malaria, in it various culturally defined forms, as a major health problem. Among the children examined clinically, 186 (20.3%) reported an illness, which they called "malaria" in the previous two weeks, and 180 had sought treatment for this illness. Data obtained from 303 shops in the area documented that a minimum of US dollars 4,000 was spent on purchases of anti-malarial drugs in the previous week. The implications of these findings for both professional and community education are discussed.

Acceptance and use of communal filtration units in guinea worm eradication.

The use of cloth to filter drinking water for guinea worm prevention is a long-standing control strategy and part of a mixed approach that includes the provision of wells, chemical treatment of ponds and protection of water supplies. As the goal of eradication nears, filters are a useful component of the quick response needed to implement case containment at village level. Various designs of filters have been used. Individual hand-sewn filters (HSFs) using monofilament nylon cloth have played a central role in village-based control to date. Problems such as the need to continually reinforce correct habitual filtering behaviour have led to the design and testing of communal filtration units (CFUs) made from metal oil drums with filter cloth inserted in the top and spigots at the bottom. Approximately one year after the introduction of CFUs in the South-western Zone of Nigeria, village surveys were conducted to determine opinions about the two types of filters and reported use. Percentage use was calculated by dividing the number of times water was filtered in the week preceding the survey by the number of times water was collected in that week. Those respondents with access to CFUs filtered an average of 91.9% of the time compared to 75.7% of those with HSFs. Using the village as level of analysis since it was the main level of intervention, the average percent of times villagers in CFU villages filtered was 91.1% compared to 77.8% in HSF villages. Although CFUs were more expensive in the short run, their greater acceptance by villagers is a factor to recommend their wider implementation to speed up elimination of guinea worm from Nigeria.

A school-based AIDS education programme for secondary school students in Nigeria: a review of effectiveness.

Nigerian secondary school students are becoming sexually active at an increasing earlier age. Sexually active students are at risk of contacting STDs, including HIV infection. As a result, health education initiatives to increase level of knowledge, influence attitudes and encourage safe sexual practices are being implemented in schools, but the effectiveness of these programmes have not been evaluated. In this study, the knowledge, attitude and sexual risk behaviors of 223 students who received a comprehensive health education intervention were compared with 217 controls. At post-test, intervention students exhibited greater knowledge about HIV/AIDS transmission and prevention (P < 0.05). Intervention students were less likely to feel AIDS is a white man's disease and were more likely to be tolerant of people living with the disease (P < 0.05). After the intervention, the mean number of reported sexual partners among the experimental students significantly decreased from 1.51 to 1.06, while it increased from 1.3 to 1.39 among the controls. Among the intervention students there was also an increase in consistent use of the condom and the use of the condom at last sexual intercourse. We conclude that students can benefit from specific education programmes that transmit important information necessary to prevent risky behavior, and improve knowledge and attitudes on HIV/AIDS.

PIP: This study evaluates the effectiveness of a school-based AIDS education program for secondary school students in the local government area of Ibadan, Nigeria. It compared the knowledge, attitude, and sexual risk behaviors of 233 senior students who received comprehensive health education intervention with 217 controls. A baseline survey was conducted prior to the implementation of the HIV/AIDS education sessions. Evaluation of the intervention was carried out after 6 months. Baseline and endline data of the intervention and the control groups were then analyzed. Baseline data showed that there was no significant difference between the two groups as to their knowledge and attitudes on HIV/AIDS and their sexual behavior. Endline comparisons, however, reveal that the knowledge about HIV transmission and prevention was significantly higher (P 0.05) in the intervention group. Furthermore, 92.8% of the intervention students as compared to only 56.7% of the controls felt AIDS constituted a problem in Nigeria, indicating better attitudes among the intervention group. The endline data also showed that there was a decrease in the number of sexual partners among the intervention students from 1.51 to 1.06, while their condom use increase. In conclusion, the education program was successful in improving the student's sexual practices as well as their knowledge and attitudes regarding HIV/AIDS.

Stigma associated with onchocercal skin disease among those affected near the Ofiki and Oyan Rivers in western Nigeria.

Skin diseases have been a major source of social stigma, whether they be infectious or not. The potential stigamtizing effect of skin disease associated with onchocerciasis is currently receiving attention because half of the 17 million victims of onchocerciasis in Africa live where the non-blinding form of the disease is prevalent. Some reports are available that onchocercal skin disease (OSD) is associated with social stigma including problems in finding a marriage partner. Previous studies have also implied positive effects of ivermectin treatment on OSD. Therefore a multi-country trial of ivermectin is underway to test the hypothesis that ivermectin treatment might affect perceptions of stigma associated with OSD. This paper presents the baseline stigma findings from the study site located in southwestern Nigeria. A total of 1032 persons living in villages near the Ofiki and Oyan Rivers were screened and interviewed and 500 (48%) were found to have an onchocercal skin lesion. A 13-item, 39-point stigma scale was used in interviews with affected persons. A mean score of 16.8 was obtained. No personal characteristics or disease factors were found to be associated with stigma score. The highest ranking items focused on issues of self-esteem such as feeling embarrassed, feelings of being pitied, thinking less of oneself, feeling that scratching annoys others, feeling that others thought less of the person and feeling that others had avoided the person. During the interviews it was discovered that only about half of those clinically diagnosed as having OSD labeled their own condition as onchocerciasis. Those who said their lesion was OSD had a lower stigma score than those who did not, conforming with previous studies wherein affected persons perceived less stigma from OSD than those without the disease. A broader community perspective on OSD was obtained through 50 interviews using paired comparisons of five skin-related local illnesses. Onchocerciasis placed midway in aversive responses between the higher end represented by leprosy and chicken pox and lower scoring papular rashes known locally as eela and ring worm. In-depth village based interviews yielded several case studies of how onchocerciasis had a negative social impact on its victims. While study on the cultural perceptions of OSD is recommended, the results indicate that with a fairly high prevalence of OSD, the community level effects of social stigma should be regarded as serious.

The effects of ivermectin on onchocercal skin disease and severe itching: results of a multicentre trial.

OBJECTIVE: To determine the effects of ivermectin in annual, 3-monthly and 6-monthly doses on onchocercal skin p6isease (OSD) and severe itching. METHOD: A multicentre, double-blind placebo controlled trial was conducted among 4072 residents of rural communities in Ghana, Nigeria and Uganda. Baseline clinical examination categorized reactive skin lesions as acute papular onchodermatitis, chronic papular onchodermatitis and lichenified onchodermatitis. Presence and severity of itching was determined by open-ended and probing questions. Clinical examination and interview took place at baseline and each of 5 subsequent 3-monthly follow-up visits. RESULTS: While prevalence and severity of reactive lesions decreased for all 4 arms, those receiving ivermectin maintained a greater decrease in prevalence and severity over time. The difference between ivermectin and placebo groups was significant for prevalence at 9 months and for severity at 3 months. Differences between placebo and ivermectin groups were much more pronounced for itching. From 6 months onward, the prevalence of severe itching was reduced by 40-50% among those receiving ivermectin compared to the trend in the placebo group. CONCLUSION: This is an important effect on disease burden as severe itching is for the affected people the most troubling complication of onchocerciasis. The difference among regimens was not significant, and the recommended regimen of annual treatment for the control of ocular onchocerciasis appears also the most appropriate for onchocerciasis control in areas where the skin manifestations predominate. The final determination of the effect on skin lesions requires a longer period of study.

Eradicating guinea worm without wells: unrealized hopes of the Water Decade.

At the start of the United Nations International Drinking Water Supply and Sanitation Decade in the 1980s, guinea worm disease was targeted as the major indicator of the success of the Decade's efforts to promote safe water. By the late 1980s, most of the guinea worm endemic countries in Africa and South Asia had established guinea worm eradication programmes that included water supply as one of their main technical strategies. By surveying the water supply situation in Ifeloju Local Government Area (LGA) in Oyo State, Nigeria, in June 1996, as a case study, it was possible to determine the role that water supply has played in the eradication effort. Although two major agencies, the former Directorate for Food, Roads and Rural Infrastructure and UNICEF, provided hand dug and bore-hole wells respectively in many parts of the LGA, coverage of the smaller farm hamlets has been minor compared to efforts in the larger towns. This is ironic because the farm hamlets served as a reservoir for the disease in the 1980s, such that when the piped water system in the towns broke down, guinea worm was easily reintroduced into the towns. The survey of 188 ever-endemic hamlets with an estimated population of 23,556 found that 74.3% of the people still drink only pond water. Another 11.3% have wells that have become dysfunctional. Only 14.4% of this rural population has access' to functioning wells. Guinea worm was eliminated from 107 of the hamlets mainly by the use of cloth filters and chemical treatment of ponds. While this proves that it is possible to eradicate guinea worm, it fails to leave behind the legacy of reliable, safe water supplies that was the hope of the Water Decade.

PIP: The 1980s were designated by the UN as the International Drinking Water Supply and Sanitation Decade, and guinea worm disease was targeted as the major indicator of the campaign's success. The campaign conceptualized guinea worm disease as a symbol of the isolation of poor rural residents from national development programs such as water supply, education, and health care. The Nigerian Guinea Worm Eradication Program, launched in 1987, committed to provide drinkable treated water to areas with endemic guinea worm disease. However, less expensive interventions such as monofilament nylon cloth filters were given priority over water supply provision. This article examines the eradication program in Ifeloju Local Government Area in Oyo State, Nigeria. The former Directorate for Food, Roads, and Rural Infrastructure provided hand-dug wells in several settlements, but made no provisions for maintenance and repairs. UNICEF assisted in the drilling of bore-hole wells, but restricted this intervention to settlements with more than 250 people. A 1996 survey of 188 ever-endemic hamlets with an estimated population of 23,556 found that 74.3% of residents drank only pond water. Another 11.3% had wells that had become dysfunctional. Only 14.4% of these rural residents had access to functioning wells. Guinea worm was eliminated from 107 of the hamlets, chiefly through use of cloth filters and chemical treatment of ponds. These results show a striking lack of commitment to the eradication of guinea worm disease through the safe water strategy. In 1995, only 43% of Nigeria's population had access to safe water. There is a need for financial investment in less expensive and more appropriate hamlet-level technologies, as well as community mobilization to dig and maintain hand-dug wells.

Gender and ethnic differences in onchocercal skin disease in Oyo State, Nigeria.

During preparation for a study on the effects of ivermectin treatment on onchocercal skin disease in the Ifeloju Local Government Area of Oyo State, Nigeria, 1032 adults aged 20 years and older were examined for skin lesions and palpable nodules. It was found that for 4 types of skin lesions, acute papular onchodermatitis (APOD), chronic papular onchodermatitis (CPOD), lichenified onchodermatitis (LOD) and depigmentation (leopard skin), as well as for subcutaneous nodules, females had a significantly higher prevalence than males. Although the area is inhabited primarily by the Yoruba people, the study also included some of the cattle-herding Fulani ethnic group. The reactive skin lesions, APOD, CPOD and LOD, were found to be more common among the Fulani, although there were no significant differences in leopard skin and nodules between both groups. While there is need for further research on both immunological and behavioural factors that may lead to these differences in disease. The need to achieve equity in health programming by ensuring that women and ethnic minorities receive full disease control services is of more immediate concern.

Perceived stress factors and coping mechanisms among mothers of children with sickle cell disease in western Nigeria.

While many studies have looked at the stressful effects of chronic illness of those who suffer such conditions, less is known about the effects on caregivers, especially in developing countries. Mothers in particular must bear the brunt of care and stress for children who have sickle cell disease (SCD). A sample of 200 mothers attending six SCD clinics in both public and private hospitals in the Ibadan-Ibarapa Health Zone of Oyo State, Nigeria, were interviewed. Stress levels were measured using an instrument comprised of stressors listed by mothers themselves in focus group discussions that preceded the survey. Higher levels of stress were associated with less educated and older women, as well as non-married women and those in polygamous households. Stress levels were also greater when there was more than one child with SCD in the family and when the index child was of school age. Coping mechanisms varied according to the category of stressor. Financial stress and disease factors were met with confrontation while family sources of stress were either complained about, accepted or avoided. Knowledge of the different types of mothers who experience more stress and of their preferred coping mechanisms can be useful in designing clinic-based counseling.