Primary Health Care: What Women in Households in A Rural Community in Imo State, Nigeria Know and Practice

Primary Health Care (PHC) is a cost-effective and action-oriented intervention strategy. It is the first- point of contact of individuals, families and communities with the national health system, bringing health care close to where the people live and work [1,2]: And for most rural women, PHC offers them their first opportunity ever to be health educated. The PHC approach to health is beyond the traditional health system that focuses on health equity-producing social policy [1-3].. It includes all areas that play roles in health, such as access to health services, environment and lifestyle [1]. Thus a synergy between PHC and public health measures could be considered the bedrock of universal health systems [2]. 

The PHC is an approach to health, and the health system; improving access to health services, disease prevention, -early detection, treatment and care [1,2,4]. It also encompasses the integrated management of health conditions such as sexually transmitted infections, the package of essential non-communicable disease interventions for PHC in low-resource settings (called PEN)-Plus).to expand access to high-quality care for severe chronic non-communicable diseases- cancer, cardiovascular diseases, diabetes and the respective associated risk factors [1,5,6] In the same vein, selective PHC approach focuses on severe health problems in certain developing countries, where a few diseases are responsible for high infant and child mortality rates. [1] The selective PHC techniques known collectively under the acronym "GOBI-FFF", have specific and measurable targets and effects [1,3]. Thus, they form a useful yardstick for assessment, employ health care planning, to prioritise conditions that define the felt health needs of specified populations and offer cost- effective interventions accordingly [1,3,4]. Oral rehydration therapy: for example, is used to combat dehydration associated with diarrhoea in children, another instance, is the use of vaccination to immunize children less than five years old, as well as pregnant women, against vaccine preventable diseases 

The Alma-Ata Conference mobilized a "Primary Health Care movement" of professionals and institutions, governments and civil society organizations, researchers and grassroots organizations that tackle the "politically, socially and economically unacceptable" health inequalities in all countries [1,2,4].  Primary health care centers are not only making a difference at the local level, they are having an impact on health planning at the national and international levels. The global experience of the adoption of the Alma-Ata Declaration by several countries has made PHC the cornerstone of most national health systems and the basis of developmental programs-(1,2).- Health For All (HFA), Millennium Development Goals (MDGs), Sustainable Development Goals (SDGs) , etc 

Primary health care thrives on the role women play, of particular reference is health education. Primary health care discussions bring women into the process of both making and implementing decisions that affect the community [1,4]. This boosts their self-esteem and empowers them to help their communities in improving women's health and that of their families. They also train other women both as health educators and as care givers. The PHC centers provide health education emphasizing family planning, hygiene, sanitation, and prevention of communicable and non-communicable diseases [1,4]. It hinges on home self-help, community mobilization, participation, involvement and technologies that are acceptable, appropriate, and affordable to the people Through PHC centers, the local population is involved in the operation, community outreach programs and encourages cultural activities, self-help programs, and health education. 

However, in the African Region, PHC is often neglected, while many of the countries that have adopted the PHC interventions are yet to implement them on a full national scale [1,7,8]. Bridging resource gaps remains key in optimizing primary health-care capacity to manage health and disease conditions, especially as it pertains to infrastructure, information systems, out of stock syndromes in relation to equipment, drugs and sundries [1,8-10]. Putting in perspective, the role women play in PHC, the benefits of knowledge and adoption of practices regarding to principles of PHC cannot be overemphasized. The findings of this study are expected to contribute to future scientific studies, fill the literature gap and equip the study population in planning and proactively. This study was designed to determine the knowledge and practices regarding Primary health care services among women in households in a rural communitiy in Imo state, Nigeria

Study Area 

This study was conducted in Ogbaku, a rural community in Mbaitoli LGA of Imo State, Nigeria. It is located at about 76km from Onitsha Anambra State, Nigeria and 14km from Owerri, the Capital of Imo State [11], Ogbaku, has an area of 84km² and a population of 143,485 persons as at the 2006 census with a 2011 population density projected at 2004.5 persons per sq. km [11].  The residents are mainly traders, farmers, civil servants and artisans. The town hosts a few private hospitals and a comprehensive PHC center under the Imo State University Teaching Hospital [12]. It is made up of 18 villages which constitute the four zones of the community. Topographically, it is made up of plain land except its southern end where it approaches Ijakaha hills, allowing geographical accessibility. Its residential buildings are popularly the “face me I face you” type (as popularly described in Nigeria) but some areas are partially planned consisting of flats and private owned duplexes [12]. Their major sources of water supply are borehole and well, while the commonest method of refuse disposal is open dumping [12]. 

Study Design: This study was a cross sectional analytical study. 

Study Population: Women in households in Ogbaku, Imo state.

• Inclusion Criteria: Women in households, who have resided in Ogbaku for at least one year..Also, women in such households who were within the age interval of 18-49 years 
• Exclusion Criterion: Women in households who were absent during the time of study ir declined full unformed consent.

Sample Size Estimation: The minimum sample size was calculated using the Cochran formula [13]: n = z²pq/d² , where; n=minimum sample size, Z= standard normal deviate corresponding to 95% confidence interval = 1.96, p= proportion of the target population that had knowledge about PHC (79.5% know the location, 89% know the name of health worker and 65% know the services provided at health center). (4) X On the average, 77.8%p = 0.778., q =1 – P, d = tolerable error of margin, set at 0.05; n=265. An additional 10% was added to make up for attrition, giving us a total of 291.5 =292 households as the sample size [14].

Sampling Technique: A multi stage random sampling technique was used to select participants. In the first stage, stratified sampling technique was used to split the rural community studied into four according to the four zones. The second stage involved the selection of the villages studied under the four selected zones by simple random sampling. Each select village was regarded as a cluster. The sample size calculated was proportionately allotted to each cluster. Thirdly, a central place in each area was located e.g. market or hall was chosen, an empty bottle was spun on the ground (the bottle made a minimum of three complete turns before stopping). When it ceased to move, the direction of the neck of the bottle was taken as the starting point. The researchers walked in a line then began again, for the inclusive households. Then systematic sampling technique was used through consecutive enrolment of households to select eligible and consenting participant from each household within the select village in the respective zones. 

Data Collection: Data were collected by interview, using semi-structured questionnaire. The questionnaire comprised of four sections which comprised: a) socio demographic and household characteristics, b) awareness and knowledge about primary health care, and c) PHC practices 

Data Management and Analysis: The data were edited and entered into the computer. Data cleaning was done. Descriptive and analytical statistics of the data were carried out using statistical package for social sciences (SPSS) Windows version 22.0 [15]. Tests of statistical significance were carried out using Chi square and Fishers tests for proportions. A p value of <0.05 was considered significant. Descriptive data were presented as simple frequencies and percentages. Five knowledge items were used with a total scale score of five (5) at one (1) point each, where (0-2= poor; 3= fair; 4-5=good).

A total of 292 questionnaires were administered to select households, all were retrieved and analysed, giving a response rate of 100%. Table 1 shows the socio-demographic and household characteristics of the respondents. The modal age group 165 (56.5%) was 20-29 years. Majority of them, 213(73%) was currently married, 281(96.2%) Christians, 247 (84.6%) Ibos, while 251(86%) attained various levels of formal education. Fifty-five (18.8 %) of respondents were unemployed, while 45(15.4%) reported Monthly household income Less than N30 000. 

Table 1: Socio- demographic characteristics of women in households in rural communities in Imo state Nigeria from June to December 2021. 

Table 2 shows the awareness of and knowledge about primary health care among respondents. Two hundred and sixty- two (89.7 %) of them reported awareness of PHC, with the key sources of information on PHC, as 151(57.6%) Health centre, 130(49.6%) Social media, 130(49.6%) Community meetings, 62(23.7%) Radio. One hundred and ninety-one (73%) respondents  reported idea/understanding of PHC, 169 (64.8) reports PHC is the first contact an individual has with National Health System, 189 (69.7%) reported PHC is an approach to health beyond the traditional health care system, only 18 (6.9%) reported that PHC focuses on health equity- producing social policy, 181(55.9%) reported that PHC includes all areas that play a role In health, such as access to health services, environment and lifestyle, while 81(44.1%), 59 (21.4%), 90 (34.5%) and 52 (20%) can mention at least three Principles, three Elements and three techniques of PHC respectively. 

Table 2: Awareness and knowledge about primary health care among women in households in rural communities in Imo state Nigeria from June to December 2021. 

* Multiple responses 

Table 3 summarizes the level of knowledge on PHC among respondents. Only fifty- three (18.1%) respondents had good knowledge on PHC.

Table 3: Practice of primary health care among women in households in rural communities in Imo state Nigeria from June to December 2021. 

• Others- Relatives, Spouse’s relatives, Church Pastor, Boss at the Office
• ** Multiple responses                            

Table 4 highlights the PHC practices among respondents. Primary decision maker on health care issues for the family were 85(29.2%) the woman, 185(65.4%) Spouse, Person who takes care of health care cost for the family were 85(29.4%) the woman, 185(63.4%) Spouse. On reasons for seeking medical care at a place other than the PHC cin the study community- 237(83.2%) for specialist care, 174 (59.6%) lack/ loss of confidence 173(592%) cost concern, 118(40.4%) poor attitude by staff. Only 23(7.8%) had medical insurance. The reported preferred mode of delivery plan were 191(65.4%) Government Hospital, 80(27.4%) Private Hospital, while the reasons for preferred mode of delivery plan include: 209 (71.6%) need for quality service, 84 (28.8%); low cost with quality intact. 

Table 4: The level of knowledge of primary health care among women in households in rural communities in Imo state Nigeria from June to December 2021. 

Table 5 shows the relationship between socio-demographic characteristics and level of knowledge of primary health care among women in these households There were statistically significant associations between  the level of knowledge on PHC among respondents and the following: age at last birthday in years- 18- 29 and 30-49 (χ2-24.394 , p= 0.0000); ethnicity- Ibos and Non-Ibos (χ2-v13.747, p-= 0.0000 ); highest level of education attained- at most secondary and tertiary (χ2-21.988, p= 0.0000); occupation- -unemployed   and employed (χ2= 4.3785, p= 0.0037), and monthly income- less than N30 000  and N31 000 and above  (χ2=12.89,9, p= 0.0000) respectively. 

Table 5: The relationship between socio-demographic characteristics and level of knowledge of primary health care among women in households in rural communities in Imo state Nigeria from June to December 2021. 

* Statistically significant association = p<0.05, χ2- Chi square test. f- fishers- exact test

The index cross sectional analytical study determines the knowledge and practices regarding PHC services among women in households in Ogbaku, a rural community in Imo State, Nigeria. From the findings of the current study, roughly nine in every ten participants reported awareness of PHC. This finding though higher, is in tandem with findings of other studies [4,16,17], 

Regarding the key sources of information on PHC, this study documents Health centre, Social media, Community meetings, Radio. This finding is however, consistent with findings of studies, where majority of participants, reported obtaining their information about PHC from the health centre (4,16,17). mass media, community meetings, etc. [18]1 Also, these findings of the current and reference studies, document informal sources such as community meetings, friends, families, which are the preferred forms of information dissemination of health needs of rural households in general [4,18-20] and are in tandem with the findings of other studies [20-22]. According to these reports, these sources are more reliable and authentic [20]. 

The finding of this study on the level of knowledge on PHC shows that roughly two in ten participants had good knowledge on PHC in general. On specifics, the participants in the index study had above 65% on (idea/understanding of PHC, this report is in tandem with that of a study done elsewhere, where the same percentage of rural women, has good knowledge about PHC [4]. This finding is worrisome considering that PHC is the first contact an individual has with National Health System, bridging the gap between healthcare provision and availability of the same to where people work and reside [1,2].  Previous studies also concur with this report that knowledge of PHC among women influences their utilization of PHC services, their participation in the same, and serves as a medium for developing community health via the promotion of health education in the community [4]. 

Furthermore, the PHC practices among participants and their household was studied. In about 60% of these, the spouses were the primary decision maker on health care issues and persons who take care of health care cost, On reasons for seeking medical care at a place other than the PHC in the study community, the commonest reasons include: need for specialist care and loss of confidence. Only about eight in ten of them possess medical insurance. Also, about seven in every ten of than, would prefer Government hospitals to the privately owned, as mode of delivery plan. This finding is in keeping with findings of studies elsewhere. [4,23].  These participants cited reasons such as need for quality service and at affordable cost too. 

Finally, the present study examines and documents some relationship between their level of knowledge on PHC and socio-demographic/ household characteristics such as age; ethnicity, highest level of education attainment, occupation-and monthly income respectively. Similar findings had been demonstrated from previous researchers, [23].

Reporting and recall biases could result from this study. These would have been minimized by the anonymity entrenched in data collection and assuring participants of strict confidentiality. A major strength of this study is the 100% response rate.

This study found apparently high awareness on PHC, with the key sources of information on PHC, as Health centre, Social media, Community meetings, and Radio. Though majority of them reported idea/understanding of PHC there were poor knowledge and poor practice of PHC. Their spouses were primary decision makers on health care issues for the family and in- charge of health care cost the reasons for preferred mode of delivery plan as Government hospital include: need for quality service, at low cost. Their level of knowledge on PHC was influenced by age, ethnicity, level of education attainment, occupation, and monthly income respectively. 

Based on the above, we recommend improved cross- sectoral, localised and need based PHC oriented programs and strategies with full involvement of the community, government and private partners. All stakeholders should muster strong political will and rational decision making in developing synergy towards empowerment of rural women, re-orientation of their spouses, re-enforcing public awareness about PHC, through efficient and viable channels so as to increase their level of knowledge and practices on PHC;

The authors have no support or funding to report.

The authors declare that they have no competing interests.

Approval was obtained from the appropriate authorities in the institution of study. Permission to conduct the study was obtained from the State Ministry of Health and the selected Local Government PHC Departments. After advocacy to relevant authorities in Ogbaku, Written consent was obtained from households involved in the study for the conduct and publication of this research freely and without coercion. Assurance of confidentiality was given. Study participants were free to refuse or withdraw from the study at any time without any penalty. The purpose and objectives of the study were explained to participants prior to interview. All authors hereby declare that the study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.

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