Drug and Alcohol Dependence,

Elsevier Scientific Publishers

Knowledge

28 (1991) 177-182

I77

Ireland Ltd.

and views on drug abuse of primary workers in Nigeria

health care

O.A. Abiodun Department

of Behavioural Sciences, Faculty qf‘Health Sciences.

lTnizvr.sity q/‘Ilorin. Iloritl (Nigeria)

(Received March 22nd, 1991)

Primary health care (PHC) in Nigeria (as in many developing countries) relies heavily on paramedical personnel. Using a selfreport structured questionnaire design, 207 PHC workers were assessed on their knowledge and views about drug and alcohol abuse. PHC workers with previous exposure to some form of drug abuse training were significantly more likely to be aware of the correct usage for the term ‘drug abuse’, although the whole range of drugs of abuse/dependence was much less well appreciated. Drugs reported by the PHC workers to be commonly abused in the study area were in keeping with previous findings on drug abuse in the country. However, 75.4% of the PHC workers perceived drug abuse as a low grade problem, in contrast to recent reports, of the increasing magnitude of drug abuse problems in the country. About one fifth of PHC workers were of the opinion that drug abusers should be punished. Only 35 (16.9%) of those who indicated the need for treatment mentioned that this could be carried out by PHC personnel. Many of the PHC workers showed limited knowledge of factors associated with drug abuse and on the scope of preventive strategies against drug abuse. Suggestions are made on the short and long term training needs of the PHC workers in order to ensure the successful incorporation of drug abuse treatment and prevention programmes into the PHC programme in Nigeria. Key uvx-ds: drug abuse;

alcohol

abuse;

primary

care

workers;

Introduction Studies from Africa indicate that drug and alcohol abuse is on the increase [l-3] and reports from Nigeria suggest that this has become a major public health problem [2,4]. The most commonly abused drugs include alcohol, benzodiazepines, psychostimulants and cannabis [1,2]. It has also been established that non-psychoactive substances such as antibiotics and nonopiate analgesics are frequently abused [ 5 1. Recent surveys indicate that in Nigeria drug and alcohol abuse now start at an early age and cuts across all social groups [ 1,6]. Multiple drug use pattern and more female involvement have also Correspondence to: O.A. Abiodun, Tower Block 1, Flat 410, Withington Hospital, West Didsbury, Manchester M20 8I1R, U.K. 0376-8716/91/$03.50 0 1991 Elsevier Scientific Publishers Printed and Published in Ireland

knowledge

and views

been reported [2,6]. The most recent observation involves the increasing use of hard drugs (e.g., cocaine and heroin) especially in the big cities [ 7,8 3, There is abundant evidence that the common problems (physical and psycho-social) associated with alcohol and drug abuse occur in Nigeria as in other parts of the world [9,10]. Both the direct (treatment of drug abuse patients) and indirect (productivity loss, property damage etc) costs of the health consequences of drug abuse may, therefore, be very significant [Ill. However, despite the increasing magnitude of drug and alcohol abuse problems in Nigeria and other developing countries, mental health personnel and facilities continue to be grossly inadequate [12,13]. It is therefore important to evolve a treatment approach that is both effective and economical [l3]. A possible strategy for achievIreland Ltd.

178

ing this goal is to incorporate drug and alcohol treatment and prevention programmes as part of the mental health component of the primary health care (PHC) programmes of developing countries. Nigeria recently adopted the PHC strategy as a means of achieving the goal of ‘Health for All by the year 2000’. Mental health has just been incorporated into this PHC programme and the modalities for its implementation is currently being worked out by the Federal Government. One of the essential preliminary steps in implementing the PHC strategy in the management of drug and alcohol abuse patients is to obtain information on the training needs of this category of health workers. The present study reports on the knowledge and views concerning drug and alcohol abuse of primary health care workers in Nigeria prior to designing a training programme for them. The study

abuse; factors associated with drug abuse and high risk groups for drug abuse. Questions were asked on whether or not drug abusers needed punishment or treatment; which categories of health workers should treat if treatment was deemed necessary; the magnitude of drug abuse problems and ways by which drug and alcohol abuse could be prevented. Other sections of the questionnaire (to be reported separately) included questions on other areas of mental health problems. The initial phase of the study involved obtaining the list of all primary health care facilities both public and private in the local government area. Primary health care workers in the health facilities who provided some form of preventive or curative health care were included in the survey which took place in February 1989. Labourers, clerks, drivers and others in PHC services not directly concerned with health care were thus excluded. The questionnaires were

area

The study took place in the Irepodun local government area (ILGA) of Kwara State, one of the 21 states in Nigeria. Nigeria operates a three-tier system of government: local, state and federal. Kwara State (located in the middle belt region of the country) with a population of about 3.5 million people is divided into 12 local government areas, one of which is ILGA from where the present study population is drawn. The study area (ILGA) was chosen because it is one of the local government areas used by the University of Ilorin Medical School for its community outreach programmes. The medical school operates a community based education and service programmes. Method

Table I. Socio-demographic

and other background

data.

No.(D/n) < 35 years > 35 years

122 (58.9) 85 (41.1)

Male Female

76 (36.7) 131 (63.3)

Categories of PHC workers:

Community Health Aides Community Health Assistants Pharmacy Technicians Staff Nurses/Midwives Public Health Nursing Officers Rural Health Superintendents Community Health Officers Medical Officers

29 (14.0) 32 (15.5) 11 (5.3) 94 (45.4) 8 (3.9) 18 (8.7) 10 (4.8) 5 (2.4)

Drug education during training:

A structured questionnaire was used with sections on sociodemographic data and on knowledge and views on drug and alcohol abuse covering such areas as definition of drug abuse and list of drugs of abuseldependence. Respondents were also requested to list drugs which people in their communities commonly

Yes No

131 (63.3) 76 (36.7)

PHC workers tlisorckrs

cvtimutrs

c$rhe proportion

ofputienrs

with mentul

in PHC,fucilities:

< 5%

170 (82.1)

5-20%

37 (17.9)

179 Table II.

PHC workers’

views

on possible

definitions

of ‘drug

Definition Excessive use of socially acceptable Use of a legally prohibited drug Drug use for nonmedical reason Use of a drug without a doctor’s Getting intoxicated only *Test of significance

@-test)

substances

prescription

based

on presence

or absence

Out of 240 eligible respondents, 207 (86.3%) participated in the study. Table I shows the

views

on possible

drugs

Cocaine Heroin Non-opiate Antibiotics

analgesics

No (Yo)

150 145 162 186 66

57 62 45 21 141

(72.5) (70.0) (78.3) (89.9) (31.9) exposure

of abuse/dependence

Potential

Alcohol Cigarette Minor tranquillizers (e.g. diazepam) Stimulants (e.g. dexamphetamine) Cannabis

Yes (YD)

drug

to drug

(27.5) (30.0) (21.7) (10.1) (68.1)

P < 0.05 P < 0.05 P < 0.05 I’ < 0.05 P < 0.05

education.

background information on the study population. It was observed that significantly more of the PHC workers with previous exposure to some form of training on drug and alcohol abuse were able to indicate some of the possible definitions of drug abuse, legal definition being the most popular (Table II). Most of the PHC workers recognised illicit drug’s like cannabis and cocaine (85% and 74% of respondents respectively) as potential drugs of abuse while the least recognised were non-opiate analgesics and antibiotics (43.0% and 33.3% of respondents respectively) (Table III). The PHC workers were more likely to have observed members of their communities use drugs like sleeping tablets (e.g diazepam, nitrazepam), alcohol, cigarettes, nonopiate analgesics and cannabis and less likely to have witnessed the use of hard drugs like cocaine and heroin (Table III). One hundred and

Results

PHC workers’

(W = 207).

of previous

distributed to various primary health care facilities in the study area by four research assistants who were very familiar with the local government area and the location of the various health facilities. The PHC workers were very enthusiastic and cooperative throughout the survey. The most senior health worker in charge of each PHC facility took responsibility for distributing the questionnaires to eligible respondents and for collecting them back. The research assistants then returned a few days later to collect the completed questionnaires. Repeat visits were necessary in some cases in order to ensure that all completed forms were retrieved.

Table III.

abuse’

(n = 207).

of:

Common in study

Abuse %

Dependence %

56.0 54.7 56.0

42.0 50.2 41.5

47.8 37.2

52.7 85.0 74.4 69.6 43.0 33.3

21.3 63.3

5.8 30.0 7.7 5.3 30.9 18.8

46.4 38.6 16.9 8.2

33.8

drug of abuse arca (%I

180 Table IV. PHC workers views on factors associated with drug abuse (n = 207). Associated

factors

% of n with positive response

Friends Ignorance

45.4 52.7

Unemployment Worries Anxiety/depression Enjoyment/social activities

30.4 67.6 35.3 33.8

Availability/accessibility Home background Physical illness Insomnia

21.7 48.9 10.6 14.4

seventy-five (75.4%) of the PHC workers perceived drug abuse as a low grace problem while it was viewed as a medium/high grade problem by 20.6% and 4.0% of respondents respectively. Students and public transport drivers were identified by the health workers (64.0% and 56.0% of respondents respectively) as constituting high risk groups for drug abuse. Other groups mentioned in smaller numbers included soldiers, farmers and health personnel of all grades. Table IV shows the 10 commonest factors which the PHC workers mentioned as being associated with the abuse of alcohol and drugs. Forty-five (21.7%) of the PHC workers were of the view that people who abuse alcohol and drugs should be punished (none of these respondents had any previous exposure to drug education). Among those who indicated the need for treatment, only 35 (16.9%) mentioned the possible involvement of primary health care personnel. Many of the health workers (44.9%) were of the opinion that drug abusers should be treated by mental health personnel. Preventive measures indicated by the PHC workers included drug education (69.5% of respondents), government control over the availability of drugs of abuse (47.4%) and the need to pay more attention to the prescription habits of health workers (14.9%).

Discussion This study has shown that the drugs indicated by PHC workers as commonly abused in their communities include minor tranquillizers, alchol, cigarettes, non-opiate analgesics and cannabis. This observation is supported by previous studies on drug abuse in the country which have found these drugs to be among the most commonly abused [2,4,7]. However, drug and alcohol abuse was perceived as a low grade problem by many (75.4%) of these health workers. This is in contrast to recent reports in the country which have shown increasing trends in the abuse of alcohol and drugs [2,7,81. The alarming rate of increase in the magnitude of drug and alcohol abuse problems recently led to the setting up of drug abuse prevention committees by both the Federal and all the 21 State Governments [14]. It can thus be concluded that most of the PHC workers surveyed were not aware of the extent of drug abuse problems in the country. This situation needs to be rectified so that the PHC workers can better appreciate the urgent need for active preventive measures. PHC workers without previous exposure to some form of drug and alcohol abuse training programmes tended by and large to view drug and alcohol abuse from moral perspectives as they advocated punishment for people who abuse drugs. Nearly half of the health workers who advocated treatment felt that this should be provided by mental health personnel. The treatment orientation of these PHC workers is in contrast to observations on drug and alcohol abuse problems at the PHC level. For instance, studies from both developed and developing countries have found that many drug and alcohol abuse patients present at PHC level [3,15,16]. Many of them, however, usually go unrecognised [3,11]. Thus the care that these patients presently receive at the PHC level may be fragmented and of low quality [17]. The reported magnitude of drug and alcohol abuse problems at PHC level and the need for early and adequate intervention in the treatment of these patients (in order to minimise associated problems such as educational and occupational

181

failure, social disorganisation etc [2,4,61) therefore implies a major role for PHC workers. This need is further strengthened by the observation from other studies of the effectiveness of measures such as the use of simple screening instruments to aid detection of drug and alcohol abuse patients and simple intervention techniques (such as information giving, single counselling session, brief advice, self-help manuals and self-help groups) which are indeed much more relevant to developing countries where resources are very limited [3]. A number of studies have found no significant differences between patients who received these brief interventions when compared to those who were involved with more extended treatment programmes [18]. In the present study, the commonly mentioned preventive measures by the health workers included drug education for the patients and government control over the availability of drugs of abuse. There is, therefore a need to emphasize other preventive strategies to these PHC workers. These include teaching them about alternatives to drug use, the importance of parental education, mass media education and the involvement of religious and other voluntary agencies [14,19-211. Since students are known to be a particularly high risk group (81, it will also be important to make the PHC workers appreciate the special role of school-based drug education campaigns (some of the PHC workers were found to be involved with school based health programmes, but these were mainly focussed on physical health problems). Studies have shown that such programmes can be used to teach youth peer pressure resistance and social competence skills for avoiding drug use [8,22]. The envisaged school-based drug education programmes will, however, need to be integrated with community programmes, mass media and other environmental influences outside the school [22]. The findings from this study suggest the need for short and long term training programmes. Short term programmes for the present core of practising PHC workers (e.g., using operational manuals) would need to focus on primary

prevention, early detection and management and community based rehabilitative efforts. On a long term basis, there is need to review the present curricula of health care personnel in the country with a view to increasing the scope of theoretical and clinical exposure to drug and alcohol abuse courses. This would require the cooperation of all the health institutions where health care personnel are trained. It is known that the currently allotted time for drug and alcohol abuse training (and indeed other aspects of mental health training) is grossly inadequate. Similar observations have also been made in other countries [23]. Finally, success of current attempts at integrating drug and alcohol abuse treatment and prevention programmes at PHC level in Nigeria will depend on ensuring adequate back-up and referral channels for the PHC personnel [12,16]. Close liaison of hospital and primary carelcommunity based services will therefore be necessary [16,24]. Regular evaluation of services will also need to be encouraged. This may generate useful data, including the need for new strategies. References 1 2 3 4 5 6 7 8 9

10 11 12 13

14 15

Asuni, T. and Pela, O.A. (1986) Bull. Narcot. 38. 55. Pela, O.A. (1989) Bull. Narcot. 41, 103. Nielsen, M.F.T. et al. (1989) BF. J. Addict. 84, 1343. Odejide, A.O. (1980) Nig. Med. J. 10. 5. Ogunremi, 0.0, and Rotimi, D.O. (1979) Afr. .I. Psychiatry 5, 21. Ebie, J.E. and Pela, O.A. (1981) Drug Alcohol Depend. 81. 301. Pela,

Knowledge and views on drug abuse of primary health care workers in Nigeria.

Primary health care (PHC) in Nigeria (as in many developing countries) relies heavily on paramedical personnel. Using a self-report structured questio...
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