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The knowledge of emergency contraception and dispensing practices of Patent Medicine Vendors in South West Nigeria

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Patent Medicine Vendors (PMVs) can play a critical role in increasing access to emergency contraceptive pills (ECPs) in developing countries, but few studies have examined their knowledge and dispensing practices. Using cluster sampling, the authors selected and interviewed 97 PMVs (60.8 per cent female) in Oyo and Ogun States of Nigeria to assess their knowledge, dispensing practices, and referral for ECPs. About one-third (27.8 per cent) of respondents were not aware of ECPs, and only half knew that ECPs could prevent pregnancy. Forty per cent had ever dispensed ECPs. Reasons proffered by those who do not dispense ECPs included barriers from the State Ministry of Health, police, other regulatory agencies, and religious beliefs. Only 50.5 per cent have referral arrangements for clients. Strategies to increase access to ECPs through PMVs include training on counseling techniques and referral, effective government regulation, and community involvement. Where unsafe abortion is a major cause of maternal mortality, these strategies offer protection for many women in the future.
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Original Article
The knowledge of emergency contraception
and dispensing practices of Patent Medicine
Vendors in South West Nigeria
Mojisola M. Fayemi
a,
*, Olufemi L. Oduola
a
,QueenC.Ogbuji
a
,
Kehinde A. Osinowo
a
,AdejokeE.Oyewo
a
,and
Olabimpe M. Osiberu
b
a
Association for Reproductive & Family Health, Qtr 815A, Army Officers Mess
Road, Ikolaba, P.O. Box 30259 Secretariat Post Office, Ibadan, Oyo State, Nigeria.
E-mail: ope3m@yahoo.com
b
Center for Research in Reproductive Health, 10 Cinema Road, Sagamu, Nigeria.
*Corresponding author.
Abstract Patent Medicine Vendors (PMVs) can play a critical role in
increasing access to emergency contraceptive pills (ECPs) in developing
countries, but few studies have examined their knowledge and dispensing
practices. Using cluster sampling, the authors selected and interviewed 97
PMVs (60.8 per cent female) in Oyo and Ogun States of Nigeria to assess their
knowledge, dispensing practices, and referral for ECPs. About one-third (27.8
per cent) of respondents were not aware of ECPs, and only half knew that ECPs
could prevent pregnancy. Forty per cent had ever dispensed ECPs. Reasons
proffered by those who do not dispense ECPs included barriers from the State
Ministry of Health, police, other regulatory agencies, and religious beliefs. Only
50.5 per cent have referral arrangements for clients. Strategies to increase access
to ECPs through PMVs include training on counseling techniques and referral,
effective government regulation, and community involvement. Where unsafe
abortion is a major cause of maternal mortality, these strategies offer protection
for many women in the future.
Journal of Public Health Policy (2010) 31, 281–294. doi:10.1057/jphp.2010.14
Keywords: emergency contraceptive pills; Patent Medicine Vendors; dispensing
practices; oral contraceptives; pregnancy; Nigeria
Introduction
Every year women experience 66 million unintended pregnancies
and more than 500 000 deaths from pregnancy-related causes.
r2010 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 31, 3, 281–294
www.palgrave-journals.com/jphp/
AUTHOR COPY
Ninety-nine per cent of these deaths occur in developing countries.
1
Approximately one in every five pregnancies in Nigeria is unintended
and nearly one-third of women of reproductive age have had
an unwanted pregnancy at some point in their lives.
2
Lack of
access and low utilization of family planning services in developing
countries contribute to the high rate of unintended pregnancies;
3
only 10 per cent of sexually active women in Nigeria ever used any
modern contraceptive method.
4
In Nigeria, unsafe abortion is often the result of an unwanted
pregnancy, which is frequently owing to low contraceptive use.
5
Induced abortion is illegal, and a criminal offense, unless the woman’s
life is threatened by the pregnancy. Yet an estimated 760 000
abortions occur annually and a quarter lead to complications.
6
Women usually obtain induced abortions clandestinely, and fre-
quently these are unsafe, accounting for 72 per cent of all deaths in
young women under age 19
7
and 20 000 of the estimated 50 000
annual maternal deaths in Nigeria.
8,9
Thus, unsafe abortion is the
single largest contributor to maternal mortality.
Emergency contraceptive pill (ECP) is an effective method for
preventing unintended pregnancy if a woman has unprotected sex,
whether consensual or as a case of sexual assault.
10
ECP is most
effective within the first 24 hours,
11
but can be effective 120 hours
after unprotected sex or contraceptive failure.
10
ECPs remain
inaccessible across much of the world, as both supply and demand
constraints undermine potential clients’ abilities to effectively use the
method. This is particularly true in developing countries where
limited commodity supplies, provider incompetency, and misinfor-
mation coalesce to restrict the availability of ECPs.
12
In Nigeria there are two main commodity procurement channels.
The United Nations Population Fund procures all public sector
contraceptives on behalf of the government. The Society for Family
Health (SFH), a social marketing program, provides the significant
proportion of contraceptives dispensed by the private sector.
13
Nigeria’s Federal Ministry of Health did distribute EC pills in
government health facilities for a short period in 1999, but
discontinued this almost immediately owing to concerns about low
demand and its use as a primary birth control method.
13
Conse-
quently, the private sector has played the central role in introducing
and promoting ECPs.
Fayemi et al
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Pharmacies and patent medicine stores (PMS) serve as important
access points for ECPs. In Nigeria, the distinction between PMS and
pharmacies is important: usually a qualified pharmacist manages the
pharmacy but a Patent Medicine Vendor (PMV), who may have little
knowledge about the commodities, manages the PMS.
14
Thus a
PMV in this context is likely to be a person without formal pharmacy
training who sells pharmaceutical products on a retail basis for
profit. Although this does not designate the PMV as a health-care
provider, PMV enterprises are the primary sources of drugs for both
urban and rural populations.
15,16
According to the National Drug Law in Nigeria, PMVs may
dispense over-the-counter (OTC) drugs, but restrictive and conflict-
ing policies guide provision of oral contraceptives. The National
RH/FP Policy Guidelines and Standards of Practice requires basic
medical examinations and prescriptions for the provision of oral
contraceptives; PMVs may not initiate, but may re-supply oral
contraceptive pills. However, under the National Drug Policy for
Nigeria, Patent Medicine Dealers are neither allowed to initiate nor
resupply ECPs, including pills for oral consumption.
17,18
Despite this
restriction, several studies have documented that especially for young
people the preferred sources of contraceptives are PMS.
19,20
The
reasons include geographical accessibility, shorter waiting times,
more reliable drug stocks, longer hours of service, greater confiden-
tiality, lower cost, and no separate charge for advice.
21,22
Unfor-
tunately, the PMVs may not be aware of the correct dosage or
duration of treatment.
23
Notwithstanding some outcomes of the negative consequences of
obtaining drugs from the PMVs (likely inability to provide accurate
information regarding the mechanism of action and side effects),
they may be strong advocates of emergency contraceptives and create
awareness in more people than health workers in hospitals
and family planning clinics have been able to do.
24
Studies in India
and Bangladesh have demonstrated that paramedics and commu-
nity workers could provide ECPs as OTC drugs as efficiently as
physicians.
25,26
In Nigeria, studies have documented the knowledge and prescrib-
ing attitudes about ECPs among professional health-care work-
ers,
27,28
but there is a dearth of information on the knowledge and
dispensing practices of PMVs. Thus, the objective of this study is to
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assess PMVs’ knowledge and ECP dispensing practices. The results
will support review of policies and conceptualization of education
initiatives to increase access and quality of ECPs services in
Nigeria – and elsewhere.
Methods
We conducted this survey in four and five communities selected by
cluster sampling in Ibadan North and Sagamu Local Government
Areas (LGAs) in Oyo and Ogun states, respectively. Ibadan North
LGA has a population of 308,119; Sagamu LGA has a population of
255,885.
29
The Pharmaceutical Units of the Federal and State Ministries of
Health (SMOH) provide oversight functions and license all
registered PMVs. According to the 2008 records at the Pharmaceu-
tical Units of the SMOH, a total of 64 and 71 PMVs were licensed to
dispense drugs in Ibadan North and Sagamu LGA, respectively.
We selected 48 PMVs from Ibadan North and 49 PMVs from
Sagamu LGAs for the study.
To assess PMV demographic characteristics (professional history,
training experience, knowledge of, and ECP dispensing practices,
average monthly clientele and categories of clients who request
ECPs, ECP promotion activities, experience of stock out, and referral
arrangements), we administered semi-structured questionnaires. The
survey followed standard ethical guidelines. Respondents’ consent
was obtained before questionnaire administration and their anon-
ymity protected by ensuring that individual identifiers did not exist
in the instruments or in the electronic data set. For analyzing data we
employed the Statistical Package for Social Scientists.
Results
Demographic characteristics of respondents
The demographic characteristics of respondents appear in Table 1.
All were located in the urban sector; all were storeowners, with one
exception. More females (60.8 per cent) participated in the survey.
Respondents’ ages ranged from 23 to 55 years and more than half
(53.6 per cent) had secondary education.
Fayemi et al
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More than one quarter (26.8 per cent) engaged in other occupations
including (in order of frequency): nursing, teaching, accounting, trans-
portation business, and farming. A larger proportion (45.4 per cent)
reported to have made a profit of between US$32 and $65 monthly.
Table 1: Demographic characteristics of respondents
Demographic characteristics Number (%) of respondents (n=97)
Gender
Male 38 (39.2%)
Female 59 (60.8%)
Marital status
Single 7 (7.3%)
Married 88 (90.7%)
Widow/Widower 1 (1.0%)
No response 1 (1.0%)
Educational qualification
No formal education 1 (1.0%)
Primary 9 (9.3%)
Secondary 52 (53.6%)
Tertiary 31 (32.0%)
Professional 1 (1.0%)
No response 3 (3.1%)
Religion
Christianity 60 (61.9%)
Islam 37 (38.1%)
Engagement in other occupations
Yes 26 (27.8%)
No 70 (72.2%)
Duration of practice as a Patent Medicine Vendors
Less than a year 1 (1.0%)
1–5 years 26 (26.8%)
5–10 years 38 (39.2%)
More than 10 years 32 (33.0%)
Net profit per month
a
Under $32 32 (33%)
Between $32 and $65 44 (45.5%)
Between $65 and $130 12 (12.4%)
Between $130 and $194 5 (5.2%)
Above $259 1 (1%)
No response 3 (3%)
a
Exchange rate of 155 to $1.
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Professional history
A third had practiced as PMVs for more than 10 years, almost 40 per
cent had practiced for 5–10 years.
Most (92 per cent) learned the trade: (73 per cent) through
apprenticeship, a few (9.5 per cent) while working in pharmaceutical
companies, and (5.9 per cent) during nurses’ training or under
supervision of medical practitioners (3.6 per cent); only 2.4 per cent
inherited the trade. A few others (5.6 per cent) did not specify their
means of becoming involved in the trade.
Training experience
Most (67 per cent) reported having had formal training to improve
their practice. About 30.1 per cent jointly mentioned the SMOH and
Association for Reproductive and Family Health (ARFH), an
indigenous NGO, as organizers of such trainings and 14.4 per cent
mentioned only ARFH. About 16.5 per cent also participated in
training organized by the National Association of Proprietary
Patent Medicine Dealers, by the National Agency for Food and
Drug Administration and Control (NAFDAC) (7.2 per cent),
by pharmaceutical societies (6.2 per cent), by the SFH, or other
NGOs (6.2 per cent).
Reports of those trained differed with respect to content add-
ressed: for 21 per cent, breast cancer, for 17.5 per cent, drug abuse
and duties of PMVs, for 16.5 per cent restrictions on dispensing
drugs, for 10.3 per cent family planning, for 8.2 per cent contra-
ceptive use, for 4.1 per cent fake drugs, for 3.1 per cent drug expiry
date, for 3.1 per cent new development in pharmacy procedures, for
3.1 per cent HIV/AIDS, and for 1.0 per cent other health issues.
Knowledge of ECPs
Most (72.2 per cent) affirmed knowing about a modern family
planning method that could be used within 3 days after sexual
experience (Table 2); but, when respondents were asked about
having heard of ECPs before the conduct of the survey, one fewer
had.
On further probing, only half (46.4 per cent) of the sample
described ECP as a drug for pregnancy prevention, 8.2 per cent said
it is a drug used after sex, and 3.1 per cent mentioned a brand name
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of ECP – ‘Postinor’. One respondent reported that ECPs reduce
abortion and two simply said ‘it is effective’. One said only the ECP
is a ‘family planning method’, two that it is a menstrogren, and
another that EP forte (menstrogen and EP forte are taken to correct
menstrual irregularities). As a way of describing the efficacy of ECP,
one respondent stated that it is safe, able to delay ovulation, and that
it must be prescribed.
Dispensing of ECPs
About two in five (40.2 per cent) of the PMVs had ever sold ECPs:
79.5 per cent of this proportion still sold ECPs at the time of the
study (Table 2). Sources of ECP supply (in order of frequency)
include: pharmaceutical companies, SFH (an NGO), and open, local
Table 2: Distribution of respondents according to knowledge and dispensing of ECPs
Variables Number (%) of respondents (n=97)
Knowledge of modern family planning methods that can be used within 3 days after sexual
experience
Yes 70 (72.2%)
No 26 (26.8%)
No response 1 (1.0%)
Awareness of ECPs
Yes 69 (71.1%)
No 28 (28.9%)
Have you ever sold ECPs?
Yes 39 (40.2%)
No 58 (59.8%)
Do you still sell ECPs?
Yes 31 (32.0%)
No 66 (68.0%)
Average quantity of ECPs sold per month
Less than 5 packs 12 (12.4%)
5–10 packs 8 (8.2%)
11–20 packs 7 (7.2%)
21–70 packs 3 (3.1%)
71 pack and > 1 (1.0)
Not applicable 66 (68.1%)
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outdoor markets. Average numbers of ECPs sold per month ranges
from 5 to 71 pieces.
For the PMVs that did not dispense ECP, reasons proffered (in
order of frequency) include: barriers from the SMOH, the police,
religious beliefs, National Drug Law Enforcement Agency (NDLEA),
and NAFDAC. Others include side effects, low demand for the
product, and product out of stock.
About 43.2 per cent reported a clientele of fewer than 20 people
monthly; one quarter (25.3 per cent) had 20–100 clients, and 6.3 per
cent had a 100 or more clients monthly.
Categories of clients who request to purchase ECPs
On the basis of a review of the PMVs’ records, the category of clients
who requested ECPs within a month preceding the survey included
young in-school girls (20.6 per cent), young in-school boys (4.1 per
cent), young out-of-school girls (16.5 per cent), young out-of-school
boys (6.2 per cent) (Table 3). About 14.4 per cent of clients who
Table 3: Characteristics of clients who request to purchase ECPs from Patent Medicine
Vendors
Variables Number (%) of respondents who
cited each category
Categories of clients who requested ECPs
Young school girls 20 (20.6%)
Young school boys 4 (4.1%)
Young out-of-school girls 16 (16.5%)
Young out-of-school boys 6 (6.2)
Adult men 6 (6.2%)
Adult women 24 (24.7)
Proximity of clients’ residence to PMV store
Within the neighbourhood 21 (21.6%)
Nearby communities 7 (7.2%)
Distant communities 6 (6.2%)
Could not respond to question 63 (64.9%)
Clients who procure ECPs with prescription
Yes 14 (14.4%)
No 20 (20.6%)
Could not respond to question 63 (64.9%)
Fayemi et al
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procured ECPs from PMVs with prescriptions had been referred (in
order of frequency) by private hospitals, health workers, government
hospitals, and other PMVs.
Experience of ECP ‘stock out’ (lack of supplies)
More than half (53.1 per cent) of PMVs who currently dispense
ECPs had a stock out at some time. Among those, 59 per cent sought
resupply from pharmaceutical companies, and 11.8 per cent from
colleagues.
Arrangements to refer ECP clients to other sources
About half (50.5 per cent) reported having arrangements to refer
ECP clients to other sources. Referral points (in order of frequency)
include family planning clinics, pharmacies, other PMS, private and
government hospitals.
Monthly, 28.9 per cent of the respondents referred fewer than
10 ECP clients. One in 10 PMVs referred 10–50 ECP clients;
2.1 per cent PMV referred more than 100 ECP clients.
Ability to disseminate information on ECP in the community
Most of the PMVs (73.2 per cent) were sure that they could
disseminate information on ECPs in their respective communities.
The motivation to disseminate this information stemmed from (in
the order of frequency): sense of duty as a PMV, the importance of
ECPs to prevent unwanted pregnancy, the life-saving quality of
ECPs, people wanting to know more about pregnancy prevention,
and the fact that ECP will reduce abortion rate.
About one quarter reported that they could not talk freely about
ECP in their communities. Reasons (in order of frequency) include: it
is against their religious beliefs, Ministry of Health does not permit
them to sell the commodity, lack of interest, it promotes promiscuity,
and fear of harassment by regulatory agencies.
Discussion
In Nigeria, unsafe abortion remains a leading cause of maternal deaths
because access to contraceptive services remains low and abortion
laws remain restrictive.
5
Recent studies offer strong evidence that
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increasing contraceptive usage can reduce induced abortion rates
30
and could prevent up to 35 per cent of maternal deaths.
3
Thus,
increased access and use of contraceptives through community-based
initiatives is a key strategy
31
and PMVs can play a significant role.
In Nigeria, the PMVs’ educational level is usually not specified in
laws licensing their practice, although by convention, the minimum
educational attainment has been primary schooling.
32
In this study,
more than half of the PMVs had secondary education or more. The
higher educational level is likely to contribute to PMVs’ abilities to
provide accurate information to clients and to appropriately dispense
ECPs. To enhance competence of PMVs, it may be necessary to review
the laws and increase the educational level required for practice.
Survey results call into question the ability of PMVs to provide
accurate information for clients having had unprotected sexual
intercourse (consensual, sexual assault, or condom rupture), as about
one-third of the respondents were not aware of ECPs and only half
knew ECPs could be used for pregnancy prevention. This is similar to
the findings from a study conducted in Ibadan, Nigeria where more
than half of the professional health-care workers were not aware that
combined oestrogen/progestin or progestin – in the form of pills –
can be used as emergency contraception.
27
The SMOH and NGOs
should increase awareness about ECPs among community-based
distribution agents
26
and PMVs to ensure proper dissemination of
information to potential clients.
Nigerians’ negative cultural disposition to providing contracep-
tives to young people makes them wary of public health institu-
tions.
26
The advantage of the PMS for young people, including the
higher number of females, may relate to their need for anonymity,
which the PMVs provide, but which public health institutions deny.
This information is particularly relevant because young persons
(15–24 years) have the greatest incidence of unwanted pregnancy
and unsafe abortion.
14
Given the reasons cited for PMVs not being able to talk freely
about ECPs and supply shortages, women who need to access
information and ECPs appear to face religious, attitudinal, supply
and regulatory, or policy barriers.
In Nigeria, the PMVs are approved by the Federal Ministry of
Health to dispense OTC drugs and surveillance occurs at three key
levels: supervision by the Pharmacy Inspection Committee to ensure
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PMVs are licensed and only dispense unexpired OTC drugs,
supervision by NAFDAC to ensure they dispense only registered
OTC drugs, and supervision by the NDLEA to ensure PMVs do not
sell psychoactive drugs. Punitive measures available to authorities
include sealing of the PMV stores and confiscation of their products.
Governmental bodies, using existing authority and procedures, can
enhance the capacity of the PMVs to ensure they provide accurate
EC information and services.
As only half of the PMV respondents reported arrangements to
refer ECP seekers to the formal health-care system, it will be
important to enhance these links, especially in cases of sexual assault,
because the women clients may need counseling, HIV post-exposure
prophylaxis, and permanent family planning methods.
Conclusion
This study demonstrated that PMVs can play a critical role in
enhancing access to ECPs’ services. PMVs may require training on
counseling techniques, service provision, and referral. Key factors for
improving their services include reducing the opportunities for PMVs
to supply sub-standard drugs through a combination of more
effective government regulation, PMV Association self-regulation,
and community involvement.
Acknowledgement
This study was conducted by Association for Reproductive and
Family Health and Center for Research in Reproductive Health,
Nigeria with support from Population Council, Kenya and New
York. We commend Professor O.A Ladipo, Mrs G.E Delano, and
Professor A Adekunle who reviewed the manuscript and all
respondents from the Nigerian Association of Patent and Proprietary
Medicine Dealers.
About the Authors
Mojisola M Fayemi, MPH, is a public health educator experienced in
the implementation of Reproductive Health and HIV/AIDS beha-
vioral change interventions.
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Olufemi L. Oduola, MPH, is a public health promoter and educator
experienced in design of project evaluations especially in reproduc-
tive health.
Queen C. Ogbuji, PhD, is a medical sociologist with nursing/
midwifery background. She has participated in several HIV and
reproductive health research programs and contributed local and
international publications.
Kehinde A Osinowo, MPH, specializes in managing sexual and
reproductive health programs, including those focused on adolescent
reproductive health, safe motherhood, training capacity develop-
ment, and reproductive health policies.
Adejoke E Oyewo, BNSC, is a nurse, midwife who has contributed
to improving the quality of reproductive health care. In 2009 she was
a fellow at the West African College of Nursing.
Olabimpe M Osiberu, MSc, is a nurse, midwife who has served in
managerial, research, and administrative posts. She has published
locally and internationally.
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... However, in some countries, some respondents incorrectly identified other products as ECP. Medicine indicated for menstrual irregularities, and the malaria therapy (quinine) were erroneously noted as ECP by medical doctors [33] and drug vendors [36] in Nigeria. ...
... Barriers to prescription and/or dispensing were noted in a few studies, including low consumer demand [26,36], and ethical, legal and religious concerns of the providers [34,36,43]. ECP were regarded by some as delivering a cost saving to the health system through reducing the abortion rate [41] and unwanted child bearing [32], as well as an opportunity to promote regular contraception [47]. ...
... Barriers to prescription and/or dispensing were noted in a few studies, including low consumer demand [26,36], and ethical, legal and religious concerns of the providers [34,36,43]. ECP were regarded by some as delivering a cost saving to the health system through reducing the abortion rate [41] and unwanted child bearing [32], as well as an opportunity to promote regular contraception [47]. ...
Article
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Emergency contraceptive pills (ECP) are one of the 13 essential commodities addressed by the UN Commission on Life-Saving Commodities for Women and Children. Although ECP have been available for 20 years, a number of barriers still limit women's access ECP in low and middle-income countries (LMIC). The workforce who prescribe or dispense ECP are diverse reflecting the varied contexts where ECP are available across the health, commercial and justice sectors and in the community. No reviews currently exist that examine the roles and experiences of the workforce that provide ECP in LMIC. We present a narrative synthesis of research to: identify provider factors that facilitate and constraint access to ECP; assess the effectiveness of associated interventions and; explore associated health system issues in LMIC. A search of bibliographic databases, meta-indexes and websites was undertaken to retrieve peer reviewed and grey literature. Literature was screened and identified documents examined to appraise quality. Thirty-seven documents were included in the review. Studies focused on formal health workers revealing knowledge gaps concerning the role of private sector and non-health providers who increasingly provide ECP. Data from the findings section in the documents were coded under 4 themes: provider knowledge; provider attitudes and beliefs; provider practice and provider training. The analysis revealed provider knowledge gaps, less than favourable attitudes and practice issues. The findings provide limited insight into products prescribed and/or dispensed, the frequency of provision, and information and advice offered to consumers. Pre and in-service training needs were noted. As the provision of ECPs shifts from the clinic-based health sector to increasing provision by the private sector, the limited understanding of provider performance and the practice gaps revealed in this review highlight the need to further examine provider performance to inform the development of appropriate workforce interventions. A standardized approach to assessing performance using agreed outcomes measures may serve to ensure a systematic way forward that is inclusive of the diverse workforce that deliver ECP. Recommendations are outlined to enhance the performance of providers to improve access to ECP. A framework is offered to help guide this process with indicators.
... Prior or concurrent employment in a health center was also common; 29% of surveyed PPMVs in Oyo had worked at a health facility [41], with rural PPMVs twice as likely than those in urban areas to be dually-employed [60]. However, apprenticeships with another PPMV remains the primary source of training for the majority of PPMVs [35,41,61,62]. PPMVs' were found to have an average of between 5.4 and 15.5 years of experience [41,42,46,55,59,61]. ...
... However, apprenticeships with another PPMV remains the primary source of training for the majority of PPMVs [35,41,61,62]. PPMVs' were found to have an average of between 5.4 and 15.5 years of experience [41,42,46,55,59,61]. ...
... PPMVs also stock a number of sexual and reproductive health products. The data in this area, which are based on small scale studies, showed that male condoms and treatments for sexually transmitted infections (STIs) are more commonly stocked than emergency contraceptives, female condoms and birth control pills [61,63]. Another study found that 13% of PPMVs sold injectable contraceptives even though they are prohibited from giving injections [41]. ...
Article
Full-text available
Interventions to reduce the burden of disease and mortality in sub-Saharan Africa increasingly recognize the important role that drug retailers play in delivering basic healthcare services. In Nigeria, owner-operated drug retail outlets, known as patent and proprietary medicine vendors (PPMVs), are a main source of medicines for acute conditions, but their practices are not well understood. Greater understanding of the role of PPMVs and the quality of care they provide is needed in order to inform ongoing national health initiatives that aim to incorporate PPMVs as a delivery mechanism. This paper reviews and synthesizes the existing published and grey literature on the characteristics, knowledge and practices of PPMVs in Nigeria. We searched published and grey literature using a number of electronic databases, supplemented with website searches of relevant international agencies. We included all studies providing outcome data on PPMVs in Nigeria, including non-experimental studies, and assessed the rigor of each study using the WHO-Johns Hopkins Rigor scale. We used narrative synthesis to evaluate the findings. We identified 50 articles for inclusion. These studies provided data on a wide range of PPMV outcomes: training; health knowledge; health practices, including drug stocking and dispensing, client interaction, and referral; compliance with regulatory guidelines; and the effects of interventions targeting PPMVs. In general, PPMVs have low health knowledge and poor health treatment practices. However, the literature focuses largely on services for adult malaria, and little is known about other health areas or services for children. This review highlights several concerns with the quality of the private drug retail sector in Nigeria, as well as gaps in the existing evidence base. Future research should adopt a more holistic view of the services provided by PPMV shops, and evaluate intervention strategies that may improve the services provided in this sector.
... s'adressent (2) n'ont pas toujours connaissance de cette contrainte temporelle (Teixiera et al., 2012)Ebuehi et al., 2006 ;Fayemi et al., 2010 ;Inde du Nord : Tripahi et al., 2003 ;Turquie : Sevil et al., 2006 ;Aksu et al., 2010 ;Laos : Sychareun et al., 2010 ;Europe : Uzuner et al., 2005 ;Szucs et al., 2010). Des études aux États-Unis ont montré que même les professionnels qui connaissent l'existence de ces produits ne savent pas toujours comment et quand les utiliser, ni quels sont leurs mécanismes d'action (Sherman et al., 2001 ;Wallace et al., 2004 ;Lawrence et al., 2010 ;Farris et al., 2010). ...
... Il est donc important de comprendre les attitudes des professionnels de santé dans ces pays. Une seule étude récente est disponible sur le sujet en Afrique subsaharienne (Fayemi et al., 2010) qui complète utilement les études Attitudes des professionnels de sAnté à l'égArd de lA contrAception d'urgence déjà anciennes sur le sujet (Gichangi et al., 1999 ;Muia et al., 1999 ;Muia et al., 2000 ;Steiner et al., 2000). La recherche dont nous rendons compte ici est la première à s'appuyer sur des entretiens approfondis pour appréhender les connaissances, attitudes et pratiques des professionnels de santé reproductive concernant la contraception d'urgence dans les capitales de deux pays d'Afrique de l'Ouest : le Ghana et le Burkina Faso. ...
Article
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Provider Attitudes to Emergency Contraception in Ghana and Burkina Faso There are few studies in sub-Saharan Africa on providers’ attitudes and delivery practices regarding emergency contraception (EC), though they could provide an important component of contraceptive programmes there. Thirty-one semi-structured interviews were conducted with a purposive sample of reproductive health service providers in Ghana and Burkina Faso as part of the Emergency Contraception in Africa study (ECAF) conducted in 2006-2007. A typology of provider-responses was constructed using two dimensions reflecting providers’ “acceptance” and “provision” of EC. Provider attitudes broadly favoured EC, although most in Burkina Faso were cautious about providing it (fearing that regular use might displace condom use, thus increasing HIV risk), while in Ghana, many highlighted useful role of EC in reducing unwanted pregnancy. Overall, respondents wanted to limit distribution to health facilities and pharmacies and were reactive, rather than proactive, EC providers. Their attitude towards people seeking emergency contraception varied: those suffering contraceptive method failure or provider failure were seen as deserving, while those who came because they had used their contraceptive method incorrectly or not used one at all were regarded less favourably.
... This study seeks to understand providers' knowledge of EC, their attitudes towards its use and how they respond to users seeking care or help. It has been shown that inadequate provider knowledge is an important barrier to EC provision and use in a range of settings (Nigeria: Ebuehi et al., 2006; Fayemi et al., 2010; Northern India: Tripahi et al., 2003; Turkey: Sevil et al., 2006; Aksu et al., 2010; Laos: Sychareun et al., 2010; and Europe: Uzuner et al., 2005; Szucs et al., 2010). Studies from the United States indicate that even " knowledgeable " providers do not always have accurate knowledge of how and when EC should be taken or of its mechanisms of action (Sherman et al., 2001; Wallace et al., 2004; Lawrence et al., 2010; Farris et al., 2010). ...
... EC has great potential to contribute to reducing abortions and maternal mortality in sub- Saharan Africa, particularly West Africa, where family planning use is very low and unwanted pregnancies, subsequent abortions and maternal mortality rates are high (Ghana DHS, 2009; INSD and ORC Macro, 2004). However, despite the importance of this question, we have found only one study on the views and attitudes of providers towards EC in sub-Saharan Africa (Fayemi et al., 2010); along with a few partial exceptions, now quite old (Gichangi et al., 1999; Muia et al., 1999; Muia et al., 2000; Steiner et al., 2000). The study reported in this paper is the first to be based on in depth interviews seeking to ascertain the knowledge, attitudes and practice of reproductive health providers regarding emergency contraception in two West African countries, Ghana and Burkina Faso. ...
... 6 Instead, individuals seek care elsewhere, including by purchasing medications directly from pharmacies or drug sellers. In Nigeria, patent and proprietary medicine vendors or PMVs play an important role in the provision of basic healthcare services 11 12 including reproductive health, [13][14][15][16] though knowledge of their role in abortion care is limited. 3 PMVs are persons without formal training in pharmacy who sell orthodox pharmaceutical products in retail for profit. ...
Article
Full-text available
Background In Nigeria, where abortion is legally restricted, individuals seek medication abortion drugs, including misoprostol, directly from pharmacies or drug sellers. However, knowledge of drug sellers or patent medicine vendors (PMVs) dispensation practices and women’s experience with self-management is limited and research suggests poor quality of services. This study assesses the knowledge and practices of PMVs and women’s experiences after a harm reduction intervention to improve the provision of medication abortion using misoprostol. Methods We conducted a retrospective descriptive analysis of anonymised logbook data collected from 141 Nigerian PMVs who provided misoprostol for abortion to 4924 clients between February 2015 and July 2018. We conducted a descriptive analysis of self-reported misoprostol dispensation practices with data from a cross-sectional survey of PMVs (n=120) from June 2016 to December 2018. We collected data on women’s experience obtaining misoprostol from 37 PMVs through a cross-sectional survey of women (n=260) from 4–19 June 2018. Results For clients where the misoprostol dose dispensed was recorded (n=3784), 86% of clients were given 800 μg or more misoprostol, pain medication (97%) and a contraceptive method (92%). Most clients with an outcome recorded in the logbook (n=4431) had a complete abortion (86%). Almost all women reported that they would return to the PMV for future services (99%). Conclusions The majority of PMVs dispensed misoprostol in appropriate dosages and provided clients with information on drug administration and methods of contraception. Interventions designed to improve PMVs’ best practices around the provision of abortion care may help ensure the quality of services received by clients.
... Abortions in Nigeria are occasioned by unwanted pregnancies in unmarried/'underaged' women, to avoid dropping out of school, as a means of contraception, to escape from harsh economic realities, to avoid the stigma attached to having pregnancies too late/ too frequently/too many, or due to problems with partners (Mitsunaga et al. 2005;Omideyi et al. 2011;Sedgh et al. 2006). Incidentally, despite the nation's restrictive abortion laws, an estimated 760,000 pregnancies were terminated (equivalent to a rate of 27 induced abortions per 1000 women aged 15-44) in 2006 (Awopetu and Fasanmi 2011;Fayemi et al. 2010;Lauro 2011), climbing to 1.25 million induced abortions (approximating to a rate of 33 abortions per 1000 women aged 15-49) in 2012 (Bankole et al. 2015). Comparatively, in the less abortion-restrictive United States of America, abortion rates fell from 16.9 per 1000 women aged 15-44 in 2011 to 13.5 per 1000 women aged 15-44 in 2017 (Jones and Jerman 2014;Jones et al. 2019). ...
Article
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Introduction The rapid and unexpected increase in the sex ratio at birth in Nigeria between 1996 and 2014 is yet to be fully explained. The contribution of sex-selective abortion has not been explored. Methods A cross-sectional survey of pregnant women was employed to address this need. Results Preference for sex-selective abortion was noted in 8.6% of the respondents. The association between parity ≥ 4 and preference for sex-selective abortion was statistically significant. Women who were child gender-biased were significantly more likely to prefer sex-selective abortion. Experiencing intimate partner violence, and having problems with in-laws for inability to give birth to their desired gender, were predictors of maternal preference for sex-selective abortion. Women who preferred sex-selective abortion, however, felt it was necessary to campaign against gender preference. Conclusion Preference for sex-selective abortion exists in Nigeria, despite our restrictive abortion laws. However, the women’s underlying reasons may include gender balancing in the family and an escape from discrimination. Improving contraceptive uptake, restriction of disclosure of fetal sex for non-medical indications, and sanctions against violent partners/oppressive in-laws are advocated. Rapid progress towards achieving a world free of the offensive gender inequalities that force women to opt for sex-selective abortion ab initio is desirable.
... Combined oral contraceptive pills (Yuzpe's) and levonorgestrel only pills (postinor) are the most common emergency contraceptive methods available in Nigeria; they are commonly available in pharmacies and can be obtained over the counter without prescription [12]. When emergency contraceptives are used within 72 hours after sexual intercourse, they have the capacity to prevent pregnancy by 75% -85% and as much as 99% with intra-uterine contraceptive device [13]. ...
Article
Full-text available
Background: Young people, especially those in tertiary institutions are vulnerable to unplanned and unprotected sexual intercourse which predisposes them to unintended pregnancies and subsequently unsafe abortions. One of the key interventions for reduction of unwanted pregnancies and unsafe abortions is effective use of emergency contraceptives. Objectives: To assess the sexuality, perception, attitude towards and determinants of usage of emergency contraception among female undergraduates in Lagos, Nigeria. Methods: Cross-sectional survey conducted in June 2016 among 805 female students of the Lagos State University. Data were collected through structured self-administered questionnaire by obtaining information on demography, sexual and contraceptive history, perception, attitude towards and use of emergency contraceptives. Data obtained were analyzed using SPSS version 16. Chi-square and logistic regression models were applied to variables to test for significance that predicts the use of emergency contraceptives. Results: Of the 725 (90%) completed questionnaires, 334 (46%) of the respondents were sexually active with 115 (34%) having previous history of pregnancy. Eighty- two percent of those pregnancies were unintended. Eighty-eight percent of those with unintended pregnancy had them terminated by induced abortions, 54% of which was carried out by untrained persons. Only 29% of those who had unprotected sexual intercourse used emergency contraceptives. Lack of knowledge and promotion of sexual promiscuity were identified as the main reasons for not using emergency contraceptives. Previous use of contraceptives, married status, increasing age and year of study were positive predictors for the use of emergency contraceptives while poor knowledge was a significant predictor of non-use. Conclusion: There was poor knowledge and low utilization of emergency contraceptives among respondents. Information oncontraceptives should be introduced in secondary schools and in general studies courses in tertiary institutions while parents and caregivers should discuss issues relating to sex and contraceptives with adolescents.
... Furthermore, programs would have to manage the dynamics of rights to financial information, as the study showed the majority of respondents were not owners of outlets. Similar studies have shown the majority of employees are relatives of owners [33][34][35]. Outlet owners are more likely to know the financials of their business compared to their employees, however, employees may have better knowledge of operational costs. ...
Article
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Background Despite making great progress in reducing under five mortality in the last three decades. Uganda still ranks high among countries with the highest under five mortality rates. More than a third (36%) of these deaths are caused by pneumonia (15%), malaria (12%), or diarrhea (9%). For many mothers and caregivers, private drug shops are a point of care seeking for these illnesses. However, many drug-shops, are unlicensed and do not stock essential commodities due to insufficient capital and operational funds. This study set out to understand the relationship, between access to credit services through financial loans or stock and i) availability of essential child medicines and ii) licensing status among medicine retail outlet including drug shops and pharmacies. Methods This was a cross-sectional study conducted between April and March 2016. The country was divided into 168 enumeration areas based on the geographical regions and household population distribution within the region; these served as the primary sampling units. Within each enumeration area, all private medicine retail outlets (drug-shops and pharmacies) that provide consultation for childhood illnesses were identified and surveyed. Data on access to credit services was collected through interviews and data on stock, through observations of shelves for Oral rehydration salts, amoxicillin dispersible tablets, amoxicillin syrup, Artemether combined therapies, and Zinc dispersible tablets. Android tablets were used for data collection and results were analyzed using STATA12. A total of 586 outlets were visited during the study, 96% were drug shops and 4% were pharmacies. ResultsFor all five essential child medicines assessed, access to credit through financial loans or through obtaining stock on credit did not influence stock availability. Access to credit services through loans or through stock on credit was seen to influence licensing status. The odds increased by more than 50% (1.53, CI: 1.27–2) among outlets who accessed loans compared to those who hadn’t and by 2 fold (2, CI: 1.03–3.8) among those who accessed stock on credit than in those who had not. Conclusions Access to credit does not influence stock availability of essential child medicines among private medicine outlets, however, it has an effect on licensing status. In addition to further research, the provision of financing mechanisms to support the licensing processes could increase the proportion of unlicensed outlets.
Technical Report
Results from an implementation research study in Nigeria found that with training, Patent and Proprietary Medicine Vendors (PPMVs), regardless of their previous health care experience, could competently administer injectable contraceptives and that clients reported receiving quality services from trained PPMVs. From 2015 to 2018, the Evidence Project conducted a study to better understand the role of PPMVs in offering voluntary injectable services (e.g., selling, counseling, referring to health centers, and administering). The study was conducted in response to Nigeria’s family planning context and the role of PPMVs in the informal health sector. http://evidenceproject.popcouncil.org/resource/nigeria-ppmv-report/
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This paper examines the rapid increase in Nigeria's sex ratio at birth from 1.03 boys born for every 1 girl born in each year from 1996-2008 to 1.06 in each year from 2009-2014, second only to Tunisia in Africa at 1.07. The average sex ratio at birth in the world in 2014 was 1.07. In most Black African nations or Black majority nations, it is 1.03 or less. Among the factors presented for this development are: historical fluctuations of sex ratio at birth; geography and ethnicity; male preference/chasing a son; Age of parents; high death rates of male infants and males in general; and wealth/socioeconomic status. Among the potential implications are: young and poor men in Nigeria may not be able to find brides and form families due to a potential shortage of females; emigration of young and poor Nigerian men to West (Africa) and elsewhere to seek brides and form families; immigration of marriage age women from West (Africa) and around the world to Nigeria to seek husbands; and low contraceptive use and high fertility rates in Nigeria.
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Context: The continued poor reproductive health behaviour and outcomes among youths informed the investigation of the knowledge, attitudes, sexual behaviour, outcomes and care-seeking among university students in Zaria, north western Nigeria. Methods: Using a cross-sectional descriptive study design, self-administered structured questionnaires were administered to a sample of 400 undergraduate students of Ahmadu Bello University students drawn by multi-staged sampling to collect information on their reproductive health knowledge and behaviour. Findings: Knowledge of most aspects of reproductive health was high. However, gaps where found in some specific areas. Apart from ethnicity and faculty of study, no significant associations were found between knowledge and other demographic variables. Attitudes to reproductive health were generally negative. Overall, 64.1% of the respondents had had sexual intercourse; 65.4% of the males and 60.2% of the females students sexually experienced. The mean age at sexual exposure for females and males were 17.8 and 19.2 years, respectively. The mean number of lifetime sexual partners was 3.4 for males and 2.4 for the females. Of the 54.7% currently sexually active respondents, 53.5% of the males and 48.0% of the females were involved in multiple sexual relationships. Only 32.4% of the sexually exposed respondents had ever used or were currently using a method of contraception. Condom use was only 30% among the sexually active respondents with use higher among the males; however, the use was inconsistent. Use of effective contraceptives was very low. Overall, 23.3% of the respondents had experienced symptoms suggestive of sexually transmitted infections within six months preceding the study, and self medication was the predominant method of treatment. Utilization of the university health services for their reproductive health needs was found to be abysmally low. Conclusion: The gaps in reproductive health knowledge, negative attitudes, high prevalence of risky sexual activity and poor reproductive health care seeking behaviour call for mounting of educational intervention programmes and development of youth-friendly reproductive health services on campus. KEY WORDS: University students; Reproductive health knowledge; Sexual behaviour; Contraceptive use; Reproductive health outcomes Journal of Community Medicine & Primary Health Care Vol.16(2) 2004: 8-16
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The provision of essential drugs and the involvement of various potential and existing health care providers (e.g. teachers and traditional healers) are two important primary health care strategies. One local group that is already actively supplying the medication needs of the community is the patent medicine vendors (PMVs), but the formal health establishment often views their activities with alarm. One way to improve the quality of the PMVs' contribution to primary care is through training, since no formal course is required of them before they are issued a license by government. Primary care training was offered to the 49 members of the Patent Medicine Sellers Association of Igbo-Ora, a small town in western Nigeria. Baseline information was gathered through interview, observation and pre-test. A training committee of Association members helped prioritize training needs and manage training logistics. Thirty-seven members and their apprentices underwent the 8 weekly 2-hr sessions on recognition and treatment (including non-drug therapies) for malaria, diarrhoea, guinea worm, sexually transmitted diseases, respiratory infections, and malnutrition, plus sessions on reading doctor's prescriptions and medication counseling. The group scored significantly higher at post-test and also showed significant gains over a control group of PMVs from another town in the district. The Igbo-Ora experience shows that PMVs can improve their health care knowledge and thus increase their potential value as primary health care team members.
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To identify bottlenecks in the delivery of comprehensive reproductive health care in Bulawayo, Zimbabwe's second city, a study was performed utilising volunteers pretending to be in need of emergency contraception. A total of 55 private, Zimbabwe National Family Planning Council, municipal and government health facilities were visited. These consultations resulted in 9 (16%) correct, 1 possibly correct and 15 wrong prescriptions for the morning-after pill (MAP); no treatment was prescribed in 30 instances. Public sector health personnel were very judgemental in their attitude toward sexually active teenagers. Although the Essential Drug List of Zimbabwe is quite clear about the MAP, many health providers are not aware of this, and others do not even have/use this book.
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There are few drugs for malaria, and those which are available for use are subject to rapid development of resistance. Curiously, little effort has been made to improve drug use in malaria-endemic countries and to assess the benefits of such improvements. Advances can be made in public understanding of the value of ingesting a full regimen of antimalarials, in order to achieve complete cure, and in improving simple technologies (blister packaging) to achieve the same result. Better efforts can be made to reduce the availability of fake or substandard drugs in the marketplace. In this article, we describe the outcome of a concerted effort to improve drug compliance and drug quality in an area of multidrug resistance for malaria. These research efforts, guided by the Task Force for Improved Use of Antimalarials, characterized the problems in drug compliance in South-East Asia, and developed interventions to improve drug use in the various countries. Interventions involved drug packaging, public information campaigns, and assessments of drug quality. Results show that blister packaging worked best to improve drug compliance and that the increased cost of packaged medication did not limit its use. Drug quality was a major problem in unregulated countries and should be improved.
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Context: Unmet need for family planning in the developing world, as measured through surveys, is high. But it is important to determine whether there is a significant level of dormant demand for actual contraceptive services waiting to be satisfied, especially in a country such as Pakistan, where efforts to promote family planning have been disappointing. Methods: Records from six household contraceptive distribution projects in Pakistan are used to determine contraceptive prevalence over 13-22-month periods. An independent professional team conducted an external evaluation, interviewing project supervisors fieldworkers and clients. Results: Contraceptive use increased dramatically in all six projects, from an average of 12% to 39% in less than two years. The external evaluation team found the contraceptive prevalence measurements to be generally accurate, but identified additional improvements in access and quality that might further increase contraceptive use. Conclusions: Increased use of contraceptives that result from improvements in service delivery confirm that a substantial unmet need exists. The evidence suggests that even greater improvements in access to and quality of services will further increase contraceptive use.
Article
Context: Nigerian adolescents generally have low levels of contraceptive use, but their reliance on unsafe abortion is high, and results in many abortion-related complications. To determine why, it is important to investigate adolescents' perceptions concerning the risks of contraceptive use versus those of induced abortion. Methods: Data were collected through focus-group discussions held with adolescents of diverse educational and socioeconomic backgrounds. All were asked what they knew about abortion and contraception, and each method of contraception was discussed in detail. In particular, youths were asked about contraceptive availability, perceived advantages of method use, side effects and young people's reasons for using or not using contraceptives. Results: Fear of future infertility was an overriding factor in adolescents' decisions to rely on induced abortion rather than contraception. Many focus-group participants perceived the adverse effects of modern contraceptives on fertility to be continuous and prolonged, while they saw abortion as an immediate solution to an unplanned pregnancy-and, therefore, one that would have a limited negative impact on future fertility. This appears to be the major reason why adolescents prefer to seek induced abortion rather than practice effective contraception. Conclusions: The need to educate adolescents about the mechanism of action of contraceptive agents and about their side effects in relation to unsafe abortion is paramount if contraceptive use is to be improved among Nigerian adolescents.
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This survey was conducted to determine the knowledge, and prescribing attitudes of emergency contraception among healthcare professionals in Ibadan, Nigeria. A questionnaire was administered to 735 health care professionals in selected healthcare facilities in Ibadan. These facilities were randomly selected as part of an ongoing programme designed to introduce emergency contraceptive pills (ECPs) as a clinic based method of family planning in service delivery outlets in the city. The response rate was 87.5%, comprising nurses (59.3%) and physicians (25.0%). Others were pharmacists, social workers and administrators. The results revealed that healthcare professionals' knowledge of various methods that can be used emergency contraception is very low. Less than half (35.1%) of the respondents were aware that combined oestrogen/progestin or progestin-only pills can be used as emergency contraception. Similarly, only 26.7% and 13.3% of the respondents were aware that intrauterine contraceptive devices and mifepristone respectively could be used as emergency contraception. While only 16.3% of the respondents had ever prescribed the combined pills as emergency contraception, 10.9% and 8.2% had prescribed progestin-only pills and intrauterine contraceptive devices for this purpose in the past. Circumstances under which emergency contraception could be used vary among the respondents but 71.4% and 64.4% were of the opinion that condom breakage and sexual assault would be appropriate indications for its use. Two main sources, hospitals (68.4%) and pharmacies (8.8%) were identified by participants. It is apparent that one of the major barriers to frequent use of emergency contraception in Ibadan is the lack of awareness of its use by healthcare professionals. Therefore, there is an urgent need to educate these practitioners and include emergency contraception in the family planning curriculum of nursing and medical schools.
Article
This paper examines the various ways through which adults' health beliefs and attitudes affect their responses to five major killer diseases during childhood. The data for the study were derived from in-depth interviews conducted between December 1988 and January 1989 in a Yoruba community, Nigeria. The diseases covered in the study include diarrhoea, measles, tetanus, pertussis and fever. It was observed that teething and food related causes were believed to be responsible for diarrhoea; the cause of measles and pertussis was generally unknown; tetanus was usually associated with convulsions; and fever was believed to be caused by roaming in the sun and by constipation. Herbal tea, modern drugs and prayers were the most commonly prescribed treatments for these diseases. It was observed that most mothers used alternative sources of health care, rather than hospitals, clinics and maternity centres, in their treatment of diseases among children. Prominent among the alternative sources were patent medicine stores where there were personalistic social interaction between clients and operators, free consultancy and flexible pricing. Parents' location at the time of a child's sickness, access to good advisers, the perceived seriousness of the sickness and religious beliefs of mothers were important determinants of their response. Avoidance of blame was noted to be a major motivating force in parents' search for potential sources of health care. The paper concludes that although some of the practices might have negative health implications, they could be usefully adapted to the goal of self-reliance in medical care as a strategy for attaining health for all by the year 2000.