Management is getting things done, or achieving results through the directed efforts of other people. It can also be defined as effective allocation and utilization of source resource achieve predetermined results.
Going by those definitions, getting things done means achieving results, the second definition points out that achievement of result could be attained with other people’s directed efforts. Directing other people involves communication. The third definitions also signifies achievement of results with effective allocation and utilization of scare resources such as man, materials, machines, Money and time hence the 4 M&T formulas. Once again we cannot effectively allocate and utilize resources without adequate information. This means that generally, management in any form cannot be effective or result –oriented without adequate information/ effective communication.
Information on the other hand involves a number of managerial activities. What is important about information is that it keeps the manager and management on top of its performance. It is very important for a man to know how many people feed in his house daily so as to know how to prepare for them. The manager who has little or no information on what he does or is doing or has to do, achieves little or no positive results. It can therefore be said that all phase of managerial performance require adequate information.
It can now be ask how manager gets information and what type of information does he get. There are control signals in management that provide information to the manager. These control signals are in two categories.
- There are some control signals that give the manager some information about what has happened so that he can take action to solve problems if there are any. Such control signals are regarded as curative. Coincidentally this forum is that paramedical personnel from who this word curative is commonly used. So it can be easily and stops it from creating further damages to the patient.
- There are also some signals that give information to the manager, warning him to prevent a potential problem. Such control signals are expected to be accurate and timely so that they will not give premature information that can force the manager to take wrong action or false steps. These are the control signals referred to as prevent. Again it rhymes with the medical information that helps his decision- making and action. Both are quite helpful and useful, although generally one is preferred to the other. It is always said that prevention is better than cure. Meaning it is better to prevent a problem than to solve it. Erwin schell has this contribute.
“An executive with only enough information to apply remedial rather than preventive measure is obviously not in a position to justify his responsibilities to top management in other word, it is the manager who can problem through organized information that is regarded as being on top of job. Some example of control signal is listed here. Please see through a find out what nature of signal they are and what information they give to the manager?
(ii) Employee turnover
(iii) Personnel Establishment figure
(v) Numbers of letter written
(vi) Time taken to reply to correspondence
(vii) Variance report
(viii) Project schedule
(xi) Volume of sale
(xii) Transaction per employee
(xiii) Maintenance cost
(xiv) Cost of labour
(xv) Total salary
(xvi) Amount of Overtime
(xviii) Advertising cost
(xix) Project Estimate
(xx) Record of absenteeism
(xxi) Alarm clock
How many these control signal have you used and for what reason? How accurate as the information given to you and how did it help to solve your problems. These signals are in the general group, because they apply to many organizations particular the private sector, some of them also apply to the public service. In any case they may give wrong information unless care is taken by the manager. What happen when control signal give us wrong information?
- Problem, unfavorable variance or shortfall are discovered too late to be corrected
- The manager find himself taking corrective action on problem that could have been prevented
- Subordinate are frequently explaining inventing excuses and apologizing for their action decisions
- The time of the manager and/ or his subordinate is misallocated; they focus on the control rather than the result to be achieved.
- Subordinate direct their energies toward circumventing control
- Important information on variance or defensive instead of focusing on early problem solving
- The manager spend a great deal of time in checking the work of subordinates
- Subordinate lack motivating and enthusiasm, they are not creative in the way they carry out their job
- Warning of deviation are premature, or the deviation are not significant
- Too much influence is attached to staff authority, which gathers and provides control information for example; the time manager is controlled by the accountant. Which of this condition exist in your organization/local government? How can you
Improve control procedure and invariably security of information to eliminate this problem? Now let’s glance through some of the information system used in the civil service/ local government service and how positively or otherwise they effect health care.
- Information gets to us through government circulars. How explicit and informative are they? How many people get such circulars and how fast do they get to the appropriate quarters?
- We get information from official correspondence. What do you think about them?
- Information gets to us through public mobile vans. What do you think about them? People to them? Immunizations programme/ outbreak of epidemics etc.
- Information is put on poster how many people read them? Who takes pain interpret them? How effective are they?
- Radio and televisions: Give us information. Do you care to listen to them? What population do they reach?
- Files in our offices are sources of information: what is your reaction to the files? Is there enough security on our files?
- Patient cards/records what do they say? How do you organize them? How helpful are they? How many patients have died?
- Patient register how do we keep them? Is it possible to get information of the last fifty years? How many people have so far been treated in the health care sector?
- Information Tank what type? How reliable is the information? Do we have records on the following?
- The Number of children born between January, 1992 and April 1996
- How many of such children have died and how many are alive?
- Can we categorize the children’s number as males and females or as Christian
- What information do we gather with regards to children’s mortality rate?
Barriers to Accurate Information
Of all the resources at the manager’s disposal the 4M&T Human Resource is the most important, the most dangerous. Unfortunately all system/ sources of information are controlled and operated by man. So he can be a barrier to accurate information. Starting from verbal or written information. Man can manipulate information either to suite his purpose or cause confusion. He might not get the information correctly while he assumes that what he relates to others is the correct information. He may not even understand the content or the importance of the information he gathered. His perception of the information may be contrary to the actual. He may decide to deform the information to connote a different meaning. The receiver can also be a problem. Since the receiver too is human he may be affected and by any of those affecting the informat he may even be deformed and pretend to be sound either in hearing or speaking i.e he may be a deaf or dumb. He may be a stammered. He may misunderstand but may not accept the objective and the importance of the information given to him. He may decide to be careless with the information. He may subtract or add to the information. By making information look reasonable and acceptable to others he may change the important words that mean something else. Therefore as managers, we should manage our human resources or system information very well otherwise they are likely to produce negative results through false information.
If the importance of man information connection is recognized as vital, then it affects all other earlier mentioned system of sources of information. The file can be used to carry false information particularly if the man is not interested in the subject matter. So the file can become unreliable since the information carried is of no value. In fact pages of relevant information could be removed from a file in order to kill the effect of information contained.
Official correspondence could carry ambiguous information that could be interpreted to mean many things. The choice of words and arrangement of ideas can produce negative results. One again the interpretation of the contents may be different from what the sender intended. In this case, the information contained in a letter of correspondence may not be reliable. This applies to all system of information enumerated earlier Public Address vans, information posters, radio, and television, the new public, circular, Radio and Television, Patient Record Cards, Registers and even the computer which is believed to be the most accurate in modern technology.
The computer may be turned to an ordinary robot or a gaining machine when the information contained or supplied is un- reliable. After all, the computer is supposed to operate on information supplied by the operator the theory of garbage in and garbage out.
MANAGING INFORMATION SYSTEM
From the foregoing it would appear that information is collected from some sources, which could be regarded as systems. It does not matter what the system or source are, human electronic written, verbal or rountine, the important thing is that they give us some information. These sources of information are what I referee to as control signals, inter alia. To ensure therefore that they give us proper information, following should be observed by the manager.
- They should relate directly to important goals and focus on significant performance areas
- They should operate in the area where your business operations or plans are most vulnerable
- They should operate in the area over which you have authority and where you can take effective action
- A standard must be act against which result can be measured, when such information supplied should facilitate comparison, usable, understandable and easily interpreted.
- They should give timely information warning against variances or deviations early enough for mistake to be corrected. They should not give false or premature warnings.
- They should be efficient, giving warnings of from expected or desired events or behavior.
- They should be few in number, simple in design, facilitating trouble shooting and problem solving.
- They should not produce devious, deceptive or dysfunctional behavior.
- They should lead to corrective action.
- A periodic review of performance is essential to ensure accurate information and where there is deficiency they could be discarded and replaced with more effective ones.
Finally the manager should note that most information received are meant for either prevention/or solution of problems. So he needs in addition the following information systems to keep him on top of this job. WE SOLVE IT.
Working conditions or layouts (7-2pm,2-9pm, who is who)equipment and supplies Hospital, dispensaries, beds, drugs system and procedures the Doctor, the pharmacist, the nurse, community health officer/ health Assistant/ health technicians etc
Other employees hospital attendants laborers etc Load or pace of work various supervisory actions Employee himself information flow training.
The Concept of Management
The term management has different meanings. To some people, management refers to the functions being performed by those who manage.
Gulick and urwick (1937) identified the functions of a manager with an acronym ‘POSDCORB’ which means planning, organizing, staffing, directing, coordinating, Reporting and Budgeting. It must be noted that the list of managerial function is both endless and overlapping.
Management is also defined as ‘getting things done through other’s ibukun (1997) felt that any useful and meaningful definition of management should take into consideration, the structure, actors, functions and goals of management.
Hence, he defined management as a process of delimiting an organization into structural levels and arranging workers and activities into performance units and coordinating resources and production procedure through appropriate leader behaviours to achieve organizational goals.
In other words, management is the effective and efficient utilization of human and material resources for the attainment of organizational goals.
Any useful definition of management must have following implications.
- Managers have functions to perform with an organization (e.g planning, organizing, staffing, leading and controlling).
- Productivity the essence of management is for the manager to create surplus or profit maximization and this is made possible through increased productivity.
- Management cuts across all kinds of organizations.
- It applies to all levels in all Organizations. This includes top level, middle level and operational level.
Elements of Management
The elements of management are planning, organizing, coordinating controlling and evaluating.
Planning is the determination of goals and objectives and selecting the policies, procedures, and strategies to achieve them in advance in such way that the programmes are executed at minimum risk of failure or problem.
Planning involves what to do? Why it should be done? Who should do it? Where to do it? When to do it? And how do it?
Importance of planning
(a) It reduces time and effort
(b) it aids optimal use of resources.
(c) It improves decision making rationally
(d) It focuses on means and ways of achieving set goals
(e) It makes it easy to identify the problems of an organization
(f) It injects rationality, critical analysis and logic into organizational activities.
(g) It ensures control.
Kind of planning
Planning is futuristic. The future may be immediate, distant or long time
To this end we have
- short term planning (0-2years)
- Medium term planning (1-5years)
iii. Long term planning (5-20years)
Stage/step in the Planning process (Ibunkum 1977)
- Identification of planning problem
- Setting of objectives
- Information collection and analysis
- Development of Alternative Plans
- Selection of Action Plan
- Contingency support Plans
- Implementation procedures
- Review and Evaluation of plains
Organizing is the establish of staffing structure and functions that could best lead the achievement of set goals. It shows authority relations in the organization. It involves departmentisation for work and people into performance units to be coordinated by superiors that is the orderly arrangement of human and material resource to achieve organizational goals.
Directing is the ability of the superior to influence his subordinates to carry out their duties in a way that will facilitate the accomplishment of organization objectives.
For the function to be effective, the goals of the organization must be made clear, the structure must be clearly defined, leaders must be ready to delegate duties to their subordinates based competency and effective communication.
Coordinating is the synchronizations, of individual efforts towards the accomplishment organizational goals in order to prevent workers form working at cross- purposes.
If the activities of members are not coordinated, they will be working towards different goals to the detriment of the organization goals.
Controlling is the measurement of performance against laid down standard so as to make appropriate adjustment where and when necessary, it deals with evaluation of tasks against the objectives. It may involve location, allocation and relocation of materials and personnel to reduce deviations from plans.
Four steps are involved in the control process;
- Establishment of standards/objectives
- Measurement of performance against standards
- Correcting deviations from standards
- Ascertaining whether control has yielded desired change
Evaluating is a process of comparing stated and theoretical standards with observed or actual performance. The difference between controlling and evaluating is that while period (1 year, 5years etc) specified by the management.
There are various types of evaluation namely programme evaluation, staff evaluation and material evaluation.
Health means different thing to different people. As a matter of fact, the concept and the real meaning of health is not properly understood by many people yet they are all expected to live in an optimal health condition. While industrialized countries with comprehensive social security and health insurance would define health primarily in term of ‘ability to work’ a different scenario may exist in other places. Linking health with work enables us to understand some basic facts. It is clearly visible the correction between risk of unemployment and sick leave. The rate of sick leave in the work place falls when there is a risk of being laid off. It should be noted that it is not that sick people are sacked nor that sick people continue to work, but that there exist a gray zone between health and disease where the individual decision of taking sick leave oscillates. This fact is equally obvious in agricultural communities when during planting and harvesting period’s hospitals are deserted by sick people and the least hand is engaged in farming activities. Defining health in relation to disease status appears confusing, complex, and grossly incomplete. It is clear that someone may be sick and still goes to work and someone may not be sick and still unable to work. Health professionals see health only as a disease entity. This is not correct. Health is not and cannot be restricted to a mere absence of disease. It is important that health workers understand the real meaning of health otherwise it will be very difficult for the make meaningful impact on the lives of the people.
The WHO defines as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmities. This definition had been criticized by many health experts in view of the problems encountered in understanding its real goal and also the thinking that it makes its concept a mere goal that will be very difficult to attain by anyone. For example, how and when do you say someone is in a state of complete physical wellbeing? Or even mental or social wellbeing? The social wellbeing comprises of something which may be called the strength to live with inescapable disabilities or handicaps. The definition of health, the acceptance of ill health obviously depends on religious, cultural, societal and scientific norms.
The WHO’s definition gives a broader concept of health and also bring into open the various important components of health which transcend the physical state of completeness. In this wise, health is seen not only a disease entity but in relation to the physical, mental and social state of wellbeing. It is the understanding that has provided another way of looking at health in the concept of wellness which is the new goal of health.
The concept of Wellness
Wellness is an expanded idea of health. While health cannot be interpreted to mean only the absence of disease, wellness transcend this understanding by considering how individual rise above their physical or mental limitations to live rich, meaningful vital lives.
Wellness in any dimension is not a static goal but a dynamic process of change and growth.
The different dimensions of health include the following areas of wellness which are deeply interrelated:
- Physical wellness
- Emotional wellness
- Intellectual wellness
- Spiritual wellness
- Interpersonal and social wellness
- Environmental or planetary wellness
These six dimensions of wellness interact continuously, influencing and being influenced by one another. Maintaining good health is equally a dynamic process and increasing the level of wellness in one area of life automatically influences may others.
While health and wellness seem largely to be an individual/personal concerns or goal, they are also of national and international concerns. Governments of various countries have programmes and vital interest in the health and wellness of her people. The Nigeria National Health system aim to ensure that all Nigerians live a healthy and productive health. This is in view of the understanding of the development implications of health. A healthy nation is a productive nation. It must be appreciate that there cannot be any meaningful development if issues relating to health are not properly attended to. In addressing the fundamental challenges of health and wellness, some factors influencing the health status of individual and the nation has to be properly understood.
FACTORS AFFECTING HEALTH:
- Cultural factors e.g customs, beliefs, taboos and practices. Some of these cultural factors are harmful to health, hence should be discouraged. Some religious practices are cultural in nature and they may have effect on health both positively and negatively. For instance, absolution as practiced by Muslims may enhance personal hygiene to some extent (depending on how one views it) while a similar practice of not eating pork for example may reduce source of protein supplies to the body where for one reason or the other there is no other source of animal proteins apart from pork. Among the Christians, some practices may have positive effect as well as negative effect on health. For example, the practice of not wearing shoe which may increase chances of hookworm infections for example. Since culture is a way of life that is passed from generation to generation, health workers should be diplomatic when trying to discourage harmful factors and at the same time promote the beneficial ones.
- Environmental factors which include water supply, sanitation refuse disposal, drainage system, housing and air pollution. Apart from being health promoting, most environmentally related facilities determines the levels of hygiene to be maintained by each person. Availability of water determines to a large extent types of latrine to be used in a premises and the extent to which it could be kept clean. Personal hygiene and cleanliness remains one of the most important environmental factors affecting personal and public health.
- Socio-economic factors which include economic activities of the community, level of income/poverty, level of education, social amenities like electricity, communication methods etc. Each of these has significant influence on health.
- Personal factors which include personal hygiene, level or knowledge of health matters, attitude to health system and health practices, habit and addict.
- Ignorance factors. Lack of knowledge about health and issues affecting health and wellness is important in determining the health of the population. In some cases, people may not even be aware of the existence of health facilities, services and opportunities. Ignorance is chief among factors influencing health particularly in many countries of Africa.
- Geographical factors i.e climatic condition, type of soil, topography land size etc. Many geographical factors influence the types of vector and /or parasites that may be prevalent in a particular place or region and also the possibility of their control and/ or elimination.
- Nutritional factors. Nutrition is a major determinant of health in that, it influences the body’s ability to resist infection otherwise known as body’s immunity. Malnutrition is a major health problem of many people in developing countries resulting from many factors ranging from lack of food supply, poverty and ignorant. In another sense, infection and illness could be result into malnutrition as a result of nutrients not being available for the body’s use.
- Political factors: – These are informing of political agenda, policies and programmes also affect health in a number of ways. The political environment prevailing at any point in time is also very important.
- Organizational factors: in term of organization and administration of the health system and the department. Also important in this case is the staffing and the availability of other resources.
In one sense, we are all being educated all the time, to the extent that everything that happens to us may bring about some change in the way we feel and think and act. We learn from the circumstances in which we live, the people we meet, ideas in books or papers, tips from internet, or on radio or from the geographical situation and time in history in which we live, the work we do. In fact, everything that surrounds us and of which we have experience, is educating us and our children all the time. It is important for us to understand this, for unless we as teachers take into account the way that these wider educational influences affect our children, a great deal that we do in our schools will be wasted.
We cannot of course, trust to the life around us to teach our children all that they need to learn. In days gone by, parents were the people who taught their children and prepared them for life, and when life was comparatively simple this was easy. A father took his son hunting with him, showed him to make weapons and nets; a mother had her daughters helping and learning in the preparation of food and clothing; while both parents and grandparents taught their children the custom and laws they must obey. So, children grew up, learning by doing and by precept, and by the example of their elders.
Today, life is much more complex, there is so much more to be learned, so many possibilities opening out before each child, that parents can no longer take responsibility for all their teaching. Children therefore spend a good part of their lives in place set apart for them, schools, with specially appointed adults – teachers – whose profession is to help the children grow and learn.
This is what is usually meant by ‘education’ in its special sense, and from this point of view it is the task of the school, and teachers, to be aware of those aspects of the environment, social, physical, spiritual, which are most necessary and helpful for teaching children.
What is education?
Education as a two – way process
But there is more to education than the impact, the influence, of the environment on a person. Education is a two-way process, and the result of any special educational experience depends as much on the way a person responds to it, as on what is being done to him. Perhaps a sermon is being preached, but of all the people who hear it, each one may learn something different; some may learn nothing. A hurricane may rage over an island, and as a result some people may become more fearful, some more competent, some braver, some more interested in meteorology, and some may be hardly affected by it at all. After an arithmetic lesson some children can work, some new sums correctly, some are beginning to understand new work, some are getting to be more interested in arithmetic, some continue to hate it and have learned nothing. If a teacher is to be in control of any educational situation he must be aware of the nature of environmental influences as they affect his pupils, and he must also understand the pupils themselves, what they are like and how they learn. Only then can he attempt to bring about the result he wishes, that is, to educate the children.
Education, then, is concerned with different aspect of environment, their effect on individuals, and the way in which individuals respond, or react. In order to be clear about this we will look briefly into what is meant by environment, and then we will consider what is meant by being an individual.
Of all the influences that surround a person from the day he is born, people are the most important. The first, of course, is his/her mother, and he/she should form his/her first social relationships with her, and these form the pattern for all others. A child’s early society Includes, or should include, his/her father, brothers and sisters, grandmother, and all who make up the group known as the family. As a child grows, he gets to know more people, those who live nearly and whom his/her parents know become part of his environment. Then he/she goes to school and his/her social environment extends to include other children of his/her age, his teacher, other teachers and the head teacher, and he comes to know these well, and these know him. He knows people at church and Sunday school, and becomes aware that he and his family are part of certain village or town, and a country. As an adolescent his social environment extends to include people of other nations, races, religion, until a fully mature person can realize himself as part of the whole society of mankind. But all the time, especially while he is growing up, he is responding in some way to his social environment. The people about him influence the way he speaks, his dress and his manners, his ideas and beliefs, the occupation he chooses to earn his living the way he brings up his children. A person may change his social background, as when a west Indian emigrate to England or the united states, as then the new social influences may bring about changes in the way he lives and what he does, this is easier the younger he is, but even so, many of the effects of his early social environment persist right through life.
Although this influence is so important in our lives, it is also true that, as each of us is part of our society, so each contributes towards it and may bring about changes. A young farmer who has been to an agriculture college may bring back new ways of cultivating and propagating, and if he is successful his neighbours may adopt them too. The radio often brings new words and songs and dance tunes, and soon people are speaking a little differently, and may be learning to dance in a novel pattern and rhythm. These and many other changes in the social environment affect the bahaviour of people in that society. But such changes do not occur by themselves, they are brought about by people, who are thus helping to alter their society.
Here then are two points to remember about our social environment, it affects in many ways the behavior of people who form that society. And it is always changing as a result of the bahaviour of its members. Education is one of the most important factors in bringing about social change. It is also most important in helping each child to be fully a member of his society, but at the same time to develop into a person in his own right, capable of making his own judgments and choices and directing his own life.
The world in which we live is part of a system of planet revolving round the sun, and in a way this universe, and the immense universe of other system of other system of which it is a part, is our physical environment, affecting in many way the lives of men on earth. But for each one of us that of earth where were born, or where we live most of our lives, is most important to us. Many matters are far beyond our control, the length of day and night, the changing seasons and tides, climate and weather; all affect the lives of men, their occupations, habit and customs. Where there is a long cold winter, for instance, men develop the habit of working hard in the summer month of provide and store up food, and qualities of hard work, thrift, and foresight become important to them, and a carefree easy going life is despised. In the same way people tend to develop special characteristics if they live in large cities, or among rugged mountains, in forests, in wide open plains, in villages, or by the sea. Man can, of course, to some extent change his physical environment, and life becomes different of new roads are built, if forests are cut down and lands cleared; if a dam is built across a river; if contour plant is adopted to stop erosion.
The physical environment of people in the Africa has its own special features, and it is important to take them into account. There is the influence of a warm climate and fertile soil; of living mostly on small Island apart from each other. All there are important in shaping the lives of people, and must be considered and understood in educating our children.
Spiritual and Emotion Environment
Just as we live in a social world which is made up of people, and in a physical world of natural features and forces, so we live in a moral or spiritual world of ideals, beliefs, and attitudes. These are in many ways the most important; for what we think and belief and feel determines the way we act. it is hardly possible, however, to consider this aspect of environment as something separate from the other two, for ideas and beliefs attitudes comes to us largely through other people, and to some extent from our physical environment. As we have seen in the previous paragraphs, new ideas come to us all the time, from parent and teacher, from church and books and newspaper, from radio and cinema, far too many for any one person to accept or absorb. From all these influence we select and some of them and let the other go by, gradually building up a system of personal belief in our environment are varied good and bad useful useless of greater or less value and those which any child adopt for his own are largely those taught and held by people he love and respects. It is generally acknowledge that our most important attitude those which influence our behavior during life are establish in the earliest year and made more definite specific during childhood it is that we get our first idea of right and wrong of the way we are expected to behave and the religious teaching which explain our relationship with God and man it follow then that the most improper people for influences from different source come into picture and the young person may seem to throw over the idea and belief of his childhood all the same they are there in the background and if his early teaching has been sound and good and the people who taught has been sound and he is to go very far a stray.
The Individual Inherited Trait
So far we have been considering those aspect of education which come from experience that any
kind of effect these may have depend on how they are receive what is made of them we will look briefly therefore at the individual children being educated to see why they respond differently to a given situation what make them different In the first place children are born with certain characteristic inherited from parent and ancestor long before birth it is determined what race a child belong to what sex he is the color of his eye and skin the kind of hair and feature and has weather he is likely to be tall and slender or short and broad, or of medium size and weight. He may inherit a sound of constitution and be generally healthy, or be born with a tendency to catch certain diseases easily.
Another inborn trait is the degree if intelligence or mental ability: one child may be born with intelligence to enable him to become a university professor while another has only a moderate degree. He may inherit a good ear for music, or he may be colour blind, or a good athlete. It is also probable that he inherits certain traits of temperament, one baby may be placid and good tempered, another easily upset, another sometimes bright and responsive, sometimes bright and responsive, sometimes dull and moody.
All these differences, physical, intellectual and emotional, exist in every child at birth, but they are only there as potentialities, possibilities. The way in which a child develops depends on his innate characteristics, but also on the way his environment treats him. The degree of warm and loving care he receives, right feeding and exercise, make all the difference to the way his physical traits develop, and his temperament too. His mental ability may be potentially very high but it only develop if he receive the right kind of stimulus from his social environment a child growing up in a home where there are stories and music and books and people wit6h interesting ideas, has the opportunity of developing his mind, even before he goes to school. When he does go to school, the better the conditions are, and the teaching, the more fully can he make use of whatever ability he has.
The opposite is, of course, true. It is unfortunate that in the Africa there are many children whose early environment is so deprived that there is little chance for them to develop fully. Children who are ill fed, neglected, hear little conversation and are restricted in their play and movement, who don’t go to school, or attend irregularly at a school that is poor and overcrowded, such children may have begin with good intelligence, but in a poor environment it has little chance of developing. Even if they are transferred to a more favorable environment later on, as when a bright child from a poor background is given a place at a secondary school, it is very difficult to make up for what has been lost. A few may succeed, but for many this early deprivation means so much wasted that, potential intelligence that is never developed. This is a matter we shall discuss more fully later on; the point to make here is that a child is the product both of this inheritance, and of his environment, acting upon each other, or interacting
We, as teachers, have no control over a child’s inherited qualities, but the better we understand them the more we can help to make good use of them. There are aspects of environment, too that we cannot control, but during school day there is a great deal that depends on the school and the teachers. The social and spiritual environment, all that comes from people with right feelings, ideas and actions, these are within our power, and we can do much to provide conditions in which our children can grow and develop as fully as they can.
Despite many efforts, the knowledge of pregnant women on mother-to-child transmission of HIV is low. By receiving information on HIV from health care providers while pregnant women attend antenatal care, they are more likely to be knowledgeable on MTCT of HIV. Strengthening women education and by reaching previously inaccessible parts of the community, integration of HIV, prevention of MTCT, and ANC service, is highly recommended. Moreover, strengthening discussion of MTCT with community health practitioners, especially those who execute the Primary Health Care Services is important. Primary Health Care workers will find more interest in their work if they continue learning after qualifying and continue developing their skills. Continued learning may be achieved through refresher course, in-service training course and internet education study.
The HIV and AIDS pandemic is one of the most serious health crises in the world. an estimated 78 million people have become infected with HIV and 35 million people have died from AIDS-related illnesses since the start of the epidemic and end in 2015. In 2015 only, there were 36.7 million [34.0 million–39.8 million] people living with HIV, while at the end of 2015, 1.1 million people died from AIDS-related causes worldwide, compared to 2 million in 2005. It is assuming that passing HIV microbe from infected mother-to-child is 15% to 45%. Therefore when there is PMTCT interventions, it can reduce this risk to below 5%.
Before the introduction and implementation of PMTCT, Mother—to—child transmission (MTCT) of HIV is a major public health challenge, and maternal knowledge on HIV transmission during pregnancy and its prevention is important in reducing childhood HIV acquisition. It is up to one point six million children who are newly infected with HIV and which have been prevented since 1995 due to the establishment of PMTCT services. Of these, 1.3 million are estimated to have been averted in the five years, between 2010 and 2015.
Despite the difference significant progress in PMTC, in 2015 23% of pregnant women living with HIV did not have access to ARVs and 150,000 children (400 children a day) became infected with HIV.
Mother-To-Child-Transmission (MTCT) is the transmission of HIV virus from an infected woman to her unborn child during pregnancy, delivery and breastfeeding. Vertical transmission of HIV occurs when an infected mother’s blood mixes with that of the baby during vaginal delivery (Kourtis et al., 2006; Adogu et al., 2013). 25-35% of breastfed infants born to infected women will be infected.
Abiodun et al., (2007) reiterated that there are cases of Mother-To-Child–Transmission of HIV/ AIDS despite the effort in implementing PMTCT. Mothers are still lacking knowledge about MTCT especially transmission through breastfeeding. Only 10% of 100 pregnant women had knowledge regarding mother to child transmission of HIV/AIDS, 13% of pregnant women knew that breastfeeding while suffering from HIV/AIDS may put the baby at risk of contracting the virus (Maputle, 2008)
Risk of transmission without interventions
Without intervention (ARV prophylaxis or treatment) up to 40% of infants born to mothers infected with HIV can become HIV-infected.
Among the 40 (out of 100) that become infected, 5 to 10 are infected during pregnancy, 15 during labour and delivery, and 5 to 15 during breastfeeding.
Risk factors for transmission:
A great deal is known about specific factors that may put a woman at higher risk of transmitting HIV to her baby. These factors might be related to mother, infant, or the type of virus. These risk factors could be present during pregnancy, labour and delivery, and breastfeeding.
- The most important risk factor for MTCT is the amount of HIV virus in the mother’s blood, known as the viral load. The risk of transmission to the baby is greatest when the maternal viral load is high, which is often the case with recent HIV infection or advanced HIV and AIDS.
- Mixed feeding is also an important risk factor. Artificial feeding increases the risk of intestinal illness and a weakened intestine associated with (contaminated) breast milk increases the chances of HIV crossing the intestinal barrier.
The intrapartum risk of MTCT is multi factorial involving viral, maternal, placental and foetal factors as well as the delivery process.
- Viral factors:
- Viral load. The higher the viraemia the higher the risk of transmission
- Presence of resistance to antiretroviral drugs.
- Transmission rates are higher with HIV 1 than HIV 2 infection.
- Maternal factors: The following maternal factors positively influence MTCT.
- Maternal immune deficiency.
- Symptomatic disease in the mother
- Poor nutritional status of the mother.
- Presence of sexually transmitted infections and other genital ulcers during labour.
- Placental factors: disruption from any cause increases the chance of feto-maternal transfusion thereby increasing the risk of HIV infection.
- Intra partum Haemorrhage
- Obstetric factors:
- Vaginal delivery
- Invasive obstetric procedures during labour like External Cephalic Version, foetal scalp electrodes and foetal blood sampling.
- Instrumental deliveries like vacuum extraction or forceps.
- Prolonged duration of rupture of foetal membranes (4 hours and above).
- Prolonged labour
- Episiotomy and lacerations.
- First born of multiple pregnancies.
- Foetal factors:
- Prematurity (Preterm birth)
- Foetal genetic characteristics
Prevention of Mother-to-Child Transmission of HIV
One of the goals of the June 2001 Declaration of Commitment of the United Nations General Assembly Special Session on HIV and AIDS (UNGASS) is to reduce the proportion of infants infected with HIV by 20% by 2005 and 50% by 2010. In the 2003 AIDS Policy, the Nigerian national goal for PMTCT is to reduce the transmission of the HIV through MTCT by 50% by the year 2010 and to increase access to quality HIV counselling and testing services by 50% by the same year. To achieve this goal, a comprehensive four pronged strategy to prevent HIV infection among infants and young children has been developed, which promotes implementation in an integrated manner within the health care delivery system. These strategies are:
- Primary prevention of HIV infection in women of reproductive age group and their partners.
- Prevention of unintended pregnancies among HIV positive women.
- Prevention of HIV transmission from HIV infected mothers to their children.
- Care and support for HIV infected mothers, their infants and family members.
Strategy 1: Primary prevention of HIV infection in women of reproductive age group and their partners
The best way to prevent HIV infection in children through mother-to-child transmission, including transmission through breastmilk, is to prevent HIV infection of parents-to-be. About 70% of the global HIV burden is borne by sub-Saharan Africa, where the main mode of HIV transmission is heterosexual contact.
The following factors are known to increase the risk of HIV infection in women:
- Multiple sex partners
- Immaturity of the genital tract
- Vaginal ectopy
- Sexually transmitted infections (STIs)
- Poor nutritional status
Other factors contributing to women’s vulnerability to HIV include:
- Lack of information
- Sexual relationships with men who have multiple sex partners
Primary prevention strategies include the following components:
- Safer and responsible sexual behaviour and practices
- Delaying the onset of sexual activity until marriage
- Practicing abstinence
- Reducing the number of sexual partners
- Using condoms
This approach has come to be known as the “ABC” approach:
A = Abstinence – Refrain from having sexual intercourse
B = Be faithful – Be faithful to one partner
C = Condom use – Use condoms correctly and consistently
Recent reports of increasing new HIV infections transmitted from husbands to wives indicate a continued need to educate people about safer sex practices and other behaviour changes. For example, being faithful to one partner not infected with HIV is a risk reduction behaviour that has been proven to be significant in slowing the spread of HIV infection.
Behaviour change communication (BCC) efforts aim to change the behaviours that place individuals at risk for becoming HIV-infected or spreading HIV infection. BCC recognises that behaviour change is not simply a matter of increased knowledge; many factors, including family, church, and community influence change. BCC attempts to create household, community, and health facility environments in which individuals can modify their behaviour to decrease risk.
Especially among young women, the successful implementation of “ABC” outlined above may require support from organised programmes. Healthcare workers can help women address these challenges through education and community linkages.
Condoms can help prevent HIV transmission when used correctly and consistently, especially in high-risk settings. Programmes that promote condom use for HIV prevention should also focus on condom use for PMTCT.
- Provision of early diagnosis and treatment of STIs
The early diagnosis and treatment of STIs can reduce the incidence of HIV in the general population by about 40%. STI treatment services present an opportunity to provide information on HIV infection, MTCT, and referral for testing and counselling.
- Making HIV testing and counselling widely available
HIV testing and counselling services need to be made available to all women of childbearing age because PMTCT interventions depend on a woman knowing her HIV status.
- Provision of suitable counselling for women who are HIV-negative
Counselling provides an opportunity for a woman who is HIV-negative to better understand how to protect herself and her infant from HIV infection. It can also serve as powerful motivation to adopt safer sex practices, encourage partner testing, and discuss family planning.
Strategy 2: Prevention of unintended pregnancies among HIV-positive women
It is every woman’s fundamental right to decide for herself, without coercion, whether or not to have children. The responsibility of the government and health services is to provide HIV-positive women and their partners with comprehensive information and education about the risks associated with childbearing. This should be part of routine information about HIV and AIDS, to ensure that HIV-positive women and their partners have real choices of action, and to respect and support the decisions they reach. This means:
- Providing good quality, user-friendly, and easily accessible family planning services so that HIV-positive women can avoid pregnancy if they choose
- Promoting condom use, either alone or combined with a more effective method of contraception (dual method) for dual protection from HIV and other STIs and from unplanned pregnancy as an effective strategy to prevent HIV infection in all sexually active women
- Integrating dual protection messages into family planning counselling services
- Offering contraception to replace the birth-spacing effect of breastfeeding in women who choose replacement feeding because of their HIV infection
In many countries in sub-Saharan Africa, bearing healthy children provides social status and access to family resources. These accesses are denied to women whose HIV-infected children fail-to-thrive and die. To that extent, interventions to reduce HIV transmission from mother-to-child can help a woman consolidate her social position, despite her HIV infection.
Strategy 3: Prevention of HIV transmission from women infected with HIV to their infants
Specific interventions to reduce HIV transmission from an infected woman to her child include:
- HIV testing and counselling
- Antiretroviral prophylaxis and treatment
- Safer delivery practices
- Infant-feeding counselling for safer infant-feeding practices
When an ARV drug is given to mother and infant to prevent MTCT, it is referred to as ARV prophylaxis.
How do these interventions work?
- Identify women infected with HIV.
- Reduce maternal viral load.
- Curtail infant exposure to the virus during labour and delivery.
- Curtail infant exposure to the virus through safer feeding options.
In industrialised countries where women infected with HIV receive triple drug ARV therapy and do not breastfeed—and where elective caesarean sections are safe, feasible, accessible and commonly performed—the rate of MTCT has been reduced to about 2%.
ARV prophylaxis can reduce MTCT by 40–70%. The impact is greater (closer to 70%) when women do not breastfeed, because current ARV prophylactic regimens only prevent HIV transmission during late pregnancy and labour and delivery.
Testing and counselling of pregnant women
In Nigeria, the high fertility rate, the premium placed on children as objects of parental hope for future survival, and the acceptance of antenatal care, enhance the cultural endorsement of testing and counseling for PMTCT of HIV in antenatal settings. The aim of testing and counselling is to help the woman take necessary action to ensure that she does not become infected with HIV. However, if she is already infected, the aim is to help her protect her own health, the health of the unborn child, of her sex partner and of her family.
ARV prophylaxis to mother-child pair
ARV prophylaxis given to a pregnant woman who is HIV-infected does not confer long-term benefits to the woman herself. Pregnant women with advanced HIV infection require combination ARV treatment to reduce the risk of AIDS-related illnesses. As treatment becomes more available, there should be integration between prophylaxis and treatment services.
Several potent regimens, either as monotherapy or combination therapy are currently in use as ARV prophylaxis. These regimens are discussed in detail in module 4.
Modification of obstetric practices
(i) Modification of routine obstetric practices for all women:
Recognition of HIV infection in pregnant women is the key to the prevention of childhood HIV infection. Issues of access to and affordability of antenatal care are crucial and must be addressed if interventions are to make any significant impact. All doctors, midwives and community healthcare workers who attend to pregnant women should be trained in HIV and PMTCT testing and counselling to effectively include HIV antibody testing among the routine booking investigations. Rapid test kits should always be available for free HIV testing. In resource-constrained settings, the introduction of any fee, no matter how small, will prevent many willing patients from determining their HIV status. Syndromic management of STIs in the antenatal setting should be strengthened. Iron and folic acid supplementation, tetanus and malaria prophylaxis should be given to all pregnant women irrespective of their HIV status.
(ii) Specific modification of obstetric care for HIV positive women:
All HIV-positive women should be given optimal health care to ensure a safe delivery. An HIV-positive woman identified in pregnancy should have a full physical examination with focus on HIV-related symptoms and illnesses and signs of opportunistic infections especially tuberculosis (TB).
In addition, apart from the routine laboratory investigations conducted on all pregnant women, other investigations for HIV-positive women should include FBC, CD4 count LFT’s, Renal function test, Lipid profile and Viral load. Details of management considerations for HIV-positive women are addressed in module 4.
Invasive procedures such as chorionic villus sampling, amniocentesis and cordocentesis should be avoided. External cephalic version should be avoided as it may also increase the risk of HIV transmission to the foetus.
Where CS is performed (either elective or emergency) in HIV-positive women, they should receive prophylactic antibiotics. If CS is performed after prolonged labour or prolonged ROM, longer courses of antibiotics should be considered.
Modification of infant feeding practices and support for mother’s choice
Breastfeeding is an important route of HIV transmission from mother-to-child. HIV-positive mothers should be counselled about this risk and where possible should try to avoid or limit breastfeeding. For HIV-negative mothers or mothers with unknown HIV status, exclusive breastfeeding remains the best infant-feeding choice.
In the context of PMTCT of HIV, the challenge is to strengthen and support mothers and partners to make breast milk substitutes acceptable, feasible, affordable, sustainable and safe (AFASS). Much as it is important to respect and support HIV-positive mothers in their decisions regarding infant feeding, they should be well-informed about the various feeding options available to prevent their infants from becoming infected through breastfeeding. (See Module 5)
Strategy 4: Provision of treatment, care, and support to women infected with HIV, their infants, and their families
Programmes for the prevention of HIV in infants and young children will identify large numbers of women infected with HIV who will need special attention. Medical care and social support are important for women living with HIV and AIDS to address concerns about both their own health and the health and future of their children and families.
If a woman is assured that she will receive adequate treatment and care for herself, her children, and her partner, she is more likely to accept HIV testing and counselling and, if HIV-positive, interventions to reduce MTCT.
It is important to develop and reinforce linkages with programmes for treatment, care, and support services to promote long-term care of women who are HIV-infected and their families.
HIV-related treatment, care, and support services for women
Services for women include the following:
- Prevention and treatment of opportunistic infections
- ARV treatment
- Treatment of symptoms
- Nutritional support
- Reproductive health care, including family planning, cervical screening, and counselling
- Psychosocial and community support
- Palliative care
Care and support of the infant and child who are HIV-exposed
Infants and children who are HIV-exposed require regular follow-up care, especially during the first 2 years of life, including immunisations, HIV testing, and ongoing monitoring of feeding, growth, and development
Children whose mothers are infected with HIV are at higher risk than other children for illness and malnutrition for many reasons:
- They may be infected with HIV and become ill, even when adequate health care and nutrition are provided.
- Those who receive replacement feeding lack the protective benefits of breastfeeding against diarrhoeal diseases, respiratory infections, and other complications.
- If the mother is ill, she may have difficulty caring for the children adequately.
- Families may be economically vulnerable due to AIDS-related illnesses and deaths among adult relatives.
Knowledge Attitudes and Practice of Health Workers:
Internationally, studies evaluating attitudes of health care providers toward HIV/AIDS patients have suggested that current negative attitudes of health care workers toward people with HIV—compounded by fear of infection in the workplace, perceptions of risk, and lack of understanding of HIV—perpetuate the prevalence and manifestation of stigma toward this population (Chen et al., 2004; Juan et al., 2004; Quach et al., 2005; Reis et al., 2005). For example, a study examining discriminatory attitudes and practices by health care workers in Nigeria found that providers inadequately trained in HIV/AIDS care and ethics were more likely to agree that it was acceptable to refuse treatment to infected patients and were more likely to have done so (Reis et al., 2005).
HIV/AIDS-related stigma has been recognized as one of the largest challenges to improving HIV/AIDS care around the world. Studies suggest that provider stigma may be affecting the quality of care and patient decisions to seek health care services. (Juan et al., 2004) One study shows that discriminatory behavior and stigma toward them do exist and may be attributable to poor HIV/AIDS-related knowledge and high perceived risk of infection (Quach et al., 2005)
Stigma has been defined as “… a real or perceived negative response to a person or persons by individuals, community or society…[that] is characterized by rejection, denial, discrediting, disregarding, underrating and social distance” (Reis et al., 2005)
HIV-related stigma and discrimination defined as: a process of devaluation that significantly discredits an individual either living with or associated with HIV/AIDS (The Joint United Nations Programme on HIV/AIDS, 2011). Delivery for HIV positive women were refused by 62% of the doctors and 80% of the patients were referred to other institutions. People living with HIV were experienced that 88% of the doctors refused to conduct surgery and 85% of doctors were also accepted about rejection of surgery. Only 3% of doctors accepted that they had performed surgeries/Invasive procedure for HIV patients. We recommend that seminars, workshops should be organized on a continuous basis for health care workers on universal precautions, stigma and discrimination reduction. The institution should also make available materials needed to protect workers against the risk of acquiring pathogenic infection in the course of providing health services to their patients. (Jeevitha et al., 2013)
Benefits of Prevention of Mother to Child Transmission of HIV:
In some parts of sub-Saharan Africa without any interventions most children that acquired HIV through MTCT die within the first two years of life. The increasing number of AIDS-related deaths in under- fives in Nigeria may reverse the gains made in child survival. The cost of care and support for HIV infected children places heavy financial burden on families, communities and the health care system.
PMTCT of HIV benefits the mother, infant, family, community and the health system.
Benefits to the Mother
- Identifies HIV positive mothers for targeted interventions to reduce risk of
transmission of infection to their babies and to access care and support services
- Promotes positive behaviour change
- Reduces HIV risk behaviour
- Increases use of dual protection methods of family planning and STI prevention
- Helps to plan for the future
- Promotes Infant feeding support system
- Promotes access to early preventive and medical care
- Helps personal and financial decision making
Benefits to the Infant
- Decreases numbers of HIV infected infants
- Promotes early diagnosis and intervention for the HIV exposed infants
- Improves child health and survival
Benefits to the Family
- Promotes communication between couples and testing of both partners
- Provides opportunity for testing other family members
- Contributes to reduction of stigma and discrimination
- Helps to plan for the future
- Provides infant feeding support system
Benefits to the community
- Promotes the understanding and acceptance of the HIV and AIDS epidemic and those living with HIV and AIDS
- Promotes uptake of risk reduction practices leading to reduction in the incidence of HIV
- Promotes acceptance and uptake of HIV testing and counselling
- Contributes to reduction of stigma and discrimination
- Helps to plan for the future
- Provides infant feeding support system
Benefits to the health system
- Decreases the disease burden on the health system
- Gives an opportunity to strengthen the health system.
Mother and Child
The healthcare providers had deficient knowledge and practice of PMTCT and still had gaps in certain areas. In Primary Health Care setting, most of the health care providers could not correctly answer the four pillars of PMTCT. And they are poorly informed on practical issues in the prevention of MTCT of HIV. They are therefore handicapped to play an effective role in this important aspect of prevention of mother to child transmission of HIV. Their attitude was fairly appropriate. There is need for improved knowledge through structured educational intervention. Resources needed for practice should always be made available and the environment should be much more conducive for practice. Most of these healthcare providers willingness to update their knowledge and improve their knowledge and improve their attitude and practice of PMTCT.
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