Jazan Health Needs Assessment

Public Health Medicine 2007; 6(3): 105-110

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Papers

Jazan Health Needs Assessment: A Key informant approach W Milaat, I Bani, H Aqeely, A Makeen, M Salih & M Alnaggar

Abstract Objective: The aim of this study was to conduct a comprehensive community health survey to identify health problems and perceived health needs in the region of Jazan. This study also addressed the expected role of Jazan medical college in the health development of the region. Setting: The area of the study was Jazan region, south east of the Kingdom of Saudi Arabia. Design: A classical key informant approach was designed using open and closed ended questions. Facilitated by a group of senior medical students and teaching assistants working in pairs, a total of 93 local key informants (municipality members, military officers, health care workers, physicians, civil servants, school teachers, religious and tribal leaders) were interviewed about their perceptions of health problems and health needs. The key informants were selected randomly from all Jazan districts. Results: The key findings from this survey included the following: 1) The most important perceived health problems in the region of Jazan were shortage of health care providers, increased prevalence of communicable diseases and poor environmental health, 2) There was a high level of awareness to the increased prevalence of communicable diseases with strong feeling of major gaps in their prevention, 3) The most perceived social problems included: Ghat chewing, health consequences of consanguinity in marriages, high poverty and unemployment, presence of illegal immigrants and cigarette smoking. 4) The most perceived health need was to expand health services with capacity building of health care providers. Conclusion: This study documented important lessons learned from the use of community key informants in needs assessment surveys for identifying health problems and needs. The study suggested means to control and prevent major health problems in the region of Jazan. The study also emphasized the role of Jazan medical college in providing skilled manpower and expertise to improve the health care service delivery in the region of Jazan.

Keywords: Health Needs Assessment, Key informant, Jazan Saudi Arabia

Introduction In most developing countries, the evolution of health services has been dominated by western models of health care.1 These models rarely took into account

how local communities describe their illness, seek advice, or the widespread use of traditional healing methods. Moreover, emphasis has been on hospitals and curative care rather than on trying to address local health needs equitably and effectively. Since the Alma Ata declaration on primary health care, more attention has been given to increase coverage of basic services and preventing common diseases. However, the bias in resource allocation towards secondary care and urban areas remains. Health needs assessment has been defined as systematic method of identifying the health problems and health care needs of local communities and making recommendations for change to meet these needs.2 It can involve both epidemiological and qualitative approaches to meet these needs. Gathering together key informants or experts to provide input for a situation analysis is one method for identifying issues. Key informant data can be used alone or in conjunction with another approach such as household community surveys. This approach requires the careful identification of a select group of formal and informal leaders, influential leaders or experts. Academic institutions have always found it a challenge to persuade community members to participate in academic research projects.3 Starting an open dialogue is usually the critical first step. The purpose of this study is to conduct a comprehensive health needs assessments survey of Jazan region using a key informants approach. The findings of this research will produce a comprehensive evaluation of the health status of Jazan population needed for policy makers to assess health programs effectiveness. It will provide baseline and reference information needed for policy formulation and subsequent planning and cost effective intervention programs. Moreover, it will also facilitate the mission of the newly established Jazan Medical College

Methods Jazan College of Medicine research team conducted key informant interviews in Jazan region during July and August, 2005. To ensure a good sampling of the community, a matrix of sectors of community leaders was developed. They included 93 persons: Members of the Municipality Council (7), military

W Milaat College of Medicine, King Abdulaziz University, Jeddah ,Saudi Arabia I Bani, H Aqeely, A Makeen, M Salih & M Alnaggar College of Medicine, Jazan University, Jazan, Saudi Arabia For corrospondence Waleed Milaat, MBchB MPH, PhD, MFPH, Department Family& Community Medicine, Medical College, King Abdulaziz University, PO Box 984, Jeddah, 21421, Saudi Arabia, Email: wmilaat @ hotmail. com, [email protected]

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Jazan Health Needs Assessment: A Key informant approach officers (5), physicians (9), health care workers (21), school teachers (24), civil servants (18) religious leader (1) and tribal leaders (8). At least one person representing sectors in each district was interviewed. Key informant interviews were conducted by teaching assistants using an interview guide that lists topics or issues to be covered during the session. Guided questions covered the following areas: main health problems in Jazan region, the role of community members in health affairs, the role of other government sectors and authorities such as education and agriculture in health, health needs in order of importance and priority, suggestions to improve health services, and the role of Jazan medical college in improving the health of the community. The interviewer framed their questions in the course of the discussion and took notes of key informant responses. A form with open-ended questions as well as scaled questions was used for this technique. Each interview session took around 45-60 minutes. A statistical analysis was applied for frequencies, proportions, mean and standard deviations using Statistical Package for Social Sciences (SPSS) version 11. The qualitative analysis was grouped in separate headings according to the topics covered during the interview in the usual qualitative format.

Results Out of the 93 interview sessions with key informants, 91 interviews were valid for analysis. Most of the key informants (50.5%) aged 30-45 years and 38.5% were 45-60 years old. Both urban and rural areas were represented in this sample of key informant (52.7% and 47.3% respectively). Table 1 describes the most important health problems in Jazan in descending priority as perceived by he key informants to include: shortage of health care providers (97.8%), high prevalence of communicable diseases (48.4%) and poor environmental health (48.4%). Moreover, they perceived Jazan social problems to be: Khat chewing (50.5%), high rates of consanguinity in marriage with its related congenital health problems (37.6%), high rates of poverty and unemployment (29%), cigarette smoking (23.7%) and high presence of illegal immigrants from neighboring Yemen (15.1%). In Table 2, over two thirds of the key informants assessed important health needs of Jazan region to be in building new health facilities (primary care centers and hospitals, 80.6% and 68.8% respectively), increasing the number of health care providers (77.4%), capacity building of health care providers (89.2%) and provision of medical supplies and medical equipments (79.6%). The key informant’s opinion was that donations from the community, including cash, land, maintenance services and furniture, could be used for improving the health needs in the region of Jazan. Missing essential health services to be provided by primary health centers as perceived by key informants were mostly related to improving health awareness of people by health education, sanitary waste disposal, safe

water supply, competent maternal and child care services and communicable disease control. Comparatively, nutritional issues and food security had low priority in the perception of key informants in Jazan. The roles of other governmental sectors in the health of the community were perceived by key informant in the following priority: Municipality (92.3%) educational institutes (79%), Agriculture ministry (67.4%) and police force (38.7%). Qualitative results of key informants perceptions of present problems in various issues were analyzed and grouped under the following key headings: health services issues, communicable diseases, environmental health, health awareness and socioeconomic problems.

Health services delivery problems: • Absence of specialist hospitals. • Low coverage of primary health care centers in the villages.

• Poor quality of services delivered in health facilities.

• Poor quality of maternity and child health programs.

• Shortage of highly qualified medical staff and health administrators.

• Shortage of female medical staff. • Shortage of medical equipments, medications and vaccinations in the health facilities.

• Absence of emergency rescue facilities for patients in remote areas.

• Poor standards of operating and maintenance contractors in health facilities. Poor health promotion programs. •

Communicable and non-communicable diseases problems: • Hereditary disorders (sickle cell disease). • Infectious diseases (Hepatitis, Typhoid, • • • •

Tuberculosis, Malaria, Bilharzia, leishmaniasis, Rift valley fever, Chickenpox, Measles). Chronic diseases (Diabetes mellitus, Hypertension, Bronchial Asthma). Other problems(Malnutrition and Iron deficiency anemia) Sleep disturbance and restlessness due to Ghat use. Increased incidence of road traffic accidents due to unpaved roads.

Environmental health problems: • Swamps and stagnant water in the region leading • • • •

to breeding of mosquitoes and poor mosquitoes control programs. Shortage in sources of clean water supply No water sanitation system. Poor food safety measures in restaurants and food establishments. Bad environmental health in school’s Cafeterias.


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Jazan Health Needs Assessment: A Key informant approach Health awareness issues: • Poor health awareness by people. • Poor attendances of antenatal care by pregnant in PHC.

• Use of herbal medicines in treatment by some people.

• Poor compliance with medical treatment. • Parental negligence for children who are playing in dirty areas.

Socioeconomic problems: • High numbers of consanguinity in marriages, • • • • • • • • • •

without premarital counseling or screening leading to hereditary diseases eg: sickle cell. Illegal border crossing of labors leading to imported diseases such as Dengue fever, Rift Valley Fever and Malaria. High divorce rate and it’s affect on the care of the siblings. Poor attention for the children rights. Increased use of Ghat chewing and cigarettes smoking. Lack of physical exercise or sport facilities. Increase numbers of motor vehicle accidents due to careless driving. Unhealthy child feeding behaviors. Poor personal hygiene High poverty in some communities especially in the villages. High unemployment in the region.

Finally, perception of key informants in the role of Jazan medical college in the improvement of health in the region documented many interesting points as follow: • Conduction of in-depth community health studies for identifying health problems and setting priorities in health programs. • Graduation of highly qualified doctors. • Developing field training programs for medical students and involving them in outreach health programs. • Establishing a continuous education programs in liaison with Regional Directorate of Health for professional development of health care providers. • Issuing a regular medical bulletin to be circulated in region. • Collaboration and coordination with the local health facilities in health programs to strengthen health services and supervise ongoing health programs. Building a university hospital with specialized • medical centers. • Feedback of the Jazan Health Need Assessment Study to the local community.

Discussion Health problems in Jazan region vary from communicable diseases, such as malaria, bilharzias and hepatitis to those

of modern society such as hypertension diabetes, peptic ulcer, and escalating rates of road traffic accidents.4 The people of Jazan are mostly animal-breeders and farmers. The close association between man and animal resulted in endemicity of zoonotic diseases such as brucellosis. Active collaboration between communities and researchers is critical in developing appropriate public health strategies that address community concerns.3 In the present study, key informants responded to elicit the main health problems, social problems, priority needs, participation and role of various sectors in health development of Jazan region. Key informants have highlighted the role of illegal cross-border immigrants in the wide spread of communicable diseases. Jazan city is only 70km from the Yemen border and it is documented that the 2000 epidemic of Rift Valley Fever occurred at border areas was a result of border population movements and the introduction of animals from neighboring countries.3 Recent reports documented the high burden of malaria as one of the main communicable diseases in Jazan region, the highest percentages of these incidents are suspected to have been imported from neighboring Yemen.4 Furthermore, environmental conditions in the region were recognized by key informants to play an important role in malaria transmission. This is mediated through high presence of stagnant water surfaces in the area which enhance mosquito life cycle and density of the mosquitoes. Control of these problems can be achieved if collaborative work been organized between neighboring countries in environmental and control programs. AlGhatani and Amin, 2005 reported that among inhabitants of Jazan region, the prevalence and intensity of Schistosoma haematobium infection have been kept very low for several years, by sustained control efforts.6 The control and prevention strategy was based on regular chemotherapy, snail control and health education with screening at primary health care centers and mobile teams. The study came to the conclusion that total elimination for this disease is possible if health authorities in neighboring areas can be persuaded to adopt a similar strategy of control. Poor coverage of health services delivery was felt very strongly by key informants in the interviews. During the discussions, they stressed the need for the expansion of health services by building new health facilities including general and specialized hospitals as well as primary health care centers.4 In most developing countries, the reorganization of health services is a continuously on going process and the people demand for wide coverage of health facilities is a common picture but their emphasis has been on hospitals rather than on PHC centers. Since Alma Ata declaration on primary health care, more attention has been given to increasing coverage of basic services and preventing common diseases using the PHC model. However, the bias in resource allocation towards secondary care and urban areas remains. Currently, there are 135 PHC centers and 13 hospitals with a total of 1338 beds in Jazan region and the bed occupancy rate is 77%


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Jazan Health Needs Assessment: A Key informant approach

Problem

Number

%

Shortage of Health Care Providers

91

97.8

Communicable Diseases

45

48.4

Poor Environmental Health

45

48.4

Shortage in Provision of Health Services

36

38.7

Lack of Health Awareness

32

32.4

Chronic Diseases

27

29.0

Shortage of Safe Water Supply

18

19.4

Imported Diseases due to Illegal cross border movements

12

12.9

Ghat Chewing

47

50.5

Consanguinity in Marriage

35

37.6

Poverty and unemployment

27

29.0

Cigarette Smoking

22

23.7

Illegal Immigrants

14

15.1

Animal Husbandry

7

7.5

1. Health

2. Social

Table 1. Health and Social Problems Perceived by Key Informants.

compared to the national figure of 63%. Judging by the high demand for extra services by the key informants and the uneven rural urban distribution of health facilities, it is obvious that there is a real urgency for the assessment of these facilities to assure proper quality and equitable coverage in quantity. Shortage of health personnel is another important underlying cause of poor service coverage and the availability of well-trained Saudi health personnel from both genders is a known difficulty. The expansion of health services in Jazan region has depended primarily on expatriates from Arab countries, Indian subcontinent and Far East. The recent Ministry of Health (MOH) annual statistics for the 1421/1422 Hegri year (2001) reported that out of the 724 doctors in Jazan, only

7% were Saudis and 6% were females and out of all 1345 nursing manpower only 23% were Saudis.4 The recruitment of large numbers of expatriates has helped, to some extent, in expanding the services to every town and most of the villages in Jazan region. However, the diversity of worker’s educational and cultural backgrounds has presented problems in service delivery. An ambitious suggestion for solving shortage in Saudi health personnel is the creation of health assistant training programs in selected hospitals and primary care centers, and training of community health workers in these areas. Encouraging new Saudi medical graduates by various incentives to work for 6 months to one year in rural areas and remote hospitals can be another strategy for solving the personnel and service


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Jazan Health Needs Assessment: A Key informant approach

Degree of need Type of Need

Important

Neutral

Not Important

No

%

No

%

No

%

Building new hospitals

64

68.8

15

16.1

14

15.1

Building new PHC

75

80.6

11

11.8

7

7.5

Maintenance of Health facilities

77

82.8

7

7.5

9

9.7

Increase Health Care Providers

72

77.4

9

9.7

12

12.9

Capacity Building of Health Care Providers

83

89.2

7

7.5

3

3.2

Provide Medical Equipments

74

79.6

12

12.9

4

4.3

Provide Medical Supplies Drugs and vaccines

18

19.4

10

10.8

3

3.2

Provide Logistics cars ambulances and warehouses

13

14

11

11.8

6

6.5

Table 2. Perceived Health Needs for Jazan Region as suggested by Key Informants.

coverage problem. Similar successful programs can be copied from similar areas in Sudan and Yemen. In any country, health development is part of overall community development. Saudi Arabia was one of the signatory of the United Nation initiative for the Millennium Development Goals (MDGs) which call for measurable progress toward improving quality of life in the developing world, by reducing poverty, hunger, illiteracy, disease and environmental degradation.7 The health sector alone can not achieve these goals without cooperation with other government sectors and community forces to reach overall community sustainable development. It was well perceived by the key informants that other government sectors like agriculture, education, municipality and police have important role in health development of the region. This is in agreement of the inter-sectorial approach for health development in Alma Ata declaration. Hence, every effort should be made by health authorities to coordinate with other sectors by establishing multi-sectorial health committees at all levels. Key informants were, also, in the opinion that donations from community, including cash, land, maintenance, and furniture, could be used for improving the health in Jazan region. Their view was also documented by Almazrou (1989) where 97% of community respondents agree to the importance of community participation in PHC which is an important principle emphasized in Alma Ata Declaration in 1978.8 In Saudi Arabia, the goals of reducing morbidity and mortality and of raising standards of health among the

people can be attainable with appropriate planning and utilization of resources for equitable coverage of health services. It is encouraging to see the political will and commitment towards achieving this goal, as evident by the recent Royal Decrees of establishing Jazan University hosting both the College of Medicine and College of Allied Medical Sciences. Another postgraduate Institute of Public Health is expected in the near future. To fulfill the expected role in health development of the region, these institutes should not replicate similar establishments in Western countries, but should be carefully planned to meet the health needs of Jazan and the Southern Saudi region at large. These institutes should develop training, research and community outreach programs for physicians, nurses, health planners, administrators and professionals in preventive medicine. It goes without saying that; academic public health plays an important role in teaching and research in collaboration with governmental departments of public health at national and local levels.9 A major objective of medical schools is to prepare their students to resolve the problems of their communities at the level of individuals, families and communities.10 Jazan College of Medicine, established 2001, is adopting an innovative curriculum oriented towards community based training approach. The community approach is tailored towards using the community as a resource in learning, teaching and service delivery. This is applied in many components of the program, such as curricular content, training settings and sites, faculty recruitment, student admission criteria and health care delivery approach.


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Jazan Health Needs Assessment: A Key informant approach Key informants pointed out these community oriented views in their answers on the expected role of the newly opened Jazan College of Medicine. They stressed that the medical school should work towards the conduct of in-depth community health studies for identifying health problems and setting priorities in health programs, developing community field training programs for the medical students, involving students in outreach health programs in the community. These are in addition to the roles of graduating of highly competent doctors, issuing regular medical journals to be circulated in the region, establishing continuous education programs in liaison with governmental health authorities for professional development of the health care providers in the region and building a reference University Hospital with specialized medical centers. A build-in limitation of this study is that needs assessment is useful only if it is continually updated to take account of changes in the composition of local population, and other health determinant and the changing needs of the community. It is known that the

hardest part of any needs assessment is translating the results into policies and practices to initiate beneficial change. Local workshops with community leaders and health providers can provide opportunities to review and update the lessons learnt from this survey and implement suitable changes. If these changes are going to be sustainable and adaptable then the appraisal should be a continuous process with ongoing feedback. Implementation of strategic changes can be facilitated if the policy makers themselves are active in the process.

Acknowledgment We are grateful to King AbdulAziz University for sponsoring and funding the study. Conduct of this study could not been possible without the logistic support and facilitation by the Director General of Health in Jazan and his staff in the PHC centers. Finally, all appreciation goes to the teaching assistants and the medical students from Jazan College of Medicine for their support and implementation of the study.

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