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Clinical biopsychosocial practice and primary health care in Eastern Nigeria
Sot. SC;. Med. Vol. 21. No. 12. pp 13X3-1389. 1985 Printed in Great Bntam. All rights reserved
CLINICAL
0277-9536185 $3.00 + 0.00 Copyright K’ 1985 Pergamon Press Lid
BIOPSYCHOSOCIAL PRACTICE PRIMARY HEALTH CARE IN EASTERN NIGERIA STACEY
Department
of Community
Health.
College
AND
B. DAY
of Medical
Sciences,
University
of Calabar.
Calabar.
Nigeria
Abstract-An account with case reports of the organization of medical education in the direction of a synthesis between divergent biological paradigms within sociological parameters (the biopsychosocial way), towards problem solving and solution finding in rural health in Cross River State, in the Rain Forest Belt of Tropical West Africa (Nigeria) is described. The objective of the biopsychosocial programme is to strengthen rural health through primary health care based on health education and health communications transfer strategies, implemented by medical students absolving their Community Health Clinical Clerkship. Informational messages and health education is transmitted in such a way as to be accepted by village communities, and to lead to community action within their own resources (Self-Health and Self-Help). Individual and Community Health is integrated with general practice medicine in the clinical biopsychosocial approach, which fulfils the WHO position of health as physical (BIO), mental (PSYCHO) and SOCIAL well being. Rural support activities are a part of biosocial development. It is believed that the biopsychosocial way has contributed to health improvement in this part of Nigeria.
INTRODUCTION
over several years, in the matter of health care, we have come to understand that quality of life is more and more a function of biosocial development. We have argued for creative policies of health and legislation recognizing basic human needs and we have taught that good health is not only good clinical health but also good social health. Although unstructured as a science. social health makes implicit understanding of the social foundation of illness [l]. In Nigeria, health problems as we see them daily in rural villages, are directly or indirectly determined by biosocial conditions. Malnutrition, malaria, measles, tuberculosis, tetanus, meningitis, dysentery, cholera, helminthiasis. leprosy. guinea worm, filariasis and poliomyelitis prevail. These diseases shorten the life span. reduce human productivity, and relatively, have engaged few attempts to eradicate their cause. It is within the social spread of these diseases that the present studies are described-among rural poor; without communication facilities (a journey by car by ‘road’ of 25 miles may take 4 hours), under conditions of overcrowding, in inadequately ventilated huts and without basic hygiene or sanitation. Indeed. the washing of faecal sewage and debris by the rains into nearby streams, ponds, rivers and wells, is a common event. This, with unboiled water used as drinking water: with limited and usually protein deficient diets. and social and civil development critically affected by infectious and parasitic diseases describes the background from which case reports cited here come. Within this environment we have sought to establish a teaching programme aimed at utilizing the community spirit of the people to provide health care Increasingly
services for themselves (Self-Health and Self-Help) at the village level. We have taught that persons themselves. individually and through their village health committees. can be responsible for good health and
that such good health is derived from the intrinsic characteristics of the psychospiritual environment of man, and his learned (artificial) problem solving capacity and behaviour, as well as upon the biologic components within his background. In West Africa, against this background of severe limitations, in large rural populations with severe health and wellness impairments, and who in general have restricted access to any form of health care delivery system or preventive/curative therapy, we have, since June 1982, instituted principles of biopsychosocial practice actively in our Community Health Clinical Clerkship and Family Medicine programmes, emphasizing primary health care strategies, in the rural villages of the Akamkpa Local Government Area of the Cross River State of Eastern Nigeria. I am grateful to Professor George Engel, of Rochester, New York, for permission to publish our experiences and results using the clinical biopsychosocial model that he described [2]. We write from a developing country, in an evolving culture, that is under the dual pressure of its own traditions and urgent need to introduce appropriate Western technology--conditions so vastly dissimilar to those of the North American Environment-and yet, as one predicted from our integrative theoretical studies [3] a system eminently capable of crossing language, racial, geographic, climatic and cultural barriersthereby demonstrating that at the human (person) level, the biopsychosocial advance is a true imperative in social and practical clinical medicine. CASE STUDIES
Three illustrative cases from 150 cases studied are briefly presented from West African (Nigeria) rural communities. The cases are reported by second year clinical medical students absolving a Community 1383
1384
STACEYB. DAY
Health Clinical Clerkship, part of the training programme of the College of Medical Sciences, University of Calabar, Department of Community Health. The medical students live for a period of 2 months in close proximity to the villages in which they deliver primary health care. Few of the village people speak English and frequently they may not speak the same regional language as the medical student working up the case. The goal of the Community Health programme is to educate physicians who are communityoriented, knowledgable of their own cultural milieu, and capable of delivering primary health care within the concept of the practice of the biopsychosocial clinical model. In the villages the students are both taught and learn by facilitation the functions of the physician in the rural community. They focus their efforts on the family and on the community as a whole, as well as upon individuals. Thus exposed to rural life, they learn to combine preventive as well as curative aspects of clinical practice and become familiar with local belief systems, relationships within the family (e.g. multiple wives), factors regulating behaviour, values and attitudes affecting daily practice, which they must take into account in decision making for good rural health. By such exercises, the medical students recognize that the family’s health is related to the physical, psychological, social, cultural and economic constructs of the Cross River State village. In short they become acquainted at first hand with biopsychosocial medicine. The principal features presented in these cases relate to the biopsychosocial method. Strict clinical cases histories (examination findings) are not included, but are available on request. case
1
Presented by Mr Godwin Ebuk John. Community Health Clinical Clerk, Group A81, December 1982. A clinical case report is presented of a 9-year old girl, living in Old Netim Village, Akamkpa Local Government Area, Cross River State, Nigeria. Features of the Akamkpa (Calabar) Model are described, and an analysis .of component issues in terms of clinical biopsychosocial practice are reviewed. Introduction
The Akamkpa (Calabar) Model is a primary health care delivery system model by which village people may find access into the health care delivery system of Nigeria. The Federal Government of Nigeria has built at Akamkpa, as it has in many other States in Nigeria, a Comprehensive Health Centre (CHC), and in association with the State, and with the University of Calabar, a hostel has been provided at the CHC where medical students are housed during their Clerkship. In addition, the University, through the Head of the Department of Community Health, provides transport into the surrounding villages (3-8 km away) and faculty interact and work with students in the field. The different organs involved in the Akamkpa gramme Cross River state government.
this programme
Pro-
In associating with the State endeavours to bring basic
health services to the rural communities at the grass roots level, but this to my mind is still far from being a reality. Most people do not turn up at the Comprehensive Health Centre (Secondary Care) perhaps because of the distance of this centre from the heart of each rural village and because of the economic duress upon the rural masses who cannot simply get to this part of the programme. Federal government. The federal government puts up the bricks and mortar, but these alone cannot access patients from a village into any health care scheme. Community health department,
Unicersitj, of’ C&bar
So far this is the arm which is really committed
to the primary health care delivery system because students and lecturers go straight to households in the villages to deliver health services to the people. In my opinion the department may thus serve a greater percentage of the rural population than does the CHC set up by the Federal/Cross River State Governments. I hope it will not be too early to say that the Community Health Department, at the village level, is the group providing the primar_v health cure, while the State Government. through the CHC, provides secondary care, (referred from the village groups), whilst through the Teaching Hospital (UCTH) via referral from the CHC. tertiary care is available. Medical students. Our role is to acquire/perfect skill in rural health clinical clerkship, and to render primary health care at the community level. We learn to recognize and liaise with primary, secondary, and tertiary components of the evolving Nigerian health care system. We are also expected to educate the rural population on principles of sanitation and self health care, campaign for immunization and assist them in understanding methods toward the prevention of locally endemic diseases. Case presentation. A 9-year old female school child presenting with ringworm infection of scalp located at the occipital region of the head, and on the upper abdomen. Associated fever (3 days) with poor appetite, yellowness of the sclera and nausea not associated with vomiting or with convulsions. Frequency of bowel motions; the stool is watery and is passed with mucous but not blood. The patient had never received any therapy before, had never visited any clinic or hospital and had never been attended by any native doctor. A meticulous family history was presented and detailed patient work up was reported. The working diagnosis arrived at what was malaria fever with a possibility of associated helminthiasis. Case analysis discussion in terms of clinical biopsychosocial model
The Akamkpa Community Health Clinical Clerkship is a clinical biopsychosocial approach working at the primary health care level and through community health, to access people into the health care delivery system of the federal government of Nigeria. Biopsychosocial medicine means taking into account the biological (physical); mental (psychic) and social well being of an individual. This three component term (biopsychosocial) is not far away at all from what the
Clinical biopsychosocial
World Health Organization gives as a definition of health“complete physical, mental and social well being not limited by any disease”. Therefore in using a biopsychosocial approach to clinical clerkship, we are keeping in touch with WHO standards and concepts in today’s medicine. Biological analysis of this case
A patient such as this, and young in age, with malaria, has probably a lower ability to resist infection than an adult. Therefore biological effects of malaria in the child can be expected to be marked. Because of high levels of parasitaemia there might be expected increased hemolysis of the patient’s RBC’s causing decrease in oxygen (0,) carrying capacity to essential organs-tissues-cells, with final negative effects at the level of metabolism and cell survival. There will be effects of hemolytic anemia and a general body weakness (a physical effect). The reticuloendiothelial system is called in to play with a resultant enlargement of spleen and liver. In this patient there was splenomegaly up to 6 cm below the left costal margin. Growth may be retarded and failure to thrive is associated with untreated chronic intermittent malaria. Psychic (mental) approach
The parasite may find (in West Africa) its way to the brain causing congestion in the small blood vessels, resulting in blockage. Cerebral malaria may lead to mental retardation and death. In young infants, recovery may be accommodated by a decrease in intelligence (IQ) following cerebral damage by the disease. Poor school performance can result as a subsequent outcome of this disease. Social aspects
Mental retardation, socioeconomic costs of illness, cultural handicaps may all follow this disease. There will result, frequently unhappiness for her, her family, her ethnic group (tribe/caste) and even for the region. Conclusion
It is my opinion that the incorporation of the three components of the Biopsychosocial approach in the clinical practice of medicine goes a long way in meeting our primary health care needs and in understanding our goals. in Nigeria. Case 2
Presented by Mr Iniobong Ene Essien. Community Health Clinical Clerk. Group A81. December 1982. Case summar).
The case is a 45 year old man named O., a native of Old Netim Village, who is anaemic and in cardiac failure. The illness started 3 years ago but for superstitious reasons, the man has constantly refused to go to any hospital for treatment. The case is analysed in terms of the Clinical Biopsychosocial Model. Introduction
The Akamkpa (Calabar) model demonstrates a network of health communications that consist of several cadres contributing to health care: (i) primary health care unit
practice and PHC
1385
(ii) secondary health care unit (iii) tertiary health care unit. The Akamkpa Model serves several villages within a 20 km radius of a central point, the CHC which provides secondary health care. Biopsychosocial aspect of cardiac ,failure as it aflects this patient
The term biopsychosocial embodies three aspects of the patient, namely biological, psychological (mental) and social. These factors all play a role in the patient’s health. Biological aspect. In this patient, the cardiac failure as provisionally diagnosed has all the physiopathological features consequent upon a disturbed circulation. These may result in severe further deterioration (organs, tissues, cells) and enhanced disease state in the patient. Psychological (mental) aspect. Generally, anybody under diseased conditions tends to be apathetic. This patient is not an exception. His dyspnoea and weakness make him unfit for work. He is worried as to how he will survive, and these stresses worsen his already poor state of health. Furthermore, he is strongly of the opinion that his illness is caused by some jujumen in the village. Unless the evil men are dealt with, his disease cannot be cured. This definitely increases the stress upon him. Social aspect. The patient has refused to take medication or accept any form of medical assistance. This increases social and psychological stress among his neighbours and family. He cannot contribute to the development of the village and may become a burden to his friends and relatives. Since he has refused all treatment he has alienated most people around him, who are losing sympathy with his case. Case 3 Presented by Miss Gloria P. Ekanem. Community Health Clinical Clerk. Group A81. December 1982. A clinical case is reported of a 35 year old male farmer, living in Old Netim village, Akamkpa, Cross River State, Nigeria, who presented with a history, signs and symptoms of pulmonary tuberculosis. Features of the biopsychosocial aspect of the case are discussed, including an account of the demography of the village of Old Netim. Introduction
The Akamkpa (Calabar) Project is a primary health care delivery programme organized by the Department of Community Health, University of Calabar, for her students. It is a clinical posting involved with the accessment to better health standards, nutritional status and health education for the community. A logical network of health communications is built which comprises (i) primary health care in the villages, (ii) secondary health care available at the CHC, Akamkpa and (iii) access to tertiary health care at the University of Calabar Teaching Hospital. Demography of old Netim village
The case study used to illustrate the principles of the Cross River State (Akamkpa) model in terms of
1386
STACEYB. DAY Villages Primary health care
Comprehensive Health Care Centre, Akamkpa
Secondary health care
University of Calabar Teaching Hospital or any general hospital I
J
Fig. 1
a clinical biopsychosocial model is taken from a little village in Akamkpa Local Government Area called Old Netim. This village is about 3 km off the main Akamkpa road at Okomita, and about 3f km from the CHC, Akamkpa. The population of the village is about 2000 with relatively younger people than the aged and the females outnumber the males. The people have a Village Head and a Traditional Birth Attendant (TBA) who has received some health education at the CHC. The main occupation of the people is farming, but some men work at the Crushed Rock Industry nearby and at Eyuma Quarry near the village. The village can be regarded as a typical one because some basic necessities are present. They have two primary schools. one for those in the junior classes l-3; the other school for the senior classes 4-6. They have a small market in the village but most people buy and sell at the market at Okomita. There is a Secondary School not yet functional although construction work and equipment projects have been completed. There is also an uncompleted church building in the village. At present people go to Okomita for church services.
The sanitary condition of the village is below standard for an average Nigerian village. No good water drainage systems leads to the formation of stagnant pools for the breeding of mosquitoes. The source of water supply is partly from the streams and partly from water tanks supplied by the Akamkpa Water Board. Most of these streams dry up during the dry season. Some families in the village make use of pit latrines, others use logs of wood and some the nearby bushes in which to defecate. The staple food of the village includes plantains and yams which they obtain from the farms. Other food crops include cocoyam, cassava and fruits like bananas, oranges, mangos and paw paw. The health status seems average for the community. Most children look well fed. Some common health problems amongst the children include bronchopneumonia, gastroenteritis, conjunctivitis, umbilical hernia, eczema, scabies and angular stomatitis. Adults suffer from fungal infections of the skin and nails, tuberculosis, cholera, ulcers, malaria and helminth infections. The Clinical Biopsychosocial Model of this case of pulmonary tuberculosis can be diagrammatically represented based on physical (BIO), mental (PSYCHO)
Clinical biopsychosoci al practice and PHC and social (SOCIAL) aspects of the case in relation both to the patient as a person, and of the person within his community and society (Figs 2 and 3). DISCUSSION
This report has presented a profile of clinical biopsychosocial practice that appears to offer an important and promising strategy in health care management and implementation of primary health care in rural village communities of Eastern Nigeria. Case reports are described by second year clinical
Events
I387
Nigerian students undertaking their Community Health Clinical Clerkship in these villages. With others, we have a strong perception that the primary health care system in Nigeria (as in many other developing countries), has yet to fulfil its potential role in promoting health of the people. More expansion of ‘health services’ (bricks and mortar) by building more CHC Centres does not alone improve health or bring about an improvement in the quality of life of rural people. Expansion of health services must take into account an infra-structure including trained personnel (health assistants, nurses. phar-
System hierarchy
lntrasystem chances
Irregular tax payment Moves made to increase health care to communities
Culture
i
Social stigma Attribution of illness to evil power
Decreased productivity Manpower and social influences
Family
Two-person relationship
Increased financial burden Stress and strain
Stress Relationship broken
possibly
Depressed Irritable Alarm Uncertaintv
Nervous system
Organ
Severe mental stress Behavioural readjustment Pulmonary caseation, fibrosis, cavitation, calcification of lesion with collapse or emphysema Infiltration and destruction of alveoli by bacilli. Hemorrhage into the tissues
Cell damage
Fig. 2
STACEYB. DAY
1388
System hierarchy
Events
1
Health policies reviewed Increase of health services to community
Nation
Rituals in honour of the dead. Consultations of magicians, with doctors for cause of death Mourning
Culture
Social influences Manpower effect Mourning
r
Irreversibly disrupted Financial burden Great loss, grief Sorrow and mourning
Irreversibly broken Sorrow rief, mourning Hardshrp 3
Patient’s behaviour
I
Disrupted
Tissue
for ever
Irreversibly
disrupted
Irreversibly
destroyea
Irreversibly
destroyed
Irreversibly
destroyed
Fig. 3
macy assistants) in the rural communities where the great majority of people live. Knowledge and attitudes of health personnel must be directed to the environment and health problems of the society and the country, and expansion of health services must take into account utilisation of all resources, especially human. As Sebai [4] has pointed out, the problem of primary health care is related to the type of medical education and training received by physicians and other health, personnel. Medical education, in both developed and developing nations, has been evolving through numerous none traditional concepts in re-
cent years [5,6]. Many of the traditional, i.e. European, objectives of medicine, when transferred to new medical institutions in developing countries, have failed to improve education and training of students. Critically these established models have often been of little or no use in rural African communities where the great majority of people live. These findings have stimulated the use of different approaches in teaching medicine and evolving patient care in rural communities in developing countries [7, 81. We have, in order to improve the primary health care system, sought to modify the focus of medical education emphasising a community based problem solving approach.
Clinical
biopsychosocial
The persuasion in African Universities has recently been to call for assistance “in the training of scientific creators, investors and innovators whose researches would be directed at finding solutions to African problems” [9]. Recognizing the need seen by Africans that the African university socially perform as ‘an instrument of development’, any educational change must take shape within the framework of the view outlined by Professor Makany, Secretary General of the Association of African Universities that “the African University in the year 2000 is first of all a philosophy. an idea to assert ourselves as African”
[91. Within this African imperative, studies devoted to the welfare of rural people must include understanding of the socioeconomic, educational and cultural thresholds of life as well as pragmatic aspects of preventive and curative medicine in general. In developing an approach to primary health care we have been mindful of two perspectives of contemporary life in Nigeria. The first, clearly, is recognition that Nigeria is a country of rural communities. The second, succinctly put by Professor Ransome-Kuti is that “we have to go back to where our people are and evolve with them” [IO]. Strategies of medical education to be of service in contemporary Nigeria, cannot, in the words of Ransome-Kuti, “leave the majority of the people further and further behind”. This can only be satisfactorily achieved by the involvement of the communities in the health changes in the nation. Recognizing that in Nigeria the expansion of health services is taking place at all levels, primary, secondary and tertiary care, our own studies are concerned with the present development of primary health cure and are based on a programme of integrated teaching and community-based training that we have espoused. We have urged the view that primary health care development increasingly is accepted as an imperative for good health. So many, for so long, have taught that socioeconomic development in rural communities interfaces with good health through improvements in better housing, sanitation, water supply, nutrition and education, all of which promote the better well being of the family, that it may be thought unnecessary to continue to stress this basic approach. It is necessary to emphasize the role 9 f biosocial derelopmen t. In the College of Medical Sciences, University of Calabar, we have introduced a problem solving, self-learning, integrated approach, in which medical students are exposed immediately in their training, in the pre-clinical phase. to social. cultural and traditional aspects of their communities and belief systems. upon which later is based their involvement with the rural communities in which they serve as ‘front line doctors’. Through the Community Health Clinical Clerkship. these young men and women, live
practice
and PHC
1389
and work within the villages of Cross River State, (Akamkpa, Old Netim, Mbarakom), learning by doing and thus are privileged, at an early stage in their professional training, to be introduced to the realities and to the needs of community health problems. Students participate in multiple phases of community health work-maternal and child health, control of diseases, epidemiologic and demographic surveys, therapeutic service programmes, leprosy and tuberculosis control, school education and other facets of community health care delivery in a rural setting, under the supervision and guidance of department of community health faculty and health staff aids. This approach to rural patient care, biopsychosocial clinical practice in community health, appears to us to fit the needs of primary health care delivery in rural Eastern Nigeria. Acknowledgements-1 acknowledge with pleasure the important contributions to these studies by: Miss Gloria P. Ekanem, Mr Godwin Ebuk John, Mr lniobong Ene Essien, Mr Aniah Michael Aniah (Group Captain A81). Mr Nkemakonam H. Ikekpeazu, Mr Udeme D. Akpan, Mr Philip Etabee Bassey, Mr J. I. Eregare, Miss Atim Nyong Inyang, Mr A. V. Diorgu, Mr Joseph E. Goin, Miss Akobundu Ngozi Chioma, Mr Isetiema Igani Koko, Mr Ado OmoIghorodje.
REFERENCES
Publica1. Day S. B. Health Communicarions. Monograph tion of the International Foundation For Biosocial Development and Human Health, New York, 1979. application of the bio2. Engel G. L. The clinical psychosocial model. Am J. Psychiat. 137, 1980. Hlth Commun. Informat. 6, 1980. 3. Day S. B. Editorial. 4. Sebai Z. A. The Health of the Family in Changing Arabia. 1981. Tihama publications (Jeddah), Kingdom of Saudi Arabia. 5. Day S. B. et al. The Faculty of Medicine and Health Sciences, Province of Asir, Kingdom of Saudi Arabia. The First Two Years. Consultation and Planning Group, Vol. I, Fat. Rep. 8/1.6.81. 6. Sebai Z. A. Community Health in Saudi Arabia. Saudi Medical Journal Monograph No. I, 1982 I. Bryant J. H. In Medical Education and the Contemporary World, p. 171. U.S. DHEW publication No. (NIH) 77-1232, 1976. 8. Day S. B. Health Communications, Chap. 9, pp. 195-232. Monograph Publication of the International Foundation for Biosocial Development and Human Health, New York; 1979. 9. Makany L. Secretary General of Association of African Universities. Role of African Universities in the promotion of culture and science as basis for the development of Africa. Inauguration of the University of Botswana, 23rd October, 1982. IO. Ransome-Kuti 0. Child health priorities in Nigeria. Keynote address delivered to the Annual Conference of the Paediatric Association of Nigeria, Calabar, 1983.
CLINICAL
0277-9536185 $3.00 + 0.00 Copyright K’ 1985 Pergamon Press Lid
BIOPSYCHOSOCIAL PRACTICE PRIMARY HEALTH CARE IN EASTERN NIGERIA STACEY
Department
of Community
Health.
College
AND
B. DAY
of Medical
Sciences,
University
of Calabar.
Calabar.
Nigeria
Abstract-An account with case reports of the organization of medical education in the direction of a synthesis between divergent biological paradigms within sociological parameters (the biopsychosocial way), towards problem solving and solution finding in rural health in Cross River State, in the Rain Forest Belt of Tropical West Africa (Nigeria) is described. The objective of the biopsychosocial programme is to strengthen rural health through primary health care based on health education and health communications transfer strategies, implemented by medical students absolving their Community Health Clinical Clerkship. Informational messages and health education is transmitted in such a way as to be accepted by village communities, and to lead to community action within their own resources (Self-Health and Self-Help). Individual and Community Health is integrated with general practice medicine in the clinical biopsychosocial approach, which fulfils the WHO position of health as physical (BIO), mental (PSYCHO) and SOCIAL well being. Rural support activities are a part of biosocial development. It is believed that the biopsychosocial way has contributed to health improvement in this part of Nigeria.
INTRODUCTION
over several years, in the matter of health care, we have come to understand that quality of life is more and more a function of biosocial development. We have argued for creative policies of health and legislation recognizing basic human needs and we have taught that good health is not only good clinical health but also good social health. Although unstructured as a science. social health makes implicit understanding of the social foundation of illness [l]. In Nigeria, health problems as we see them daily in rural villages, are directly or indirectly determined by biosocial conditions. Malnutrition, malaria, measles, tuberculosis, tetanus, meningitis, dysentery, cholera, helminthiasis. leprosy. guinea worm, filariasis and poliomyelitis prevail. These diseases shorten the life span. reduce human productivity, and relatively, have engaged few attempts to eradicate their cause. It is within the social spread of these diseases that the present studies are described-among rural poor; without communication facilities (a journey by car by ‘road’ of 25 miles may take 4 hours), under conditions of overcrowding, in inadequately ventilated huts and without basic hygiene or sanitation. Indeed. the washing of faecal sewage and debris by the rains into nearby streams, ponds, rivers and wells, is a common event. This, with unboiled water used as drinking water: with limited and usually protein deficient diets. and social and civil development critically affected by infectious and parasitic diseases describes the background from which case reports cited here come. Within this environment we have sought to establish a teaching programme aimed at utilizing the community spirit of the people to provide health care Increasingly
services for themselves (Self-Health and Self-Help) at the village level. We have taught that persons themselves. individually and through their village health committees. can be responsible for good health and
that such good health is derived from the intrinsic characteristics of the psychospiritual environment of man, and his learned (artificial) problem solving capacity and behaviour, as well as upon the biologic components within his background. In West Africa, against this background of severe limitations, in large rural populations with severe health and wellness impairments, and who in general have restricted access to any form of health care delivery system or preventive/curative therapy, we have, since June 1982, instituted principles of biopsychosocial practice actively in our Community Health Clinical Clerkship and Family Medicine programmes, emphasizing primary health care strategies, in the rural villages of the Akamkpa Local Government Area of the Cross River State of Eastern Nigeria. I am grateful to Professor George Engel, of Rochester, New York, for permission to publish our experiences and results using the clinical biopsychosocial model that he described [2]. We write from a developing country, in an evolving culture, that is under the dual pressure of its own traditions and urgent need to introduce appropriate Western technology--conditions so vastly dissimilar to those of the North American Environment-and yet, as one predicted from our integrative theoretical studies [3] a system eminently capable of crossing language, racial, geographic, climatic and cultural barriersthereby demonstrating that at the human (person) level, the biopsychosocial advance is a true imperative in social and practical clinical medicine. CASE STUDIES
Three illustrative cases from 150 cases studied are briefly presented from West African (Nigeria) rural communities. The cases are reported by second year clinical medical students absolving a Community 1383
1384
STACEYB. DAY
Health Clinical Clerkship, part of the training programme of the College of Medical Sciences, University of Calabar, Department of Community Health. The medical students live for a period of 2 months in close proximity to the villages in which they deliver primary health care. Few of the village people speak English and frequently they may not speak the same regional language as the medical student working up the case. The goal of the Community Health programme is to educate physicians who are communityoriented, knowledgable of their own cultural milieu, and capable of delivering primary health care within the concept of the practice of the biopsychosocial clinical model. In the villages the students are both taught and learn by facilitation the functions of the physician in the rural community. They focus their efforts on the family and on the community as a whole, as well as upon individuals. Thus exposed to rural life, they learn to combine preventive as well as curative aspects of clinical practice and become familiar with local belief systems, relationships within the family (e.g. multiple wives), factors regulating behaviour, values and attitudes affecting daily practice, which they must take into account in decision making for good rural health. By such exercises, the medical students recognize that the family’s health is related to the physical, psychological, social, cultural and economic constructs of the Cross River State village. In short they become acquainted at first hand with biopsychosocial medicine. The principal features presented in these cases relate to the biopsychosocial method. Strict clinical cases histories (examination findings) are not included, but are available on request. case
1
Presented by Mr Godwin Ebuk John. Community Health Clinical Clerk, Group A81, December 1982. A clinical case report is presented of a 9-year old girl, living in Old Netim Village, Akamkpa Local Government Area, Cross River State, Nigeria. Features of the Akamkpa (Calabar) Model are described, and an analysis .of component issues in terms of clinical biopsychosocial practice are reviewed. Introduction
The Akamkpa (Calabar) Model is a primary health care delivery system model by which village people may find access into the health care delivery system of Nigeria. The Federal Government of Nigeria has built at Akamkpa, as it has in many other States in Nigeria, a Comprehensive Health Centre (CHC), and in association with the State, and with the University of Calabar, a hostel has been provided at the CHC where medical students are housed during their Clerkship. In addition, the University, through the Head of the Department of Community Health, provides transport into the surrounding villages (3-8 km away) and faculty interact and work with students in the field. The different organs involved in the Akamkpa gramme Cross River state government.
this programme
Pro-
In associating with the State endeavours to bring basic
health services to the rural communities at the grass roots level, but this to my mind is still far from being a reality. Most people do not turn up at the Comprehensive Health Centre (Secondary Care) perhaps because of the distance of this centre from the heart of each rural village and because of the economic duress upon the rural masses who cannot simply get to this part of the programme. Federal government. The federal government puts up the bricks and mortar, but these alone cannot access patients from a village into any health care scheme. Community health department,
Unicersitj, of’ C&bar
So far this is the arm which is really committed
to the primary health care delivery system because students and lecturers go straight to households in the villages to deliver health services to the people. In my opinion the department may thus serve a greater percentage of the rural population than does the CHC set up by the Federal/Cross River State Governments. I hope it will not be too early to say that the Community Health Department, at the village level, is the group providing the primar_v health cure, while the State Government. through the CHC, provides secondary care, (referred from the village groups), whilst through the Teaching Hospital (UCTH) via referral from the CHC. tertiary care is available. Medical students. Our role is to acquire/perfect skill in rural health clinical clerkship, and to render primary health care at the community level. We learn to recognize and liaise with primary, secondary, and tertiary components of the evolving Nigerian health care system. We are also expected to educate the rural population on principles of sanitation and self health care, campaign for immunization and assist them in understanding methods toward the prevention of locally endemic diseases. Case presentation. A 9-year old female school child presenting with ringworm infection of scalp located at the occipital region of the head, and on the upper abdomen. Associated fever (3 days) with poor appetite, yellowness of the sclera and nausea not associated with vomiting or with convulsions. Frequency of bowel motions; the stool is watery and is passed with mucous but not blood. The patient had never received any therapy before, had never visited any clinic or hospital and had never been attended by any native doctor. A meticulous family history was presented and detailed patient work up was reported. The working diagnosis arrived at what was malaria fever with a possibility of associated helminthiasis. Case analysis discussion in terms of clinical biopsychosocial model
The Akamkpa Community Health Clinical Clerkship is a clinical biopsychosocial approach working at the primary health care level and through community health, to access people into the health care delivery system of the federal government of Nigeria. Biopsychosocial medicine means taking into account the biological (physical); mental (psychic) and social well being of an individual. This three component term (biopsychosocial) is not far away at all from what the
Clinical biopsychosocial
World Health Organization gives as a definition of health“complete physical, mental and social well being not limited by any disease”. Therefore in using a biopsychosocial approach to clinical clerkship, we are keeping in touch with WHO standards and concepts in today’s medicine. Biological analysis of this case
A patient such as this, and young in age, with malaria, has probably a lower ability to resist infection than an adult. Therefore biological effects of malaria in the child can be expected to be marked. Because of high levels of parasitaemia there might be expected increased hemolysis of the patient’s RBC’s causing decrease in oxygen (0,) carrying capacity to essential organs-tissues-cells, with final negative effects at the level of metabolism and cell survival. There will be effects of hemolytic anemia and a general body weakness (a physical effect). The reticuloendiothelial system is called in to play with a resultant enlargement of spleen and liver. In this patient there was splenomegaly up to 6 cm below the left costal margin. Growth may be retarded and failure to thrive is associated with untreated chronic intermittent malaria. Psychic (mental) approach
The parasite may find (in West Africa) its way to the brain causing congestion in the small blood vessels, resulting in blockage. Cerebral malaria may lead to mental retardation and death. In young infants, recovery may be accommodated by a decrease in intelligence (IQ) following cerebral damage by the disease. Poor school performance can result as a subsequent outcome of this disease. Social aspects
Mental retardation, socioeconomic costs of illness, cultural handicaps may all follow this disease. There will result, frequently unhappiness for her, her family, her ethnic group (tribe/caste) and even for the region. Conclusion
It is my opinion that the incorporation of the three components of the Biopsychosocial approach in the clinical practice of medicine goes a long way in meeting our primary health care needs and in understanding our goals. in Nigeria. Case 2
Presented by Mr Iniobong Ene Essien. Community Health Clinical Clerk. Group A81. December 1982. Case summar).
The case is a 45 year old man named O., a native of Old Netim Village, who is anaemic and in cardiac failure. The illness started 3 years ago but for superstitious reasons, the man has constantly refused to go to any hospital for treatment. The case is analysed in terms of the Clinical Biopsychosocial Model. Introduction
The Akamkpa (Calabar) model demonstrates a network of health communications that consist of several cadres contributing to health care: (i) primary health care unit
practice and PHC
1385
(ii) secondary health care unit (iii) tertiary health care unit. The Akamkpa Model serves several villages within a 20 km radius of a central point, the CHC which provides secondary health care. Biopsychosocial aspect of cardiac ,failure as it aflects this patient
The term biopsychosocial embodies three aspects of the patient, namely biological, psychological (mental) and social. These factors all play a role in the patient’s health. Biological aspect. In this patient, the cardiac failure as provisionally diagnosed has all the physiopathological features consequent upon a disturbed circulation. These may result in severe further deterioration (organs, tissues, cells) and enhanced disease state in the patient. Psychological (mental) aspect. Generally, anybody under diseased conditions tends to be apathetic. This patient is not an exception. His dyspnoea and weakness make him unfit for work. He is worried as to how he will survive, and these stresses worsen his already poor state of health. Furthermore, he is strongly of the opinion that his illness is caused by some jujumen in the village. Unless the evil men are dealt with, his disease cannot be cured. This definitely increases the stress upon him. Social aspect. The patient has refused to take medication or accept any form of medical assistance. This increases social and psychological stress among his neighbours and family. He cannot contribute to the development of the village and may become a burden to his friends and relatives. Since he has refused all treatment he has alienated most people around him, who are losing sympathy with his case. Case 3 Presented by Miss Gloria P. Ekanem. Community Health Clinical Clerk. Group A81. December 1982. A clinical case is reported of a 35 year old male farmer, living in Old Netim village, Akamkpa, Cross River State, Nigeria, who presented with a history, signs and symptoms of pulmonary tuberculosis. Features of the biopsychosocial aspect of the case are discussed, including an account of the demography of the village of Old Netim. Introduction
The Akamkpa (Calabar) Project is a primary health care delivery programme organized by the Department of Community Health, University of Calabar, for her students. It is a clinical posting involved with the accessment to better health standards, nutritional status and health education for the community. A logical network of health communications is built which comprises (i) primary health care in the villages, (ii) secondary health care available at the CHC, Akamkpa and (iii) access to tertiary health care at the University of Calabar Teaching Hospital. Demography of old Netim village
The case study used to illustrate the principles of the Cross River State (Akamkpa) model in terms of
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STACEYB. DAY Villages Primary health care
Comprehensive Health Care Centre, Akamkpa
Secondary health care
University of Calabar Teaching Hospital or any general hospital I
J
Fig. 1
a clinical biopsychosocial model is taken from a little village in Akamkpa Local Government Area called Old Netim. This village is about 3 km off the main Akamkpa road at Okomita, and about 3f km from the CHC, Akamkpa. The population of the village is about 2000 with relatively younger people than the aged and the females outnumber the males. The people have a Village Head and a Traditional Birth Attendant (TBA) who has received some health education at the CHC. The main occupation of the people is farming, but some men work at the Crushed Rock Industry nearby and at Eyuma Quarry near the village. The village can be regarded as a typical one because some basic necessities are present. They have two primary schools. one for those in the junior classes l-3; the other school for the senior classes 4-6. They have a small market in the village but most people buy and sell at the market at Okomita. There is a Secondary School not yet functional although construction work and equipment projects have been completed. There is also an uncompleted church building in the village. At present people go to Okomita for church services.
The sanitary condition of the village is below standard for an average Nigerian village. No good water drainage systems leads to the formation of stagnant pools for the breeding of mosquitoes. The source of water supply is partly from the streams and partly from water tanks supplied by the Akamkpa Water Board. Most of these streams dry up during the dry season. Some families in the village make use of pit latrines, others use logs of wood and some the nearby bushes in which to defecate. The staple food of the village includes plantains and yams which they obtain from the farms. Other food crops include cocoyam, cassava and fruits like bananas, oranges, mangos and paw paw. The health status seems average for the community. Most children look well fed. Some common health problems amongst the children include bronchopneumonia, gastroenteritis, conjunctivitis, umbilical hernia, eczema, scabies and angular stomatitis. Adults suffer from fungal infections of the skin and nails, tuberculosis, cholera, ulcers, malaria and helminth infections. The Clinical Biopsychosocial Model of this case of pulmonary tuberculosis can be diagrammatically represented based on physical (BIO), mental (PSYCHO)
Clinical biopsychosoci al practice and PHC and social (SOCIAL) aspects of the case in relation both to the patient as a person, and of the person within his community and society (Figs 2 and 3). DISCUSSION
This report has presented a profile of clinical biopsychosocial practice that appears to offer an important and promising strategy in health care management and implementation of primary health care in rural village communities of Eastern Nigeria. Case reports are described by second year clinical
Events
I387
Nigerian students undertaking their Community Health Clinical Clerkship in these villages. With others, we have a strong perception that the primary health care system in Nigeria (as in many other developing countries), has yet to fulfil its potential role in promoting health of the people. More expansion of ‘health services’ (bricks and mortar) by building more CHC Centres does not alone improve health or bring about an improvement in the quality of life of rural people. Expansion of health services must take into account an infra-structure including trained personnel (health assistants, nurses. phar-
System hierarchy
lntrasystem chances
Irregular tax payment Moves made to increase health care to communities
Culture
i
Social stigma Attribution of illness to evil power
Decreased productivity Manpower and social influences
Family
Two-person relationship
Increased financial burden Stress and strain
Stress Relationship broken
possibly
Depressed Irritable Alarm Uncertaintv
Nervous system
Organ
Severe mental stress Behavioural readjustment Pulmonary caseation, fibrosis, cavitation, calcification of lesion with collapse or emphysema Infiltration and destruction of alveoli by bacilli. Hemorrhage into the tissues
Cell damage
Fig. 2
STACEYB. DAY
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System hierarchy
Events
1
Health policies reviewed Increase of health services to community
Nation
Rituals in honour of the dead. Consultations of magicians, with doctors for cause of death Mourning
Culture
Social influences Manpower effect Mourning
r
Irreversibly disrupted Financial burden Great loss, grief Sorrow and mourning
Irreversibly broken Sorrow rief, mourning Hardshrp 3
Patient’s behaviour
I
Disrupted
Tissue
for ever
Irreversibly
disrupted
Irreversibly
destroyea
Irreversibly
destroyed
Irreversibly
destroyed
Fig. 3
macy assistants) in the rural communities where the great majority of people live. Knowledge and attitudes of health personnel must be directed to the environment and health problems of the society and the country, and expansion of health services must take into account utilisation of all resources, especially human. As Sebai [4] has pointed out, the problem of primary health care is related to the type of medical education and training received by physicians and other health, personnel. Medical education, in both developed and developing nations, has been evolving through numerous none traditional concepts in re-
cent years [5,6]. Many of the traditional, i.e. European, objectives of medicine, when transferred to new medical institutions in developing countries, have failed to improve education and training of students. Critically these established models have often been of little or no use in rural African communities where the great majority of people live. These findings have stimulated the use of different approaches in teaching medicine and evolving patient care in rural communities in developing countries [7, 81. We have, in order to improve the primary health care system, sought to modify the focus of medical education emphasising a community based problem solving approach.
Clinical
biopsychosocial
The persuasion in African Universities has recently been to call for assistance “in the training of scientific creators, investors and innovators whose researches would be directed at finding solutions to African problems” [9]. Recognizing the need seen by Africans that the African university socially perform as ‘an instrument of development’, any educational change must take shape within the framework of the view outlined by Professor Makany, Secretary General of the Association of African Universities that “the African University in the year 2000 is first of all a philosophy. an idea to assert ourselves as African”
[91. Within this African imperative, studies devoted to the welfare of rural people must include understanding of the socioeconomic, educational and cultural thresholds of life as well as pragmatic aspects of preventive and curative medicine in general. In developing an approach to primary health care we have been mindful of two perspectives of contemporary life in Nigeria. The first, clearly, is recognition that Nigeria is a country of rural communities. The second, succinctly put by Professor Ransome-Kuti is that “we have to go back to where our people are and evolve with them” [IO]. Strategies of medical education to be of service in contemporary Nigeria, cannot, in the words of Ransome-Kuti, “leave the majority of the people further and further behind”. This can only be satisfactorily achieved by the involvement of the communities in the health changes in the nation. Recognizing that in Nigeria the expansion of health services is taking place at all levels, primary, secondary and tertiary care, our own studies are concerned with the present development of primary health cure and are based on a programme of integrated teaching and community-based training that we have espoused. We have urged the view that primary health care development increasingly is accepted as an imperative for good health. So many, for so long, have taught that socioeconomic development in rural communities interfaces with good health through improvements in better housing, sanitation, water supply, nutrition and education, all of which promote the better well being of the family, that it may be thought unnecessary to continue to stress this basic approach. It is necessary to emphasize the role 9 f biosocial derelopmen t. In the College of Medical Sciences, University of Calabar, we have introduced a problem solving, self-learning, integrated approach, in which medical students are exposed immediately in their training, in the pre-clinical phase. to social. cultural and traditional aspects of their communities and belief systems. upon which later is based their involvement with the rural communities in which they serve as ‘front line doctors’. Through the Community Health Clinical Clerkship. these young men and women, live
practice
and PHC
1389
and work within the villages of Cross River State, (Akamkpa, Old Netim, Mbarakom), learning by doing and thus are privileged, at an early stage in their professional training, to be introduced to the realities and to the needs of community health problems. Students participate in multiple phases of community health work-maternal and child health, control of diseases, epidemiologic and demographic surveys, therapeutic service programmes, leprosy and tuberculosis control, school education and other facets of community health care delivery in a rural setting, under the supervision and guidance of department of community health faculty and health staff aids. This approach to rural patient care, biopsychosocial clinical practice in community health, appears to us to fit the needs of primary health care delivery in rural Eastern Nigeria. Acknowledgements-1 acknowledge with pleasure the important contributions to these studies by: Miss Gloria P. Ekanem, Mr Godwin Ebuk John, Mr lniobong Ene Essien, Mr Aniah Michael Aniah (Group Captain A81). Mr Nkemakonam H. Ikekpeazu, Mr Udeme D. Akpan, Mr Philip Etabee Bassey, Mr J. I. Eregare, Miss Atim Nyong Inyang, Mr A. V. Diorgu, Mr Joseph E. Goin, Miss Akobundu Ngozi Chioma, Mr Isetiema Igani Koko, Mr Ado OmoIghorodje.
REFERENCES
Publica1. Day S. B. Health Communicarions. Monograph tion of the International Foundation For Biosocial Development and Human Health, New York, 1979. application of the bio2. Engel G. L. The clinical psychosocial model. Am J. Psychiat. 137, 1980. Hlth Commun. Informat. 6, 1980. 3. Day S. B. Editorial. 4. Sebai Z. A. The Health of the Family in Changing Arabia. 1981. Tihama publications (Jeddah), Kingdom of Saudi Arabia. 5. Day S. B. et al. The Faculty of Medicine and Health Sciences, Province of Asir, Kingdom of Saudi Arabia. The First Two Years. Consultation and Planning Group, Vol. I, Fat. Rep. 8/1.6.81. 6. Sebai Z. A. Community Health in Saudi Arabia. Saudi Medical Journal Monograph No. I, 1982 I. Bryant J. H. In Medical Education and the Contemporary World, p. 171. U.S. DHEW publication No. (NIH) 77-1232, 1976. 8. Day S. B. Health Communications, Chap. 9, pp. 195-232. Monograph Publication of the International Foundation for Biosocial Development and Human Health, New York; 1979. 9. Makany L. Secretary General of Association of African Universities. Role of African Universities in the promotion of culture and science as basis for the development of Africa. Inauguration of the University of Botswana, 23rd October, 1982. IO. Ransome-Kuti 0. Child health priorities in Nigeria. Keynote address delivered to the Annual Conference of the Paediatric Association of Nigeria, Calabar, 1983.