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Assessing the efficacy of health literacy on rural pastoral women of Northern Nigeria.

Abstract

The focus of the article elucidates the efficacy of health literacy program on the pastoral Fulani rural women and their families, as well as ascertains the extent to which the stated aims and objectives of the Nomadic Educational Policy (NCNC, 1996) have been obtained. The article adopts the qualitative descriptive narrative approach as a means of reporting the findings of a past study conducted with the women to ascertain the efficacy of the literacy program in general and specifically to the health section. The framework of the study was guided by postulated research questions as; to what extent have the health education objectives been achieved? did the health literacy program change women's attitude and practices of orthodox pre and post natal morbidity practices? how has the literacy delivery program responded to the need for women's awareness, care and prevention against the current polio children immunization debate in northern Nigeria; to what extent has the health literacy program provided knowledge, awareness and prevention of the current epidemic on the HIV/Aids to women?, and how has the program impacted and improved women's levels of children care in the modern method i.e. immunization, complementary feeding etc. The responses to the study questions were derived from the women in focus group interviews in five active adult education centres in northern Nigeria as case studies. The contextual organization reflects the orthodox identity and social statues of women in the family and the community in general. An exposition of the health care curriculum process and policy, and the attainment of the literacy objectives as well as challenges experienced by the women are reinforced in their own voices, to enable a better understanding of their positive development and change of practice to their health progress. The concluding aspect reiterates how the challenges could be minimized to ensure an increase in success and outcome of the adult literacy program in the changing lives of women for good.

Introduction

Rural health care system in Sub-Sahara Africa is considered one of the lowest in the world (Okojie, 1994; World Bank, 1988). The population segment worst affected are children and women, with the later saddled with family responsibility on health care as major care givers of the family. They are engaged in tackling common ailments as fevers, malaria, cholera, dysentery as well as manage their reproductive concerns as mothers. In the continent, rural women are described as custodians of water, which in essence requires them to meet the supply of clean water for household domestic use (Mazurai, 1990). In meeting the demands of water supply, the role of hygiene is highly required. With pastoral nomadic women, the need to ensure clean water supply for the household is of paramount importance, considering their managerial role in dairy production and marketing of quality milk and butter (Dupire, 1971; Reisman, 1984). The limitation of the women to modern health care system in meeting their family health care is attributed to their dependence on spiritualism, myths, superstitions, taboos and herbal therapy (Kissekka, 1980; 1992) in dealing with ailments or disease. These knowledge pathways to health care are not bad by themselves, but are limited by lack of modern checks and balances, that will regulate their excesses and minimize error in management which often results to acute fatality, especially in the area of reproduction (Okojie, 1994).

Pastoral rural women's overdependence on traditional health practices is associated with its low cost, proximity to access and supply, as well as continuous patronage to orthodox knowledge for cultural continuity. Additionally, systematic failures and shortcomings of government commitment to affordable health care services to rural northern Nigeria have left women in this category with no other options but to patronize traditional health care services and practices for sustainability (FORWARD, 2002; Mohammed, 2002). Bororo'en and Fulbe pastoral women of Northern Nigeria's interior rural geographic location creates further gap to their access and proximity to towns and cities with modern health care services, especially in emergency situations as child birth (Mati, 1998). Recognizing the need for health literacy as pathway to improve quality of life of the pastoral women population in the region, the federal government of Nigeria through the Nomadic Education Commission implemented the Adult Education unit for women to improve the women's health literacy and improve general health standards of their families regardless of the shortcoming of health services (FME, 1987; NCNE, 1989).

Socio-cultural identity and marital status of the women

Fulani and Bororo'en rural pastoral women or rewbe of northern Nigeria and indeed across West Africa are considered to be rewbe at the sight of their first menstrual cycle, which in retrospect requires them to be married immediately and become 'child wives and mothers' from as early as ten years of age, depending on the physiological development of the girl-child(ren) (de St. Croix, 1972; Ezeomah, 1983; Hopen, 1959; Kibera, 1995; Tahir, 1991). The age of marriage cited above interrupts the young rewbe from completing primary level of education, which means that they leave school before the level of permanent literacy is attained (Ezeomah, 1987). Prior to the NEP (1989) most Fulani rural males as heads of households perceive schooling of women and girls as an attempt to reduce ethnic numerical strength through the long schooling periods or years . Male parents hold the view that the period of study is also the prime age for girls' reproductive period and should not be 'wasted' (Usman, 200 l b). The practice of early arranged marriages is a common practice within the ethnic tribe, specifically cross cousin-marriages koggal (de St. Croix, 1970) are highly encouraged and considered to be ideal marriages because it facilitates stronger family ties and detainment of family wealth of herds within the extended families. Parents who make such marital arrangements proudly say, as paraphrased by Stenning (1959), "If you betrothed to your cross cousin or your patrilateral parallel cousin, does not this retain pride, since they are more closely related and the lineage group has not scattered" (p.84).

As a patrilineal society, a woman leaves her family and goes to live with her husband or his family, but she could return where she is ill-treated by her husband or his relations or in the case of divorce or death of spouse (Bruijn, 1997).Marriage enables women to establish new social relations and have children who will ultimately take care of them at old age, hence, children are considered as social securities. Additionally, the women automatically become members of their husband's household or wuro (Hopen, 1958; Junaid, 1987). A pastoral Fulbe woman is evaluated primarily by her obedience and subservience to her husband, which is subsumed under the concept of dewal which means service, derived from rew which means to follow or serve. Hence, women's servitude is unconditional as the decision of their literacy participation is controlled or decided by the men as spouses or parents. Symbolic social relations within clans and families are the responsibilities of the women, as they use milk to foster positive relationship as well as settle interpersonal family conflicts (de Bruijin, 1997).They are considered symbol of peace. Their symbolic identities as married women are displayed with their different hairstyles called durol bedyeli pu DaaDo which indicates the main stages of their lives (Junaid, 1987; Mbahu, 1999).

Traditional justification to early marriage is a mandatory aspect of their culture as well as commitment to religious practice as Muslims (Adamu, 1984). In another dimension, child marriages are encouraged based on ethical values of protecting females from sexual imprudence and also to provide the girl-wife/mother the chance to utilize her higher chances of experiencing less complicated child birth and increase in number of children as compared to late marriages (Kissekka, 1984). Unfortunately, these expected norms have had some rather boomerang effects as most of the girls or child-wives have increasingly become victims of pre and post reproductive morbidities as Vesico Vaginal Fistula (VVF) or Recto Vaginal Fistula (RVF) (Braddock & Mohammad, 1996). These reproductive complications are described as "holes resulting from the breakdown in the tissue between the vaginal wall and the bladder or rectum caused by unrelieved obstructed labor. The consequences of such damage are urinary or faecal incontinence and related conditions such as dermatitis and erosion of the skin and other tissues in the vulva and vagina from constant leaking of urine and faeces" (Mohammad, 2006:5). Often the young mothers become VVF casualties due to direct cause as in traditional procedures commonly employed by traditional birth attendants on the child bearing women in 'minor' 'surgery or a cut' referred as "Gishiri" and "Angurya". These unsupervised 'birth vaginal cuts or extensions' involve the removal of tissues removed from the vagina for the treatment of coital pain, or obstructed labor amongst others (Mohammad, 2006; Kissekka, 1986). The lack of modern health care knowledge or education by female traditional midwives has caused and resulted in women becoming more victims of VVF (LaFraniere, 2003; Magashi, 2004). In a study profile of women that developed VVF in northern Nigeria, Mohammed (2006) stated "lack of education invariably results in poor uptake of antenatal services. Where these services are available, girls [and women] are often unaware of the importance of its utilization due to their timidity. Dangers of early pregnancy are often not understood by the girl [wife /mother] .... Or even the traditional birth attendants..." (p.3). The social implications of VVF on affected women includes divorce from their husbands, banishment from participating in social activities as weddings, while in some cases the affected women are taken to the hospitals and are forgotten by the relatives, which invariable make the young women roam the streets in the cities begging for alms to survive (Mohammad, 2006). The issue of providing the women literacy is of necessity, which questions the degree to which the implementation of the program has provided the women and the entire rural ethnic community the change of attitude and commitment to better health care knowledge for a safer childbirth.

Informal health knowledge, training and practices of the women

Considering the legendary myth on the Fulani origin of Kumen and Foforundu, the narrative distinguished the role of men as superior in knowledge and skills over women, who according to the legend are required to be confided to domestic functions and knowledge (Ezeomah, 1991). The oral traditional narrative duly specified the right of men, not women, to knowledge and by virtue of their status as wives they can only acquire knowledge through their spouses. This myth has placed the institution of marriage as paramount for nomadic women to acquire religious, moral and general knowledge.

There are few training and knowledge women inherit as part of their family tradition or lineage. These include traditional childbirth services, as well as the use of spiritual and herbal therapy, which women are obliged to inherit. All nomadic Fulani women acquire informal training in dairy management practices, to enable them become self-reliant economically (Ezeomah, 1983).

Training and knowledge of traditional family planning is learnt by all rural nomadic women regardless of their age. Women are required to learn at heart some verses of Qu'ran which are inscribed and sealed in leather small pieces as talismans and amulets and are worn on any parts of their body for protection against unprepared pregnancies, sicknesses and bad luck in trading and marriage (de. St. Croix, 1972; Usman, 2001a). However, with the family health education program provided for the women, many of them have discovered the shortcomings of such orthodox family planning practices in terms of reliability and dependability, as compared to proper knowledge of the natural method of safe days through the knowledge of arithmetic in calculating days on the calendar as the Billings method as part of their natural path to family planning.

Another form of traditional family planning method used by the women is the prolong breast feeding practice. Most women consider the practice more dependable as compared to the first type earlier explained (Usman, 2001b). There is the question on the quality of breast milk produced by the affected lactating women, as most of them using such methods are observed to be malnourished, which affects the quality of breast milk. The undernourishment of nomadic Fulani mothers and their babies has enabled the implementation of practical nutritional seminars and workshops by UNICEF Nigeria on "Breast feeding and complementary feeding for mother and child" (Usman, 2001b). The proceeding discussion expounds on the curriculum policy and processes of the literacy health education provided for the women by the Nomadic Educational Policy (1989).

Health literacy curriculum policy and process targeting women

The provision of adult education program for the pastoral rural women in northern Nigeria is considered by the federal government as a developmental program, which invariably will include a relevant representation of these invisible populations in the national educational statistics against illiteracy (FRN, 1986). Hence, it can be considered an inclusive educational strategy. Additionally, the government's general purpose of targeting the rural women is to provide them with up to date hygiene methods and techniques that will support their income generating activity in their production of quality milk and allied dairy products, as major suppliers across the country. Historical foundation of the women's literacy program is related to the national Blueprint on female education in Nigeria (FRN, 1986). The educational innovation approach targeting such rural women was more prescriptive and adaptable to the theoretical developmental paradigm of Women In Development (Boserup, 1971). Even though WID aimed at reducing productivity gap between women and men through education and training through advocacy i.e. by the government, rural women were still under represented in enrollment and completion of basic education in rural Nigeria (Omolewa, 1981). Hence, the adoption of the Gender and Development GAD theory of development in education was adopted as part of developmental reforms in Nigeria. GAD adult educational policy implementation adopted a holistic approach of educating both genders concurrently in the same rural social settings or communities to meet their needs and demands. This approach is not only people centered but it addresses the social domain of the women as the family, as structured by culture and traditions. The women's adult education (NCNC, 1991) was popularized with the action plan document targeting a ten to twenty year period of active literacy programs. Considering the implementation of the women literacy program side by side with that of the males, the educational theoretical principles is within the Gender and Development GAD implementation strategies, which is central to facilitating knowledge\ power relationship between women and men as well as addressing equality in access to education, the development of self, the family [the unit of existence of the women] and the community. This is for the purpose of rural development and improved quality of life (CORDESIA, 2005; Umar, 1991).

Specific to nomadic Fulani and Boror'en women, the adult education program specified on health education in Section: 11:11 of the Action Plan Document (NCNC, 1999) has the following objectives; "functional literacy and numeracy and skills acquisition relevant ...... to improve maternal responsibilities ... to empower and enable them to improve themselves and also contribute more meaningfully to the improvement of their occupational and domestic duties, general health of their children and family growth for the development of their communities" These objectives are similar to other women's literacy programs in urban areas across Sub-Sahara Africa (Diven, 1998; Stromquist, 1986). The approach questions the involvement of women with educational structures and processes, and in sum questions the dividend of education to their changing lives as engendered groups in patriarchal ethnic communities of the continent.

To achieve the stated health education objective, the Nomadic Education Commission in Nigeria, adopted a curriculum which includes subjects like family education (maternal and child healthcare, food processing and nutrition, survival skills), integrated science and home economics at the basic level. These curriculum contents are typical to rural education, which focuses on meeting the needs and wants of the rural population for self-reliance and community development (Ezewu, 1997; UNESCO, 1996; Usman, 2001b). These subjects are taught in conventional literacy sessions in the mother tongue of the nomads (Fulfulde) and the language of the environment (Hausa) as well as basic English, depending on the language versatility of the instructor(s) (Usman, 2006). Practical health training aspects are provided to the women with the assistance of professionals from international health care organizations as Pathfinder International, Africare, Rotary International and UNICEF, Nigeria (Usman, 2001b). These multilateral organizations provide practical literacy programs through workshops and seminars to support the curriculum process prescribed by the women's adult education action plan document. Despite the compatible delivery method, the question remains as to what extend do these programs provide or improve the quality of health of the women and their families? How has the curriculum content and process been negotiated with the women's orthodox health practices for a more acceptable change for the women, their families and the community in general, without offending their cultures?

In addition, radio public education programs on health are being broadcasted for the pastoral women listeners from popular radio stations as Radio Kano in programs such as Daddo Jauren. The purpose of these programs is to conscientize women on current public health issues as AIDs/HIV and VVF for their safety, prevention and exposure to treatment, at the same time keep them knowledgeable of the modern health facilities available to them to promote their quality of health. Despite the effective implementation strategies of the health education curriculum, like other rural educational projects in most developing countries, there are some identified challenges. Women expressed the need for more female involvement as facilitators and leaders of the workshops i.e. UNICEF programs, than men. They consider an 'all women' workshop or seminar' more inclusive as well as interactive than with men. The socialization process of the ethnic tribe de-emphasizes cross gender interaction with the opposite sex that are not relatives let alone 'strangers' as male workshop leaders [often belonging to different ethnic group and some times expatriates].

Despite the challenges experienced by the women in literacy classes, the program has yielded positive dividends, which justifies the implementation cost as well as the time invested by the women. The impact of the program has contributed to a loose coupling of cultural barriers and taboos restricting women to access modem health facilities, as well as negotiating their reproductive demands with their spouses i.e. on issue of antenatal and postnatal hospital visits, child spacing and other natural and safe family planning procedures that do not interfere with their Muslim beliefs and culture as well as increase their active enrolment and participation to formal education (Coombs, 1975; Divan, 1998).

Positive outcome of the health education literacy on the women

African feminists as well as developmental theorists in support of GAD developmental theory (Dighe, 1998) believe that, access and participation of women in education can only be promoted when there are improved gender relations in the family and the community. Such improved relations, according to them, will encourage dialogue between men and women for cooperative decision-making on issues of family planning, and participation in schooling for girls in the family unit (Alfa, 1991). To access the extent to which the health educational objectives has been achieved or not requires an elucidation of the women's expressed opinions to confirm or disconfirm the success (E1-Hafiz, 2005) so, the women's expressed comments were validated and analyzed to ascertain consistency of their responses as well as provide them a contextual space in the article (Creswell, 2005).

Knowledge, training and skills acquisition in modern pre and post gynecological morbidity

As mentioned earlier that a proportionate population of women suffer from reproductive morbidity as obstetric and gynecological types during pregnancy, delivery and post-partum periods as with the cases with VVF (Mati, 1984), the emerging records of major government university teaching hospitals in the north (Kissekka, 1984; Okojie, 1998) have recorded a drop of the increase of victims as well as increase of better care and management of the diseases by the affected women after obtaining practical training in the women's literacy classes. The attainment of numeracy in the adult education program has provided the women knowledge and skill in basic arithmetic, supported by methods learnt from nurses and allied medical practitioners as guests speakers, on how to calculate their expected date of birth (EDD) than relying on the miscalculation of the traditional birth attendants. This helped women to avoid miscalculations based on local counting methods that invariably make traditional birth attendants force the young mothers into unripe labor that may result to VVF diseases (Kissekka, 1981; Mati, 1984). Other pregnancy diseases common with the nomadic young mothers is Eclampsia, caused by a high blood pressure often displayed with fits. Most traditional birth attendants believe it is caused by evil spirit (Usman, 2001). The participation of rural nomadic birth attendants to health education training and workshops by international health agencies as UNICEF, Pathfinder and AFRICARE has enabled them acquire modern birth skills of managing child birth crisis, thereby decreasing the number of women affected. The processes of training without coercion from the trainers, enabled them make critical judgments on their existing taboos and myopic superstitious beliefs attached to childbirth (Pathfinder, 2004; Usman, 2001b).

Antenatal and post-natal training and care is applauded by the women and their spouses which has generated circle of interest of other non participating women to be enrolled in the program, thereby increasing women's participation. Some of the trained and certified local birth attendants are officially recognized and hired on part-time basis by the local health board, thereby providing them with job opportunities, a means of appreciating their additional skills.

According to WHO data base, two thirds of the worlds infected populations with AIDs/HIV are in Sub-Sahara (Okojie, 1994). In ethnic societies women are more victims to the diseases because of the customary practices of men's control of women's sexuality with the desire to have children which makes it obligatory to continue sexual relationships with infected husbands (Okojie, 1994:1239). Even though there are no coherent and exclusive available data on nomadic Fulani and Bororoe'n women affected by AIDs/HIV diseases, the fact that the epidemic exists in Nigeria is worrisome and stirs a great concern to them. Hence, family education on this issue is considered a necessity. The nomads have taken a self initiative through public radio educational/enlightenment programs Daddo Jauro'en in Fulfulde language to make conscious both rural and urban Fulbe women and men on the epidemic. Health officials of Fulani kinship participate as discussants to acquaint their kinsmen on prevention, causes, symptoms and available medical facilities and treatment of the disease. Developmental health agencies like Pathfinder international are involved in the training of men in Kano as family outreach to provide further understanding between couples on how to protect themselves from the disease (Pathfinder, 2004). A woman commented,

We can now communicate with our husbands on such issues in our bedrooms without feeling embarrassed, which we couldn't before, because issues regarding sex are considered sacred and taboo to share even with your husband in our culture. If a woman seeks inquiries on such sensitive issues she is considered wayward and not to be trusted sexually (Usman, 2001b).

From the comment above it is apparent that training men and women improves sexual relationship and better understanding between spouses for healthier families.

Improved Family Nutritional Level

Nutritional morbidity as in nutritional anemia due to deficiencies in iron, folate or B12 in the diet generally common with African women and children (Okojie, 1994; Kisekka, 1981) is not uncommon with nomadic women. The over concentration of nomadic diet with dairy products makes them vulnerable to nutritional morbidity. The deficiency of balanced diet is noted on their children with visible diseases as Kwashiorkor which is a physical displayed symptom of swollen and protruding stomach; puffy hands and face are visible amongst anemic nomadic rural Fulani children like others in rural Nigeria. The intervention of health educational programs and extension services through organized workshops by UNICEF provided training to the nomadic women on food classifications and preparation using local available ingredients commonly found in their environment for a balance diet for their children and the entire family. Such health education workshops demonstrated the use of soy beans in making different meals for breastfed and weaned children (Usman, 2001b).

Better management of common tropical child diseases in the family

Diarrhea and dysentery associated with teething and malaria infect many nomadic Fulani rural children like others in Nigeria. Nomadic mothers often use herbs to control the frequent flow of stool with affected children. Most women do not have sufficient knowledge of managing dehydration and loss of energy on the affected children. However, with the training offered to them on Oral Dehydration Therapy by health workers of multilateral organizations and NGOs, the women become familiar with the management and control of dehydration and diarrhea in general. They did not only acquire child care skills, but have reduced the pains and suffering of their ailing babies as well as saved the cost of purchasing commercialized ORT from pharmacies in the cities. In ascertaining the gains of literacy on this issue, a woman literacy program attendant commented:

After attending the UNICEF training on the processes of ORT, we have been practicing it and administering the solution to our children successfully. This training has enabled us save money by not purchasing the custom prepared ORT from the pharmacy which is sold at very high prices (Usman, 2001b).

Hence, their participation in the literacy program has enable them obtain knowledge in the "Body Literacy" for the promotion of their well being.

Improved modern medication management in the family

Women further mentioned that, their ability to read basic English has assisted them to administer prescribed medication for themselves, their children and other family members, which has improved the safety procedures of medication. Previously, most of them are often unclear on instructions provided to them verbally by the pharmacist at the counter. They are shy and embarrassed to ask for more clarification for fear of being publicly humiliated by peers and sometimes the pharmacists as they explained, but rather use their assumptions to administer such medications wrongly which in many cases have costed them their health and that of their children (Usman, 2001b). They end up either administering over dose or under dose and in some cases the wrong prescribed medication at the wrong time. A mother of four commented:

"At the pharmacy counter, we are provided instruction in Hausa on how to administer the dosage of prescribed medication, which sometimes is repeated twice and in haste that we are not able to understand the instructions clearly. With our shy nature as Fulani's, we often do not want to ask further clarification for fear of being shouted at by the pharmacists who are so impatient because of the crowd before them. To avoid such embarrassment, we leave the queue and begin to ask each other if any one had listened to the instructions. It was hurting then. But our knowledge of the languages allows us read the instructions very carefully and administer the correct dosage of medication to ourselves and other family members ".

In addition, the women confirmed that their knowledge of basic English communication assists them to understand at least some basic discussions between the doctors and the nurses during follow-up visits for themselves or for the children especially on ante natal and postnatal hospital visits (Usman, 2001b). The overall knowledge acquisition exemplified above facilitates stronger bonding of relationship within the family structure and indeed within the community.

Conclusion:

Educating pastoral rural women in Nigeria is considered as a basic right as well as a pathway to successful democratic governance, by most educational policy makers.

The social and economic returns of educating women cannot be underestimated considering their major role as primary suppliers of milk in the country. Hence providing them with literacy program with health orientation will also not only make them improve their personal health and that of their families but have a positive multiplier effect on the hygiene and sanitation of their products to meet the set standards by the food and drugs ministries at the state and federal levels. Additionally, women participation in such programs minimizes cultural barriers of female schooling in orthodox religious groups as that of the Fulani and Bororo'en. It can be considered as a progressive rural development means that not only improves the quality of life of women's families but elevate their communities to civility in modern learning.

Re-assessing the implementation strategies by the government through the commission will encourage, international agencies to further support the program in all ramifications as well as guarantee its sustainability for the benefit of women, the communities and indeed the nation.

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Lantana M. Usman, PhD. Education Program, University of Northern British Columbia,3333 University Way, Prince Geirge, BC. V2N4Z9
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Author:Usman, Lantana M.
Publication:Ahfad Journal
Article Type:Report
Geographic Code:6NIGR
Date:Jun 1, 2010
Words:5875
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