Integrated disease surveillance and response strategy for epidemic prone diseases at the primary health care (PHC) level in Oyo State, Nigeria: what do health care workers know and feel?

Introduction Effective diseases surveillance remains an important operational tool in countries with recurrent epidemic prone diseases (EPDs). In Nigeria, insufficient knowledge among Health Care Workers (HCWs) on Integrated Disease Strategy and Response Strategy (IDSR) have been documented. This study assessed knowledge and attitude of HCWs towards IDSR strategy for EPDs at the Primary Health Care (PHC) level in Oyo State, Nigeria. Methods A cross-sectional facility based study using an interviewer-administered questionnaire was used to obtain information from 531 HCWs. In addition, 7 Key Informant Interviews was conducted. Discrete data were summarized as proportions while chi-square test was used to assess association between variables. A logistic regression model was used to assess predictors of knowledge of HCWs. All statistical significance was set at 5%. Results Mean age of respondents was 42 ± 8.1 years with female preponderance (86.1%). Community Health Extension Workers (CHEWs) (36.9%) constituted the highest proportion of HCWs. About 70% and 90% of HCWs had good knowledge of EPDs and IDSR surveillance data flow respectively. Majority of HCWs 333(67.3%) knew how to use IDSR form 003 but less than 10% knew how to use other IDSR forms. The majority of HCWs {492(99.4%) and 345(69.7%)} agreed that reporting EPDs is necessary and IDSR tools are simple to use. Number of years post basic qualification was a predictor of HCWs' knowledge (AOR: 1.6; 95% CI: 1.0-2.3). Conclusion This study showed poor knowledge on the use of IDSR forms although majority of HCWs had good knowledge and positive attitude towards IDSR strategy for EPDs. Thus, regular evaluation of health workers' knowledge and attitude towards IDSR strategy as a performance function of the surveillance system is recommended.


Introduction
Epidemic prone diseases (EPDs) like viral haemorrhagic diseases, cholera and measles continue to pose major health risks to the health and welfare of human populations in developing countries including Nigeria [1]. These diseases have the potential to spread rapidly and affect a large number of people within a very short time period [2,3]. This spread is being further worsened with increasing population mobility, globalization and increased risks of infectious diseases such as emerging and re-emerging diseases [4]. Effective disease surveillance remains one of the pillars of effective communicable disease control programme in most low and middle income countries [5]. The scope of a surveillance system is broad, from early warning systems for rapid response to communicable diseases, to planned response to chronic diseases, which `generally have a longer lag time between exposure and disease [5]. In response to the prevailing poor surveillance systems in the African region, the World Health Organization (WHO), African region adopted an improved surveillance system called "Integrated Disease Surveillance and Response (IDSR) strategy" as a regional strategy in 1998 [6][7][8][9]. The IDSR refers to a strategy and a tool that promotes rational use of resources by integrating and streamlining IDSR priority diseases (including EPDs) surveillance activities. Despite its importance, the IDSR strategy still suffers some setbacks especially in developing countries including Nigeria [10]. The weaknesses in the IDSR strategy in most countries had resulted in failures in detecting epidemics with an attendant spread of diseases and associated human suffering, and loss of lives [11]. The flow of information in the IDSR system in Nigeria is from the health facility to the Local Government Area (LGA), then to State Ministry of Health (SMOH) and finally to Federal Ministry of Health (FMOH). At the FMOH, data are collated and forwarded to the statistics division, analysis and feedback is carried out, as well as planning for appropriate intervention based upon the results of analysis [12].
In this regards, primary health care workers at the LGA level remains the mainstay of an effective and functional surveillance system. Apart from being a prerequisite for an effective surveillance system, Health Care Workers' (HCWs) knowledge of IDSR also enhances the performance of both technical and organizational tasks [13]. Similarly, knowledge amongst other factors has been identified to greatly influence HCWs' attitude towards reporting of EPDs [14]. Despite this, the knowledge of reporting requirements and responsibilities among HCWs has not been examined adequately as a cause of under-reporting [15]. In Nigeria, the collection, collation, analysis, interpretation and dissemination of data in healthcare facilities are often unsatisfactory, and this has been attributed partly to insufficient awareness and knowledge among HCWs on the importance of this process [16]. This is particularly important especially in the area of core IDSR activities like case definition, case detection, case registration, case reporting and data management. Moreover, only a few studies have been conducted on the evaluation of IDSR core functions in Nigeria (Edo, Kaduna, Anambra, Ekiti, and Osun) but none has been carried out in Oyo State especially with regards to the HCWs' knowledge of IDSR strategy for EPDs [17][18][19][20] LGAs. (Only six MOHs and seven DSNOs were interviewed due to the absence of one of the MOHs). The KII guide used was adapted from a tool used by Sahal et al, to obtain staff views about the quality of communicable disease surveillance in Sudan [24].
Information was collected on extent of implementation of IDSR strategy for EPD, its feasibility, existing gaps and opportunities and resources needed for performing the core functions of the IDSR strategy. Quantitative data were collected with the use of tools adapted from the WHO/Centre for Disease Control (CDC) protocol for communicable disease surveillance system monitoring [25,26].
Quantitative data collected include HCW's socio-demographic characteristics, knowledge of IDSR strategy and EPDs. The knowledge of the HCWs was assessed by asking questions on types of IDSR forms and their uses, epidemic prone diseases, and basic surveillance actions to be taken during epidemics. The types of IDSR forms asked for were IDSR 001A: used for immediate case based reporting of any notifiable disease; IDSR 001B: is the Laboratory Request form for notifiable diseases; IDSR 001C: -Line listing form which is a comprehensive summary of all suspected cases in an outbreak; IDSR 002-weekly reporting for 9 epidemicprone diseases and public health events of international concern and the IDSR 003: which is the monthly reporting form for 41 priority diseases. In addition, knowledge of IDSR data flow and uses of IDSR forms was assessed by determining the proportion of HCWs with correct responses. In addition, knowledge of HCWs on EPDs was assessed by scoring correct responses as 1 and incorrect responses as 0. Using percentiles, a score of ≥75% was used as cut off mark for grouping the scores into good and poor knowledge of EPDs. The maximum obtainable score was 10 while the minimum obtainable score was 0. In addition, a cut off of 75% was chosen because a good surveillance system needs to be timely and complete and this depends on knowledge which should approach

Results
Healthcare workers' assessment:   (Table 2). In all, a sizeable proportion of HCWs 341 (68.9%) had good knowledge of the selected EPDs. These EPDs include cholera, shigella, measles, tuberculosis, viral haemorrhagic fever, leprosy, human influenza, yellow fever. Table 3  proportion of HCWs with good knowledge was slightly higher among those who have ever had formal training on core IDSR activities 120(75.0%) compared with those without any formal training 221(66.0%). All these associations were found to be statistically significant (p < 0.05). However, the associations between the age, gender, focal site, no of years in specialty and "ever been involved" in core IDSR functions and knowledge of EPDs were not statistically significant (p>0.05).
The predictor of knowledge of EPDs among HCWs is displayed in Table 4 and a slightly above average 288(58.2%) respectively agreed that they were too busy to report EPDs and that reporting EPDs is time consuming, a sizeable number of HCWs 425(85.9%) agreed that a good reward system will increase their willingness to report EPDs.
Despite the fact that the majority of the HCWs 482(97.4%) agreed that reporting EPDs is their public health responsibilities, about twothird of them 309(62.4%) still agreed that consents must be taken from patients before reporting EPDs. The qualitative findings showed that a number of factors influenced implementation of IDSR strategy for EPDs as highlighted by the majority of the respondents.
The factors that negatively affect implementation of IDSR strategy for implementation of IDSR strategy for EPDs include poor funding, lack of adequate training and retraining of HCWs, paying too much attention to only focal sites, inadequate staff strength, and lack of logistic support e.g. Generators, computers, calculators, means of transportation, freezers, and IEC materials. A male respondent said "we have so many challenges which include reduced staff strength, lack of logistic supports, and financial crisis. Also, people are retiring every day. Since six or seven years there was no appointment given to any health worker, we are short-staffed.
Secondly, financial crisis and thirdly, the people working have overworked for so long and they are tired and sometimes forget disease that should be reported immediately. So the immediate reporting system may be a bit delayed" (KII12). Similarly, a female respondent from a rural LGA stated "lack of communication services is a major problem that sometimes delays immediate reporting of EPDs is necessary and that reporting EPDs is a public health responsibility of HCWs [32]. They also opined that good reward Page number not for citation purposes 6 system for reporting and penalty for not reporting EPDs will increase HCWs' willingness to report EPDs. This similarity can be attributed to the fact that HCWs renumeration may be inconsistent and inadequate and often may not include allowances for additional duties. Contrary to the above findings, Karim and Dilraj in Saudi Arabia in their research among doctors found that most doctors were of the perception that it is useless to report EPDs [30]. This disparity in attitude was attributed to the fact that most doctors in that setting found notification forms too complicated and laborious to fill. On the other hand, most HCWs in this study agreed that reporting forms are simple to fill. Also, in contrast to the finding of this study, Karim et

Conclusion
This study concluded that a majority of HCWs were aware of the IDSR strategy, had good knowledge of EPDs and surveillance data flow. However, adequacy of knowledge on the use of the various IDSR forms was low. Therefore, more attention need to be devoted to regular evaluation of health workers knowledge and attitude to the IDSR strategy as a performance function of the surveillance system.
What is known about this topic  Primary health care workers are aware of the IDSR strategy;  Primary health care workers are fully involved in the surveillance system using the IDSR strategy.