O.T. Bankole1, G. Abbass2, T.A. Obembe3, I.O. Ajayi1

  1. Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University
    of Ibadan, Ibadan, Nigeria.
  2. Department of Planning Research and Statistics, Ministry of Health, Oyo State Secretariat, Oyo State, Nigeria.
  3. Department of Health Policy and Management, Faculty of Public Health, College of Medicine, University
    of Ibadan, Ibadan, Nigeria


Introduction: Primary Health Care (PHC) workers are usually the frontline health workers involved in disseminating health education to the community and implementing cholera prevention and management guidelines. Given that inadequate health worker performance has been a problem in resource-limited settings such as Nigeria and poor health worker knowledge has been implicated in poor health status in developing nations, continuous training of health workers to improve their knowledge has been recommended to improve health outcomes.

Objectives: This study seeks to ascertain the level of improvement in the knowledge of health workers on cholera, if any, after one of such interventions was carried out in Oyo State. Similarly, the study seeks to discern the specific domains of knowledge on cholera, if any, which were significantly affected by the intervention.

Methods: The research was conducted utilizing a pre-post study design to recruit PHC health workers from four local government areas of Oyo State between October and November 2016. Baseline and endline data were collected at both intervention and control sites using a self-administered questionnaire with sections eliciting responses to questions on general knowledge of symptoms of cholera, prevention methods, knowledge and practice of safety procedures health workers. Descriptive statistics and chi-square tests were used to present the data and test for statistical associations between categorical variables at 5% respectively.

Results: A total of 542 health workers divided into 2 groups (intervention and control), were interviewed at baseline and at endline. At baseline, the 40-49 years age group was the most represented in the intervention arm (40.0%), the 30-39 years age group was the most represented in the control arm (34.2%). At baseline, only 35.2% of health workers in the intervention sites had good knowledge on cholera. This figure was increased to 52.7% after the intervention. This difference in proportions was also statistically significant (p=0.004). In the control sites, the opposite was observed as the proportion of health workers with good knowledge on cholera slightly reduced from 47.2% to 43.6%. This difference was however not statistically significant (p=0.563).

Conclusion: The results from the evaluation of the intervention show that the training significantly improved the overall knowledge of health workers. However, future training interventions can be aimed at improving knowledge of health workers on alert threshold of cholera. In addition, continuous education programs on disease and surveillance and notification should be planned for PHC workers to improve their knowledge

Keywords: Keywords: Cholera, Primary health care, Case-fatality rates, Case management, Epidemic


Dr. T.A. Obembe
Dept of Health Policy and Mgt,
Faculty of Public Health
College of Medicine,
University of Ibadan,
Ibadan, Nigeria


Cholera is an acute enteric infection, resulting from the ingestion of Vibrio cholera, a bacterium found in faecally contaminated water and food. The disease kills several thousands of people worldwide annually, usually due to severe dehydration caused by acute watery diarrhea. Cholera is also extremely contagious and can spread across communities within days resulting in public health epidemics with accompanying high mortality rates.1
It has been accepted that the best form of defence against cholera remains prevention by ensuring that hygienic condition in living surroundings are maintained in order to stop the proliferation of the causative bacterium. A second important aspect to cholera control is the prompt, accurate and effective identification and management of outbreaks when they occur. In these two aspects health workers play a critical role in several communities as they are regarded as verified sources of health education while their job function includes disease outbreak surveillance and notification.2,3

However, weak health systems manned by ineffective health workers have been implicated in countries where cholera outbreaks have continued to occur.4 For example, in Nigeria, cholera outbreaks continue to occur on a yearly basis. Similarly, it has been observed that these outbreaks in the country continue to result in case-fatality rates (CFR) of more than 1%. In 2017, a cumulative total of 4,221 suspected cholera cases and 107 deaths (CFR 2.5%), including 60 laboratoryconfirmed were reported from 87 LGAs in 20 States. In the first 3 weeks of 2018, there were 210 suspected cases including two laboratory-confirmed and 16 deaths (CFR 7.6%) from 28 LGAs in nine states.5,6 Authors have linked this persistent pattern of cholera outbreaks to poor hygiene practices, which may be exacerbated by inadequate or inaccurate health information by health workers while the high CFRs are indicators of a weak surveillance and response system.5,7

The state of Human Resources for Health (HRH) in Nigeria remains a challenge that could be contributing to the high incidence and CFR of cholera in the country. Most of HRH lack continued education and the necessary tools and infrastructure to carry out their jobs adequately.8,9 According to the National Policy on Health, Primary Health Care (PHC) workers are those responsible for health education and awareness among community members, frontline cholera surveillance and in many cases cholera control and case management. Primary health care workers are the closest health care providers to the community. By virtue of the location of their duty-post at the periphery of health care delivery network, they serve the important function of ‘triaging’ patients at the first point of call. They are trained to treat minor ailments, administer vaccinations, refer very ill patients to the secondary and tertiary care levels and provide health education members of the community directly. Furthermore, they function as frontline disease surveillance and notification officers whose duties are to detect and report outbreaks of epidemic-prone diseases such as cholera.10

However, studies have shown that these health workers often lack the required knowledge to carry out their duties. For example, Aisen and Shobowale discovered that more than one-third of the health workers in their study believed that HIV could be spread through tears, feces and urine.11 Similarly, Ebuehi et al. observed that although PHC workers had a high degree of awareness of emergency contraceptives, they showed a dearth specific knowledge of the time frame for effective use, mechanism of action, legal status and correct prescription of emergency contraceptive pills. 12 Specifically, Bawa et al. found that PHC workers had poor knowledge of notifiable diseases and reporting procedures. 13 Other studies have shown that knowledge gaps exist with Nigeria’s PHC staff, with the extent of the gaps largely influenced by factors such as cadre, experience and location.10,14

Continued education, retraining of health workers through workshops and seminars as well as other interventions have been suggested as methods of improving health worker knowledge and in turn, improving the health status of the community. Studies have indicated that these interventions can significantly improve knowledge of health workers and in turn reduce the cholera problem in the country.15,16 This study sought to ascertain the level of improvement in the knowledge of health workers on cholera, if any, after one of such interventions was carried out in Oyo State. Similarly, the study sought to discern the specific domains of knowledge on cholera, if any y, that were significantly affected by the intervention.