EVALUATION OF ROLL BACK MALARIA PROGRAMME IN IGBO-EZE SOUTH LOCAL GOVERNMENT AREA OF ENUGU STATE

Abstract

The study was to evaluate RBM programme in Igbo-Eze South Local Government Area. The study evaluated the availability and adequacy of RBM services, qualified service providers, materials and health facilities, the factors that influenced the utilization of RBM materials and the extent of utilization of RBM materials, community participation and patient attendance in health facilities. The factors evaluated in relation to the utilization of the materials and services were  weak  health  system,   community  participation,  drug  resistance,  discontinuity  of programme and non vaccine development. To achieve the purpose of the study twelve research question  were  posed  and  three  null  hypotheses  were  postulated.  The  study  adopted  a descriptive survey research design. It covered all the government health facilities. All the four LGA team members, 326 professional health staff, 26 RBM role model caregivers and 57 community/opinion leaders were used. There was no sampling as the entire population was studied through the use of two sets of questionnaires and programme data stored in the LGA headquarter and health facilities. Data collected were analyzed quantitatively using frequency and  percentages in respect  of research questions one  and  then while  mean and  standard deviation for research questions two through nine and eleven and twelve. The student t-test hypotheses and ANOVA were used to verify the three null hypothesis formulated for the study at .05 level of significance. The data generated from programme records were used to confirm information got from respondents. The study revealed that artemisimin based combination therapies,  intermitted preventive treatment  in pregnancy and  insecticides treated  bed  nets distribution   health   education   and   rapid   diagnostic   treatment   were   available   while environmental techniques was virtually absent. It also reveal that some RBM materials and service providers were available and adequate. The study further revealed that majority of the respondents indicated that majority of the factors influenced the utilization of RBM services. The study further revealed that the utilization of these RBM services did not differ by age, gender and occupation. Based on the major findings and conclusion, it was recommended among others that environmental health techniques should be incorporated into RBM control programme intervention. More Doctors, Environmental Health Officers, Nurses should be trained and employed for RBM control programme services delivery.

CHAPTER ONE

Introduction

Background to the Study

Malaria is a major public health problem and poses a major challenge as it impedes human and economic development. According to World Health Organization, WHO (2001) malaria is both a cause and consequence of leading causes of morbidity and mortality in the world including Nigeria today. It has proven to be the most horrendous and intractable among the health problems confronting countries in the sub-Sahara Africa. In Nigeria, the disease is responsible for sixty per cent of out patient visits to health facilities, thirty per cent childhood death, twenty five per cent death in children under one year and eleven per cent maternal deaths (Federal Ministry of Health (FMOH), 2007). FMOH, (2005) submitted  that about fifty per cent of adult population in Nigeria experience at least one episode of malaria yearly while children under five years of age have up to 2-4 attacks of malaria annually. The financial loss due to  malaria annually is  estimated to  be 132 billion Naira  in  form of treatment  costs, prevention, loss of man-hours and so on. Yet, it is a treatable and completely evitable disease. Therefore, malaria contributes to both poverty and under development of Nigeria families and individuals because people spend huge part of their yearly income on prevention and treatment of malaria.

Malaria is an infectious disease caused by protozoa parasite plasmodium from the plasmodium family that can be transmitted by the sting of the anopheles mosquito (Beare; Taylor; Harding, Lewallen and Molyneux (2006). It is characterized by cycles of chills, fever, muscle aches and sweating that recur every few days. There can also be vomiting, diarrhea, coughing and jaundice of the skin and eyes. Historically, records suggested that malaria has infected human since the beginning of mankind. Today, approximately 40 per cent of the world’s population mostly those living in the world’s poorest country are at the risk of malaria. This present study adopt the definition of malaria as provided by Beare, Taylor, Harding, Lewallen and Molyneux (2006).

Based on the recognition of the unacceptable morbidity and mortality rates in Africa and the availability of number of evidence based on cost effective interventions, health reform was carried out in 1998 with the adoption of a health policy. Within the policy, malaria was to

be  controlled  by  using  the  concept  and  technology of Primary Health Care  (PHC).  The implementation of malaria control in the context of PHC strategy demands national commitment, community participation and intersectoral co-operation which are the diverse strength of expertise of Roll Back Malaria (RBM) partners. In an effort to combat the growing threat of malaria, RBM programme was launched in 1998 to reduce the burden due to malaria in Africa region by fifty per cent by the year 2010.

Roll Back Malaria (RBM) is a global partnership established in 1998 by World Health Organization   (WHO),   United   Nations   Children’s   Fund   (UNICEF),   United   Nations Development Programme (UNDP) and  World Bank with the goal of halving the world’s malaria burden by 2010. RBM is an initiative to improve malaria control in the context of health sector reform (FMOH, 2009). It  serves as a strategic approach to disease control, mitigation and the overall fight against malaria. In this study, it is a tool for executing health projects which are carried out in partnership with public, private, research institutions, professional Associations, UNICEF, WHO, UNDP and World Bank.

Nigeria  hosted  Africa  summit  on  RBM  in  Abuja  in  the  year  2000.  The  summit concluded with the signing of declaration and plans of Action. The declarations stated that at least  60  per  cent  of those  suffering  from Malaria  should  have  access  to  affordable  and appropriate treatment within 24 hours of the onset of symptoms. It further stated that at least 60 per cent of those at risk of malaria particularly pregnant women and children under 5 years of age should benefit from the most suitable combination of personal and community protective measures such as insecticide treated nets (ITNs) and other interventions which should be accessible and affordable to prevent infection and sufferings. As part of the declaration, it was also agreed that’ at least 60 per ‘cent of all pregnant women who were at risk of malaria especially those in their first and second pregnancies should have access to chemoprophylaxis and chemotherapy medicine (FMOH, 2002). WHO, UNICEF and UNDP promised reliab1e, sustainable case management, prevention, research, effective and affordable tools, human and institutional resources to fight against malaria scourge.

Also, in the declaration RBM partnership supports effort to tackle Malaria wherever it occurs but the burden of the disease and death falls mainly on two venerable groups. The venerable groups are children and pregnant women. As a result, the focus of RBM and its greater challenges are to reduce the burden of malaria in the two vulnerable groups in the

African regions. The objectives of RBM are to reduce morbidity and mortality by keeping malaria under effective control (less than 2 per/1000 per year) so that it does not become a major public health problem. It also promised to halt malaria by 2010 and begun to reverse the incidence  of  malaria.  It  will  help  to  strengthening  community  participation  (Burton  and Thomas 1990). The RBM objectives were targeted to achieve universal access and utilization of  preventive  measures  and  its  sustenance.  It  also  hope  to  accelerate  development  of surveillance system and achieve universal access to case management at health facility and community level. RBM in Nigeria anchors on three global strategic approaches for malaria control which are multi-pronged and of proven efficacy. These include prompt and effective case management, promotion of intermitted preventive treatment in pregnancy (IPTp) and multiple prevention with promotion of the use of insecticide treated nets,  indoor residual spraying (IRS) and environmental management (FMOH, 2010).

Case  management  is the clinical management  of malaria cases (i.e.  diagnosis and treatment). Roll Back malaria partners have made concerted efforts to ensure that Nigerians especially children under five years and pregnant women have prompt access to effective treatment within 24 hours of the onset of malaria by working with pharmaceutical manufacturers to  ensure that  prepackaged drugs  for  malaria are produced and  distributed (Foster, 1991). Health workers, patent medicine vendors and role model RBM caregivers have also been trained on home managements of malaria to ensure that vulnerable groups have access to effective treatment (Alfred, 2006).

Moreso, intermittent preventive treatment in pregnancy (IPTp) is the use of anti-malaria drugs given to  pregnant  women in  treatment  doses at  predefined intervals after  the  first movement of baby in the womb to clear presumed burden of malaria parasites and provide significant protection against  maternal anemia, mortality as well as low birth weight and abortion (Hill and Kazembe, 2006). IPTp is a curative dose of sulfadoxine – pyrimethamine (SP) given two times during pregnancy. This approach has been shown to be safe, inexpensive and effective. Therefore, IPTp is designated as the preferred approach to reduce the number of malaria parasites in pregnant women during critical periods of greatest foetal weight gain.

Again, multiple prevention is another strategy that use multiple preventive strategic approaches such as the use of insecticide treated nets (ITNs), indoor residual spraying (IRS) and environmental management. ITNs are designed in various shape, colours, and sizes to

appeal to local tastes and meet local needs. These nets have insecticides incorporated into the fibre or bound around the fibre at factory stage. If treated with insecticides, the effectiveness of nets is greatly improved by generating a chemical halo that extends beyond the mosquito net itself. This tends to kill, or deter mosquitoes from biting or shorten the mosquito life span so that she cannot transmit malaria infection. Insecticidal Residual Spray is the application of long acting chemical insecticides on the inner walls, eaves, ceilings and roofs of all houses in a given area in order to kill the adult vector that transmit Malaria. Environmental management as a strategy is the act of rendering the environment unsuitable for mosquito breeding.

The strategies of RBM as contained in the Abuja declaration seek to ensure building and strengthening its partnership, contributing to health system reforms and integrating malaria control activities into PHC. They also included strengthening community and international participation,  reducing  mortality  and  morbidity  rate  due  to  malaria  among  children  and pregnant women. They also pledged to reduce overall morbidity and mortality to ensure that malaria will not be public health problem (UNICEF/WHO, 2003).

Furthermore, initiating programme is one thing  and  implementing it  objectively is another thing. There are some factors that may hinder RBM programme objectives. They are weak health system, community participation, drug resistance, discontinuity of programme and non-vaccine development (WHO, 2009).

Weak health system has been identified as a strong factor that influences RBM. Due to poor capacity of the health system with poor access to diagnosis and treatment, a lot of malaria cases are out-of reach by health services. Also, drugs have been critical in limiting morbidity and mortality but treatment coverage of population is well below the larger proportion of suspected case and death due to malaria.

Community participation has influenced RBM activities. RBM can only be effective when individuals and communities are actively involved. Ruebush, Zeissig, Klein & Godoy, (1992) states that if the communities are actively participating they will adopt and maintain healthy behaviour such as early recognition of symptom and signs of malaria, prompt treatment seeking, proper use of ITNs, appropriate use of anti:-malaria drugs and appropriate use of other vector control options. But if community participation is poor, the technical know-how will not reach  the   grassroot  needed  by  RBM  programme  thereby  frustrating  partnership  and intersectoral collaboration required by RBM programme (RBM, 2004).

Another key factor that  influences RBM is  drug resistances. Malaria burden have shown increasing levels of malaria morbidity and mortality due to widespread resistance of malaria parasites to conventional anti-malaria drugs (Sukwe, Kassankogno & Kabore, 2005). Spurious, counterfeit and substandard drugs have contributed to the situation. Consequently, diagnosis and treatment are often inappropriate thereby complicating health care delivery in their direction.

Also, discontinuity of programmes is another factor that influences RBM. A lot of strategies have been tried in attempt to interrupt malaria transmission but sometimes along the implementation, it stops either due to logistic, cost, or political problems. Development of vaccine has been a long-term objective of the research community but progress has been difficult. The above factors may have led to the increased morbidity and mortality due to malaria,  despite all  effort  of RBM. Therefore, it  is  necessary to  evaluate RBM multiple prevention strategy as to pinpoint whether RBM is progressing or not.

Evaluation is a process which attempt to determine systematically and objectively as possible the relevance, effectiveness and impact of activities relative to their objective (Egwu,

1996). To ensure good evaluation of RBM programme, availability, adequacy and extent of utilization of RBM materials should be properly assessed to provide useful feedback to the health care providers and care givers. Availability could be seen as whether something can be assessed or used while adequacy is the state of being sufficient for the purpose concerned. This does not suggest abundance or excellence or even more than what is absolutely necessary. Firefox (2010) defined extent as the point or degree which something extends. The point or degree  could  be  the  coverage,  range,  limit  or  scope  to  which  something  might  extend, indicating utilization of RBM programme materials. Tochim (2006) defined evaluation as the systemic acquisition and assessment of information to provide useful feed back about some object.

Habicht, Victoria and Vaughan (1999) defined evaluation as systematic enquiry designed to provide information to decision makers and other parties interested in a particular programme, policy or intervention. Evaluation strengthens or improves the programme by examining the delivery of the programme, the quality of its implementation, the organizational context and personnel procedures and in puts. Evaluation can be seen as impact indicators which allow periodic assessment of the way in which strategies and implemented activities

reached the planned objectives. Evaluation in this work is the measuring of outcome and impacts of intervention by the RBM programme. It is needed to document periodically whether defined strategies and implemental activities lead to expected results. Examples of outcomes are treatment seeking, coverage of ITNs while impacts are reduction of morbidity, mortality and economic losses.

Evaluation indicators fall  into  two  groups –  outcome  based  indicators and  impact indicators. Outcome indicators are changes observed in coverage, adequacy and quality of interventions, services and practices of something. For example, the number of malaria victims who have been able to access timely treatment, the level of ITNs coverage among a particular target population and by measuring changes in the population knowledge, attitude and practice of the  population to  malaria.  Impact  based  indicators means changes  in  health  status as consequence of programme activities. For example, the reduction of mortality and morbidity or even the economic loses caused by malaria.

Remme, Binka and Nabarro, (2001) states that five indicators are considered so important by all RBM partners globally. It consists of two impact indicators and three outcome indicators. The two impact indicators are malaria death rate (Probable and confirmed cases) among target groups (under 5 years children and pregnant women) and number of severe and complicated malaria cases (Probable and confirmed) among target groups. For instance, in Nigeria malaria is responsible for the death close to 300,000 children annually as it cause 30 per cent of deaths in under five and 25 per cent of death in infants. Also, malaria is responsible for 11 per cent maternal mortality, at least 50 per cent of the population have one episode of malaria annually and about 60 per cent hospital attendance (FMOH, 2007). The three outcome indicators are – proportion of household having at least one ITNs, percentage of patients with uncomplicated malaria getting correct treatment at health facilities and community level according to the national guideline within 24 hours of onset of symptoms and percentage of health facilities reporting no disruption of stock of anti-malaria drugs as specified in the drug policy for more than one week within the previous three months. For example in the year 2005-

2008 about 13.9 million ITNs/LLNs were distributed to various households in Nigeria (WHO/UNICEF, 2005). It shows estimate of national coverage of households with at least one net to be 30-35 per cent (Baker, 2000). This study used both outcome and impact based indicators. It will help both individuals and other Roll Back Malaria programme partners to

make positive change in the RBM programme strategies. This positive change in the RBM

programme may be influenced by some socio-demographic factors.

There are many socio-demographic factors that are associated with malaria epidemiology. The present study is concerned with the demographic factor of gender, age, and occupation.

Gender  has  been  identified  as  strong  factor that  influences  malaria  epidemiology. Studies have indicated that men are more frequently exposed to the risk of acquiring malaria than female because of out door life they live. Park (2005) confirmed that males were more exposed to the bite of mosquito, especially those who were farmers. Although, females are more likely than males to practice protective health behavior.

Again, age has influence on malaria distribution. Malaria affect all ages but more dangerous on children below 5 years age though newly born infants have considerable resistance to infection with P. falciparum. This has been attributed to high concentration of foetal haemoglobin during the first few month of life.

Occupation exposes  someone  to  malaria  attack.  Malaria  is  predominantly a  rural disease and is closely related to agricultural practices. Igbo-Eze south is predominantly rural area who depends on farming to make their life needs. In farms, water holding weeds, shrubs trees and open receptacles provide ideal resting and breeding places for mosquitoes. Malaria are acquired in most instances by mosquitoes bites within the occupation environment (WHO,

2009).

This study shall be anchored on two theories. These are theory of discrepancy model and Health belief model. Provus (1971) developed the discrepancy model for evaluating school programmes. He opined that the purpose of evaluation is to determine whether to improve, maintain or terminate a programme. Discrepancy model based methodology for educational programme component in order to identify discrepancies between programme specification and actual outcomes. The model provides a comprehensive process for education evaluation which is equally appropriate for health education programme. Discrepancy analyses provide information leading  to  appropriate decisions  for  outcome  and  impact  evaluation (Cantor,

1990). The model suggested comparing the standardized targets with the actual situation and identifies any differences for interpretation. As a result, this model provides a very good frame

for the present study. The researcher will compare the standardized target for RBM programme in Igbo-Eze South with the actual situation to identify the differences for value judgment.

Health belief model focuses on the  relationship of health behaviour practices and utilization of the health services. It is used both to explain change and maintenance of health behaviour. Also, it is used as a guiding framework for health education and health promotion practices in various fora. This model will also explain the widespread failure of people to participate in programme that prevents or detect diseases (Rosenstock, 1990).

The present study on evaluation of Roll Back Malaria programme will be carried out in Igbo-Eze South local government area of Enugu state. Igbo-Eze South L.G.A is one of the seventeen local government area of Enugu state of Nigeria. It shares boundaries with Udenu L.G.A. in the East, Kogi state in the west, Igbo-Eze north in the north and Nsukka L.G.A. in the south. The inhabitants are mostly farmers and business people. There are eighteen autonomous communities and all these communities are of rural location. These community lie within Guinea Savanna vegetation that harbor forest and water logged area. The major occupation of the people is subsistent agrarian farming and this factor has made them spend most of their live in open field with their body exposed to the bite of anopheles mosquitoes Skinnenen et al (2003) observed that people that stay in rural areas are often neglected and isolated from the benefit that accrue from research. Therefore, it is crucial that any differences between rural and urban areas are addressed sinced the significant proportion of people in developing countries lives in the rural areas (Bajunirewe & Muzoora (2005). It was in line with this that the investigator focused on evaluation of Roll back malaria programme in Igbo Eze South Local Government Area of Enugu State. The success of this study enlighten the people of Igbo-Eze South LGA on various interventions about RBM that help to treat malaria and reduce its burden.

Statement of the Problem

RBM is a strategy adopted by WHO and other partners to reduce the burden of malaria in the developing nations. The real principles and practices of RBM shows that patients with malaria should have access to appropriate and adequate treatment within 24 hours of the onset of signs and symptoms, pregnant women should have access to effective anti-malaria prophylaxis and treatment. Also, ITNs should be available and accessible to persons at risk of malaria particularly pregnant women and children under 5 years of age. It further states that

epidemic of malaria should be recognized and steps should be initiated for their containment within one week of their onset.

In Igbo-Eze South Local Government Area, two ITNs were distributed to every household in the Local Government Area. Also, ACTs, and IPTp are distributed free of charge to the target population routinely at various health facilities and communities in the local government area. These  efforts notwithstanding, morbidity and morality rate due to malaria still remains stubbornly high among children under 5 years of age and pregnant women in Igbo-Eze South L.G.A. Moreso, there is an increase cases of anaemia, low birth weight, pre- term deliveries, still birth, prenatal mortality, neurological problems and absence from school due to malaria.

Following from the above, the possibility of interference in the programme beckons the need arose therefore, to evaluate RBM programme in Igbo-Eze South Local Government area.

Purpose of the Study

The purpose of the study is to evaluate RBM programme in Igbo-Eze South Local

Government Area of Enugu State. Specifically, the study seek to determine the:

1.  availability of RBM control services in Igbo-Eze South LGA

2.  availability of RBM control materials in Igbo-Eze South LGA.

3.  availability of qualified RBM service providers in Igbo-Eze South LGA.

4.  availability of health facilities that provide RBM services in Igbo-Eze South LGA.

5.  adequacy of RBM control services in Igbo-Eze South LGA.

6.  adequacy of RBM control materials in Igbo-Eze South LGA.

7.  adequacy of qualified RBM service providers in Igbo-Eze South LGA.

8.  adequacy of Health facilities that provide RBM services in Igbo-Eze South LGA.

9.  extent of utilization of RBM materials

10. factors that influence the utilization of RBM materials.

11. extent of community participation in RBM in Igbo-Eze South LGA.

12. extent of malaria patient attendance to health facilities in Igbo-Eze South LGA.

Research Questions

The following research questions have been posed to guide this study.

1.        What RBM services are available in Igbo-Eze South LGA.

2.        What is the extent of availability of RBM control materials in Igbo-Eze South LGA?

3.        What is the extent of availability of qualified RBM service providers in Igbo-Eze South

LGA.?

4.        What is the extent of availability of health facilities that provide RBM service in

Igbo-Eze South LGA.?

5.        How adequate are RBM control services in Igbo-Eze South LGA?

6.        How adequate are RBM control materials in Igbo-Eze South L.G.A.?

7.        How adequate are qualified RBM service providers in Igbo-Eze South LGA?

8.        How  adequate  are  health  facilities  that  provide  RBM services  in  Igbo-Eze  South

LGA.?

9.        What is the extent of utilization of RBM materials in Igbo-Eze South LGA?

10.      What factors influence the utilization of RBM materials in Igbo-Eze South LGA?

11.      What is the extent of community participation in RBM in Igbo-Eze South LGA?

12.      To what extent do malaria patient attend health facilities in Igbo-Eze South LGA?

Hypotheses

The following null hypotheses are postulated and will be tested at .05 level significance.

1.        There is  no  statistically significant difference in the  extent  of utilization of RBM

control materials by the people of Igbo-Eze South LGA according to age.

2.        There is  no  statistically significant difference in the  extent  of utilization of RBM

control materials by the people of Igbo-Eze South LGA based gender.

3.        There is  no  statistically significant difference in the  extent  of utilization of RBM

control materials based on the occupation of the people Igbo-Eze South LGA.

Significance of the Study

Health workers and caregivers may find the information on evaluation of Roll Back Malaria programme useful to check if their health facilities provide full RBM activities and to press  for  improvement  in  line  with  the  standards  made  for  the  target  population.  The information will also be helpful to local government Chairman to recognize and train their

health staff for full RBM programme implementation in the local government area realizing her responsibilities in health care provision for their populace.

The information generated on the availability of RBM materials may reveal to people the  existence  and  types  of  RBM  material  that  are  available.  The  data  will  help  local government area Chairman to facilitate procurement of more materials for RBM. The data may help the local government authority to solicit for more material support from WHO and other donor agencies.

The data obtained from the availability of qualified RBM service providers will help the local government authority in planning and decision making. The data may also provide basis for recruitment of qualified staff to render general health care services.

The information generated from health facilities providing RBM material will help the local government council to know the number of health facilities providing health care to her citizens. The data will enable the local government council boss to construct and put into use more health facilities.

Moreso, the data obtained from adequacy of materials will help WHO, LGA and other donor agencies to know the number of material required and shortfall. WHO and other partner agencies will create awareness for maximum utilization of the materials.

The information generated from adequacy of qualified RBM service providers will help the local government council authority to employ more professionals. The data may help the government to restrain professionals from migrating to other areas looking for job. This will in variably place check on unemployment.

The data generated on adequacy of health facilities will help  to reveal the actual distance  between  communities  and   health   facilities.   The  data  will  help   to   improve accessibilities of RBM materials to the citizens.

The data generated on the extent of utilization of RBM materials may help WHO and other partner agencies to encourage pregnant women and other caregivers to access RBM materials. The data generated may help health care providers to support community mobilization to increase acceptance of RBM material. It will help to bring about efforts to

support global efforts to negotiate reduced costs of RBM materials and foster partnership among other organization to purchase RBM materials collectively at low cost.

The information generated from extent of community participation will reveal the level of involvement of community members in RBM programme. It will also show the level of acceptance and safety of RBM materials. It will also inform RBM and its partners the essences of capacity building on human and institution who always provide answers to any change.

Information from extent of patient attendance will help to reveal the level of awareness and places to receive correct medical care and RBM materials. It also reveals the impacts of RBM programme to the citizens of Igbo-Eze South Local Government Area. It will reveal the efficacy of new anti-malaria drugs.

The data generated on the factors that influence the utilization of RBM materials will help to address the weak area identified. WHO and RBM partners can press for improvement of RBM materials for pregnant women and children under five years. The information will help LGA in development of plans based on the areas of weakness identified by this report and to  ensure  that  those  plans  are  achieved  through  incentives  for  improvement  in  RBM programme. The LGA and RBM partners will use it in decision making and in carry out their responsibilities in multiple strategic approaches for RBM control.

Finally, the theories that were used in this study will be of benefit to the investigator. The theories as were used, explained to the investigator how certain behaviours lead to failure of programme. For example, discrepancy model provides explanation on how to compare standardized targets with the actual situation and identities any difference. The health belief model (HBM) explains who perceived susceptibility, perceived severity, perceived benefits and perceived barriers influences the  likelihood that  a person will adopt  a recommended preventive actions.

Scope of the Study

The study is on the evaluation of RBM control programme in Igbo-Eze South LGA of Enugu state. It  covers eighteen communities with 231 villages and 23 government health facilities covering them. Private health facilities were not involved because RBM materials are not given to them free of charge to distribute. The study covered the programme area of RBM. This include the supply of ACTs, IPT and ITNs by the donors which the availability, adequacy

and utilization will be evaluated. The indicator lies on outcomes and  impacts. All health personnels that provide RBM services in various health facilities were used as respondents. Also, community leaders and Role model RBM care givers were used as respondents. The independent variables used in this study were age, gender, and occupation. The study was limited to goal based evaluation and were guide by the discrepancy model and health belief model.

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