Comparative Assessment of the Implementation of Integrated Disease Surveillance and Response in Public and Private Health Facilities in Jos North Local Government Area of Plateau State, Nigeria.

Background: Due to the continuous increase in the spread of epidemic-prone diseases and the associated morbidity and mortality, integrated disease surveillance and response (IDSR) was introduced as the main strategy in resource-poor settings for the detection and notification of these diseases. Integrated disease surveillance is a combination of active and passive systems using a single infrastructure that gathers information about multiple diseases or behaviors of interest.
Methods: : A comparative cross-sectional study was conducted between March and July 2018 among selected public and private health facilities in Jos North Local Government Area (LGA), Plateau State. Quantitative data were collected with the aid of a semi-structured interviewer-administered questionnaire and facility-based checklist. Data were analyzed using SPSS version 23. Statistical significance level was set at P ≤ 0.05 at a 95% confidence level.
Results: A. total of 126 health workers were studied. IDSR-trained health personnel was found in 52.7% of the public health facilities compared with only 16.7% of the private health facilities studied (P < 0.001). Awareness of IDSR was higher in the public health facilities than in the private ones (P < 0.001). IDSR implementation was poorer in the private health facilities 40.7% compared with 76.4% in public health facilities (P < 0.001). Evidence of previous disease notification and reporting was seen only in 33.3% and 16.7% of public and private health facilities, respectively (P < 0.001).
Conclusion: This study revealed that awareness and attitude of health workers in public health facilities in Jos North were higher than that of those in private health facilities and there is the sub-optimal implementation of IDSR among the health workers in Jos North LGA, especially among the private health facilities.

INTRODUCTION

The integrated disease surveillance and response (IDSR) strategy is by far the most pragmatic strategy in resource-poor settings for the control of priority communicable diseases.[1] A notifiable or priority disease refers to diseases which the law or regulations mandate that they be reported to health or government authorities after diagnosis.[2] Disease surveillance and notification (DSN) has been recognized as an effective strategy for the prevention and control of diseases most especially epidemic-prone diseases. It is crucial to note that disease outbreaks do not give notice before their occurrence neither do they respect the borders of nations hence communicable disease surveillance attains importance more than ever due to marked reductions in travel time and improved communication systems that essentially catalyze the rapid spread of pathogens.[3] The goal of IDSR, therefore, is to strengthen surveillance and response capabilities at each level of the health system by building local capacities to detect, confirm and respond to emerging public health threats.[4]

The disease surveillance system in Nigeria was introduced in 1988 following a major outbreak of yellow fever in 1987, which affected ten out of the then nineteen states of the federation. The magnitude of the outbreak was attributed to weak or nonexistent DSN system in most states. Between 1988 and 1989, a DSN system for the country was developed. Forty diseases of public health importance in the country were identified and designated for notification out of which ten epidemic-prone diseases were selected for immediate reporting. There are standard reporting forms which were also introduced for disease reporting. They are DSN 001 for immediate reporting, DSN 002 for weekly reporting, and DSN 003 for monthly routine reporting. The flow of information in IDSR in Nigeria is from the community to the health facility to the local government area (LGA), to the state and then to the federal level from where it is disseminated to all the vertical programs, partners, and other stakeholders. Feedback is expected from the partners and government on measures to reduce disability, morbidity, and mortality caused by these diseases.[56]

IDSR implementation should include both public and private health facilities since the health care delivery system in Nigeria is a mixture of public and private health facilities. The level of implementation of IDSR in Nigeria, however, has not been optimal due to several factors including inadequate training and supervision of health workers. Previous studies conducted in Imo and Plateau states in Nigeria revealed that only 26% and 63% of sampled health care workers had received training on IDSR, respectively.[78] Implementation of IDSR has been especially limited in private health facilities, probably as a result of their low involvement in disease control efforts.[91011] Other factors identified as responsible for the poor implementation of IDSR include low knowledge about IDSR, unavailability of reporting tools, and lack of feedback from local and state governments.[567912]

Many of the previous studies on IDSR implementation have been conducted either solely in public or private facilities, hence our study aimed to do a comparison between public and private facilities in Jos North LGA to assess awareness, attitude towards and level of implementation of IDSR in Jos North LGA Plateau State, North-central Nigeria.

METHODS

The study was conducted between March and July 2018. The LGA has a total of 62 health facilities, consisting of 37 public and 25 registered private health facilities. Out of the 37 public health facilities, two are tertiary and the others are primary health care facilities. For the private facilities, there is one tertiary, three secondary and 21 primary health care facilities. These health facilities carry out a range of activities which include consultation, counseling, emergencies services, laboratory services, and disease notification and surveillance among others. The health facilities are expected to routinely report any of the priority diseases to the Disease Surveillance and Notification Officer (DSNO) at the LG office. The DSNO reports to the state epidemiology unit at the Ministry of Health, from where reports are sent to the Federal Ministry of Health, Nigeria Centre for Disease Control, and development partners, and feedback is given to the state and subsequently the LGA.

The study population comprised clinical staff selected from both public and health facilities and these included the head of each facility and two other health personnel. All the heads of facilities were clinical staff.

Sample size calculation

A minimum sample size was calculated using the appropriate formula for a comparative cross-sectional study.

n = minimum sample size

2 = Design effect

zα = standard normal deviate (1.96)

zβ = power of the study (0.84)

P1 = percentage of health workers in private health facilities that were aware of IDSR from a previous study was 11.2%[11]

P2 = percentage of health workers in public health facilities that were aware of IDSR from a previous study was 38.2%[13]

A two-stage sampling technique was used in the selection of health facilities and study participants.

Stage 1 (selection of health facilities)

From the list of health facilities, two tertiary health facilities were selected (one was private and one public). The public tertiary health facility was selected using simple random sampling technique by balloting. For secondary health facilities, none was selected because all the secondary health facilities in Jos North LGA were privately owned. The primary health care facilities were selected using simple random sampling technique by balloting. Twenty-three public and 17 private health facilities were selected to maintain the public to private ratio of health facilities, and proportionate sampling was used. Altogether, a total of 42 health facilities were selected (24 public and 18 private).

Stage 2 (selection of respondents)

This was purposively done as the head of each facility, the officer in charge of IDSR and one other clinical staff were interviewed from each selected facility. Three staff per facility were interviewed.

Informed verbal consent was obtained from each respondent before being enrolled into the study; after being assured of confidentiality and anonymity without any loss of benefits or penalty. A semi-structured interviewer-administered questionnaire and facility-based checklist adapted from the previous study were used to assess the level of IDSR implementation in each health facility. The questionnaire was made up of four sections: sociodemographics of respondents, awareness of IDSR, attitude of staff toward reporting of IDSR, and disease reporting practices among staff. There were five questions on attitude; four of them had three options of positive negative and neutral. Frequencies and proportions of respondents with positive and negative attitude were analyzed. The checklist was used to check for the presence of a staff designated to IDSR, the presence of IDSR forms (001, 002, 003), and evidence of reporting and logistics support for reporting.

Data collected were analyzed using Statistical Package for Social Sciences IBM SPSS version 23 and quantitative data were presented using means and standard deviation while qualitative data was presented using frequency tables, percentages, and charts. Tests of statistically significant relationships were carried out using the Chi-square test. A probability value of ≤ 0.05 was considered statistically significant.

RESULTS

A total of 126 respondents were interviewed, 72 (57.1%) and 54 (42.9%) from the public and private health facilities, respectively. Table 1 shows that for both public and private facilities, more respondents were aged 21–40 years. There was a statistically significant difference between the different age groups in public and private health facilities, (P = 0.001) and also between the mean ages 40.37 ± 9.76 years for public and 40.28 ± 9.73 years for private, (P = 0.003). In both types of facilities, there were more females than males and the proportions were similar 47 (65.3%) and 35 (64.8%) for public and private health facilities respectively (P = 0.957). The highest proportion of health professionals interviewed was CHEW, 36 (50.0%) and 26 (48.1%) in both public and private health facilities respectively (P = 0.810).

Table 1

Sociodemographic characteristics of respondents

Variables	Frequency (%)		χ 2	P
	Public (n=72)	Private (n=54)
Age group (years)
21-40	38 (52.8)	47 (87.0)	16.499	0.001
41-60	34 (47.2)	7 (13.0)
Mean age	40.37±9.76	40.28±9.73	56.428***	0.003
Gender
Male	25 (34.7)	19 (35.2)	0.003	0.957
Female	47 (65.3)	35 (64.8)
Professional cadre
Doctor	7 (9.7)	9 (16.7)	1.607	0.810
Nurse	15 (20.8)	9 (16.7)
CHEW	36 (50.0)	26 (48.1)
Lab technician	6 (8.3)	5 (9.3)
Others*	8 (11.1)	5 (9.3)

***Student’s t-test. *CHO=Community health officer, EHO=Environmental health officer, CHEW=Community Health Extension Worker

Table 2 shows that awareness of IDSR was higher among respondents from public health facilities as 57 (79.2%) respondents compared with 26 (48.1%) from private health facilities had heard about IDSR (P < 0.001). Only 54 (75.0%) respondents from public health facilities were aware of disease reporting forms compared with 20 (37.0%) from the private health facilities (P < 0.001) while 67 (93.1%) respondents in public health facilities compared with 43 (79.6%) of those in private health facilities could correctly mention the importance of IDSR (P = 0.025). Only 26 (36.1%) respondents in public health facilities compared with 9 (16.7%) of those in private health facilities could correctly list the IDSR reporting forms (P = 0.016). Among the respondents, 35 (48.6%) and 19 (35.2%) from public and private health facilities respectively correctly mentioned the function of form 001 (P = 0.132) while 25 (19.8%) and 30 (23.8%) from public and private health facilities respectively correctly mentioned the function of form 002 (P = 0.020).

Table 2

Awareness of integrated disease surveillance and response among respondents

Variables	Frequency (%)				χ 2	P
	Public (n=72)		Private (n=54)
	Aware	Not aware	Aware	Not aware
Ever heard of IDSR	57 (79.2)	15 (20.8)	26 (48.1)	28 (51.9)	13.207	<0.001
Aware of disease reporting forms	54 (75.0)	18 (25.0)	20 (37.0)	34 (63.0)	18.348	<0.001
Importance of IDSR correctly mentioned	67 (93.1)	5 (6.9)	43 (79.6)	11 (20.4)	5.017	0.025
IDSR forms correctly mentioned	26 (36.1)	46 (63.9)	9 (16.7)	45 (83.3)	5.815	0.016
Function of form 001 correctly mentioned	35 (48.6)	37 (51.4)	19 (35.2)	35 (64.8)	2.271	0.132
Function of form 002 correctly mentioned	25 (34.7)	47 (65.3)	30 (55.6)	24 (44.4)	5.445	0.020

IDSR=Integrated disease surveillance and response

Table 3 shows that almost all the respondents in the public health facilities 70 (97.2%) and 48 (88.9%) in the private health facilities felt that IDSR reporting was very important (P = 0.073). Forty-six (63.9%) respondents in public health facilities felt that IDSR was useful in disease surveillance compared with 34 (63.0%) in private health facilities (P = 0.915). Only 8 (11.1%) and 14 (26.4%) respondents in both public and private health facilities respectively felt IDSR did not limit disease spread (P = 0.030). Fifty-two (72.2%) respondents in the public health facilities and only 25 (46.3%) in the private ones felt that the LG provided adequate support for IDSR (P = 0.003) while 56 (77.8%) respondents in the public health facilities and only 27 (50.0%) in the private ones felt that the state government provided adequate support for IDSR (P = 0.001). More than half, 49 (68.1%) and 24 (44.4%) respondents in the public and private health facilities, respectively, felt that there was effective communication in coordinating IDSR in the state (P = 0.008). On suggestions to improve IDSR in the state, the aspects of IDSR that respondents said needed improvement were availability of funds for IDSR activities, training of health workers on IDSR, and prompt feedback.

Table 3

Attitude toward integrated disease surveillance and response among respondents

Variables	Frequency (%)				χ 2	P
	Public (n=72)		Private (n=54)
	Positive attitude	Negative attitude	Positive attitude	Negative attitude
IDSR reporting is important	70 (97.2)	2 (2.8)	48 (88.9)	6 (11.1)	0.073*
IDSR is helpful in disease surveillance	46 (63.9)	26 (36.1)	34 (63.0)	20 (37.0)	0.011	0.915
IDSR does not limit disease spread	8 (11.1)	64 (88.9)	14 (25.9)	40 (74.1)	4.699	0.030
Local government adequately supports IDSR	52 (72.2)	20 (27.8)	25 (46.3)	29 (53.7)	8.727	0.003
State government adequately supports IDSR	56 (77.8)	16 (22.2)	27 (50.0)	27 (50.0)	10.591	0.001
There is effective communication in coordinating IDSR in the state	49 (68.1)	23 (31.9)	24 (44.4)	30 (55.6)	7.059	0.008
Aspect of IDSR that needs improvement
Availability of funds (1)	12 (16.7)	60 (83.3)	8 (14.8)	46 (85.2)	15.495	0.030
Training of health workers on IDSR (2)	35 (48.6)		21 (38.9)
Prompt feedback (3)	2 (2.8)		0 (0.0)
One, two and three	11 (15.3)		3 (5.5)
One and two	4 (5.5)		3 (5.5)
Two and three	1 (1.4)		0 (0.0)
Don’t know	7 (9.7)		19 (35.3)

*Fisher’s exact test. IDSR=Integrated disease surveillance and response

Table 4 shows that 55 (76.4%) respondents in public health facilities compared with 22 (40.7%) in private health facilities said that there was IDSR reporting in their facilities (P < 0.001). Fifty-three (73.6%) and 21 (38.9%) respondents in public and private health facilities respectively said that they had ever reported a disease using IDSR (P < 0.001). Only 29 (40.3%) and 7 (13.0%) respondents in public and private health facilities respectively said that IDSR reporting was carried out all the time. Almost half of respondents 34 (47.2%) in the public health facilities and only 16 (29.6%) of those in private health facilities said that IDSR reporting was done in their facility in the last 3 months (P = 0.269). A little more than half of the respondents 42 (58.3%) in the public health facilities and only 5 (9.3%) of those in private health facilities said that there was designated IDSR personnel in their facility (P < 0.001). Slightly more than half of the respondents 38 (52.7%) in public health facilities and just 9 (16.7%) in private ones had ever been trained on IDSR (P < 0.001).

Table 4

Integrated disease surveillance and response implementation among respondents

Variables	Frequency (%)		χ 2	P
	Public (n=72)	Private (n=54)
IDSR reporting carried out in your facility
Yes	55 (76.4)	22 (40.7)	16.674	<0.001
No	9 (12.5)	19 (35.2)
Don’t know	8 (11.1)	13 (24.1)
Ever reported a disease using IDSR
Yes	53 (73.6)	21 (38.9)	15.349	<0.001
No	19 (26.4)	33 (61.1)
Frequency of IDSR disease reporting
Always	29 (40.3)	7 (13.0)	11.298	0.004
Sometimes	28 (38.9)	30 (55.5)
Never	15 (20.8)	17 (31.5)
Last time IDSR used to report disease
Within the last 3 months	34 (47.2)	16 (29.6)	3.990	0.269
Within the last 6 months	13 (18.1)	13 (24.1)
Between 6 months and 1 year ago	18 (25.0)	18 (33.3)
Later than 1 year ago	7 (9.7)	7 (13.0)
Designated IDSR personnel in health facility
Yes	42 (58.3)	5 (9.3)	31.774	<0.001
No	30 (41.7)	49 (90.7)
Had any training on IDSR
Yes	38 (52.7)	9 (16.7)	17.205	<0.001
No	34 (47.2)	45 (83.3)

IDSR=Integrated disease surveillance and response

Table 5 shows that Forms 001 for immediate individual case reporting of diseases was found in only 13 (54.2%) public health facilities and just 3 (16.7%) private health facilities (P < 0.001). Forms 002 were seen in 7 (29.2%) and 2 (11.1%) public and private health facilities respectively (P = 0.002). Forms 003 for individual case reporting was found in only 13 (54.2%) public health facilities and just 3 (16.7%) private health facilities (P < 0.001). Evidence of the previous reporting of diseases was seen in only 8 (33.3%) and 3 (16.7%) public and private health facilities respectively (P = 0.024).

Table 5

Assessment of integrated disease surveillance and response implementation in selected facilities

Variable	Frequency (%)		χ 2	P
	Public (n=24)	Private (n=18)
001 forms seen	13 (54.2)	3 (16.7)	20.432	<0.001
002 forms seen	7 (29.2)	2 (11.1)	10.179	0.002
003 forms seen	8 (33.3)	3 (16.7)	5.585	0.018
Evidence of previous reporting of diseases seen	8 (33.3)	3 (16.7)	5.106	0.024
Available logistic support
Electricity	2 (8.3)	6 (33.2)	<0.001*
Electricity/mobile	2 (8.3)	1 (5.6)
Mobile	7 (29.2)	1 (5.6)
Internet	0 (0.0)	1 (5.6)
None	13 (54.2)	9 (50.0)

*Fishers exact test

DISCUSSION

The workers interviewed in this study were drawn from public and private health facilities and were found to be similar in terms of sex and cadre composition. There were more females than males which is not surprising since the World Health Organization in 2019 estimated that women made up about 70% of the total health workforce.[14] About half of the workers in both facility types were CHEW; nurses made up only a fifth of the workforce in both facility types. This implies that facilities in the local government employ CHEWs to carry out nursing functions along with the nursing staff. The private facilities have a higher proportion of younger workers than the public ones and one reason for this may be the higher attrition rate seen among workers in private health facilities.

This study revealed major differences between public and private health facilities with respect to the level of implementation of IDSR in the LGA. The study revealed a lower awareness of IDSR in the private health facilities compared with public ones. This may make disease surveillance and control efforts more difficult and limited in reach in the LGA. More than a quarter of respondents in the public health facilities compared with less than half of those in the private health ones were aware of IDSR. This may be due to the inadequate engagement of the private health facilities in disease control activities by the government at both local and state levels resulting in a lack of awareness of IDSR. This is in keeping with a study carried out in India where there was low awareness of IDSR in the private health facilities,[15] but is contrary to the findings of a study carried out in public health care facilities in Rufunsa, Zambia where majority of the respondents had heard of IDSR.[16] Our study also differs from a study carried out in the eastern part of Nigeria which revealed a comparable level of awareness of IDSR among staff of both public and private health facilities.[17] This might be because the public health facilities in Nigeria are very involved in IDSR activities including training right from the primary level of care to the tertiary level. Most of the health personnel in these facilities are assured of their job security and so tend to stay longer in the public health facilities than in private, where staff turnover is more rapid, hence a better awareness of IDSR activities than their private counterparts.

About a third of the respondents in private health facilities were aware of the disease reporting forms and only a few of these could correctly list the IDSR forms as opposed to majority of those in the public health facilities who knew the disease reporting forms and a third who could correctly list the IDSR forms. This is probably due to low reporting of diseases using the IDSR forms in the private hospitals than the public hospitals and this finding also has dire implications for disease control efforts. A small percentage of public and private health personnel correctly identified form 001. This finding was consistent with that of the study carried out in Enugu, Nigeria where identification of disease reporting forms was consistently better among workers in public health facilities than their counterparts in the private ones.[17]

Attitude towards IDSR was positive among respondents from both types of facilities studied as almost all respondents in the public facilities and majority of those in the private ones felt that IDSR was important. This positive response is important in achieving high standard of surveillance and notification and ultimately effective disease control. This is in keeping with the findings of studies carried out in Oyo State, Nigeria; Zambia and India on disease surveillance where all the respondents felt it was important to report notifiable diseases.[151618] A similar proportion of respondents in both public and private health facilities felt that IDSR was useful in disease surveillance and this is also commendable and only a small proportion felt that IDSR did not help to limit disease spread. In terms of support for IDSR activities by local and state governments, more respondents in the public than the private health facilities felt that the governments provided adequate support for IDSR activities. The public health facility workers are government employees and previous studies have shown that public health facilities are more involved in IDSR activities than the private ones.[1119]

More than half of respondents in the public and a little less than half of those in private health facilities felt that there was effective communication in coordinating IDSR in the state between the health facilities, local governments and the state Ministry of Health. This poor perception about effective communication is certainly a reflection of the low involvement of these facilities in IDSR co-ordination in the local government and state. This is consistent with the study conducted in South-east Nigeria where half of the respondents felt that there was lack of adequate coordination and communication between the health facilities, the district health office, provincial health office as well as the Ministry of Health Headquarters.[7]

Implementation of IDSR has been shown to be less than optimal in many health facilities in Nigeria. Our study revealed that even though majority of public health facilities in the LGA were implementing IDSR, this was not the case with the private health ones as less than half of those studied said that IDSR reporting was taking place in their facility. Almost half of the respondents in the public health facilities and only a third of those in private health facilities said that IDSR reporting was done in their facility in the last 3 months. It meant that many diseases diagnosed and treated at private health facilities did not get reported. This was in keeping with a study carried out in eastern Nigeria where more than half of public health personnel and only a few private health personnel reported a disease.[17] This was lower than figures reported from a study carried out outside Nigeria which showed that majority of the respondents had reported disease in the last 12 months before the study.[3] In comparison with half of the respondents from public health facilities, only a small proportion of those from private health facilities said that there was designated and trained IDSR personnel in their facility. In analyzing the checklist that was used for this study, our findings also revealed that only a fraction of the public and private health facilities had a trained staff for IDSR. This will affect the quality of any IDSR activity taking place in these facilities. This is in keeping with studies carried out within and outside Nigeria where only a small proportion of the personnel had received training on IDSR and this was said to have been provided by the provincial health office.[3416] A study carried out in eastern Nigeria also revealed that very few health workers in public and private health centers had attended training/courses in IDSR.[17] The poor participation of the private health sector in IDSR could be due to the little attention given to private hospitals during the introduction and implementation of the IDSR strategy in Nigeria. This is an unfortunate situation which needs to be reversed since private health facilities in Nigeria are said to be responsible for more than 60% of healthcare contact in the country.[10]

CONCLUSION

IDSR is a very important strategy that aids in curtailing the spread of epidemic-prone diseases and other diseases of public health importance. The proportion of health workers in public health facilities that were aware of IDSR was higher than those in private health facilities. Even though there was a fairly positive attitude towards IDSR among the workers, the level of implementation of IDSR was found to be sub-optimal in Jos North LGA and especially among the private health facilities.

There is a need to improve the knowledge and attitude towards IDSR among workers in these facilities to enhance its implementation thereby contributing to preventing and controlling more disease outbreaks in our communities and health facilities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.