Introduction

Background of the Study

Primary health care the essential health care based on practical

scientifically sound and socially acceptable methods and technology

made universally accessible to individuals and families in the community

through their full participation and at a cost that the community and

country can afford to maintain at every stage of their development in

the spirit of self-reliance and self-determination. Similarly primary ear

nose and throat care have to be an essential health care which has to

be practical scientifically sound socially acceptable accessible available

with full participation of the individual families in the community at

affordable cost to maintain at every stage of development in the spirit of

self-reliance and self-determination (World Health Organization “Alma

Ata Declaration/Globe Spring 2009).

The current health policy making process in Nigeria is embodied in the

National Health Policy and Strategy to Achieve Health for All Nigerians

introduced in 1988 and subsequently revised in 2004 (10 11) founded

on egalitarian principles the policy making process seeks to improve the

health of all Nigerians by devising a sustainable health system based on

primary health care (PHC) that is promotive preventive restorative and

rehabilitative and which will ensure a socially and economic productive

and fulfilling life to every individual. the policy process adopts WHO’s

strategy for realizing primary health care (PHC) as elaborated in the

Declaration of Alma Ata (II). The main focus of the National Health

System and its management National Health Care Resources National

Health Interventions and Services Delivery; National Health Information

Systems; Partnership for Health Development and Health Research and

Health Care Laws. Though they are still in embryonic stages each of

these areas represents important component of an effective health

system and would if fully developed and implemented go a long way in

plugging the gaps and inadequacies of the current policy making system

in Nigeria(5). The policy provides for a health system with three levels:

Primary health care which is supposed to be the first point of entry for

individuals and communities the managerial process refers to the

organisation and management of infrastructures that have to exist at

various levels (villages districts) a vital health care system being the

responsibility of the local government area. The secondary health care

provides medical care beyond primary health care (PHC) capacity after

receiving referrals from the primary health care (PHC) levels and

managed by the state government and the tertiary receives referral of

cases beyond secondary capacity which are highly specialized medical

care supported by advanced diagnostic capability. According to the

National Health Policy of 1978 the federal government is responsible for

policy formulation strategic guidance coordination supervision

monitoring and evaluation at all levels (7). It also has operational

responsibility for disease surveillance essential drugs supply and vaccine

management. In Nigeria health policy making is highly influenced by

politics and some of the characteristics of the political setting pose a

great advantage to evidence-informed decision making. The national

health care system are to be organized in a coordinated manner noting

that health services are also provided by the voluntary agencies private

practitioners public and private sectors (Uneke et al 2010).

In most developing countries where health management health facilities

and other resources are major constraints one popular strategy that has

been adopted is the training and use of corps of volunteer workers to

provide primary health care services (NPH CDA FMH Care and Social

Services 1978).

In the national PHC programme it was planned that each village and

neighbourhood within the urban centre will nominate and have a trained

volunteer health worker for approximately 500 people she or he will

attend to those problems for which she or he has been trained such as

mobilization for health actions treatment of minor ailment supply of

essential drugs and refer cases for which she/he has not been trained

those at risk and those she/he is in doubt to the first referral health

facility. In our population children under one year of age constitute 4%

under fives constitutes 20% and women of child bearing age 20%.

These groups are the most vulnerable to disease and death (Adeyemi et

al 2005)

The World Health Organisation estimated that in 2005 there are 278

million people in the world with Two thirds of these

are in developing countries many more have mild hearing loss and

many kinds of ear diseases. These problems can cause life-long and

sometimes life-threatening difficulties to people with them; they may

have a profound effect on the ability of individuals to communicate with

others on their education on their ability to obtain and keep

employment in social relationships and through stigmatization. Those

problems also produce surprisingly large economic burdens on society as

a whole. In developing countries there are few programmes to prevent

and treat ear diseases and help people with hearing impairment and in

many of these countries few or no trained health workers to implement

them. some of the most effective and cost-effective interventions

against ear and hearing disorders can be implemented at the primary

level by trained primary ears and hearing care (PEHC) workers or

primary health care (PHC) workers or their equivalent. If there

interventions are used on a large scale they will have a major impact on

the burden of ear disease and hearing loss. However most developing

countries do not have PEHC workers in community-based rehabilitation

(CBR) programmes rarely deal with this field. The WHO Primary Ear and

Hearing Care Training Resource is intended to address this urgent need.

It consists of manuals and other materials for interactive and culturally

appropriate training of village health workers PEHC PHC and CBR

workers and also more experienced personnel working at primary level.

It comprises basic intermediate and advanced level components. The

resource focuses on community involvement and raising awareness and

covers basic measures for prevention and management. A section on

hearing aids is included for communities where there are no other

trained personnel to help people use them effectively. The resource has

been developed by a wide process of consultation in many developing

countries and has been field tested in Africa and Asia. It will be made

freely available to projects and programmes that wish to conduct

training in this field. The Alma Ata Declaration forms an integral part of

the country’s health system of which it is the nucleus and of the overall

social and economic development of the community. It is hoped that

the resource will contribute to primary health care and will stimulate and

enable greater priority to be given by developing countries to addressing

ear and hearing disorders and hence staff to make a substantial

reduction is their burden in the developing world primary health care

report of the International Conference on Primary Health Care:

Alma-Ata (WHO 2012).

Each year 12 million people need medical treatment due to impacted

ear wax (Cerumen) according to National Public Radio (Palca 2012).

The human body naturally creates earwax in the outer ear canal

between the..... ‘cleaning’ the ear is still considered a common hygiene

practice even though it has potentially hazardous implication

(www.chwo-foundation.org/tag/earwas2012). One gene makes earwax

wet or dry by mutation (news.bbc.co.uk/2/hi/health/4661. Dry earwax

is seen in up to 95% of East Asians but no more than 3% of people of

European and African origin. In both Europeans and Africans the most

type completely dominates (Dr. Sally D. 2012). ENT complications are

often the first symptoms prompting patients to consult their physician

(Peter 2002).

The ears comprise three anatomical sections; the outer ear the middle

ear and the inner ear. Ears are extremely sensitive device with the help

of which we are able to hear. These consists of three basic parts; the

outer ear the middle ear and the inner ear. Each part of the ear has

specific role in the task of detecting and interpreting sound. The outer

ear (pinma) collects and transients the sound to the middle ear through

the auditory canal. At the end of the auditory canal there is a thin

membrane called the ear drum or tympanic membrane. The ear drum

moves inward and outward as the compression or rare faction reaches it.

In this way the ear drum vibrates. These vibrators are amplified by the

three bones namely the hammer anvil and stirrup in the middle ear.

The middle ear transmits these vibrations to the inner ear. Inside the

inner ear the vibrations or the pressure vibrations are converted into

electrical signals by the cochlea. These electrical signals are sent to the

brain via the auditory nerve and the brain interprets them as sound

(Tutor Vista.com 2012).

A top cause of hearing loss is wax blockage which can be caused by

attempts to use a swab (cotton bud) to clean the ear. That is because

this actually pushes the wax deeper into the ear canal in most cases.

Instead of cleaning leads to an ear canal infection and definitely don’t

put anything sharp in your ear because it can cause bleeding or serious

damage. If you think you have dirt or too much earwax in your ear have

your ears examined at least once every year by your physician

audiologist or any hearing specialist. In a newly pierced ear leave

earrings in until your ears are completely healed to prevent the holes

from closing and infections wash hands before touching and apply

antiseptic. Sometimes swimming can lead to a case of swimmer’s ear’.

That is when your outer ear gets infected causing swelling and pain.

This happens when water gets stuck in your ear canal. This can irritate

the skin making it easier for bacteria to invade the skin and cause an

infection. if you notice it you need to see a health worker. Most of the

time the ear canals are self-cleaning; that is there is a slow and orderly

migration of the earwax. It protects the skin of the human ear canal

assists in cleaning and lubrication and also provides some protection

from infections (Dowshen et al 2009).

Anatomy and Physiology of the ear nose and throat EAR

The ear is divided into three distinct parts

1) Outer ear

2) Middle ear

3) Inner ear

Structure of the Ear Related to Hearing and Balance

Structure Function

a) Outer Ear

1) Pinna (auricle)

2) External auditory canal

3) Tympanic membrane (eardrum)

Collects sound waves

Directs sound waves to tympanic membrane

Sound waves cause it to vibrate and

transmit to ossicles

b) Middle Ear

1) Auditory ossicles: harmer

(mullaes) incus (anvil) stapes

(stirrup)

2) Auditory (Eustachio) tube

3) Oval window

4) Round window

Transmit sound waves from tympanic

membrane to oval window

Equalizes pressure on both sides of the TM

Channel or passage for sound waves

c) Inner Ear

1) Cochlea

2) Cochlea nerve

Transmits sound waves to cochlea nerve

Transmit sound waves to brain for

interpretation

Function: Balance

3) Semicircular canal

4) Vestibule (utricle/saccle)

Contains receptor for balance (dynamic

equilibrium)

The expanded part nearest the middle ear

contains the oval and round windows.

Diseases of the Ear

Outer ear disease is known as otitis external middle ear disease – otitis

media inner ear disease – labrynthitis collectively. On the posterior wall

there are the pharyngeal tonsils (odenoids) consisting of lymphoid

tissue. They are most prominent in children up to approximately 7 years

of age. Thereafter they gradually atrophy.

Nose

The nasal cavity has a dual functions a passageway for respiration and

sense of smell.

Nose Sense of Smell

The nose the door of respiratory tract is the important organ to

perform metabolism in the body. it helps us to breathe smell filter air

that travels to our lungs and also helps us to taste. That is why when

we have a stuffy nose we often feel like we can’t breathe easily smell

anything or taste as well. When we breathe through our nose there are

advantages that we don’t get when we breathe through our mouth. The

nose has ancillary hairs that catch airborne particles that we don’t want

to reach our lungs. Nose hairs also filter out viruses which typically

attach themselves inside the nostrils. These particles mix with natural

secretions and are transported into the throat for elimination in the

stomach. Remarkably the brain can recognize tens of thousands of

odors from our past and instantly reminds us what we are smelling.

When we inhale through our nose air passes through our nostrils into a

short and narrow area known as nasal passage that leads to the back of

the throat (pharynx0 and on down into the windpipe and lungs. From

there it continues throughout the respiratory system:

Structure of the Nose Related to Respiration and Smell

Structure Function

2 Nostrills

Olfactory nerves

Olfactory bulb

Olfactory tract

3 conclia (superior middle

inferior)

Ethmond and wormer bone

Hylaine cartilage

Passages for inspired air

Sensory nerves of smell

Where interconnections and synopses occur

Passage of nerve fibres

Place where specialized olfactory nerve

endings originates

Bone of the nose give shape support and

contain sinuses which contain air give

resonance to voice and lighten the bones.

Tissue covering the nose

Ross and Wilson (2005) 9th Edition.

Disease of the Nose

“Nose bleeds” causes such as blood thinners trauma nose picking

living in dry cold or dry hot environments.

Nose bleeds (epitaxis) can be dramatic and frightening; fortunately

most nose bleeds are not serious. They are divided into two types

depending on whether the bleeding is coming from the anterior (front of

the nose) or posterior (back of the nose). Anterior nose bleeds make up

more than 90% of all nosebleeds. The bleeding usually comes from

blood vessel at the very front part of the nose. Anterior nosebleeds are

usually easy to control either by measures that can be performed at

home or by a health personnel. Posterior nosebleeds are much less

common than anterior nosebleeds. They tend to occur more often in

elderly people. The bleeding usually comes from an artery in the back

part of the nose. These nosebleeds are more complicated and usually

require admission to the hospital and management by an

otolaryngologist (an ear nose and throat specialist). In the United

States one of every seven people will develop a nosebleed at sometime.

They can occur at any age but are most common in children aged 2 to

10 years and adults aged 50 to 80 years. Nosebleeds is commonly

caused by trauma to the nose (outside) triggers a nosebleed such as a

blow to the face or trauma inside the nose such as nose picking or

repeated irritation from a cold can cause a nosebleed. Less commonly

an underlying disease process such as an inability of the blood to clot

and most often due to blood-thinning drugs such as warfarin

(coumadian) or aspirin liver disease can also interfere with blood

clotting abnormal blood versed or cancer in the nose are rare causes of

nosebleeds. High blood pressure may contribute. There are nerve

endings that detect smell located in the roof of the nose in the area of

the intriform plate of ethmoid bones and the superior conchae. These

nerve ending are stimulated by chemical substances given off by

odorous materials. The resultant nerve impulses are conveyed by the

olfactory nerves to the brain where the sensation of smell is perceived.

The structures associated with the nose are 2 nostrils; a large irregular

cavity divided into two equal passages by a septum the posterior bony

part of the septum is formed by the perpendicular plate of the ethnoid

and vomer bones. Anteriorly it consists of hyaline cartilage. The nose

apart from its function as a sense of smell first organ of respiration

functions in speech and also lightens the skull with the help of the

sinuses. The nose contains shelf-like structures called turbinates which

help trap particles entering the nasal passages. Material deposited in

the nose is transported by ciliary action to the back of the throat is

10-15 minutes. Cold viruses are believed to be carried to the back of

the throat where they are deposited in the area of the adenoid. The

adenoid is a lymph gland structure that contains cells to which cold

viruses attach (Gerard et al 2012).

The Throat

A tube-like structure containing other structures like the pharynx larynx

epiglottis situated in the anterior part of the neck in front of the

vertebral column extending from the mouth to the shoulders and held in

place by cervical part of the vertebral column. The pharynx is divided

for descriptive purpose into three parts the nasophyarynx which is

important in respiration also connects to the auditory tubes of the

middle ear the oropharynx connecting the mouth to the nose to the

oesophagus. Food passes from the oral cavity into the pharynx then to

the oesophagus below with which it is continuous the laryngopharynx

extends from the oropharynx connecting the mouth nose to the

oesophagus these are passages common to both the respiratory and

the digestive systems. The epiglottis in the throat controls water and

air going into the body. Farache cold and sore throat cause misery for

millions of us every year. The ear nose and throat specialists of UPMC

treat a variety of diseases and conditions (Bruce 2012). Infective

agents of the throat most often enter through the mouth or nose

infections are viral; others can be caused by bacteria (such as

streptococcus pyogenes or group of streptococcus. Streptococcal

bacteria are the agents that cause the painful and well-known condition

known as strep throat symptoms of throat infection most commonly

include pain and a sensation of heat in the throat or pharynx. The

infection may also affect other structures within the throat in particular

the tomsils (which is referred to as tonsillitis) symptoms can range from

mild to severe and may or may not be accompanied by fever cough

congestion and other flu-like symptoms such as body aches. You may

also experience swollen lymph nodes in the neck.

Most virus caused throat infections clear up on their own while certain

bacterial infections are easily treated with antibiotics. Serious symptoms

needing quick attention includes choking or severe difficulty breathing

which may be combined with pale or blue lips rapid heart rate

(tachycardia) and anxiety; high fever (higher than 101 degrees

Fahrenheit) sudden swelling of the tongue or throat structures; change

in level of consciousness or alertness such as passing out or

unresponsiveness of a change in mental status or sudden behaviour

change such as confusion delirium lethargy hallucinations or

delusions. Fortunately many throat infections resolve by themselves

over time or are usually curable with timely treatment with antibiotics

such as penicillin amoxicillin and if needed fever-reducing agents. The

most important step in treating throat infections is to practice

prevention. However even with the most conscientious efforts

infections can still occur (Richard 2011).

Oropharynx

The oral part of the pharynx lies behind the mouth extending from

below the level of the soft plate to the level of the upper part of the

body of the 3 rd cervical vertebra. The lateral walls of the pharynx blend

with the soft palate to form two folds on each side. Between each pair

of folds there is a collection of lymphoid tissue called the palatine tonsil.

During swallowing the nasal and oral parts are separated by the soft

palate and the uvula.

Laryngopharynx

The laryngeal part of the pharynx extends from the oropharynx above

and continues as the oesophygeal below i.e. from the level of the 3rd to the 6th

cervical vertebrae.

Structures of the Throat in Connection to the Ear Nose Mouth

and Oesophagus

Your nose helps your breathing smell and taste kids health. The

pharynx is about 12 to 14cm long that extends from the base of the

skull to the level of the 6th

cervical vertebra. It lies behind the nose

mouth and larynx and is wider at its upper end.

Nasopharynx

The nasal part of the pharynx lies behind the nose above the level of the

soft palate. On its lateral walls are the two openings of the auditory

tubes one leading to each. Outer ear disease is known as otitis externa

middle ear – otitis media and the inner ear is the labyrinthitis. Two of

the major ear diseases are the otitis and hearing disorders. However

not all hearing disorders are due to structures of the ear. Ear disease is

a subfield of otolaryngology addressing the pathology of the ear (View

Google in Mobile © 2012).

Functions

Passageway for Air and Food

The pharynx is an organ involved in both the respiratory and the

digestive systems: air passes through the nasal and oral parts and food

through the oral and laryngeal part.

Taste

There are olfactory nerve endings of the sense of taste in the epithelium

of the oral and pharyngeal parts

Warming and Humidifying

By the same methods as in the nose the air is further warmed and

moistened as it processes through the pharynx

Awareness is defined as having knowledge or cognizance; act of being

interested in something and knowing a lot about it; knowing about a

situation or fact; interested and involved in something. If you are aware

of something you know about it or realize that it is there. Awareness

therefore means being interested knowing and involving in primary

(basic) care of ear nose and throat.

Awareness: Knowing about a situation or fact being interested and

involved in the essentials of primary ear nose and throat care. It is

aimed at creating or emphasizing on the fact that “prevention is better

than cure” in the area of the study with the view of stating the findings

of the situation on ground. If the problem under study is solved the

solution will make significant contribution to education and the world of

knowledge (Elsevier 2004).

Creating (verb) present participle of create (verb) means; bring

(something) into existence cause (something) to happen as a result of

one’s action to cause to exist bring into being to give rise to to cause

to come (View Google in Mobile © 2012). In creating awareness the

preventive or simple care of ear nose and throat will not be neglected by

people concerned (mothers health personnel children etc). How it is

done who does what and under what condition. The services which are

also the indicators for quality of care include:

1. Enlightenment of ENT common diseases

2. Counselling on screening (check up)

3. Encouraging screening

4. Detection of existing diseases

5. Prevention of diseases and promoting of health

6. Referral of ENT complications

A mother (or mum/mom) is a woman who has raised a child given

birth to a child; a female parent to take care of someone as if they were

a child (Free Encyclopedia 2012); home health is to a large extent in

the hands of the housewife (Radiant Health Howard E. et al 1977

2011). A mother is the first contact in every person’s life who can easily

pass down or put information to good use if properly educated (Howard

2011).

Essentials means important and necessary; most important or basic a

collection of useful commands and features made up of multiple

components (Google by Search 2011).

Statement of the Problem

Although awareness on primary care of ear nose and throat (ENT) alone

cannot be expected to have total impact on the diseases and disorders

of the ear nose and throat the purpose is to improve the state of health

as regards hearing speech (voice disorders) and neck problems.

The fact that the National Ear Care Centre has been moved to Kaduna

and has been training health/medical personnel which has been proven

by WHO a significant improvement should have been documented in

primary ENT. In Fada district of Kagoro (ECWA Comprehensive Health

Clinic) adequate supply of resources both human and material to

sustain the PEHC. There is gross insufficient in the number of skilled

service providers at the grassroots level PEHC training duration is longer

for other health practitioners and more thorough at the secondary health

facility who do not live nor work where the communities live.

This implies that awareness of PEHC lacks the thoroughness which

makes it effective in improving the state of health. This research work

therefore seeks to highlight the areas of problem and more action

through creating awareness of essentials of primary ENT care in Kagoro.

Purpose of the Study

The study is designed to create awareness on the essentials of primary

ear nose and throat (ENT) among mothers in ECWA Comprehensive

Health Clinic Fada District of Kagoro Kaduna state specifically the study

would:

1) Create awareness on possible causes of ear nose and throat

disorders among mothers in ECWA Comprehensive Health Clinic

Fada District of Kagoro Kaduna state.

2) Determine how primary ENT care is implemented among mothers

in ECWA Comprehensive Health Clinic Fada District of Kagoro

Kaduna state.

3) Find out the resources (human and material) available for creating

the awareness among mothers in ECWA Comprehensive Health

Clinic Fada District of Kagoro Kaduna state.

Significance of the Study

When the awareness on essentials of primary ear nose and throat care

is created in ECWA Comprehensive Health Clinic Fada District of Kagoro

Kaduna state the following people will benefit from the study”

i) Mothers: Who will pass the information to their spouses

children extended family and community after knowing the

connectivity and the diseases associated and also the harmful

cultural practice relating to the ear nose and throat.

ii) Community Health Workers: People who live work speak the

local language knowledgeable about and share the community’s

culture attitudes and beliefs will understand better and improve

in their services as grassroots or primary (ENT) health care

providers.

iii) Government: Maintain it’s stand of providing the policy

resources both human and material training to improve and

sustain health care delivery.

Research Questions

The following research questions are formulated to guide the study:

i) What are the possible causes of ear nose and throat disorders

among mothers in ECWA Comprehensive Health Clinic Fada

District of Kagoro Kaduna state?

ii) How is primary ear nose and throat care implemented among

mothers in ECWA Comprehensive Health Clinic Fada District of

Kagoro Kaduna state?

iii) What are the resources (human and material) available for

creating awareness on essentials of primary ENT in ECWA

Comprehensive Health Clinic Fada District of Kagoro Kaduna

state?

Scope of the Study

This study will access and create awareness in Fada-Kagoro ECWA

Comprehensive Health Clinic ECWA College of Health Technology and

Mothers in Fada-Kagoro of Kaura local government area of Kaduna state.