The Condition of Pestiside Management and Possible Health Hazards in Butajira , Ethiopia Essay

KAROLINSKA INSTITUTET Department of Public Health Sciences Division of International Health (IHCAR) SE-171 76 STOCKHOLM, Sweden  The conditions of pesticide management and possible health hazards in Butajira, Ethiopia A Minor Field Study Report January 2004 by Malin Ahrne MFS-Report No. 1/2004 Department of Community Health Addis Ababa University Department of Public Health and Clinical Medicine Umea International School of Public Health Department of Public Health Sciences Karolinska Institutet 2004-01-12 The Conditions of Pesticide Management and Possible Health Hazards in Butajira, Ethiopia

Investigator: Malin Ahrne Student of Public Health Karolinska Institutet, Sweden malin. [email protected] se Advisers: Dr Abera, Department of Community Health, Addis Abeba University Mr Wakgari Deressa, Department of Community Health, Addis Abeba University Mr Anders Emmelin, Department of Public Health and Clinical Medicine, Umea International School of Public Health Dr Yalemtsehay Mekonnen, Department of Biology, Addis Abeba University Key words: Pesticides, Ethiopia, Butajira, health, agriculture.

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This report on a study visit to Ethiopia, March 27 – May 16 2003, constitutes my Minor Field Study (MFS)-report. The grant from the International Programme Office, through IHCAR, Karolinska Institutet, to carry out an MFS, is gratefully acknowledged. Abstract: Since the introduction of pesticides and chemical fertilizers in agriculture the production of food has increased substantially. The use of pesticides is an occupational hazard for farmers all over the world, but special problems occur in low- and middle-income countries. 80 % of the population of Ethiopia works within the agricultural sector.

The health hazards with handling, storing and applying pesticides depend on for example the classification of the chemical, the handling practices and the amount of exposure to the chemical. The aim of this study is to assess the risk of acute pesticide poisoning for farmers and their families in smallholder agriculture in Butajira, rural Ethiopia, when storing, handling and using pesticides. A random sample of 140 households was conducted amongst the farmers in two villages. A structured questionnaire on the storage and handling practices of pesticides has been used.

The data has been analysed with Epi Info version 6. The data analysis indicates that the use of agro-chemicals is widespread in this setting, but not very frequent. The use of pesticides/insecticides for other purposes such as for household use, and for livestock, is also quite extensive. The usage seems to increase according to larger land and cultivation of cash crops. This is likely to depend on the fact that farmers with less land cultivate, to a higher extent, only maize, which does not acquire pesticides and does not generate any specific income.

Proper PPD is not available, the storage sites are highly hazardous, and pesticides for household purposes are often re-packed and sold in non-original containers. Professional spray men, together with the farmers, mainly conduct application of pesticides. Poisoning with agro-chemicals is not believed to be a major health problem, compared to other types of injuries or diseases, for farmers in this study. Due to economic constraints the use is limited in volume and time. However, the handling practices is a potential hazard for the farmers and their families, and the usage is likely to increase.

Abstrakt: Sedan man borjade anvanda kemiska bekampningsmedel och godningsmedel inom jordbruket har livsmedelsproduktionen okat dramatiskt. Anvandandet av kemiska bekampningsmedel ar ett arbetsmiljoproblem for jordbrukare over hela varlden, men anvandandet moter speciella problem i lag- och medelinkomst lander. 80 % av Etiopiens befolkning arbetar inom jordbrukssektorn. Halsoriskerna med att forvara, hantera och applicera bekampningsmedlen beror bland annat pa kemikaliernas klassificering, rutiner for hantering och pa under hur lang tid man utsatts for exponering.

Syftet med den har studien ar att gora en bedomning av riskerna for akut forgiftning med bekampningsmedel i det smaskaliga jordbruket i Butajira, pa den etiopiska landsbygden, vid forvaring, hantering och spridning. Ett slumpmassigt urval av 140 hushall gjordes bland bonderna i tva byar. Ett strukturerat frageformular om forvaring och hantering av bekampningsmedel har anvants. Data har analyserats med Epi Info version 6. Data analysen antyder att anvandandet av kemiska bekampningsmedel ar relativt utbredd, men ej sa frekvent.

Anvandandet av kemiska bekampningsmedel for andra andamal som insektsbekampning inomhus i hemmen och till boskap var ocksa ganska omfattande. En okad anvandning av bekampningsmedel kan ses bland bonder som har lite storre landareal och som odlar en storre andel grodor for vidare forsaljning. Troligen beror detta pa det faktum att jordbrukare med de minsta landarealerna framforallt odlar majs, som inte kraver 5 bekampningsmedel i lika hog grad, och som inte genererar nagon inkomst, for egen konsumtion.

Lamplig skyddsutrustning finns inte tillganglig, kemikalierna forvaras pa ett riskfyllt satt och bekampningsmedel for hushallen paketeras ofta om och saljs i icke original forpackning. Forgiftning med kemikalier ar inget storre halsoproblem, jamfort med andra typer av olycksfall och sjukdomar, for bonderna i den har studien. Pa grund av ekonomiska svarigheter ar anvandandet begransat i tid och volym. Men forhallandena vid forvaring, hantering och applicering utsatter bonderna och deras familjer for potentiell fara, och anvandandet kommer troligen att oka. 6 Contents 1. Background 1. 1 Introduction 1. History of pest management 1. 3 Categories of pesticides 1. 4 Pesticide related health hazards 1. 5 Reducing the risks with pesticide use 1. 6 Manufacturing and trade 1. 7 Agriculture and Pesticides in Ethiopia 1. 8 Legislation 1. 9 Disposal 1. 10 Sustainable agriculture 2. Objectives 2. 1 General objectives 2. 2 Specific objectives 3. Methodology 3. 1 Study design 3. 2 Study site; Butajira Rural Health Programme (BRHP) 3. 3 Study population 3. 4 Sample size 3. 5 Sampling methods 3. 6 Data collection 3. 7 Data analysis 3. 8 Data quality management 3. 9 Ethical considerations 4. Communication of results

Page 9 15 15 18 7 5. Results 5. 1 Crops 5. 2 Pesticide use 5. 3 Farm size 5. 4 Spraying equipment 5. 5 Storage 5. 6 PPD and other protective methods 5. 7 Disposals 5. 8 Health effects 5. 9 Training 5. 10 Vendors 5. 11 Other chemicals 6. Discussions 6. 1 Analysing results 6. 2 Compatible data? 6. 3 Limitations 6. 4 Summary 7. Conclusions 8. Acknowledgements 9. References 18 23 26 27 27 8 Definitions: Teff (Erogrostis tef); a hardy grain first cultivated in the Ethiopian highlands between 4000 and 1000 BC. It is most frequently served as injera, the bread/pancake with which the Ethiopians eat their food.

Teff can be cultivated under both drought-like and rainy conditions and grows relatively quickly. (www. pbs. org) Enset (Ensete ventricosum); looking like a large banana plant (also called “false banana”), this is one of four wild species of enset in Africa, but it has only been domesticated in Ethiopia. The leaves, pulp and stem can be prepared as foodstuffs. It has other non-food uses as well. (www. aaas. org) Timad A traditional land measurement unit in Ethiopia where four timad is approximately one hectare. Tukul A traditional hut. Keywords: Pesticides, Ethiopia, Butajira, health, agriculture. 1. 1. 1 Background Introduction 0 % of the population of Ethiopia work within the agricultural sector and the whole country is dependent on the food production generated here. A large amount of crop yields are lost to pests and diseases, about 30-40 % annually. The demand for food self-sufficiency and food security may lead to an increasing use of pesticides. The attempts to bring about increased food security may result in increased demand for pest control. Interest groups supporting pesticide sales may also put pressure on farmers to increase their use of pesticides, and persuade them that pesticide use is the only way to reduce crop losses. (Abate T. 996. ) Postharvest losses are also significant due to a multitude of pests, particularly insects and rodents, attacking stored products. (Clarke E et al 1997. ) The use of pesticides is an occupational hazard for farmers especially in low-income countries, because of lack of regulations and knowledge. One recent study from Ethiopia by Mekonnen Y and Agonafir T (2002) showed the need for safety education, provision of better facilities, appropriate PPD (Pesticide Protective Device) and improved hygiene and sanitation for pesticide sprayers. 1. 2 History of pest management A short history of pesticide use (WHO 1990. describes that the use of chemicals to control insects possibly dates back to classical Greece and Rome. The Chinese were using chemical insecticides at least by the sixteenth century, for example arsenic and nicotine. In the middle of the nineteenth century the first systematic scientific studies were carried out in order to find chemicals to use for crop protection. Paris Green was introduced in 1867. The widespread use of Paris Green lead to probably the first pesticide legislation in the world in 1900, in the USA. DDT was discovered during the Second World War for its insecticidal potential.

New pesticides developed during the 1970s and 1980s are more often effective at lower doses, and they are based on a better understanding of biological and biochemical mechanisms. 1. 3 Categories of pesticides 9 Pesticides are used in areas like agriculture, horticulture, fish farming, forestry, homes and gardens, food and commodity storage, animal husbandry, public hygiene and pest control. These are the different groups of pesticide in use worldwide: Herbicides Insecticides Fungicides Molluscicides Rodenticides Growth regulators Seed treatment (Arnold E 1990. 1. 4 Pesticide related health hazards Since the introduction of pesticides and chemical fertilizers in agriculture the production of food has increased substantially. Pesticides have also been of use to fight endemic diseases with transmission by vectors in low-income countries, such as malaria. On the other hand pesticides cause two million cases of unintentional poisonings every year and 20 000 of these lead to death, according to the WHO, and many disease vectors have developed resistance to some pesticides (Forget G, Goodman T, de Villiers A. 993). The WHO used chemical pesticides in its global plan to eradicate malaria and saved millions of lives, but by 1980, 51 of the 60 malaria-carrying mosquitoes had developed a resistance to three insecticides, which were crucial to the eradication programme; DDT, lindane and dieldrin. At least ten species were also resistant to the organophosphates malathion and fenitrothion. 84 countries now have malaria mosquitoes resistant to at least one of the major pesticides, and the incidence of malaria is increasing again.

WHO does not use DDT anymore. (Arnold E 1990. ) The WHO admits that the figures on pesticides poisonings, both unintentional and intentional ones, are rough estimates, extrapolated from the few countries where records of poisonings exist. (Arnold E 1990. ) A study from Ghana on irrigation workers (Clarke E et al 1997) showed that high-risk practices in pesticide use included long duration of use and frequent handling of the chemicals, home storage of pesticides and short re-entry intervals.

Re-entry interval in this case meaning intervals between the end of field application and return to work in the field. The same study also showed that despite knowledge of some health risks associated with pesticides, the use of personal protective device (PPD) was minimal primarily due to financial constraints, but also that they are uncomfortable in a hot climate. The most popular storage site in this study (Clarke E et al 1997) was the bedroom (31%), for security reasons, since pesticides are expensive and not always readily available.

Other hazardous practices identified in a similar setting are “stored within children’s reach”, “stored near food”, “stored in non-original containers”, “stored in unlabeled containers”, “open fire near pesticides”, “equipment not checked”, “pesticide leftovers” and “mixing instructions missing”. (Ngowi et al 2001. ) Intoxication, morbidity and mortality by pesticides can occur occupationally, nonoccupationally, involuntary or as voluntary poisoning in suicide attempts. 10

Pesticides are synthetic chemicals that are released purposely into the environment, they are designed to be toxic to some forms of life and humans are unavoidably exposed. The exposure levels can be measured in different ways. In food and water the pesticide residues can be measured. There are adverse health effects of pesticides that can be divided into different categories such as acute or chronic, immunotoxic effects, neurotoxicity, reproductive toxicity, carcinogenesis and developmental effects (Baker R S, Wilkinson F C. 1988).

Almost immediate effects evidence acute toxicity. Pesticides enter the body through three different routes, the skin, the lungs and the gut. When it comes to chronic toxicity there is concern about five possible outcomes: carcinogenicity (the ability to cause cancer), mutagenicity (damage to genetic material), teratogenicity (effects on the foetus), allergy and other effects on the immune system and, finally, effects on the nervous system. (Arnold E 1990. ) Two insecticides that are used extensively in pest control are organophosphates and carbamates.

Their way of affecting insects and humans is by inhibiting an enzyme called acetyl cholinesterase at nerve endings, which leads to subsequent accumulation of acetylcholine. The symptoms include neuromuscular paralysis and central nervous system dysfunction. Death may result from respiratory failure secondary to pulmonary oedema, bronchoconstriction and respiratory muscular paralysis. Cardiac arrhythmias and epileptic seizures may also occur. (Clarke E et al 1997. ) 1. 5 Reducing the risks with pesticide use The standards of risk reduction do not vary so I have used information from Sweden on some of the issues that must be regarded.

The health hazards with handling, storing and applying pesticides depends on for example the classification of the chemical, the handling practices and the amount of time exposed to the chemical. It is important to have strategies to avoid putting people at risk of exposure. Certain techniques, substances and equipment minimize the risks. According to The Swedish Authority for Protection of Workers the storage place should be kept clean and the chemicals should be kept apart from other goods, from human beings and from the protective equipment, otherwise this can get contaminated.

There should be no outflow or sewage in the storage place, good ventilation and if needed it should be locked. If possible the containers should be considered in terms of safety, that they are easy to empty and do not splash. About safety when using hand sprayers the recommendation is to be extra careful. The chemicals are carried very close to the sprayer’s body and the sprayer gets very close to mist and vegetation that has been treated. It is important to look for leakage in the equipment and the material in the straps of the sprayer must not absorb chemicals.

Cleaning of the equipment should be performed where there is no risk of drainage, and obsolete pesticides should be taken care of by trained persons. (Arbetarskyddsstyrelsens forfattningssamling AFS 1998:6. ) Personal Protective Device (PPD) is the equipment needed to prevent poisoning in pesticide application. It includes boots, overalls, trousers (that flow over the boots), oro-nasal masks, gloves and goggles. Other protective measures are hand washing before food in-take and smoking, and post-spraying baths. (Clarke E et al 1997. ) 11

The Swedish Authority for Protection of Workers regulates the use and handling practices of pesticides in Sweden. Their recommendation on safety includes that there should always be PPD provided. The protective equipment should be kept in good condition and cleaned after it has been used. Gloves should be cleaned on both sides. Contaminated protective devices can instead of protecting put the user under exposure. The same goes for contaminated clothes, they should be changed and washed carefully and the wearer should take a bath. Next there should be washing facilities available with water and soap or something similar.

If pesticides splash on a person’s skin should they immediately be washed away. Before breaks, meals and such, it is important to wash one’s hands and take off one’s protective clothes, and foodstuff and drinks should be kept in a safe way in the field. The recommendations for re-entry intervals vary due to the choice of pesticide. The level of pesticides in the air may decrease quite quickly, but the level of pesticides on the vegetation can still be high. Generally one should not return to the sprayed field for at least 1-2 days after application, and not without wearing personal protective devices. Arbetarskyddsstyrelsen ADI nr 520). 1. 6 Manufacturing and trade Large international companies that have interests in a wide range of chemical products dominate the pesticide manufacturing market. The top ten companies are Ciba Geigy, Bayer, ICI, Rhone, Poulenc, Du Pont, Monsanto, Shell, BASF, Hoechst and Dow. By 1981 33,5% of all pesticide use was in the developing world and it is increasing. Insecticides are the most important plant protector used in low-income countries. In Africa they account for 63% of the total pesticide use.

Insecticides are significant in those settings because insects are the most common pests and because hand weeding, which is still very much practised, means that less herbicides are used. All pesticides include an active ingredient and additional chemicals to make it a usable formulated product. Pesticides can be sold in a number of different forms, broadly divided into liquid and powder form. A single active ingredient can occur in many different brandname products. The last stage of the formulation process involves the packaging and labelling of the product.

After that there is the transportation, distribution, storage and selling of the products. Good package design is an important factor in reducing the incidence of spillage and splashing by operators. Pesticides are often packed in quantities that need repackaging at the retail level. In a low-income setting there have been incidents with repackaging in inappropriate containers with incomplete safety information, often in a language other than that of the local community. Development of new pesticides is a very costly and time-consuming activity, and the safety requirements are high.

Health hazards during manufacturing and formulation are also a reality. Accidents occur. The worst one so far was in Bhopal, India in 1984 where 2352 people died (and probably this figure is an underestimation). The FAO Code of Conduct on distribution and use of pesticides lays down clear standards for testing, distribution, promotion, product information, labelling and advertising, and since 1989 also includes a “red alert” list of more than 50 pesticides and other chemicals that have 12 been banned or severely restricted in five or more countries.

Products on this list will be subject to the principles of Prior Informed Consent (PIC), which means that an exporting country should secure the importing country’s specific consent before shipment and that the importing government should have full knowledge of the domestic regulatory status of the pesticide, including any bans or restrictions on its use. (Arnold E 1990. ) 1. 7 Agriculture and Pesticides in Ethiopia The peasants in Ethiopia have been exposed to different attempts to handle the constant risk of famine, and efforts to bring about an increase in food production, often ending with failure, during the years.

Before the revolution in 1974 the system of landowning was a feudal one. In 1975 the derg initiated the formation of Peasants Associations (PAs), that still exist, and other inventions were for example villagization, resettlement programs and state farms. Up to this day land reforms with real ownership and proximity to the land is believed to be a very crucial step towards a positive development in the agricultural sector. (Mammo T 1999. ) Traditionally, agriculture in Ethiopia is diverse and complex. Inter-cropping is a common practice.

Different crops are often grown side by side, like cereals and vegetables or cereals and trees. The production technologies are primarily traditional. A large number of insect pests have been recorded on major crops in Ethiopia, but only a few of these are considered to be of economic importance. Examples of these pests are migratory pests like locusts and the African armyworm. Crop yield losses due to pests and diseases in Ethiopia and in Africa are about 30-40 %. However, these great yield losses are seen mostly in commercial agriculture, with monoculture.

In diverse cropping systems pests become a significant problem in particular when the proper cultural practices are not followed (except for migratory pests). The complex, traditional agricultural system in Ethiopia encourages natural enemies of pests, and farmers have an accumulated knowledge of when and what to plant in order to minimize losses. The state sector, with the former Ministry of State Farms Development, has been the major user of pesticides in Ethiopia. Research on pesticides has been going on in Ethiopia since the 70s.

Almost all pesticides are imported. Some come as donations from industrialised countries. Between 1983 and 1993 the import was approximately 3. 800 tonnes annually and about 203 tonnes annually was donated. Of the imported pesticides 72 % were insecticides, 25 % herbicides, 2. 6 % fungicides and 1. 3 % others. (Abate T. 1996. ) The most commonly used pesticides in Ethiopia are organophosphates, carbamates and to some extent organochlorides. They are usually applied as an aerosol produced from knapsacks and from simple hand sprayers. (Mekonnen Y and Agonafir T, 2002. In a study from Tanzania by Ngowi et al (2001) they found that more pesticide formulations were used for coffee production than for cotton and also more pesticides were used in individual then in cooperative farms. Hazardous practices were also more pronounced at individual than cooperative farms, with significant differences in pesticide storage areas, as well as unlabeled and non-original containers. That same study (Ngowi et al 2001) demonstrated the need to train farmers in pesticide safety, strengthen advisory and regulatory services, and to extend protection to farm worker’s families.

Other findings from the same Tanzanian study were that empty pesticide containers were used to fetch drinking water and 13 water for pesticide mixing and that food contamination was possible in about one fifth of the farms. 1. 8 Legislation There are regulations concerning registration and use of pesticides in Ethiopia, but there are still some pesticides in use that have been restricted in some industrialised countries. (Abate T. 1996. ) 1. 9 Disposals The disposal of obsolete pesticides is a huge problem.

The lack of funds and of trained personnel makes it difficult to take care of these chemicals. In 1996 the total stock of obsolete pesticides was estimated to be nearly 5,400 tonnes. (Abate T. 1996. ) 1. 10 Sustainable agriculture In Agenda 21 from 1992, in the plan of action for implementing sustainable development, it is stated: “Major adjustments are needed in agricultural, environmental and macroeconomic policy, at both national and international levels, in developed as well in developing countries, to create the conditions for sustainable agriculture and rural development.

The major objective of sustainable and rural development is to increase food production in a sustainable way and enhance food security. This will involve education initiatives, utilization of economic incentives and the development of appropriate and new technologies, thus ensuring stable supplies of nutritionally adequate food, access to those supplies by vulnerable groups, and production for markets; employment and income generation to alleviate poverty; and natural resource management and environmental protection. It is also stated that extensive use of agro-chemicals contributes to soil destruction, and that an integrated approach is to be endeavoured, like the IPM (Integrated Pest Management). (Agenda 21 1992) Alternative methods of pest management are constantly under construction. One approach is the IPM, the Integrated Pest Management (this phrase was first used in 1959), which takes traditional cultural methods such as crop rotation, fallowing, manual weeding, intercropping and the encouragement of natural predators, and combines them with modern chemical techniques.

There are many examples of effective IPM in the so-called developing world. Chinese agriculture has used IPM successfully in for example rice production, and in Cuba IPM has been used for sweet potatoes, peppers and sweet corn with methods like biological control with parasites. In Nicaragua the cotton crop is protected by closer supervision and monitoring and with physical trapping of pests (boll weevils). (Arnold E 1990. ) The political events during the derg also had quite an impact on the environment, and strongly contributed to for instance soil erosion and e-forestation. (Mammo T 1999. ) According to the FAO there is also a huge problem in Ethiopia with pesticide dumps in nearly 1000 sites around the country leaking, and threatening to contaminate rivers and water systems. (www. fao. org) In Ethiopia there has been research on preventing the spread of schistosomiasis by killing the vector snail with a natural plant called endod. (Forget G, Goodman T, de Villiers A. 1993. ) 14

There are efforts made to try to implement alternatives to pesticides in low income countries, for instance by an organization called PAN UK (Pesticide Action Network UK) and there are movements like this in Ethiopia, working with crop protection and safe environment. (http://www. pan-uk. org) 2. 2. 1 Objectives General objectives To assess the risk of acute pesticide poisoning for farmers and their families in smallholder agriculture in Butajira, rural Ethiopia when storing, handling and using pesticides. 2. 2 Specific objectives – To investigate the use of different types of pesticides in Butajira. To observe where and how these pesticides are being stored and handled. – To observe how leftover chemicals and empty containers are being disposed. – To investigate the use of insecticides in the homes. 3. 3. 1 Methodology Study design The study design is that of a quantative cross-sectional risk assessment household survey. Some background information and additional data will be gathered from interviews with key informants. 3. 2 Study site; Butajira Rural Health Programme (BRHP) Butajira is a town situated 130 km south of Addis Ababa, Ethiopia.

Since 1986 there has been a demographic health surveillance project going on here as research cooperation between the Department of Community Health, Addis Ababa University and the Division of Epidemiology and Public Health Sciences, Umea University. The aim of the project is to gain information on fertility, mortality and the disease patterns and health status in a rural population in a sub Saharan setting, through registration of births and deaths, in order to make scientific interventions on public health and to use this data for prevention and disease control.

The Butajira “field laboratory” was also thought to provide a population and study base for essential health research and intervention in the area, including the assessment of coverage and utilisation of health services. 10 villages have been randomly selected and surveyed. Data on births, deaths and migration has been collected every month and put together in a database. This collection, analysis and interpretation of health data are considered essential to the planning, implementation and evaluation of health programmes.

Epidemiological surveillance activities are usually the responsibility of governmental institutions dealing with the health information systems. In low-income countries adequate and reliable health information is often lacking and therefore population studies are needed. A number of surveys have been done within the project concerning specific diseases, on lifestyle factors and on different determinants of health. The main ethnic group in the area is the Gurage, and the language is also called Gurage. (Berhane Y et al. 1999. ) 15 3. Study population: The study population for this study was all farmers in the nine rural peasant associations (PA? s) covered by the Butajira Rural Health Programme. The main respondent was the head of the household, which was believed in most cases to be equivalent with the farmer. Two kebeles (villages), or PA? s, has been chosen within the study population. My first intention was to choose one PA in the lowlands and one in the highlands, but I have had no reason to believe that there are any special differences in utilisation of pesticides between the PA? in the project. If the farm size has an impact on the management of pesticides this would be clarified anyway from the questionnaires. The two PA? s were selected out of convenience and due to the serious time limitations for this project. They are easily accessible and there was a conviction that the selection of these PA? s would not interfere with the results of the study. The first PA is Bido (011), which is located in the highlands and has a population of 1894 people in 433 households, in 2003. The second one is Wurib (06B), which is located also in he highlands and has a population of 5230 people in 1028 households. 3. 4 Sample size: In one study by K Lakew and Y Mekonnen (1997) the percentage using complete protective gear while spraying pesticides among Ethiopian agricultural workers was 18. 1%. In the same study 88. 1% were unaware of the danger of pesticides and only 26. 7% of the workers bathed after pesticide exposure. Other studies by Clarke et al. from Ghana (1997) and by Aiwerasia et al (2001) from Tanzania also show high prevalence of hazardous management of pesticides, especially in small farms.

The farmers in the study area were very much occupied at the time of the data collection, as “the small rains” for this season had come and the cropping season had started. Because there are no exact figures of hazardous management of pesticides, a prevalence of hazardous management of 70% has been chosen in order to calculate a sample size. With a 95% confidence interval this gives an estimated sample of 138 people. n=(1. 96)2 (0. 7×0. 7)= 138 (0. 05) 2 16 3. 5 Sampling methods: A random sample was drawn amongst the farmers in the two kebeles.

All the houses are numbered in the PA? s in the project. By picking every fifth household starting from number one, 70 households in each PA were selected. 3. 6 Data collection For some more in depth background information interviews have been made with key informants in order to give a better understanding of the use of pesticides in Butajira. Mr Abayne at the Regional Agricultural Department in Butajira has contributed with valuable information. A structured questionnaire on the storage and handling practices of pesticides has been used.

The questionnaire was developed by a combination of two standardized questionnaires with some additional questions of interest for this study. It contains both open-ended and closeended questions. Data was also obtained through observations during the home visits. The observational data that was collected was also listed in the questionnaire. The questionnaire was translated to Amharic. The data has been collected through visits to the different households by five trained enumerators that are also employed as supervisors in the Butajira Rural Health Project, and that speak the local language as well as Amharic.

The data collection was done in May 2003. Outcome variables are the use of Personal Protective Devices (PPE), personal hygiene, pesticide containers, storage place and spraying practices. Other variables that are important for the association of risks are training, supervision, size of farm, crops grown etc. 3. 7 Data analysis The data has been analysed with the Epi Info version 6. Frequencies and proportions will be used to describe the outcome of the study. The investigator has done the data entry. 3. Data quality management The questionnaire was first translated to Amharic, then translated back to English by a separate translator, in order to secure the content of the questions asked. Still there were some problems with some of the questions because of misunderstandings due to language constraints. Pre-testing of the questionnaire took place before the actual data collection. The questionnaire was tested on five households by the enumerators, in an area different from the study site, but with the same demographic pattern.

A half-day of training with the enumerators was conducted before the data collection began, including information on pesticides and health-associated risks, and on different kinds of problems that can occur during the data collection. The investigator participated in as many home visits as possible, together with two of the enumerators. The amount of households visited by the investigator was about 10 % of all households. 17 3. 9 Ethical considerations The study proposal was submitted to the Department of Community Health, Addis Ababa University. The study took place after their approval.

Informed verbal consent was obtained from leaders of the kebeles, from the head of the families, from the Regional Agricultural Office and from the Regional Health Department. 4. Communication of results This paper will be handed in at Department of Community Health, Addis Ababa University, Umea International School of Public Health, at Karolinska Institutet and at the funding agency Sida. The results will be communicated to the Health Department in Butajira, the Regional Agricultural Office in Butajira and the BRHP. If it is possible attempts will be made to publish the results.

The intention is that the final report will be translated to Amharic. 5. Results Amongst the 140 informants one person stated that he was working for somebody else and did not cultivate any land. The rest were all farmers with their own land. Some stated that they had a piece of land that they shared with someone who worked for them. Some also stated that they had a piece of land and then rented another piece. The respondents were the head of the family, both male and female. 5. 1 Crops The crops grown by the farmers in this study were mostly maize and teff. 38 respondents in the study state that they cultivated maize, and 120 stated that they cultivated teff. Sorghum is the thirdly most cultivated crop. Most farmers in the study cultivate 3-4 crops. Table 1 shows the crops grown and the use of pesticides for each crop. Maize is by far the most important staple food in the area. Teff is both sold as a cash crop and consumed by the farmers and their families. The situation is similar with sorghum and wheat. Chat is grown as a cash crop, and so are pulses of various kinds. 5. 2 Pesticide use The use of pesticides does not differ between the two PA? in this study. 81 % use pesticides in Wurib and 85 % in Bido. In the study there were a total of 117 farmers who stated that they use pesticides for agricultural purposes. The majority said that they spray 1-2 times per season. There are two cropping seasons per year, belg from February to June and meher from May to December. Pesticides are used mainly for teff; 91 % of the users use weed killers for teff. Pesticides are used by 14 % for chat and by 24 % for crops like pulses. Maize is grown by 98 % of the farmers in this study but only 8 % use pesticides for maize. 18 Table 1;

Crops grown and the use of pesticides Crops: Farmers who grow each crop: % Maize 138 Tef 120 Sorghum 52 Wheat 19 Chat 18 Others 39 Total: N=140 99% 86% 37% 14% 13% 29% N=140 Farmers who use pesticides for each crop: 10 113 2 13 18 30 N=117 % 7% 94% 4% 68% 100% 77% N=117 5. 3 Farm size The size of the farm affects the use of pesticides. The smaller the land the less the use of pesticides. Amongst the farmers with 1-2 timad only about half used pesticides. All farmers that have more then 4 timad use pesticides. How the farm size relates to the use of pesticides and crops cultivated is shown in table 2 and 3.

In the group of farmers with 1-2 timad there was a larger amount of respondents who only grow maize, and no other crop. The farmers with 3-4 and 5-8 timad grow almost as much teff as maize. The cultivation of chat does not seem to differ depending on farm size, but there is a strong bias for answers on growth of chat as it is classified as a drug and illegal. Table 2; Size of farm and the use of pesticides by farmers in this study Size of farm 1-2 timad 3-4 timad 5 and more timad Total: Use pesticides 29 (61. 7%) 66 (94. 3%) 20 (100%) N=115 (84%) Do not use pesticides 18 (38. %) 4 (5. 7%) 0 (0%) N=22 (16%) Total N=47 100% N=70 100% N=20 100% N=137 100% 19 Table 3; Size of farm and the crops grown by farmers in this study Note that more than one crop can be grown. 70 60 50 40 30 20 10 0 1-2 3-4 5-8 timad timad timad Maize Teff Sorghum Chat Wheat Others 5. 4 Spraying Equipment Almost all farmers used manual sprayers and hired a spray man who brought the equipment with him, and then took it back with him after the job was finished. The farmers usually accompanied the spray man in the field, but some farmers did not take part in the spraying at all.

Being asked about precautions taken in order to avoid poisoning, 21 % (24/117) said they stayed at a distance, and did not partcipate in the spraying. The farmers who did the spraying themselves, still hired equipment. Only very few had their own equipment. 5. 5 Storage The pesticides for agricultural use were usually kept for a very short period of time in the household, in conjunction with the spraying, see table 4. They were then kept in the house hanging from the roof or on the wall, or as some stated, outside on top of the roof.

From one other source, I also found out that pesticides are sometimes buried in the ground, as they are safe there, from thieves, children and other unauthorized people. At the time of the data collection only 9 farmers had pesticides in storage. Very few have answered the questions on containers and labelling on pesticides considered for spraying. The ones who have pesticides in storage or have answered anyway, have all stated that they have the original container, that they can understand the labelling and that the language is English and Amharic.

Table 4; Storage time for agricultural pesticides in the households in this survey Time: 0-7 days 1 week- 1 month More then one month No answer Total Number of respondents 40 9 15 53 117 % 34. 2 7. 7% 12. 8% 45. 3% 100% 20 5. 6 PPD and other protection methods 54/117 have answered that they use hats for protection when spraying. This ought to protect more against the sun than against pesticides. The second most common way of protection is to cover mouth and nose with cloth, which is mentioned by 34/117 users. Shoes are mentioned by 28/117 of the respondents (24 %).

I believe this aims at wearing shoes, and not at wearing special protective shoes/boots. Overalls, aprons and old clothes are used by 7-14 %. 39 % state that they change clothes after spraying. Hand washing is performed by 69 (59%) of the respondents, after application. As mentioned above 24 (21%) stand far away from the spraying. Table 5 lists the PPD and other precautions taken by the respondents. Almost 1/5 of the respondents return to the field within a few hours after application, and more than half of the respondents go back within two days. These re-entry intervals are shown in table 6.

Table 5; PPD (Personal Protective Device) and other protective measures taken by the respondents in this study while applying pesticides Note that more than one item can be stated in this table. PPD and other protective measures: Cover mouth and nose with cloth Hats Overalls Safety shoes Aprons Use old clothes while spraying Change clothes after spraying Hand washing after spraying No protection at all Total of exposed: Stand far away from the spraying (i. e. does not take active part in the spraying) Number of respondents 34 53 9 28 12 18 50 69 21 N=93 24/117 (20%) % 37% 57% 10% 30% 13% 19% 54% 74% 23%

Table 6; Re-entry to field after application of pesticides Re-entry intervals: Few hours One day 2-3 days One week No answer Total: Number of respondents: 21 42 38 6 10 117 % 18% 36% 32% 5% 9% 100% 21 5. 7 Disposals 48/117 informants said that they never had obsolete pesticides. Those who said they got leftovers either sold or saved them for next time. Equipment is usually cleaned by the spray man. The farmers who clean the equipment themselves do it in the compound, or in the river. Table 7; Disposals of obsolete pesticides by informants in the survey Note that more than one answer is possible.

Disposal: Never had any leftovers: Save for next time: Sell it to someone else: Use even though it’s not needed: Throw them away: No answer: Total: Number of respondents 48 26 22 9 2 13 N=117 % 38 26 17 7 2 11 5. 8 Health effects 120/140 (85. 7 %) informants believe that pesticides can be dangerous for their own and/or their family’s health. Hardly anybody has experienced any negative health effects. 7 informants have had symptoms that they connect with the use of pesticides, and they are nausea, dizzyness, swollen stomach, stomach pain, watery stool and loss of appetite.

Many answer that “no, we have no problems because we are being very careful” or “no, we haven’t had any problems so far”. 5. 9 Training 95/139 (68,3 %) says that they have received training/information about pesticides, the majority from the vendors. Some also mention neighbours and friends with more experience. There is no information on the quality of this training/information, or what it contains. There is one question in the questionnaire about whether the respondent can read and understand written instructions on the labels of pesticide containers, and the majority state that they can. 5. 10 Vendors

According to the informants at the Regional Agricultural Department the only vendor with a permission to sell pesticides was a NGO with a shop in Butajira town. The Regional Agricultural Department distributes pesticides only in case of emergency, when the entire harvest is being threatened. However, private grocery stores are the most common source for buying pesticides in this study, 98/131 (75 %). In second place comes the government shop and in third place the NGO shop. 22 respondents have stated that they sell obsolete pesticides to others, so this is also a source for buying pesticides. 22 5. 11

Other chemicals Some questions were asked about the use of other household chemicals, such as insecticides for the home, insecticides for animals and pesticides for stored food. Most respondents did not know the names of the products they used because they were sold in non-original containers that were not labelled. A typical answer would be” It was a powder in a bottle, I don’t know the name” or “I bought it in a paper bag, I don’t know what it is called”. One respondent mentioned that they used DDT for insects in the house. Insecticides in the homes were being used for lice and flee mainly, by 69%.

Chemicals for livestock, in this case cows and sheep, were used by 35% of the respondents, but there is no figure on how many that actually kept animals. For stored food the main purpose for use of pesticides mentioned was mealworm beetle, and was used by 16%. At the time of the questioning there was no food in storage for most people due to drought. Rats are not mentioned at all as a reason for using chemicals. Table 8; Chemicals for other purposes than agriculture Number of respondents 96 49 22 % 69% 35% 16% N= 140 140 140 Insecticides in the house Insecticides for livestock Pesticides for stored food . 6. 1 Discussion Analysing results The use of pesticides for agricultural purposes is widespread in this study. The non-users are the informants with the smallest farm areas. This indicates that it is the lack of economic resourses that keeps the usage down, and that the usage will therefore increase when these farmers can afford to buy weed-killers and other agro-chemicals. Crop protection is an essential issue of great importance. The chemicals are kept for short periods of time in the homes, but during that time they are kept in the tukuls in the only room where people sleep and animals are kept.

This implies that the storage is both near open fire and near food containers. The chemicals are kept out of the reach of children and animals if they are hung from the roof or on the wall, but the risk for contamination of water and foodstuffs is there. People seem well informed about the dangers of pesticides, but there are not many alternatives as to where to hide the chemicals so that they are safe. Professional spray men conduct the spraying of the chemicals in almost all cases, and supply the spraying equipment. This implies that the cost of hiring a spray man is less than that of buying own equipment.

Proper Personal Protective Devices (PPD) is not available but respondents seem well aware of the importance of protecting themselves when distributing pesticides. 23% do not use any form of protection while spraying or accompanying the spray man in the field. The rest use protective gear that is not suitable for its purposes. 37% cover mouth and nose with cloth, 23 which is not a good substitute for masks. Hats do not give any protection against the chemicals. Other precautions in terms of hygiene are hand washing after spraying, and 74 % of the respondents state that they do so. Also ? f the respondents state that they change clothes after spraying. I believe that if the PPD were affordable the usage would be quite high because the respondents seem to worry about the health impact from pesticides, even though very few have experienced any symptoms. The mean re-entry interval in this study is pretty satisfying, 1-2 days, but 1/5 of the respondents return to the field within a few hours, and they are therefore exposed to risks. Insecticides for household use were often sold in non-original containers/bottles. Most likely they are being re-packed in the shops. One informant mentioned DDT.

One question was asked on traditional methods for pest control. The conception of “traditional methods” could have been more carefully defined, and there is a possibility that it could have been misunderstood. The respondents have mentioned manual weeding and some have confirmed that they use sand for stored maize to avoid pests. But very few have answered. Other methods to protect from poisoning by pesticides that are mentioned by some are to eat lemon or wash hands with lemon, and to drink arrakhi, local liquor. Manual weeding was a spontaneous answer to an open question, and therefore the figures are not reliable.

I believe that most farmers would have answered that they use manual weeding if they would have been asked this specific question in a prompted way. In other studies (Clarke E E K et al. 1997) it has been shown that the responses differ significantly when being spontaneous or prompted. Information and education on both handling and application practices is gained through the vendors in the shops. The quality of this training/information has not been more carefully examined. It was also common to ask neighbours and friends with more experience about issues concerning pesticide use. . 2 Compatible data? Other studies in Ghana, Ethiopia and Tanzania have focused mainly on state or cooperative farms (Aiwerasia V F et al. 2001. Y Mekonnen and T Agonafir 2002. Clarke E E K et al. 1997. ) and there are very few studies on smallholder private farms. Some studies focus on the health of highly exposed job categories, such as irrigation workers and pest control workers. Aiwerasia V F et al. (2001) have found that individual farms have a higher prevalence of a number of hazardous practices, compared to cooperative farms, and higher risks of exposure to pesticides.

This was significant for storage of pesticides in bedrooms, within the reach of children, near food, near open fire, and for storage in non-original, unlabelled containers. These findings agree with findings in this study, except on the question of original containers, as the frequency of responses is low on that matter. The findings differ when it comes to stocking up pesticides. Surplus pesticides did not occur in this survey in Butajira, and the disposal of obsolete pesticides was therefore not a problem.

Y Mekonnen and T Agonafir (2002) show that the majority of spray men in their study considered careful working and the use of PPD to be essential, but PPD was not always provided and, when available, it was sometimes worn out or inappropriate. The usual types of 24 PPD in their study were overalls, safety shoes, respirators, gloves and goggles. Their findings on hygiene amongst sprayers are similar to findings in this study. On the issue of understanding instructions and language on pesticide labels, the findings differ slightly, but the frequency of response is low in this last study.

Compared to the findings of Y Mekonnen and K Lakew (1998) when investigating risk factors of occupational pesticide poisoning, this study shows a better awareness of possible health hazards, but the degree of unsafe handling practices corresponds in both studies, in terms of hygiene, changing clothes and the use of PPD. In one study by Clarke E E K et al. (1997) the duration and frequency of pesticide application is used as a surrogate of exposure dose. But as the informants in that study were more exposed the results are not compatible with this study.

It seems again, as if respondents in this study are well informed on risks, because the re-entry interval is longer. On storage site and the use of PPD the results correspond with each other. In the study by Clarke E E K et al. (1997) there were questions on attitudes towards PPD, and they found that non-use was primarily due to financial constraints, but it was also being mentioned that PPD was uncomfortable to use in the prevailing hot and humid climate. This is also the case in other studies on PPD (Y Mekonnen and T Agonafir 2002). 6. 3 Limitations The frequency of missing answers is very high for some questions in the survey.

There was no time to go back to the respondents for completing the questionnaires. This is of course a weakness of this study. The health conditions of the respondents have not been investigated in this study. One question has been asked on health problems that the respondent relate to pesticide handling and/or application. Very few had experienced any symptoms that they could relate to pesticide poisoning, and of course these symptoms could very well depend on other health conditions. There was no report off any serious accidents or unmistakable occasions with acute pesticide poisoning leading to injury.

It is possible that this could have been further investigated in the questionnaires, by adding some questions. There is also a risk that the high demand for agro-chemicals might have influenced the farmers not to mention suspected incidents with pesticide poisonings. The timing of the data collection could possibly affect the outcome, as the farmers were very much occupied during this period. Preferably there should also have been PAs from both highland and lowland represented in the study. There has not been any comparison between male and female head of families, so it could be possible that there is difference there, in the utilization f pesticides. Enset (false banana) is not mentioned by the informants in this study but it is seen everywhere and it is a staple food in this area. The fermentation of enset is time-consuming, but the plant does not require a lot of work, and the final product, the meal can be stored for a long period of time. (Berhane Y et al. 1999. ) The reason for not mentioning enset in this study could be that it is not cultivated the same way as the other crops, but this could have been investigated further. 25 The figures for chat are not believed to be fully reliable, as chat is illegal.

Only nine farmers had pesticides in storage at the time of the data collection. The trade names of these chemicals were given in the questionnaires but the active substances and their hazardous classification has not been traced. In those cases where the respondent/head of household is a woman it could be that she is in reality not responsible for the handling of pesticides, if her husband lives in a household different from hers, and that could present a bias in this study. 6. 4 Summary This study indicates that the use of agro-chemicals is widespread in this setting, but not very frequent.

The use of pesticides/insecticides for other purposes such as for household use and for livestock is also quite extensive. The usage seems to increase with larger land and cultivation of cash crops. This is likely to depend on the fact that farmers with smaller land cultivate, to a large extent, only maize, which does not require pesticides. Maize, and sorghum, is consumed rather than sold, and therefore these farmers cannot afford to buy agrochemicals and do not need to buy as much either. When the cultivation of cash crops increase there is a higher demand for pesticides to secure yields.

It is likely that there is a relation between having more land, a more frequent cultivation of cash crops and a higher demand for pesticides. In the future the use of agro-chemicals is likely to increase in this setting and the risks for farm workers handling these materials will therefore probably continue to be a problem. Proper PPD are not available, storage sites are highly hazardous, and pesticides for household use are often being sold in non-original containers. There is also a lack in hygiene and in training on safe use. The respondents were well informed on the risks with handling pesticides.

Poisoning with agro-chemicals is not a major health problem for farmers in this study in comparison with other types of injuries, or diseases, but it is a major, occupational health risk. Due to economic constraints the use is limited in volume and time. But the handling practices are putting farmers and their families at risk of hazardous exposure. The professional sprayers were not addressed, as it was not in the aim of this study. The findings point out the professional sprayers as a group at especially high risk of hazardous exposure, and it is an area where there is further research needed. . Conclusions The finding on pesticide and insecticide use, storage, handling and application indicates that the usage is held down due to economic constraints, and will most likely increase, with possibilities of improving food production and to secure high yields. Together with the findings on inappropriate use of PPD, hazardous storing of pesticides and insufficient training/information, that are supported in other studies in a similar low-income setting (Aiwerasia V F et al. 2001. Y Mekonnen and T Agonafir 2002. Clarke E E K et al. 1997. , this brings about a demand for subsidized PPD from the agro-chemical companies and governments and to take farmers health seriously in consideration when looking at occupational health. Training and information on safe use should be provided, and a 26 continuous work should be done towards achieving an Integrated Pest Management that works in this specific setting. The use of pesticides in smallholder agriculture in resource poor settings, and the need for improved pest control and food security, in connection with a sustainable development is not fully explored.

But the biggest task is to implement all that we do now about the safe use of pesticides, for farm workers, other exposed, and the environment. 8. Acknowledgements I am grateful to IHCAR, Karolinska Institutet and SIDA (The Swedish Development Agency) for their approval of my research proposal and the MFS scholarship. Also I would like to thank all the people at the BRHP (Butajira Rural Health Programme) that have helped me, and at The Department of Community Health at Black Lion Hospital, AAU. Last, thank you to everyone who has helped me go through with this, babysitters, family and friends. 9.

References Agenda 21. Rio Declaration on Environment and Development. UNCED Rio de Janeiro, Brazil 1992. Abate T. Ethiopian experience with pesticides-no foundation for food security; Pesticide News 1996; 33:12-13. Arbetarskyddsstyrelsen ADI nr 520. Arbetarskyddsstyrelsens forfattningssamling AFS 1998:6. Arnold E. The BMA guide to Pesticides, Chemicals and Health. London: British Medical Association, 1990. 215p. Berhane Y et al. Establishing an epidemiological field laboratory in rural areas – potentials for public health research and interventions; The Butajira Rural Health Programme 1987-1999.

The Ethiopian Journal of Health Development, Vol. 13, Special Issue, 1999, ISSN 1021-6790. Clarke E E K, Levy L S, Spurgeon A, Calvert I A. The problems associated with pesticide use by irrigation workers in Ghana. Occupational Medicine 1997; 47:301-308. Impact of pesticide use on health in developing countries: proceedings of a symposium held in Ottawa, Canada, 17-20 September 1990/ed. by Forget G, Goodman T, de Villiers A. Ottawa, Ont. : International Development Research Centre, 1993. 335p. Lakew K, Mekonnen Y. Use of pesticides and causal factors of poisoning. A study among agricultural workers in Ethiopia.

African Newsletter on Occupational Health and Safety. 1997;7:68-70. Lakew K, Mekonnen Y. Cholinesterase Status of some Ethiopian State Farm Workers Exposed to Organophosphate Pesticides. Journal of Occupational Health. 1998;40:83-90. 27 Lakew K, Mekonnen Y. The Health Status of Northern Omo State Farm Workers Exposed to Chlorpyrifos and Profanifos. Ethiopian Medical Journal 1998:36. Mammo, Tirfe. The Paradox of Africa’s Poverty; The role of indigenous knowledge, traditional practices and local institutions-the case of Ethiopia. Lawrenceville, NJ. The Red Sea Press, Inc. 1999. 268p.

Mekonnen Y, Agonafir T. Personal Protective Equipment use by farm workers in Ethiopia. Pesticides News 2002:55. Mekonnen Y, Agonafir T. Pesticide sprayers? knowledge, attitude and practice of pesticide use on agricultural farms of Ethiopia; Occupational Medicine 2002; 52(6): 311-5. Mekonnen Y, Agonafir T. Effects of Pesticide Applications on Respiratory Health of Ethiopian Farm Workers. International Journal of Occupational and Environmental Health 2002; 8:35-40. Ngowi AV F et al. Pesticide-handling Practices in Agriculture in Tanzania: Observational Data from 27 Coffee and Cotton Farms.

International Journal of Occupational and Environmental Health 2001; 7:326-332. Ngowi AV F et al. Assessment of the ability of health care providers to treat and prevent adverse health effects of pesticides in agricultural areas of Tanzania. International Journal of Occupational Medicine and Environmental Health 2001:14(4): 349-356. The Effect of Pesticides on Human Health: Proceedings of a Workshop, May 9-11, 1988, Keystone, Colorado/ed. by Baker R S, Wilkinson F C. Princeton, N. J. : Princeton Scientific Pub. Co. 1990. 438p. Public health impact of pesticides used in agriculture.

Geneva: Published by the World Health Organization in collaboration with the United Nations Environment Programme: 1990. 128p. Web-sites: http://www. pan-uk. org http://www. pbs. org www. aaas. org www. fao. org 28 Department of Public Health Sciences Division of International Health (IHCAR) Minor Field Study (MFS)-REPORTS Karolinska Institutet IHCAR MFS-REPORTS (New series) 1/89-90: 2/89-90: Karin Ekstrom ”The integration of the traditional maternity care into maternity care at Chikankata Hospital in Zambia” – April 1990. Magnus Goransson ”Women in development. A study of a community-based health care project in southern India” – June 1990. *************** 1/90-91: 2/90-91: 3/90-91: Anna Cerne, Anders Odeback ”Maternal deaths at the University Teaching Hospital Lusaka, Zambia” – January 1991. Lena Netjaeff ”Vietnamese midwives’ training and working conditions” March – April 1990. Jerker Jonsson, Ann Lindstrand ”Nosocomial infections at the neonatal ward, Department of Paediatrics, Maputo Central Hospital, Maputo, Mocambique October – December 1991. Solveig Stock ”Preliminary investigation to an interdisciplinary research project within maternal health care in Leon, Nicaragua, focusing on maternity ward routines” – February – April 1991. **************** 1/91-92: Karin Bostrom ”A rural hospital in Loni, India – Retained placenta and postpartum hemorrhage and a maternal health information system” September 4 – November 30, 1990. Louise Laurell ”A study of the Nicaraguan antenatal card, Nicaragua” – July 1992. Lena Arvidson ”Women’s situation during childbirth. Data on a certain group of women in Ethiopia and Sweden” – September 1992. Maria Sorensson ”Hygiene education with a participatory approach for women in Madras, India. A Minor Field Study Report. Study period January 9 – April 10, 1992” – June 1993.

Asa Andersson ”Peer-education as an information strategy. A description of a youth project concerning sexual and reproductive health in Tanzania using peer-education as an information strategy. A Minor Field Study Report. ” Spring 1995. ******************** 1/93-94: Ann-Sofie Fransson, Nils Olsson ”Management of suspected malaria at different health care levels in Tanzania. A Minor Field Study Report 91/92” July 1993. 4/90-91: 1/92-93: 2/92-93: 3/92-93: 4/92-93: 29 2/93-94: 3/93-94: Eva Engdahl, Anna-Karin Olofsson ”Assessment of the control of diarrhoeal diseases (CDD) case management in Lusaka, Zambia” – July 1993.

Knut Lonnroth ”Reflections on epilepsy care in Vietnam. An explorative study on care provided for people with epilepsy, utilization patterns and psychosocial consequences of having epilepsy” – March 1994. Maria Eriksson ”The use of herbs in the area of Coban, Alta Vera Paz, Guatemala. An ethnomedical study of the healing properties of plants and curative phenomena” – March 1994. Eva Johansson ”Community based rehabilitation in Zimbabwe – a case study” – May 1994. Mats Nordgren ”Vaccination program and missed opportunities on Java, Indo 4/93-94: 5/93-94: 6/93-94: 30

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