(I'm sorry for the formatting it got all messed up copying and sadly this isn't a publicly available article but i have attached a PDF of it you can read if this is too illegible)
Method Procedure
Eight research assistants from Enugu were recruited. All assistants were proficient in Englishand the Igbo language. Training of research assis-tants occurred in several phases. First, the assistantscompleted the ‘Human Participant Training’ offeredby the US National Institute of Health. During thesecond phase, all research assistants were familiar-ized with the questionnaire and procedures. Thisensured that the assistants understood the technicalterms and medical concepts in the survey so theywere able to explain the terms and concepts to theparticipants. Regular meetings were held with theassistants during data collection where progress andissues were discussed and resolved.All adults above 18 years of age within the sam-pled area were eligible to participate in the survey,while those that were under 18 years of age wereexcluded from the study. Each research assistantbegan sampling on one street, which was randomlyselected, and then proceeded to each house on thestreet where a resident answered the door. Once theentire block of houses was sampled, the researchassistant began the same process at a second street.The survey was translated into Igbo and English,the two major languages spoken by Enugu resi-dents. Respondents were told that their answers tothe questions would be kept confidential. Mostefforts to contact the respondents occurred in theevenings when more respondents were available intheir homes. In 98 percent of households, theresearch assistant provided directions for complet-ing the questionnaire and then left the questionnairewith the respondent and returned at a scheduledtime to pick up the questionnaire. Only 2 percent ofrespondents requested to fill out the survey whilethe interviewer was in the home.
Seven of the 17 (41%) individuals who screenedpositive for CFS-like illness and five of five (100%)individuals randomly selected from 1057 screenednegative participants at phase one agreed to com-plete phase two. These participants in the CFS-likegroup and a non CFS-like control group completeda psychiatric and medical evaluation. After fillingout a Human Subjects Consent Form, the SCID wasadministered by a trained master’s level clinician.This was followed by a complete medical examina-tion. The examining physician conducted a detailedmedical evaluation at Annunciation Hospital Enugu,Nigeria to rule out exclusionary medical conditionscausing the fatigue. A tender point examination wasused to examine for fibromyalgia. Non-medicallyexplained chronic fatigue was defined as a chronicfatigue for which no medical explanation could befound. None of the participants had fibromyalgia.The participants completed the laboratory examina-tion, which included a chemistry screen (glucose,calcium, electrolytes, uric acid and liver and renalfunction tests), complete blood cell counts, thyrox-ine, thyrotropin, erythrocyte sedimentation rate,arthritic profile, hepatitis B surface antigen, humanimmunodeficiency virus screen, malaria parasites,typhoid screen and urinalysis. Three physiciansreviewed the data on these 12 persons, and thosewho met the Fukuda et al. (1994) CFS definitionwere classified as having CFS. Three of the sevenCFS-like group received a final diagnosis of CFSJOURNAL OF HEALTH PSYCHOLOGY 12(3)466while none of the five screened negative met the CFS criteria.
Pediatric prevalence rates
The prevalence of chronic fatigue was determinedfrom parents’ reports of their children or teenagershaving constantly or repeatedly during the past sixmonths a lack of energy or missing activities due tobeing too tired or sick. Thirty-seven cases out of atotal of 249 reports completed by parents indicatedchronic fatigue, yielding a chronic fatigue prevalencerate of 15,000 cases per 100,000 (15%). Of these 37cases, three individuals had at least four additionalcriteria symptoms (out of eight Fukuda et al. symp-toms and four additional symptoms mentioned in themethods section). Defining CFS-like illness as atleast six months of lack of energy or missing activitybecause of tiredness or sickness, and the presence offour or more criteria symptoms, the prevalence of CFS-like illness is 2400 cases per 100,000 (2.4%)
Discussion
The present study reports for the first time rates ofCFS in a community-based sample in a developingcountry. Whereas a 0.68 percent CFS adult prevalencerate was noted in this study, two community-basedCFS epidemiologic studies in the USA found preva-lence rates of 0.42 percent (Jason et al., 1999) and0.24 percent (Reyes et al., 2003). The slightly higherCFS rates in Nigeria might be due to the fact thatpoverty and malnourishment, which occur more fre-quently in developing countries, increase a person’srisk of having health problems (Singer & Clair, 2003;Whiteside & Friberg, 1998). Other factors that mighthave contributed to slightly higher rates of CFSinclude lack of access to healthcare resources, lack ofadequate nutrition and higher prevalence of a varietyof other medical illnesses (Patel et al., 2005). In termsof participants’ attributions, dominant causes ofNJOKU ET AL.: THE PREVALENCE OF CFS IN NIGERIA469Table 3. Percentage of symptomsSymptom Chronic fatigue CFS-like CFS Sig.Fatigue 100.00 100.00 100.0Headaches+ 25.2a 92.9a 66.7 **Muscle pain+ 18.4a 57.1a 66.7 **Unrefreshing sleep+ 24.3a 78.6a 66.7 **Post-exertional malaise+ 19.4a 85.7a 66.7 **Impaired memory & 17.5a 71.4a 66.7 **concentration+Fever & chills 17.5 a 85.7a 66.7 **Multiple joint pain+ 10.0a 64.3a 66.7 **Muscle weakness 19.4 a 58.8a 66.7 **Sore throat+ 11.7a 42.9a 33.3 **Sensitivity to alcohol 8.7 a 42.9a 0 **Nausea 14.6 a 64.3a 0 *Tender/sore lymph nodes+ 7.8a 28.6a 0 *+ Fukuda et al. (1994) symptomsComparisons were between CF and CFS-like groups. CFS group was too small to be includeda Indicate groups that are significantly different for each symptom** = significant at 0.01 level; * = significant at 0.05 levelfatigue were ‘overwork, not having enough money tocare for family, stress, sickness, malaria/typhoid, lackof money and lack of job, family problem, lack ofhealthcare, and health condition’.Adult rates of chronic fatigue were also higher inthis study than in the two US community-based stud-ies (Jason et al., 1999; Reyes et al., 2003). In thisNigerian sample, the rate of chronic fatigue was 9.5percent, whereas the rates in the US studies were 4.2percent (Jason et al., 1999) and 4.9 percent (Reyeset al., 2003). The higher rate of chronic fatigue foundin this Nigerian sample may be due to the higherprevalence of fatiguing illnesses such as malaria andtyphoid. This pattern is consistent with a multi-national study conducted by Skapinakis et al. (2003),which found that individuals from less developedcountries such as Nigeria, in contrast to more devel-oped countries, reported higher rates of fatigue tophysicians. Poverty, lack of proper nutrition (Jasonet al., 1999; Patel et al., 2005), and other environ-mental conditions (e.g. lack of jobs, and inflation)might make inhabitants of developing countries morevulnerable to persistent fatiguing illnesses.In the present study, the Igbos reported greaterfatigue severity than other ethnic groups. It is possi-ble that socio-political factors such as unequal dis-tribution of basic amenities may play a significantrole in the Igbos’ experience of fatigue. Since 1967when the Nigerian civil war began, the Igbos havehad a strained relationship with the Yorubas andHausas. The stress of needing to fight for theirrights, and lack of access to basic amenities, mayhave contributed to more severe fatigue experiencedby the Igbos. However, participants of the Igbo eth-nic group attributed their chronic fatigue to factorssuch as ‘stress, hard work, lack of healthcare, lackof funds and family problems’.In the current Nigerian study, women did not sig-nificantly differ from men in any of the fatiguegroups examined. While the three individuals iden-tified with CFS were all women, and this does cor-roborate findings in developed countries (Jason et al.,1999; Reyes et al., 2003), the small sample size lim-its any firm conclusions regarding gender. In addition,women and men did not differ on fatigue severity.This is in contrast to studies in other countries thathave found that women experienced greater fatigueseverity than men (Jason et al., 1999; Reyes et al.,2003; Taylor et al., 2003).
Fatigue severity was highest among individualsin the 40 to 49 years age range and lowest in the 18to 29 years age range. In the Nigerian context,younger individuals have less pressure to providefor family needs. By age 40 to 49, Nigerians areexpected to contribute to the financial well-being oftheir immediate and extended family. With thisadditional obligation, the older individuals may bemore vulnerable to fatigue. This finding is consis-tent with other studies that have found that olderindividuals are at more risk for fatigue (Jason et al.,1999; Reyes et al., 2003).Educational level did not impact rates of fatigueand its severity among this Nigerian sample. This isin contrast to other research that has found that lesseducation is associated with higher levels of fatigue(Bierl et al., 2004; Jason et al., 2000; Patel et al.,2005). It is possible that in a country such asNigeria, where many individuals encounter unem-ployment, inadequate amenities and access tohealthcare, education may not play a significant rolein the experience of fatigue.Regarding occupation, unskilled workersreported higher rates of chronic fatigue than skilledworkers. Other researchers have also found thatindividuals working in unskilled jobs are at greaterrisk for having fatiguing illnesses (Jason et al.,1999; Lloyd et al., 1990). These findings might bedue to unskilled workers being required to workmore hours, being compensated less, experiencingmore economic difficulties and ultimately havingfewer resources to buffer the effect of stress.Psychological distress increased progressivelyamong the four fatigue groups. Psychological dis-tress was also a significant predictor of fatigue sever-ity. Other studies have found an association betweenfatigue syndromes and psychological distress(Pawlikowska et al., 1994; Wessely, Chalder, Hirsch,Wallace, & Wright, 1996). Some researchers havesuggested that psychological distress may be a reac-tion to this chronic illness and, therefore, a secondarydiagnosis. Others consider that the overlapping cri-teria for chronic fatigue and psychological disordersmay contribute to the association between fatigueseverity and psychological distress (Cope, Mann,Pelosi, & David, 1996; Skapinakis, Lewis, & Meltzer,2000).PediatricThe prevalence of CFS-like illness for the pediatricsample in Nigeria was slightly higher than the ratesfound in other pediatric studies. Whereas a 2.4 per-cent CFS-like prevalence rate was noted in thisNigerian sample, two community-based CFS-likepediatric studies in the USA found prevalence ratesJOURNAL OF HEALTH PSYCHOLOGY 12(3)470of 0.3 percent (Jones, Nisenbaum, Solomon, Reyes,& Reeves, 2004) and 2.05 percent (Jordan et al.,2000). This pediatric Nigerian CFS-like rate ishigher than the CFS-like rate found among theNigerian adult sample (1.3%). It is to be noted thatboth the Nigerian pediatric and Jordan et al. (2000)CFS-like rates are based on a symptom checklistthat included four symptoms in addition to the eightFukuda et al. (1994) minor CFS symptoms.Rate of chronic fatigue was higher among thisNigerian pediatric sample (12.4%) than in the twoUS community-based studies (1.3%, Jones et al.,2004; 4.4%, Jordan et al., 2000). The pediatricchronic fatigue rate (12.4%) was higher than the ratefound among the adult sample (9.5%). It is possiblethat the higher chronic fatigue rates in Nigerian chil-dren were due to malnourishment, which might leadto greater risks for health problems. Studies indicatethat 30.7 percent of children in Nigeria are malnour-ished and more than 50 percent of all childhooddeaths have malnutrition as the underlying cause(World Bank Group, 2005; US Agency forInternational Development (USAID), 2002).
Gender was not a significant factor among thepediatric sample. Some studies have found that girlsreport chronic fatigue more often than boys(Farmer, Fowler, Scourfield, & Thapar, 2004; Viner& Hotopf, 2004), while others such as Jones et al.(2004) and Jordan et al. (2000) found that girls didnot differ from boys in rates of chronic fatigue. It ispossible that factors such as malnutrition and otherillnesses experienced by both genders in Nigeriamake them equally susceptible to chronic fatigue.The present study found that children zero to sixyears of age were reported by parents as experienc-ing more chronic fatigue than those of seven to12and 13 to18 age ranges. Other studies have foundthat older children and adolescents are at higher riskfor chronic fatigue (Chalder, Goodman, Wessely,Hotopf, & Meltzer, 2003; Dobbins et al., 1997). Thedifferences in findings may be explained by theimpact of malnourishment and childhood diseasessuch as malaria, diarrhea, acute respiratory infec-tion and vaccine-preventable diseases in Nigeriaand children aged zero to five years are more at riskfor these illnesses, which are associated with severefatigue (USAID, 2002).Overall, this study shows that fatigue and CFS arenot solely illnesses that affect individuals in devel-oped countries but rather are illnesses that occur inboth developed and developing countries. As thisis the first community-based CFS prevalence studyin a developing country, the findings need to bereplicated in other countries before any firm conclu-sions can be made about the rates of CFS in devel-oping countries. Also, the small sample size limitsthe generalizations that can be made. For example,the CFS group was not included in all demographicanalyses because of small sample size. In addition,the Igbos were overrepresented in this sample andtherefore the ethnic differences found should beinterpreted with caution. Future research with largersamples is needed to prospectively follow-up theparticipants over time to estimate the natural historyof CFS, and determine the incidence of CFS.Community-based studies are needed to betterunderstand the onset, prognosis, risk factors andsymptom types among samples in both developedand developing countries (Jason et al., 2005–2006).
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