Cultural Epidemiology for Malaria Control

Abstract

Malaria is a threat to more than 40% of the world’s population and responsible for more than 300 million acute cases each year, which resulted in 1.2 million deaths in 2002. Over 80% of the malaria-related morbidity and mortality occur in sub-Saharan Africa with children under five and pregnant women at highest risk. The malaria situation in Ghana is typical of sub-Saharan Africa, where malaria is ranked first among the ten diseases most frequently seen in most health facilities in the country. Due to widespread poverty, however, many households depend on a combination of herbs and over-the-counter drugs, usually consisting of inadequate doses of antimalarials, chiefly chloroquine and analgesics. In Ghana, as in other parts of sub-Saharan Africa, where malaria is due mainly to Plasmodium falciparum and potentially fatal, early and effective treatment saves lives by preventing disease progression to severe malaria. In view of this, prompt recognition and effective timely treatment of malaria is a critical element of global malaria control strategies. The overall goal of this study was to determine the occurrence, distribution, and determinants of MRI experiences, meanings and behaviours, inasmuch as these affect risk, and protective behaviours relevant for intervention to reduce malaria-related morbidity and mortality in children and pregnant women. The study was carried out in two rural communities (Obosomasi, located in the forest vegetation zone, and Galo-Sota, in the coastal savannah zone) in Ghana, over the period from October 2002 to April 2004. This was a cultural epidemiological study employing two-stage data collection strategies. The first stage was ethnographic study, which made use of free listing and rating, participatory mapping, focus group discussions and in-depth interviews to generate relevant local malaria-related illness experiences, meanings and behaviours. The second stage made use of these relevant categories and representations to design EMIC (insiders’ perspective) interviews, which are tools to assess the occurrence, determinants and distributions of these categories to guide appropriate interventions for all segments of the population studied. Results: Malaria is recognised as a leading health problem in these communities, affecting children and pregnant women more than other segments of the population. Mosquitoes were identifies as the leading causes of malaria-related illness without convulsions, a finding at odds with earlier studies in southern Ghana, indicating changing local perceptions. Local people reported that heat from the sun is a major cause of malaria-related illness without convulsions, and this finding suggests a need for further study to determine the link between heat from the sun and triggers of clinical malaria episodes. Home treatment for malaria-related illness is very common and entails the use of herbal and biomedical medications. The clinic and hospital were preferred sites for treatment of MRI, including convulsions, outside the home, but most patients get there rather late. Convulsions were identified as a component of the malaria-related illness complex, and mosquito bites and febrile malaria episodes were identified as two important causes of MRI with convulsions. This finding was also a departure from most previous reports from sub-Saharan Africa. Despite relating mosquito, malaria and convulsions to one another, local people continue to implicate supernatural forces among causes of convulsions, but explaining that spirits take advantage of malaria attacks to make their mischief.Local healers continue to play an important role in the management of convulsions, but mainly as one aspect of the holistic healing process, involving both rituals to drive away mischievous spirits and biomedical treatments. That is, local healers perform rituals to drive away the spirit causing the convulsions, which paves the way for biomedical treatment and a complete cure. Local healers are also reputed to have ‘medicine’ to protect children from convulsive attacks. Despite the general agreement between the accounts of pregnant women and the general population, there were some significant differences suggesting the need for gender-specific interventions to control malaria-related illness in pregnancy. The recent introduction of intermittent preventive treatment appears responsive to this need, but it may need to be extended as a community programme to achieve the goal of reducing the malaria-related disease burden in pregnancy. Vignette-based interviews evoke responses specifying categories of malaria-related illness experiences, meanings, and behaviours similar to case-based interviews, but with differences in frequencies of reporting these categories. This is the first time that the cultural epidemiology framework has been applied to study the socio-cultural aspects of malaria covered in this thesis, and it substantially adds to the growing body of knowledge of the importance of socio-cultural factors in malaria control. The implications of the findings for interventions are discussed in individual papers presented in the thesis, and in consisting of a discussion of the overall study and conclusions.