This study was conducted from October, 2002 to April, 2004 in two malaria-endemic villages, Galo-Sota in the Keta District and Obosomase in the Akuapim North District of Ghana. Keta District is located in the coastal savannah vegetation zone of the Volta region, where about a third of the total surface area is covered with lakes and ponds. The district has a population of 137,751 (Government of Ghana national population census, 2000), consisting mainly of the Anlo patrilineal descent group (98.8%). The Anlo language is one of the closely related dialects spoken among the Ewe-speaking people of Ghana (Keta District Annual Report, 2001). The Anlo people are predominantly subsistence food-crop farmers, but they also cultivate shallot (a tropical spice grown in commercial quantities). Some are fishermen and petty traders. Galo-Sota is a rural village with a population of about 6,000 to 7,000. A health post is situated at the centre of the village, staffed by a nurse/midwife, two community nurses and two auxiliary workers. Malaria was the most common health problem treated at the community health post in 2002. A tributary of the Volta River passes through the village, demarcating a boundary between Galo and Sota, which together constitute Galo-Sota.

The Akuapim North District in the eastern region of Ghana is situated in the forest zone. The district population is 113,915, according to the last census (National population census, 2000). The Akuapim-Twi-speaking people, members of the Akan matrilineal descent group, predominate in the district. These Akuapim people are also mainly food-crop farmers and petty traders. Oil palm, a cash crop, is cultivated on a limited scale. The district is currently being prepared as a designated site for a malaria vaccine trial. Among health science activities in the area is a Centre for Scientific Research into Plant Medicine (Akuapim North District Annual Report, 2001). Obosomase (population 7,000 to 8,000) is the rural study village in the Akuapim North District. It has a community clinic staffed by a nurse/midwife, a community health nurse and one auxiliary staff. As in Galo-Sota, malaria was the most common health problem treated at the community clinic in 2002.

Two EMIC interview tools were developed locally to study the relationship between sociocultural factors and appropriate treatment-seeking for children up to five years of age. EMIC interviews are locally adapted instruments for assessing representations of illness or specified health problems from the perspective of affected persons, their family or community members. They elaborate the distribution of local insiders' illness-related experience, meaning and behaviour integrating qualitative and quantitative approaches 1718. The designs of these semi-structured vignette-based interviews were informed by baseline ethnographic data which generated illness narratives that specified locally relevant MRI-related categories of distress, perceived causes and help-seeking behaviours. The vignettes for MRI-CP and MRI-CN are included in an appendix "a" and "b". To account for gender differences, two vignettes were presented with men responding to male vignettes and women responding to female vignettes.

Respondents aged 20 years or more were selected randomly from community registers to participate in the interviews. However, younger respondents between the ages of 20 and 25 years of age were unwilling to participate in the interview using the vignette depicting MRI with convulsion, which introduced some age difference between the two groups of respondents. The reason for refusal was, they claimed, that they did not have any experience to talk about. Informal discussions, however, revealed that some people believed that if they talked about convulsions, this might bring that condition to their children. This attitude was observed in both communities. One hundred interviews were conducted using vignettes depicting MRI-CN and 101 using vignettes depicting MRI-CP. Respondents were evenly distributed by sex and community. Few of those originally selected eventually refused to participate in either of the interviews – two men and one woman at Obosomase and three men at Galo-Sota. The dissenting individuals were replaced from the registers.

Interviews were conducted by the first author in the local languages, and data were recorded by a research assistant with a degree in sociology, who was trained to record both qualitative and quantitative interview data. The EMIC instrument was pre-tested to refine it and gain experience. The pretesting showed it was unnecessary to tape record the interviews, inasmuch as the data were recorded very well by the research assistant.

Data from the two communities were pooled for this analysis. Item-specific qualitative narrative data were entered into a word processor (Microsoft Word) and imported in a structured format for automatic coding, referencing text segments of EMIC interview items in MAXqda, a programme for textual analysis 19. These data were analysed to complement and elaborate the quantitative accounts and to clarify relevant aspects of illness-related experience, meaning and behaviour. Variables of interest in the quantitative data-base were imported into MAXqda as selection variables. This integrated approach to quantitative and qualitative analysis enabled us to perform a phenomenological analysis of relevant coded segments from selected respondents to categories that were analysed with quantitative methods.

Quantitative data were double entered in DOS EpiInfo version 6.04 and subsequently analysed with the EpiInfo Windows version 3.3 20. The frequencies of spontaneously reported and probed responses were examined to specified categories of cultural epidemiological variables for patterns of distress (PD), perceived causes (PC), self-help at home (SH), outside help-seeking (HS) and preventive measure (PC). The prominence of reported variables (2 = spontaneously reported, 1 = probed and 0 = not reported) was compared in the MRI-CP and MRI-CN groups using the Wilcoxon test. The percentage reporting each category and the fraction reporting the category spontaneously are presented in tables. Respondents were also asked to identify the most troubling symptom (PD) and the most important perceived cause (PC). These variables were compared in the two groups with Fisher's exact test. The variables, as initially coded, were also grouped and analysed under relevant subgroups, based on investigators' judgement of shared meanings under a broader heading.

Reported duration from illness onset to observe, wait or treat at home before seeking-help from outside the home for the children presented in the two vignettes was analysed to compute anticipated timely, appropriate help-seeking for MRI-CP and MRI-CN within 24 and 48 hours. The reported timeliness was then compared for the two vignette groups.

Reported symptoms of both conditions are presented in Table 3. Some of these were distinctive for each presentation, and others were reported for both presentations, but with some differences. Convulsion-related symptoms were more prominent in the MRI-CP group, and more frequently reported as most troubling. On the other hand, MRI-CN respondents reported significantly more fever-related symptom and identified them more frequently as most troubling. Non specific symptoms, except for breathlessness, were also most prominent in responses of the MRI-CN group.

The following narratives indicate how people explain the symptoms presented in the vignettes. A woman speaking about convulsive illness characterized typical features: "In most cases, the child's jaws are locked, and the child becomes very stiff. Also, foaming fluid comes from the mouth. In some cases the child becomes unconscious."

Another respondent explained, "Among most typical symptoms, the child begins to shiver and all of a sudden becomes very stiff and hot, and rolls the eye balls."

A man explained typical symptoms for MRI-CN: "The first sign is that the child feels very cold and then at certain times feels hot. It is also possible that the child loses weight and sweats so much. The child's eyes also turn yellow because of the fever. The colour of his urine will look yellowish, and he may become very weak."

A woman explained, "The child's body becomes hot and this makes her cry a lot. She may complain of headache, and feels cold and shivers. She may also find it difficult to eat; her eyes become yellow, and she looks pale and weak."

Most troubling symptoms reported more frequently by MRI-CP respondents included unconsciousness and stiffness. For MRI-CN respondents, most troubling symptoms more frequently reported were yellowish eyes, refusal of food, and weight loss. Weakness was identified by some respondents in both groups as most troubling.

Among features of distress, apart from somatic symptoms of malaria, a number of problems were reported to affect the families of the children in the vignettes with and without convulsions (as specified by percent reported/ fraction spontaneous). Nearly all respondents reported loss of income for families of the affected children (99.0% reporting/0. 42 fraction spontaneous for MRI-CP, and 100% reporting/0.46 fraction spontaneous for MRI-CN), concern about the course of illness (100.0%/0.90 MRI-CP, and 99.0%/0.90 MRI-CN) and sadness, anxiety or worry (99.0%/0.94 MRI-CP, and 100%/0.93 MRI-CN). However, financial concerns (unavailability of funds for treatment and inability to work for money), which leads to anxiety, were frequently reported as the most troubling categories of distress for the family, (71.3% for MRI-CP, and 76.0% for MRI-CN). Concern about the course of illness was also considered one of the most troubling categories of distress for the family (26.7% for MRI-CP, and 21.0%% for MRI-CN). These were common features of both groups without statistically significant difference between them.

The following representative narratives explain the importance of income loss to the family of a child with MRI. An MRI-CP respondent elaborated: "Generally, if a child becomes ill, the parents are worried because they do not know what could happen to their child, and in addition to that, it could lead to financial problems for the family." Another respondent lamented: "The child's condition can adversely affect her in the future, so the parents would become so bothered and worried about the child, especially if they do not have money. The child could become deaf and mute or have a mental problem. I have seen one like that before."

Referring to MRI-CN, a man said: "Fever kills so the family would be worried. Also money issues could be a problem for them."

Another respondent explained: "It is very normal that when your child is sick, you become worried, especially if you do not have money."

The prominence of many perceived causes differed for the two groups (Table 4). The most frequently reported perceived causes of convulsions reported by MRI-CP respondents were spirits, phlegm, worm infections and atridii/asra/malaria; this last category refers to local terms for MRI as a cause of convulsions. Most frequently reported perceived causes of MRI by MRI-CN respondents were mosquito bites, eating too much fatty or oily food and heat from the sun.

Overlapping meanings were also reported in respondents' accounts of perceived causes. For example, a woman in the MRI-CP group explained: "Some people claim that if children play on refuse dumps they easily get convulsion, but I also think that a child can get it through mosquito bites, because these give fever, which can lead to this condition. Worms can also cause a child to get this condition, because worms release some substances into the child's stomach, which in turn gives the child phlegm. And this can cause a convulsion. Evil spirits can also cause children to have this illness."

A man said: "Malaria is the major cause, but in some cases, spiritual forces can also cause a convulsion. It also depends on the kinds of food that children take, like unbalanced diet."

Explaining MRI-CN, a woman commented: "This condition could have been caused by worm infestations or houseflies that perch on food and contaminate it before it is eaten. Sometimes too mosquito bites can cause it."

Another said: "Maybe she wasn't eating good food. Bad food like fatty/oily foods can lead to this problem. I know that mosquito bites or living in a dirty environment could also cause it. And exposure to the heat from the sun can also cause it."

Respondents reported various self-help options for both conditions. The most prominent among reported sources of self-help for MRI of both types was herbal-based remedies for drinking (Table 5). Among pharmaceutical medicines, purchasing drugs from the drug or chemical shops was most prominent in responses of both groups, but significantly more so for the MRI-CN group. Other traditional remedies, such as scarification were reported more for the MRI-CP vignette.

A woman emphasized the value of various traditional remedies for MRI-CP: "In some cases they say that water kept in a 'banku pot' (utensil for preparing a local maize meal) overnight, mixed with urine, can be used to bathe the child for relief. Herbal preparations can also be used to bathe the child. Some people prefer to prepare some herbs for the child to drink. Some also give honey, while some people may buy drugs from the chemical sellers."

Commenting on MRI-CP vignette, a man indicated how various interventions might all be appropriate: "Some of the possible actions may be to buy drugs from a chemical seller for the child to drink or prepare herbs for drinking or enema."

A respondent in the MRI-CN vignette group indicated the value of diverse treatment for that condition as well: "Some medicine could be given at home as a measure to reduce the severity of the illness. The medicine could be bought from the drug stores if there are no leftovers. Some herbal medications can also be given to the child."

Another said: "The family may decide to buy drugs for the child; they could also decide to prepare herbs for the child to drink."

The need to seek help outside the home was reported by nearly everyone for both conditions (Table 6). More MRI-CP respondents, however, were concerned about getting treatment right away. In the MRI-CP group, 29.0% said outside help should be sought within 24 hours, compared with 9.0% for the MRI-CN group (p < 0.01). The same relative priority was indicated by responses advising treatment within 48 hours (53.0% MRI-CP and 34.0% MRI-CN, p = 0.01).

Similar outside sources of help were identified by respondents in both groups (Table 6). Although more MRI-CP respondents recommended traditional healers, other health care providers were suggested by similar percentages from both groups.

Commenting on outside help-seeking for MRI-CP, a woman explained that home remedies at some point were not enough: "If the herbs used at home do not work other people who know more herbs, like traditional healers, could be consulted. The child could also be taken to the clinic or hospital, but this costs money."

Another observed: "As soon as it is clear that what is done at home does not work, the child would have to be sent to a clinic or hospital. The hospital or clinic is the best place, and the family must go, but they can also see a traditional healer for treatment."

Some MRI-CN respondents like this woman, compared modern and traditional health care providers favourably: "A clinic or a hospital should be the best places to go but some traditional healers also know about herbs that work."

A man emphasized the importance of not waiting too long before getting help from a doctor: "As soon as the child's condition does not get better after the home treatment, the family should consult a doctor."

Most respondents in both groups (74.3% MRI-CP and 84.0% MRI-CN) said the conditions in the vignettes could have been prevented, there was, however, a borderline significant difference (p = 0.06). Categories of preventive measures suggested for both presentations were similar (Table 7). Preventive measures frequently reported included preventing mosquito bites, staying less in the sun, maintaining personal hygiene, environmental cleanliness, drinking clean water, avoiding fatty or oily foods, and reducing strenuous or hard work/play. These were reported more frequently by respondents in MRI-CN group. Preventive measures based on magico-religious ideas were mentioned more frequently in the MRI-CP group. Measures frequently reported by similar percentages in both groups included taking medications regularly (herbal or biomedicine) and deworming children regularly.