RA644.D75 
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G364046
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FACTORS ACCOUNTING FOR THE FAILURE TO 
ACHIEVE ERADICATION OF GUINEA WORM IN 
THE TAMALE MUNICIPALITY
BY
REGINALD E. N-O. ARYEE
PRESENTED TO THE SCHOOL OF PUBLIC HEALTH 
UNIVERSITY OF GHANA, LEGON,
IN PARTIAL FULFILLMENT FOR THE AWARD OF MASTER 
OF PUBLIC HEALTH DEGREE.
SEPTEMBER, 2000
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DECLARATION
I declare that this dissertation is the result o f my own research and no one else can 
be held accountable for the ideas and arguments presented. All sources cited have, 
however, been dully acknowledged. Further, this dissertation has not been 
presented in whole or in part to any educational institution for a degree.
Mr. Noye Nortey 111 i  \1 'f r  
(Academic Supervisor) \ (J ^ "—*
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TABLE OF CONTENTS
DECLARATION............... ................................................................  i
TABLE OF CONTENTS------------------------------------------------- ii
DEDICATION ----------------------------------------------------- vi
ACKNOWLEDGEMENT -------------------------------------------  vii
LIST OF ABBREVIATIONS ---------------------------------  viii
TECHNICAL TERMS -------------------------------------------  viii
LIST OF TABLES AND FIGURES ---------------------------------  ix
ABSTRACT --------------------------------------------------------------  x
CHAPTER ONE
1. INTRODUCTION: -------------------------------------------  1
1.1 Background Information. ----------------------------------  1
1.2 Organisation and management o f the Programme. —  2
1.3 Programme strategy and Activities. ------------------------- 3
CHAPTER TWO
2.1 LITERATURE REVIEW: ---------------------------------  5
2.2 THE TAMALE MUNICIPAL PROFILE ------------  8
2.3 PROBLEM STATEMENT. --------------------------------  9
2.4 PROBLEM ANALYSIS------------------------------------------  14
2.5 OBJECTIVE OF STUDY:   15
CHAPTER THREE
3.0 METHODOLOGY:   17
3.1 Type of Study. --------------------------------------------  17
3.2 Variables. ------------------------------------------------------  17
3.3 Data Collection Techniques. ..............................................  18
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3.4 Sampling Method. ------------------------------------------- iU
3.5 Study Unit. ----------------------------------------------------  20
3.6 Sample Size. ----------------------------------------------------  20
3.7 Data analysis. ----------------------------------------------------  21
CHAPTER FOUR
FINDINGS: --------------------------------------------------------------- 22
4.1 INTERVIEWS WITH QUESTIONNAIRE -------------  22
4.1.1 Characteristics o f respondents ------------------------- 21
4.1.2 Community Mobilisation. --------------------------------- 22
4.1.3 Health education. ------------------------------------------  24
4.1.4 Knowledge on preventive activities o f  the programme 25
4.1.5 State o f filter and practices. --------------------------------- 26
4.1.6 Fatigue (Loss o f initial momentum o f the programme and
enthusiasm o f the people) ------------------------------------  27
4.1.7 Effect o f beliefs on the GWEP. -----------------------  27
4.1.8 Practices during ethnic conflict. -----------------------  28
4.2 FOCUS GROUP DISCISSION. -----------------------  28
4.2.1 Filters.--------------------------------------------------------------  28
4.2.2 Protection o f dams ------------------------------------------  28
4.2.3 Treatment o f dams with Abate -----------------------  29
4.2.4 Reward system ------------------------------------------- 29
4.2.5 Inadequate incentives for volunteers & unfulfilled promises 29
4.2.6 Beliefs about aetiology o f the disease ------------  30
4.2.7 Neglect o f rural Tamale -------------------------------- 31
4.2.8 Poor training o f volunteers -------------------------------- 31
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4.2.9 Ethnic con flict and imported cases -------------------------  31
4.3 KEY  INFORMANT INTERVIEW. -------------------------  32
4.3.1 Training. ------------------------------------------------------  32
4.3.2 The use o f insecticide “Abate”. ------------------    32
4.3.3 Filters.------------------------------------------------------  32
4.3.4 Incentives and reward system   34
4.3.5 Political commitment-----------------------------------  34
4.3.6 Collaborators ------------------------------------------------------  34
4.3.7 Imported cases. --------------------------------------------  35
4.3.8 Ethnic conflict --------------------------------------------  35
4.3.9 Lack o f supplies --------------------------------------------  35
4.3.10 Unfulfilled promises. --------------------------------------------  36
CHAPTER FIVE
5 DISCUSSIONS AND RECOMMENDATIONS. —  37
5.1 Community mobilization and knowledge o f on preventive 
activities.----------------------------------------------------  37
5.2 Factors responsible for the failure to achieve eradication. 38
5.3 Lack o f filters.---------------------------------------------- 38
5.4 Unsatisfactory monitoring. -----------------------------------  39
5.5 Failure to abate all dams and unidentified dams and farm ponds.
5.6 Lack o f supplies and failure o f  the reward system. —  41
5.7 Unfulfilled promises. ---------------------------------------------  41
5.8 Neglect o f rural Tamale. -----------------------------------  43
5.9 Fatigue. -------------------------------------------------------  44
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5.10 CONCLUSION (SUMMARY). ----------------------  44
REFERENCES ----------------------------------------------------- 47
APPENDIX I --------------------------------------------------------------- 49
APPENDIX I I --------------------------------------------------------------- 53
APPENDIX III -----------------------------------------------------  55
V
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DEDICATION
This work is dedicated to my Creator for His love and all the great things that 
have happened to me. Also my son, Donald Nii Ayitey Aryee for his 
companionship and to all family members who encouraged me supported both in 
good and difficult times.
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ACKNOWLEDGEMENT
I wish to express my sincere thanks to the following people for all the assistance 
they gave me during the preparation, fieldwork and write up o f this dissertation:
1. Dr. Eric Amuah and Mr. Noye Nortey, my academic supervisors for their
guidance throughout the preparation o f this work.
2. Dr. Nsiire Agana, the Municipal Director o f health Services, Tamale, for 
his exceptional assistance as my field supervisor and great hospitality 
throughout my stay in Tamale.
3. Professor Ofosu Amaah and Dr. Pappoe o f the School o f Public Health for 
their contributions throughout the preparation and write up o f this project.
4. The staff o f  the Municipal Health Administration and the sub-district of 
Vittin and Bulpela for the warmth and remarkable cooperation throughout 
my fieldwork.
5. All households in the Bulpela and Vittin sub-districts.
6. Mr. Afful (the care taker o f the MOH guest house, Tamale) and the family. 
Also members o f Gym 1000, Tamale.
7. The Regional Guinea Worm Coordinator, Mr. Apooya and the secretary, 
Umu Kusum Ibrahim for all their assistance.
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LIST OF ABBREVIATIONS
CHNS - Community Health Nurse
DCD District Coordinating Director
DCE - District Chief Executive
GWEP - Guinea Worm Eradication Programme
JSS Junior Secondary School
KAPB - Knowledge, Attitude, Practices and Beliefs
MDHS - Municipal Director o f Health Services
MHMT - Municipal Health Management Team
MOH - Ministry O f Health
RHMT Regional Health Management Team
SPH School o f Public Health
sss - Senior Secondary School
UNICEF United Nations International Children’s Fund
TECHNICAL TERMS
1. Dracunculus Medinensis: the guinea worm
2. The Cyclops: the intermediate host o f the guinea worm
3. Abate or Temephos: insecticide effective against the Cyclops 
intermediate host
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Table 1: Control and eradication
Table 2: Distribution o f population, communities, health facilities, water sources, 
and major industries in the sub-districts.
Table 3: Guinea worm case surveillance report.
Table 4: Table o f factors contributing to persistent endemicity and variables.
Table 5: Distribution o f respondents by age group.
Table 6: Distribution o f respondents by occupation.
Table 7: Number o f  community durbars attended by respondents in 1st half o f  year 
2000.
Table 8: Number o f film shows attended by respondents in 1st half o f  year 2000. 
Table 9: Number o f drama attended by respondents in 1st half o f year 2000.
Table 10: Number o f interactive discussions with village volunteers in 1st half o f year 
2000 .
Table 11. Number o f visits by village volunteers this year (2000)
Table 12. Preventive measures and number o f respondents aware o f the measure 
Table 13. Number / % o f respondents who stopped using filters; used veils as filters 
and dam or pipe-borne water
LIST OF FIGURES
Figure 1: Ghana GWEP annual distribution o f cases (1998-1999).
Figure 2: Guinea worm cases in Tamale District (Municipality) from 1989-1999. 
Figure 3: Analysis Diagram.
LIST OF TABLES AND FIGURES
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ABSTRACT
Factors Accounting For The Failure To Achieve Eradication Of Guinea 
Worm In The Tamale Municipality.
The Guinea Worm Eradication Programme (GWEP) began in Tamale 
Municipality 1989 with the objective o f eradicating the disease in five years or by 
1994. This could not be achieved. Further extension o f  the program for 2 years 
was disrupted by an ethnic conflict. Even further extension to the end o f the 
millennium, year 2000, failed to yield the desired results. The problem o f 
prevalence / endemicity o f the disease persisted.
The objective o f the study, which was descriptive, was to probe for factors 
responsible for the persistence o f the disease and make recommendations aimed at 
improving the programme strategy in order to achieve eradication.
Data collection method included the use o f existing records, structured interviews, 
focus group discussions, and key informant interview.
Major findings were: poor programme strategy because the programme was not 
foolproof. Treatment o f dams with Abate were done only in endemic 
communities; there were no mechanisms in place to identify new and even old but 
previously unidentified dams; filter coverage was not 100% in all the communities 
more so in larger communities; monitoring o f  dams for the presence or absence of 
Cyclops -  the intermediate host -was only by sampling. Resources committed to 
the programme were inadequate, including dressing materials for containment and 
filters for households and farms. Volunteers were dissatisfied with incentives 
given them and promises made by program managers and politicians that could 
not be kept. Community members appear to be tired o f filtering their drinking
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water for over a decade. The initial momentum o f the programme is lost despite 
the high level o f awareness o f the GWEP and activities o f the programme.
There is the need to replace the programme strategy with one independent o f  the 
activities o f the people -  filtration and early reporting for wound dressing 
bandaging. Comprehensive dam treatment with Abate and monitoring o f all dams 
for Cyclops regularly could be the answer. Mechanisms to detect new and old 
dams must be in place and resources required must be available at all times. 
Filtration o f water and wound bandaging should be considered adjunct to this 
strategy.
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DISTRICT MAP OF GHANA LEGEND
■  S I T E  CO VER ED  BY SURV E Y  
troo.m  S I T E  NOT CO V E R ED  BY  S U R VE Y
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CHAPTER ONE
INTRODUCTION:
1.1 BACKGROUND INFORMATION:
Guinea worm is a disabling waterborne, helminthic disease targeted for 
eradication globally.
In the life cycle o f the Guinea worm - Dracumculus Medinensis, the larvae is 
discharged into water sources when the blister formed by the worm usually at the 
which are roughly the size o f a dust particle, known as the Cyclops or copepod 
ingest the larvae which undergoes development into the infective form in about 
two weeks while in the Cyclops.
When swallowed in drinking water the copepod is killed and the larva is liberated. 
It penetrates the stomach wall into connective tissues o f the human abdomen and 
thorax where they remain and mature and mate three months later.
The male worm dies and it is resorbed in about a year. However, the female worm 
migrates usually to the lower extremities to form a blister, ready to discharge its 
larvae when the blister bursts open on contact with water.
Besides skin ulcer, which may be secondarily infected, the worm can have 
debilitating effects as it travels down the victims body causing pain especially 
around joints accompanied by fever nausea and vomiting. Partial or total disability 
may last several months as the worm perforates the skin.
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The disease is now confined to rural communities in countries o f Africa and Asia, 
including Ghana, Sudan, Togo, Nigeria, Ethiopia, Burkina Faso and Yemen. In 
1998, Pakistan, Kenya and Senegal reported zero cases.
1.2 ORGANISATION AND MANAGEMENT OF THE PROGRAMME.
The organisational structure o f the GWEP is made up o f the Guinea Worm 
Secretariat at the national level, the Regional Coordinators under the Regional 
Directors o f Health Services at the regional level, and the District and Zonal 
coordinators under the District Director o f Health Services and the District Health 
Management Team whose members are expected to supervise the activities o f the 
Village/Field Volunteers at peripheral level.
The village volunteers who reside in the communities are required to perform the 
following functions:
1. To detect and record cases.
2. To perform occlusive bandaging o f the Guinea worm wounds.
3. To carry out health education o f the patient and the villagers.
4. To distribute filters and supervise their utilisation.
5. To protect water sources, and
6. To refer patients to appropriate treatment centers.
The district coordinators, with the assistance o f the Zonal Coordinators at 
the sub-district level, plan and manage the district programmes. They also provide 
training, supervision, monitoring, evaluation and logistic support for the 
peripheral activities. They collect, collate and transmit the monthly data to the 
National Secretariat through the Regional Coordinators.
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At the regional level, the regional coordinators are responsible for training, 
supervision, monitoring, evaluation and the provision o f support to the district 
programmes.
The National Secretariat, which prepared the national Plan o f Action, 
provides detailed guidelines for the management o f all program activities. It 
compiles and reports on surveillance and other operational information. The 
Secretariat also provides logistic support to the regional programmes as well as 
funds directly to the regional and district programmes before the implementation 
of the Government’s decentralisation policy. Funding o f the programme is now 
provided indirectly through spending officers o f the Municipal / District Health 
Management Team. Usually, the Municipal / District Director o f Health Services.
1.3 PROGRAMME STRATEGIES AND ACTIVITIES.
The programme employs the following strategies aimed o f eradicating the disease.
1.3.1 Health education:
•  Creating greater awareness o f the disease, the social impact, the need 
to eradicate the disease and the methods used to achieve eradication
1.3.2 Vector Control:
• Filtration o f dam water for household use by the provision and 
utilisation o f monofilament filters.
• Abating o f dam with the resultant destruction of the vector carrying 
larvae.
1.3.3 Advocacy for improved water supply
• Protection of dams from getting infested with eggs from open sores.
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• Provision o f bore holes and hand-dug wells with pumps.
1.3.4 Case containment
• Early dressing and bandaging o f open cases and surgical extraction of 
the worm.
1.3.5 Surveillance.
• The surveillance o f Guinea worm is part o f community Based 
Surveillance System, which include other diseases like measles, 
cerebro-spinal meningitis, acute flaccid paralysis, neonatal tetanus 
among others. Provision o f money incentive for:
i. Those who report cases which are eventually treated
ii. Those who report themselves for treatment have their 
transport expenses reimbursed.
iii. Those who treat cases are given money incentive for the 
procedure e.g. surgical extraction or dressing.
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CHAPTER TWO
2.1 LITERATURE REVIEW:
Guinea worm eradication effort can learn from programmes aimed at small pox 
and malaria. Small pox eradication differed from that o f guinea because one 
proven and relatively inexpensive prevention technology, immunisation, was the 
intervention to achieve eradication. The cyclops, the intermediate host o f  guinea 
worm is not as ubiquitous and mobile as the mosquito o f malaria, the insect 
vector-the cyclops- is limited to ponds and drinking water, but like malaria there 
are several intervention strategies, none o f which may be perfect for every 
situation.
Aside technical lessons, previous disease control programmes have shown the 
need to understand and account for the human behavioural aspect o f  disease 
transmission, prevention and treatment. It is often the behaviour, not only o f the 
consumer but also the provider o f services that is responsible for programme 
lapses. (9) This is the major focus o f this study - factors responsible for the failure 
to achieve eradication o f guinea worm in the Tamale Municipality despite over a 
decade o f eradication programme activities.
Multi strategy approach
Experiences in rural Nigeria have shown that a multi-strategy approach is 
necessary to account for differences in geographical settlement problems, local 
culture and beliefs, geology of the area, economy to the villages and leadership. In 
the same study, it was concluded that generally low standard o f living exacerbated
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by scattered outlying settlements made self-help difficult. Programme planners 
must involve consumers in diagnosing community characteristics and in planning 
supervision, and maintaining the resultant project. The multi-strategy approach 
will help avoid wasted resources and false expectation that arise when project staff 
impose their plans to solve a complex problem. (9)
Operational research in GWEP
In order to achieve global eradication o f guinea worm in the 1990’s, it is o f paramount 
importance for guinea worm endemic countries to immediately identify and solve the 
existing deficiencies and inconsistencies in GWEP. This is possible only through 
concurrent evaluation and operational research. (11)
Eradication and control programmes
It may be necessary, at this point, to distinguish between eradication and a control 
programme in order to bring out what an eradication programme entails. A 
communicable disease can be controlled or eradicated. In control o f a disease 
transmission rate is kept low in communities to render the disease no longer o f public 
health importance. Eradication, however, is the complete elimination o f the disease. 
The difference between them is tabulated below in Table 1. (7)
Table 1. Operational differences between disease control and eradication.
Control Eradication
Objective Minimal incidence Complete elimination
Duration Indefinitely Limited
Coverage Areas o f high incidence Entire area
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Method Effective Perfect
Reservoir Animal or environmental Human only
Organisation Good Perfect
Cost Moderate for long term High for limited period
Complications Acceptable Extremely serious
Imported cases Not important Very important
Surveillance Reasonable Very good
Effectiveness of Abate (temephos) application
Abate the common name o f temephos is used in the treatment o f dams / ponds to 
destroy the intermediate host, the Cyclops, o f the guinea worm (Dracunculus 
Medinensis). Examination o f drinking water stored at the household level for the 
presence o f Cyclops with or without Dracunculus larvae can provide some 
information on the efficacy o f the multi-strategy approach besides serving as an inter­
personal health education to the communities.
In 1991, observations carried out in two villages in India revealed that while in one 
village the complete absence o f Cyclops in stored water containers was attributable to 
the use o f Abate and filtration o f water in the village, the other village which 
employed the use o f only filters without Abate application had 15.6 percent of 
containers with varying numbers o f Cyclops in them. Therefore, Abate when applied 
appropriately is highly efficacious. (8)
In Ghana, the Guinea Worm Eradication Programme (GWEP) was initiated by 
Global 2000 o f the Carter Center -  a Non Governmental Organisation (NGO) in
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1989 with an initial national case count o f 180,000. The programme gained 
support from several aid agencies and organisations as it gathered momentum, 
including USAID, UNICEF, ODA (Overseas Development Agency) now 
Department for International Development (DfID), Actionaid, Rotary Club o f 
Ghana, Danish Bilhaziar Laboratory, American Cyanamid, Government o f Japan 
and Ministry o f Health o f Ghana.
2.2 THE TAMALE MUNICIPALITY PROFILE:
•  General Information:
The distribution o f population, communities, health facilities in the sub-districts 
and sources o f water supply, valid for 1999. (See table 2) (2)
Table 2.
ITEM SUBDISTRICT
Tamale
central
Bulpella Kamina
/Taha
Sagnerigu Choggu Vittin Total
(District)
Population 148,863 47,742 35,353 33,843 21,757 14,602 302,160
% Dist pop. 49.1 15.8 11.7 11.2 7.2 4.8 100
Area (km2) 1,101
# communities 32 29 31 24 19 35 170*
# health 
facilities
3 1 3 3 2 2 14
# school 365
Major water 
source
pipe dam pipe pipe pipe dam
Major industry trading farming farming farming farming farming Trade/
farming
The Tamale, regional capital o f the Northern Region, is situated in the savanna 
zone, north-east o f Ghana. It has a population o f 302160. The people are 
predominantly Muslims and o f the Dagomba tribe. Dagbani is the main language 
spoken. The majority o f the people live in small communities outside Tamale
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municipality where the main occupation is farming. Food crops cultivated include 
yam, maize, rice and groundnuts.
The Study Communities:
Most o f the communities outside the Tamale township proper - and yet part o f the 
municipality - rely on dam/pond for their water supply, including the study areas 
o f Wamale and Kotingly with populations o f 126 and 1,615 respectively, in the 
Vittin sub-district. Kudula and Kakpagyili with populations o f 3,500 and 10,500 
respectively, in the Bulpella sub-district. Some areas o f Kakpagyili had pipe-borne 
water supply recently which is, however, irregular. Wamale is a new community 
located on the outskirts o f Tamale comprising o f indigenous Dagomba refugees of 
the 1994 ethnic conflict between the Dagombas and the Konkonbas.
2.3 PROBLEM STATEMENT.
The Guinea worm eradication programme was started in 1989 in Ghana with an 
initial case count o f approximately 180,000. The programme had the objective o f 
eradicating the disease in 5 years o f programme activities.
By 1994, five years after the inception o f the programme, the number o f cases 
nationwide was down to 8,432. The Northern Region contributed a substantial 
number o f 5,852 cases to the national total. It was found necessary to extend the 
programme another 2 years in order to achieve the set objectives. But no sooner 
had this started than the ethnic conflict began in the Northern Region. The GWEP 
was thus, disrupted for nearly 2 years in the Northern Region including the
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Tamale Municipality. By 1997 the total national case count had risen to 8,921, 
the Northern Region contributing 5,989 cases as a result. See figure 1 below.
Figure 1.
Ghana Guinea Worm  Eradication Programme 
Annual D is tribu tion  o f Cases (1989-1999)
The problem regions were the Northern in particular, the Brong Ahafo and Volta.
In Tamale the pattern o f guinea worm prevalence over the years (1989- 1999) was 
quite similar to that o f the Northern Region as a whole. (Figure. 2 below).
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Figure 2
G.W. CASES IN TAMALE DISTRICT (1989-1999)
YEAR
The number o f guinea worm cases recorded in 1998 more than doubled in 1999. 
The relative percentage o f cases contained fell from 50.7% to 27.1% in 1998 
and1999 respectively, an indication o f a recent poor performance o f  programme 
activities that should engage the attention o f programme managers and interested 
parties. (See Table 3).
Table 3. Guinea worm case surveillance report (10)
Item 1998 1998
(%)
1999 1999
(%)
Remarks
Infected
communities
56
Cases recorded 211 100 590 100 Repeat counting
Cases extracted 107 50.7
Cases bandaged 104 49.3
Total cases 
con tamed
107 50.7 160 27.1
Cases not contained 104 49.3 430 72.9 More public education 
& more scouting 
needed
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At a national review meeting in February 1998, Regional Ministers and 
District Chief Executives pledged to achieve eradication in their respective areas 
by the end o f the millennium or soon afterwards, but this has not been realised. In 
fact, in December 1999 there were 759 new cases in the Northern Region, 41 o f 
them from 49 endemic communities in the Tamale Municipality.
More than 10 years after the inception o f the GWEP, in the Tamale Municipality, 
Guinea worm continues to afflict the people. It has not been eradicated.
Out o f the 6 sub-districts o f the Tamale Municipality, 5 are mainly farming 
communities. With the exception o f two sub-districts, Bulpella and Vittin, which 
depend on dams as water supply source, the remaining four sub-districts depend 
mainly on pipe borne water, bore-hole or hand-dug wells with pumps for their 
water needs.
There were 58 guinea worm endemic communities in the municipality by 
January 2000. Almost all o f them were in areas using dams for their water 
needs.
The beliefs o f the people regarding the etiology o f Guinea worm could present 
difficulties in changing behaviour during the programme period. The beliefs that:
1. Eating half an egg instead a full size egg is the cause o f Guinea 
worm infection.
2. Taking soup made o f Baobab leaves may cause the infection,
3. Jumping over a coiled rope on a footpath may cause the infection.
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4. D rink ing  water from dams is not the cause o f Guinea worm 
because all members o f the community drink the dam water but not all 
o f them get the disease.
5. The disease is in the blood or from the earth.
6. A disease given to them by the gods as punishment.
The major problem, therefore, is the persistence o f the Guinea worm disease despite 
over a decade o f programme activities.
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2.4 PROBLEM ANALYSIS 
Analysis Diagram
The diagram depicts the inter-relationship o f factors contributing to the core problem 
— persistence o f guinea worm infection in the communities.
Figure 3.
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2.5 OBJECTIVES OF THE STUDY
■ Broad Objective
To determine the factors accounting for the failure to achieve eradication o f 
guinea worm in the Tamale Municipality
■ Specific Objectives
i. To ascertain whether there is a gap between the knowledge o f the people 
on Guinea worm prevention and their practices
ii. To determine whether the beliefs o f  the people regarding the aetiology o f 
the disease have influenced their practices negatively, in the prevention o f 
the disease.
iii. To determine the contribution o f imported cases to the persistence o f 
guinea worm in the Municipality.
iv. To ascertain whether there is 100% filter coverage.
v. To verify whether the people filter their water at all times before drinking.
vi. To verify whether the filtration process is foolproof.
vii. To determine whether Abating o f dams are done efficiently and 
effectively.
viii. To establish the effect o f  the ethnic conflict on the GWEP.
ix. To verify whether the people axe showing signs o f fatigue after 10 
years o f GWEP
x. To make recommendations based on the research findings.
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CHAPTER THREE
3.0 METHODOLOGY:
3.1 TYPE OF STUDY:
The study is descriptive, involving the use o f existing records, non­
participant observation, interviewing with questionnaire, focus group 
discussion and key informant interview. Presentation o f findings is 
expected to give a clear picture o f the situation regarding factors 
responsible for the failure to achieve eradication o f guinea worm in the 
Tamale Municipality.
3.2 VARIABLES:
Operational definition o f factors contributing to the prevalence o f guinea worm. 
(See table 4 below).
Table 4.
Factors. Variables:
Lack o f knowledge on preventive 
activities o f  the GWEP.
Knowledge on preventive activities
Poor supervision o f village 
volunteers and zonal coordinators
Number o f supervisory visits.
Poor case containment Number o f cases reported 
Number o f cases contained
Shortage o f Abate and poor 
application of Abate.
Supplies o f Abate in a year.
Number o f times o f Abating 
dams/ponds in a year.
Lack of regular retraining of 
programme workers and poorly 
motivated workers.
Number o f retraining in a year.
Bad preventive practices as a 
result o f the ethnic conflict.
Wartime preventive practices.
Ineffective health education Number o f health educational talks 
organised
Impediments due to beliefs 
regarding disease causation.
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Low level o f education. Level o f  education.
Bad filters. State o f filters.
Shortage o f filters. Availability o f filters.
Lack o f political commitment at 
the district level.
Number o f meetings with the district 
administrators
DCE, DCD, on GWEP in a year.
Poor inter-sectoral collaboration. Number o f meetings with Agricultural 
and Educational ministries, and Ghana 
Water Company representatives.
Increase in number o f imported 
cases.
Number o f imported cases.
Poor community mobilisation Number o f community durburs in a 
year.
Fatigue(loss o f initial enthusiasm) 
after 10 years o f GWEP
Initial enthusiasm (before the war) 
Enthusiasm (after the war)
3.3 DATA COLLECTION TECHNIQUE.
3.3.1 The review of available data:
1. Records on supply o f Abate and filters.
2. Records on supervisory visits to zonal coordinators and village
volunteers.
3. Records on Abating o f dams.
Is this done regularly and effectively (right concentration). Is there 
monitoring for vector presence or absence in the dams?
4. Records on old and new cases.
Is case containment being done efficiently and effectively?
5. Records on retraining o f zonal coordinators and village
volunteers.
Is retraining being done regularly to sustain their interest and 
commitment to the programme?
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3.3.2 Non-participant observation:
During household interviews respondents were made to demonstrate the 
filtration process with their own filters or veil as the case may be. The 
techniques o f filtration were observed for any flaws and filters examined for 
defects.
3.3.3 Interviewing using questionnaire ( Structured interview ):
This was aimed at gaining insight into the knowledge, attitude, practices and 
beliefs (KAPB) o f the respondents in relation to the expectations o f the 
eradication programme. Questions probed into the activities o f village volunteers, 
district and zonal coordinators in the areas o f health education, distribution and 
inspection o f filters. Beliefs and their influence on behavior with respect to 
activities o f the eradication programme were explored. Questions were structured 
to elucidate whether there has been adequate community mobilisation as well as 
political commitment.
3.3.4 Focus group discussion:
Two focus group discussions were conducted one for males and one for 
females. The male group was composed o f mainly village health workers, 
including village volunteers and members o f Village Health Committees. The 
female group was composed o f housewives both young and old. The 
discussions were conducted in the local language.
3.3.5 Key Informant interview.
The key informant was the Regional Guinea worm Coordinator. The interview 
was conducted in his office and recorded on a voice-operated tape recorder. 
There was the advantage of checking guinea worm records on computer
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(Database) during the interview. A floppy diskette copy o f guinea worm data 
on Tamale Municipality was collected after the interview.
3.4 SAMPLING METHOD:
Two sub-districts were selected because they were the only two districts not 
served by pipe-borne water. They depended largely on dam water. Four 
communities were selected, two from each sub-district. They were selected 
because there was a rise in incidence o f guinea worm cases in the communities. 
Houses were selected at random by spinning a bottle in the middle o f the 
community and the direction o f the open end is taken. The first house in that 
direction was selected. The first household was picked at random and every other 
household was interviewed. Houses were picked in one direction and when 
exhausted continued in the opposite direction.
3.5 STUDY UNIT:
My study unit was the female adult- 15years and above - in the households.
3.6 SAMPLE SIZE:
Sample size calculation:
The margin o f error is given by +2 times the size o f the standard error 
(e) if precision o f 95% (Confidence interval) is required.
Sample size for a single proportion o f population (n) is given
by:
n = p (100-p) / e2 
where “p” is the proportion o f cases estimated in the population.
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In 1999 approximately 50% of the national case count o f 
guinea worm was from the Northern Region. Total number o f cases 
nationwide was 8,965. Total number o f  cases in the Northern Region 
was 4,324.
If  a confidence interval o f  45% and 55% is expected at 95%,
then
+2e = 5 where 5 is the ‘margin o f error.’ Therefore, e = 5/2 = 2.5 
Sample size (n) = 50(100-50') / (2.5)2 = 400.
A sample size o f 200 was selected instead o f the statistically calculated 400 
due to limited resources.
3.7 DATA ANALYSIS.
Computer data entry and analysis was done using Epi-info (epi 6).
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CHAPTER FOUR
4.0 FINDINGS:
4.1 INTERVIEWS WITH QUESTIONNAIRE (STRUCTURED 
INTERVIEW)
4.1.1 CHARACTERISTICS OF RESPONDENTS.
All respondents were females between the ages o f 15 to 70 who were 
responsible or involved in household water provision.
Distribution o f  respondents by age and occupation
35 to 39 years age group constituted the highest number o f respondents - 
22.4%, followed by the age group of 25 to 29 with 18.2%. The least number 
o f respondents were in the age group o f 60 to 69, comprising 1% o f the total 
number o f respondents. (See Table 5)
Table 5. Distribution o f respondents by age group in all four communities
under study.
Age group Number of 
respondents
Percentage (%)
15-19 9 4.7
2 0 -24 22 11.5
25 -29 35 18.2
30 -34 22 11.5
35 -39 43 22.4
4 0 -44 22 11.5
4 5 -49 15 7.8
50 -54 11 5.7
55 -59 6 3.1
6 0 -64 5 2.6
6 5 -69 2 1.0
Total 192 100
Table 6 shows the distribution o f respondents by their occupation. Traders
comprised 44.6% of respondents followed by housewives comprising 32.8%.
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Shea nut processing workers and farmers comprised 13.3% and 6.1% 
respectively.
Table 6. Distribution o f respondents by occupation
Occupation Number o f 
respondents
Percentage (%)
Housewife 64 32.8
Trader 87 44.6
Sheanut processing 26 13.3
Cotton spinning 3 1.5
Farming 12 6.1
Apprenticeship 2 1.0
Charcoal making 1 0.5
Total 195 100
4.1.2 COMMUNITY MOBILISATION.
Questions sought to find the level o f  awareness o f  guinea worm as a public 
health problem and level o f  awareness o f the ongoing GWEP and therefore, 
the extent o f health education thus far.
195 (97.5%) o f 200 respondents identified Guinea worm as a health problem. 
182 (93.8%) o f 194 respondents were aware o f the Guinea Worm Eradication 
Programme (GWEP).
156 (80%) o f 195 respondents attended at least one community durbar on 
guinea worm last year (1999). (See table 7 for details)
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Distribution of respondents by the number o f durbars attended on guinea 
worm. (See table 7)
Table 7.
Number of Number of Percentage of
community attendants attendants
durbars
0 39 (did not 20 ( % that did
attend at all) not attend)
1 82 42.1
2 44 22.6
3 26 13.3
4 4 2.1
Total 195 100
66 (33.9%) o f 195 respondents attended at least one film show. 66.2% did not 
attend any by the middle o f June 2000. (Refer to the Table 8).
The mobilization o f the people entailed the health education methods o f film 
shows, drama and interactive discussions with village volunteers among 
others. Tables 9 11 show the level o f  involvement o f the people in the
mobilization process.
Table 8. Distribution o f respondents by the number o f film shows attended.
Number of 
film shows.
Number of 
attendants
Percentage 
o f attendants
0 129 66.2
1 53 27.2
2 13 6.7
Total 195
159 (81.1%) of 196 respondents attended at least one drama by the middle o f 
June 2000. See table 9 below.
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Table 9. Distribution o f respondents by the number o f drama attended.
Number of 
drama
Number of 
attendants
Percentage
of
attendants.
0 37 18.9
1 145 74.0
2 13 1 6.6
3 1 0.5
Total 196 100
124 (63.6%) o f 196 respondents had at least one interactive discussion with a 
village volunteer or a health worker on guinea worm by the middle o f June 
2000. See table 10 below for details.
Table 10. Distribution o f respondents by the number o f interactive discussions
with Village Volunteers.
Number of
interactive
discussions
Number of 
people who 
had the 
opportunity.
Percentage 
o f people.
0 71 36.4
1 93 47.7
2 23 11.8
3 4 2.1
4 3 1.5
5 1 0.5
Total 195 100
4.1.3 HEALTH EDUCATION.
Health education is one o f the major strategies o f  the programme and this is 
done by village volunteers through interactive discussions during their visits 
to households.
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In the first half o f  this year, 2000, 131 (70.4%) o f 186 respondents had at least 
one visit by a village volunteer. 55 (29%) had no visit. (See table 12 for 
details)
Distribution o f respondents by frequency o f  visits to households by Village 
Volunteers. (See table 11)
Table 11.
Number o f visits Frequency o f visits Percentage (%)
0 55 29.6
1 20 10.8
2 56 30.1
3 41 ~ 122.0
4 11 5.9
5 3 1.6
Total 186 100
134 (72%) o f 186 respondents had health education during the visits. This is 
usually not only on Guinea worm but also environmental sanitation and 
domestic hygiene.
Only 31 (16.7%) o f 186 respondents had their filters inspected for any defects 
or damages. 19 (10.2%) o f them were made to demonstrate the filtration 
process in order to correct any flaws.
4.1.4 KNOWLEDGE ON PREVENTIVE ACTIVITIES OF THE 
PROGRAMME.
Respondent were asked to volunteer information on preventive activities o f 
the programme rather than being asked whether they knew specified activity 
as a preventive measure.
192 (96%) of all respondents knew filtration o f water as a preventive measure 
o f Guinea worm. 51(25.5%) mentioned dam/pond water treatment, 28 (14%)
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mentioned avoidance of water source if one had the infection and 26 (13%) 
mentioned provision o f  pipe-borne water as a preventive measure. Only 2 
(1%) mentioned occlusive dressing o f the wound as a preventive measure A 
few others mentioned boiling o f water, which the programme does not 
prescribe.
Distribution o f respondents and their awareness o f preventive activity 
specified. (See table 12)
Table 12
Preventive measure # / % o f 200 
respondents
Dam water treatment 51 (25.5%)
Filtration 192 (96.5%)
Avoidance o f water source (dam) if 
infected
28 (14.0%)
Provision o f pipe-borne water 26(13.0%)
Surgical extraction 4 (2.0%)
Occlusive dressing 2 (1.0%)
4.1.5 STATE OF FILTERS AND PRACTICES.
123 (84.8%) of 145 filters examined were in good condition, 22 (15.2%) were 
bad or defective. 55 (27.5%) o f 200 respondents did not have filters at all. The 
majority o f them were, however from Kakpagyili (The largest o f all the 
communities).
Filtration process was acceptable or good in 134 (92.4%) o f 145 filtration 
processes observed.
98 (51.3%) o f 191 respondents did not have reserved filters to change when 
the one in use got damaged. 29 (29.6%) o f those who did not have filters to
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replace damaged ones (98) stopped using filters; 48 (49%) resorted to the use 
o f veils often bought from secondhand clothing dealers. The remaining 21 
(21.4%) either continued to use damaged filters or used a newly installed 
public standpipe when water flowed (i.e. in Kakpagyili) or bought water 
supplied by tankers or used dam/pond water. (See table 13)
Table 13. Distribution o f respondents and their behaviour where filters were 
lacking
Practices Number of 
respondents
Percentage of 
respondents 
(%)
Stopped using filters 29 29.6
Use o f veil 48 49
Use o f dam or pipe-borne 
water
21 21.4
Total 98 100
4.1.6 FATIGUE (LOSS OF INITIAL MOMENTUM OF THE 
PROGRAMME AND INITIAL ENTHUSIASM OF THE PEOPLE).
Respondents were made to state their commitment to the preventive measure 
of filtration o f water at the beginning o f the programme and their current 
commitment to filtration.
155 (79.5%) out o f 195 respondents were fully committed to filtration at the 
beginning of the programme. This level o f commitment has fallen to 124
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(65.2%) o f 190 respondents more than 10 years o f the GWEP. The percentage 
o f those who did filter sometimes or not at all at the beginning o f the 
programme was 20.5% (40/195) and has now risen to 34.7% (66/190).
4.1.7 EFFECT OF BELIEFS ON THE GWEP.
Traditional beliefs about the cause o f guinea worm might be so entrenched 
that it could continue to affect behaviour despite the high level o f  awareness 
of the actual cause.
185 (93.4%) o f 198 respondents were illiterates. 21 (10.8%) o f 194 
respondents had beliefs other than scientifically known factors leading to 
cause o f disease. 5 (23.8%) o f them were influenced by the beliefs to an extent 
that their filtration behaviour was affected negatively (5 out o f 21 people). 
They constitute only 2.6% o f the total respondents (194).
4.1.8 PRACTICES DURING ETHNIC CONFLICT.
Movement and displacement o f people in time o f war affect normal practices 
and behavior o f the people and so were GWEP activities affected by the 
Northern conflict.
130 (65.7%) o f 198 respondents were in their present communities during the 
ethnic conflict. 118 (91.5%) out o f  129 o f respondents in the communities 
filtered their water at the time. 157 (83.1%) o f 189 respondents had their 
water supply from sources other than pipe-borne, well or borehole during the 
conflict. 89.3% of those in this category filtered their water.
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133 (69.3%) o f 192 respondents affirmed that village volunteers were working 
or visited them during the war.
4.2 FOCUS GROUP DISSCUSSION.
The first focus group was composed o f eight village volunteers and zonal 
coordinators, some o f them teachers. The second focus group was composed 
o f women, all o f them housewives and involved in household water provision.
4.2.1 FILTERS:
It came out clearly that filters were in abundance at the beg inning o f the 
programme but as at June 2000, there were not enough filters to go round 
every household. The difference in result between the two situations is that, 
whereas “cases reduced drastically at the beginning o f the GWEP, now 
however, for the lack o f filters guinea worm cases have increased.”
4.2.2 PROTECTION OF DAMS.
This is very difficult because volunteers cannot guard dams 24 hours a day.
4.2.3 TREATMENT OF DAMS WITH ABATE
This is not done regularly. “Some dams have never been Abated on grounds 
that they are too large to be treated with Abate, e.g. Lahagu, Duunyin, 
Pagazaa and Tugu zone dams”.
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4.2.4 REWARD SYSTEM.
There was a high level o f awareness o f the reward system but it was not 
reliable. Some village volunteers had problems with patients they accompany 
to sub-district health facilities for containment. The patients accused village 
volunteers o f collecting and keeping money meant for patients as rewards 
when, in fact, no money would have been collected due to unavailability o f 
reward funds. When containment cannot be done at the village level for lack 
of supplies (bandage and tamale oil), volunteers are often, not interested in 
accompanying patient to health facilities for containment, because o f the 
accusations leveled against them and the fact that they, the volunteers, do not 
get the reward due them as escorts. “There was a time when every volunteer 
had adequate supplies for containment, now these cannot be obtained easily.”
4.2.5 INADEQUATE INCENTIVES, UNFULFILLED PROMISES AND 
EXPECTATIONS OF VOLUNTEERS.
Village volunteers and zonal coordinators lamented about the lack or 
inadequate incentives. Some o f their concerns include paying for their health 
care as health workers when that is free for other volunteers in the adjacent 
district o f  Savlugu-Nanton. Promises made by programme managers and 
politicians have not been fulfilled despite the strife o f village volunteers to 
attain the targets that attract the promised rewards. These include some 
reward for zero record o f cases in a community for a year; a grinding mill for 
the volunteer and a borehole for the community, if a community record o f 
cases remains zero for six consecutive years.
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“Sometimes we just relax in our efforts and no one will want to take over our 
work as volunteers because there are no benefits. I used to go to the dam with 
a Ministry o f Health (MOH) worker from 5.30am to 7pm and what I get is a 
bottle o f  mineral Village volunteers are the bedrock o f the GWEP we spend 
more time on guinea worm programme activities than on ourselves”. 
Expectations o f volunteers including zonal coordinators, o f being employed 
after several years o f voluntary service never materialised. Having worked for 
well over a decade, some o f them lamented, “We have families to feed. We 
need support”. They expressed their desire to be placed on salaries.
Their frustration was, however, expressed thus: “We are here because o f 
Vitamin A programme, if it were about guinea worm we will not have come.” 
(NB the FGD took place after training on Vitamin A dosing)
4.2.6 BELIEFS ABOUT AETIOLOGY AGAINST GWEP RESULTS. 
Traditional beliefs regarding the cause o f guinea worm were proven wrong by 
the GWEP.
“ Some people argue that in a village everybody drinks from the dam and yet 
some individuals get the guinea worm disease others do not, (Therefore 
guinea worm may not originate from water). I feel guinea worm is from water. 
When the GWEP was launched in Tugu, there were numerous cases due to 
ignorance, at that time, every input needed for the programme was available. I 
used to suffer from it but now no more because we were educated on how to 
prevent it.”
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4.2.7 NEGLECT OF RURAL TAMALE.
Many NGO’s do not provide rural Tamale with bore-holes or wells with hand 
pump because Tamale is designated urban. They therefore, “have their 
preferences, they support some villages leaving others.”
4.2.8 POOR TRAINING OF VOLUNTEERS.
Some volunteers have difficulty in identifying a case o f  guinea worm before 
the worm emerges and therefore insists on seeing the worm break through the 
skin before giving any attention to patients.
4.2.9 ETHNIC CONFLICT AND IMPORTED CASES.
During the ethnic conflict “guinea worm cases increased due to the influx o f 
refugees, even villages which had no guinea worm started recording cases. 
Those that had no cases had no refugees. The problems we faced during the 
conflict were numerous, there was no food, diseases were many so we could 
not carry out educational programmes as expected because we were worried”
4.3 KEY INFORMANT INTERVIEW.
The key informant, here, was the regional guinea worm coordinator.
4.3.1 TRAINING.
Last year (1999) two training sessions were organised for district coordinators 
and one each for village volunteers and the sub-district staff. Training is a 
normal yearly programme. So far, this year (June 2000), one has been
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organised. It is timed to coincide with the peak transmission period to prepare 
and renew the commitment o f village volunteers for work.
Total number o f new cases from January to June this year for Tamale was 
263. Average containment as at June 2000 was 70%. Last year the average 
was 65%. The following criteria are met before any case is declared 
contained:
1. Bandaging not later than 24 hours o f worm emergence.
2. Patient must confirm that he/she has not entered any dam/pond since 
the blister opened.
3. The patient must be followed up from the day o f bandaging till the
worm is fully expelled.
4. He/she must be given health education.
4.3.2 THE USE OF INSECTICIDE “ABATE”.
This is done only in endemic communities. In communities where guinea 
worm is not endemic dams are not treated with Abate. There are 52 endemic 
communities out o f 162. Dam /  Pond treatment with Abate normally begins 
within 10 days o f first reported case from a community and ends a month after 
the last reported case. Abating schedule depends on the size o f the dam. Dams 
bigger than 2,500 cubic meters are treated once every three weeks and those 
less than that are treated monthly (every 28 days).
Underdosing o f the dam with Abate may occur when the volume o f water is 
difficult to determine often due to irregular shape o f the dam. Monitoring for 
the presence o f the cyclops in the water reveal high population as a result.
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Coordinators and volunteers have no problem Abating circular and 
rectangular dams.
Monitoring for Cyclops population is by sampling, therefore, not all dams are 
checked for the presence o f the Cyclops.
There are chances o f not Abating a dam. Recently, in the latter part o f 1999, a 
village in Tamale called Fukuo has consistently been endemic in the last three 
years. It was widely known to use a particular dam but, unknowingly, there 
was another dam in a narrow location o f  the village, which was discovered to 
be the source o f endemicity in the village. A more common feature is 
unidentified farm ponds as reservoirs o f  infection. Advocacy for the use o f 
farm filters has not caught on well, probably, because there are not enough 
filters to go round household, let alone farms.
4.3.3 FILTERS.
Household filter coverage for this year (2000) is approximately 78%. That is 
78% of communities have 100% filter coverage, and 22% do not have 100% 
coverage. There is prioritisation in the distribution o f filters due to shortage 
and the criteria used in the process include:
1. Endemicity, from most endemic to the least endemic community.
2. Proximity to potable water source. The closer a community is to 
borehole or pipe-borne water supply the less likely o f it getting full 
filter coverage.
3. Populations beyond 5,000 are not fully covered with filters.
Last year filter coverage was 50%.
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4.3.4 INCENTIVES AND REWARD SYSTEM.
Incentives for village volunteers come during yearly training sessions in the 
form o f T-shirts, lunch allowance and mosquito nets as well as cash incentive 
for containment.
Decentralisation o f the GWEP under the MOH reform programme is 
responsible for the collapse o f the reward system, where funds for the 
programme are placed in a common pool and disbursed at the district level. 
The spending officers could also attribute shortfalls in programme funding to 
budget cuts and delays in receiving budget allocation.
4.3.5 POLITICAL COMMITMENT.
Politicians have pledged to get involved in the mobilisation o f the people but 
there has been only one occasion when a politician addressed a community 
durbar and talked about guinea worm. Their initiatives have remained at the 
planning stage. They have not been translated into action. “I will rate political 
involvement in Tamale the last o f all the districts o f the Northern Region.”
4.3.6 COLLABORATORS.
The Ministry o f Health, through its school health programme, targeted school 
children for health education on guinea worm in the Tamale Municipality. In 
1998 a meeting was held with regional Ministers, District Chief Executives 
and other collaborators to explore and specify areas in which each stakeholder 
could contribute. This was intended to continue every year but could not take 
place in 1999. Ghana Water Company has the responsibility for urban water
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supply but it is incapable o f funding installation o f water supply systems to 
needy areas o f rural Tamale due to lack o f funds.
4.3.7 IMPORTED CASES.
In Tamale town proper, where water supply is pipe-borne, up to 80% of cases 
are imported from the outskirts and neighbouring districts, namely savlugu- 
Nanton, Gushegu-Salaga and Bimbila.
4.3.8 ETHNIC CONFLICT.
Between 1994 and 1995 the first rise in new cases was recorded. The increase 
in transmission was in the east o f Northern Region where the conflict was 
intense. The west was relatively free. The GWEP was disorganised because of 
movement and displacement o f people at the time.
4.3.9 LACK OF SUPPLIES.
Under the decentralisation programme o f MOH, inputs for containment o f 
guinea worm are to be supplied by Health Centres which, almost invariably, 
do not have enough for their own use.
4.3.10 UNFULFILLED PROMISES.
The regional guinea worm coordinator acknowledged that promises made to 
village volunteers at the beginning o f the programme have not been honoured, 
including the provision o f com mill and boreholes if no cases were recorded 
in a community for six years.
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CHAPTER FIVE
5.0 DISCUSSION AND RECOMMENDATIONS.
5.1 COMMUNITY MOBILISATION AND KNOWLEDGE ON 
PREVENTIVE ACTIVITIES:
Community mobilisation has been adequate considering the high level o f  
awareness o f  the GWEP and the involvement o f the people regarding 
patronage o f drama in particular (81.6% o f respondents attended at least one 
drama by June 2000) and also film shows and community durbars. This has 
been so despite the unimpressive contributions by politicians in the 
municipality.
70.4% o f 186 respondents had at least a visit by a village volunteer, the first 
half o f  the year 2000. The cumulative effect o f these visits in the last 10 years 
of GWEP must have yielded the high level o f awareness o f guinea worm as a 
problem in the ongoing eradication programme.
Thus, knowledge on the preventive activities particularly filtration o f water is 
indeed high (96% of respondents).
5.2 FACTORS RESPONSIBLE FOR THE FAILURE TO ACHIEVE 
ERADICATION IN THE TAMALE MUNICIPALITY:
There is a combination of factors responsible for the failure to achieve the 
objectives of the GEWP the Tamale Municipality. They are as follows:
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• Lack o f adequate filters for every household and for use on the farms.
•  Unsatisfactory programme o f monitoring to ensure that dam/pond water is 
free o f the cyclops.
• Failure to treat all dams with Abate and unidentified dams and farm 
ponds.
• Lack o f containment supplies and failure o f the reward system.
• Unfulfilled promises made to volunteers and expectations o f the 
volunteers.
• Neglect o f rural areas o f Tamale by stakeholders and interested parties.
• Fatigue (Loss o f initial momentum and enthusiasm).
5.3 LACK OF FILTERS:
Filters were not in adequate quantities to ensure 100% coverage for all 
communities and farms and also, to provide additional filter to keep in reserve 
for replacement as was stated by the key informant, the Regional Guinea 
worm Coordinator. In any eradication programme there should be no room for 
flaws like shortage o f filters as seen in the GWEP. With shortages, people are 
forced to drink unfiltered water. In principle a problem like this, if anticipated, 
should forestall the onset o f  the programme unless a solution is found. (7) 
Therefore, there should be enough filters to cover households and farms.
The use o f veils as a substitute for monofilament filters is questionable, since 
veils from different manufactures may have different sizes o f hole in them 
(mesh sizes). The effectiveness o f veils in separating the cyclops from water
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through filtration should be carefully examined, if the use o f veils is to be 
promoted as an alternative to monofilament filters.
5.4 UNSATISFACTORY MONITORING OF DAMS:
The programme as at now, samples dams for monitoring for the presence or 
absence o f cyclops. It may be prudent to monitor all dam/pond water sources 
for cyclops. This is achievable if the parasitology department o f a district 
hospital is charged with the responsibility o f  examining all water samples for 
cyclops. Reports from the laboratory should reach the district and regional 
programme managers regularly to ensure prompt intervention where Abating 
has not been effective.
To achieve global guinea worm eradication, it is paramount for guinea worm 
endemic countries to immediately identify and solve existing deficiencies and 
inconsistencies in the GWEP. This is possible only through concurrent 
evaluation and operational research. (11)
5.5 FAILURE TO TREAT ALL DAMS WITH ABATE AND 
UNIDENTIFIED DAMS AND FARM PONDS:
In this programme, dam treatment with Abate is limited only to endemic 
communities, which is not acceptable if guinea worm is to be eradicated. It is 
mandatory to make any eradication programme foolproof and therefore all 
dams must be treated with Abate.
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The effectiveness o f Abate is impressive if properly applied. In 1999 in India, 
observations in two villages revealed that while in one village the complete 
absence o f Cyclops from stored water containers was attributable to the use of 
Abate (Temephos) and filtration o f drinking water, in the other village with no 
Abate application, 15.6% o f containers contained varying numbers o f Cyclops 
in them. (8)
From the afore discussion, a comprehensive mapping out o f all dams in the 
district and regular application o f Abate in the right quantities with regular 
monitoring o f all dams for Cyclops could be enough to eradicate the disease in 
one or two years, even if  the people show signs o f  fatigue in their filtration 
habits.
Dams that have not been identified constitute a grave threat to achieving 
eradication. A mechanism must be put in place that will detect any dams that 
have not been identified including new ones in every community by using 
village volunteers and zonal coordinators.
A surveillance system that makes inquiries about sources o f water supply for 
work places and residences should reveal any unidentified dams/ponds.
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5.6 LACK OF SUPPLIES AND FAILURE OF THE REWARD SYSTEM 
Lack o f supplies from Health Centers and the failure o f the reward system 
have been well noted by the programme managers. This is the result o f MOH 
reforms including the decentralisation policy, which allows spending officers 
(Often District Directors o f  Health Services) to release funds for various 
projects. Management lapses result in deficiencies in supplies.
Programmes budgeted for are not fully financed by government and often 
districts / Municipalities have to wait till the end o f first or second quarter 
before funds are made available. The implication for the GWEP is undesirable 
-  shortages. The Municipal Director o f  Health Services was quoted as having 
said “I will spend all my money on GWEP if I were to adequately fund it”.
It might, therefore, be appropriate to reintroduce the vertical supply system, 
exclusively for this eradication programme to ensure regular and 
uninterrupted supply o f inputs as it was at the beginning o f the programme 
and before the MOH decentralization reforms.
5.7 UNFULFILLED PROMISES AND EXPECTATIONS OF 
VOLUNTEERS:
Promises made by programme managers and politicians to village volunteers 
at the beginning of the programme have not been fulfilled. This includes the 
provision of com mill and boreholes, if  a community records zero cases for 
six years in succession. Some o f them worked hard to achieve the set goal in 
order to get the promised rewards, which never came. As a result, many o f the
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volunteers are demoralised. The problem is compounded by the fact that they 
are not satisfied with the yearly incentive o f training and good lunch. Some 
lamented about spending the greater part o f their time on GWEP than on 
themselves without any befitting benefits and threatened to give up the work.
Expectations o f volunteers including the prospect o f being employed 
permanently after several years o f voluntary work did not materialize. There 
must be a limit to the period o f voluntary service. It is true that at the 
beginning o f the programme the implications o f  being a volunteer were 
explained to them, that there would be no salaries but incentives in the form o f 
a workshop in a cosy hotel with good lunch, and donations like bicycles and 
T-shirts. Little did they know that the programme would stretch beyond 5 
years to over a decade! The expectation o f the Village Volunteers and Zonal 
Coordinaors was that, by their voluntary service, they were laying the 
foundation for a more permanent employment as community health workers 
of MOH, which has obviously eluded them. There was no change in their 
status as volunteers.
A review o f the status o f volunteers might be necessary to sustain their 
commitment to the work. For now, their interest in the work and commitment 
to it are questionable because they would prefer to attend to any other call, 
like one for training in Vitamin A dosing, than that for a guinea worm 
programme. They would rather not accompany a guinea worm patient to a 
health facility for extraction because cash incentive offered by the programme
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for the patient and the escort might not be given, raising the suspicion that the 
volunteer has kept the amount.
A review o f the package o f incentives has become necessary in view o f the 
widespread dissatisfaction among the village volunteers. Incentives should be 
directed at addressing some o f their concerns, for example, free medical care 
for the volunteer, a spouse and a limited number o f children. This offer cannot 
be too much for any district health facility to absorb. Alternatively, the health 
facility may be reimbursed by government similar to what pertains for the 
aged and expectant mothers.
5.8 NEGLECT OF RURAL TAMALE:
Rural areas o f Tamale may remain without potable water supply for a 
protracted period, if  Ghana Water Company (GWC) is to provide them with 
water. The company is beset with problems. It cannot regularly supply many 
areas o f Tamale with fully installed water pipe lines, sometimes for months, 
and residents have to rely on tanker water supply. Shunting o f water from one 
area to another to even out water distribution is common. There is therefore, 
little hope for rural Tamale getting water supply in the near future. Even if 
they do, villagers may have to go back to their dams at one time or another 
with the present irregularity in water supply. Boreholes may provide a much 
better answer to guinea worm eradication in rural Tamale since there will be 
no water supply interruptions.
To deepen the plight of Tamale rural dwellers, aid agencies e.g. Actionaid and 
UNICEF are not interested in helping Tamale with potable water in the guinea
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worm eradication effort for the reason that it is a municipality with all the 
advantages over other areas. Tamale is however, not entirely urban. The rural 
folks o f Tamale see other rural areas o f adjacent districts benefit from NGO s 
who provide boreholes with hand pumps to their neighbours while they 
remain helpless.
5.9 FATIGUE (LOSS OF INITIAL MOMENTUM AND 
ENTHUSIASM).
Commitment to filtration fell from 79.5% o f adult female respondents at the 
beginning o f the GWEP to 65% by June 2000 and those who did not filter or 
filter occasionally rose from 20.5% o f respondents to 34.7% during the same 
period. This may be an indication o f fatigue, on the part o f the women, due to 
over 10 years o f daily filtration o f drinking water. Village health workers and 
zonal coordinators gave that indication during the focus group discussion. 
“We will soon come out and appeal for support because we are tired, so that 
the work will be transferred to health personnel”
This calls for a new strategy o f eradicating guinea worm with filtration only as 
an adjunct to the eradication effort. The comprehensive mapping and 
treatment of all dams with Abate insecticide, suggested previously, may be the 
answer.
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5.10 CONCLUSION AND RECOMMENDATIONS 
The GWEP in the Tamale Municipality is more o f a control programme than 
eradication programme. Eradication programmes are comprehensive, covering 
entire areas. Resources needed must be readily available including filters, 
dressing materials, Temephos (Abate), the requisite manpower, cash for the 
incentives, vehicles including bicycles e.t.c.
Inadequacies are not acceptable in any eradication programme. Organization 
o f the programme must be perfect and entire area covered as opposed to areas 
of high incidence in control programmes. A concurrent operations research is 
extremely useful to enable programme managers to track progress and make 
modifications to improve efficiency and effectiveness. These attributes o f an 
eradication programme make it expensive and, therefore, when resources are 
lacking, control programmes are a better option.
There is the need to strengthen the programme management to ensure regular 
and timely supply o f filters and dressing materials including Tamale oil. 
Similarly, the reward system must be made to work by improving 
management. This may require reorientation o f spending officers or the 
reintroduction of the vertical programme.
Lapses in the eradication programme must be avoided by making it foolproof 
as a matter of principle. All dams should be regularly and adequately treated 
with Abate. All dams should be monitored for the presence or absence o f the
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cyclops to enable timely corrective intervention if any dam is found to contain 
any cyclops.
There is the need to address some of the concerns o f the village volunteers 
resulting in widespread dissatisfaction among them, since they play a pivotal 
role in the eradication programme.
It may be prudent not to make any promises at all than to make them and fail 
to fulfill them. Village volunteers, by their achievements, have looked forward 
to promises made by programme managers and politicians who have failed to 
honour them. They are demoralised by this.
Boreholes with hand pumps may be the most reliable source of potable water 
for rural areas o f Tamale rather than irregular supply o f pipe-borne water for 
the municipality. This will ensure that rural dwellers do not go back to the use 
of ponds/dams when there is water supply failure.
NGO’s must give some attention to rural Tamale, as the situation in these 
areas is no different from their preferred areas. Their absence in rural Tamale 
may unnecessarily prolong the period o f them getting potable water.
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REFERENCES:
1. W. H.O, Division o f Control o f Tropical Diseases. 1998, 
Eradicating Guinea worm Disease. The last Painful Steps. Vol. 11.
2. Agana Nsiire. 1999. Health Brief on Health Situation in the 
Tamale Municipality
3. Municipal Health Management Team. 1996. Tamale 
Municipality Medium Term Health Plan.
4. D ’Almelda S. A. January 2000. Report o f  fie ld  
Observations/Activities in the Kete Krachi District o f  the Volta 
Region. National Secretariat (GWEP), Ghana
5. Grant F.C. February 2000. A Report on the Guinea Worm 
Eradication Programme. National Secretariat (GWEP).
6. Varkevisser et al. 1991. Designing and Conducting Health 
Systems Research Projects. International Development Research 
Center. Canada.
7. Webber Roger. 1996. Communicable Disease Epidemiology 
and Control. Cab International. Wallingford.
8. Kaul S.M. et al. 1992. Monitoring the efficacy o f  temephos 
application and use o f  fine mesh nylon strainers by examination o f  
drinking water containers inguinea wormendemic village. 
Communicable diseases (India). P159-163.
9. Brieger. W.R et al. 1991. Guinea worm control case study: 
planning a multi-strategy approach. Social Science Medicine. 
P1319-1326.
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10. MHMT. 1999. Annual Health Report, 1999. Municipal Health 
Management Team, Tamale. Page 7.
11. Kumar A. 1990. Operational research need in guinea worm 
eradication programme. Communicable disease (India) page 236­
42.
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APPENDIX I 
QUESTIONNAIRES 
QUESTIONAIRE WOMEN IN HOUSEHOLDS
FACTORS AFFECTING GUINEA WORM ERADICATION PROGRAMME IN THE 
TAMALE MUNICIPALITY
Time interview started 
ID_______________
Name of respondent:_
Occupation:
Community:_
Number of children: 
Size of household:
Date Interviewer 
_______ Age
Sub-district
Marital status: Married 
Address:
Single
u.
iii.
iv.
v.
vi.
1. Do you think Guinea worm is a health problem here? Yes. No.
2. Are you aware of any programme to eradicate guinea worm? Yes.
3. What are the things done to prevent guinea worm infections? (Please tick.)
i. Filtration of water.
Avoidance of water source if  one is infected.
Dam/Pond treatment.
Occlusive dressing of wound.
Surgical extraction of wound.
Cash incentive for reporters/diseased 
Provision of pipe-borne water.
Other (Specify)._____________________________
Wartime practices
4. Were you in this community during the war? Yes. No
5. If yes, did you filter your water before drinking during that period?
No. Sometimes. Always.
6 If no, where were you?
No
7 What was your source of water supply where you were? Pipe-borne water
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Dam /Pond.
Well/Bore hole with pump
Well without pump.
River /Stream.
8. If  river, stream, dam or pond, did you filter your water before drinking? 
Yes. No.
9. Were the village volunteers /field workers workine.during the war?
Yes. No.
EUjg
Ineffective health education:
10. How many visits have you had by a village volunteer this year?
11. What did he do during the visit?
i. Health education on guinea worm.
ii. Inspection of filters.
iii. Observation/Demonstration of filtration process.
iv. Others
12. Have you been to school before? Yes. 
How far did you go? Primary.
Secondary.
JSS.
No. 
Middle 
Tertiary. 
SSS.
Others (e.g. Non-formal education)
Beliefs about aetiology
13. What do you think is the cause of the disease?
i. Drinking untreated pond/dam water
ii. Drinking unfiltered water.
iii. Other(s). Explain.
14. Do you know any belief as the cause of GW disease? Yes.
15. Explain that belief
Number.
No.
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16. Does that belief of the cause of the disease afFect your filtration behaviour? 
Yes. -----------------  No.
If yes, explain.
State of Filters
17. May 1 have a look at the filter you use currently? State of filter: Good. Bad.
18. Observation of filtration process. (Respondent should demonstrate the filtration process) 
Good. Bad.
No.
Shortage of filters:
19. Do you always have filters to change when it gets damaged or tom? Yes.
If  no, what do you do? i. Continue to use the damaged filter.
ii. Stop using filters.
iii. Other (Specify).___________________________
Community mobilization:
20. How many community durbars have you had about guinea worm this year? Number.
21. How many film shows on guinea worm have you had this year, if any?
22. How many drama this year on guinea worm, if  any?
23. How many interactive discussions with a health worker/village volunteer this year?
24. Have you seen a Cyclops/copepod before? Yes. No.
Fatigue (loss o f initial enthusiasm) after 10 years of GWEP.
25. How was your commitment to the filtration of water at the beginning of the GWEP? 
Filtration was done always.
Filtration was done sometimes.
l .
ii.
in. Filtration was not done at all.
26. How is your commitment to filtration now?
i. Filtration of drinking water is done always.
ii. Filtration of drinking water is done sometimes.
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iv. Filtration of drinking water is not done at all. 
Time interview ended._________________
Prepared by Reginald Aryee.
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APPENDIX II
OIIF.STIONA1RE FOR ZONAL COORDINATORS
Time interview started._____________ Date.________________Interviewer ID .____________
Supervision:
1. How many supervisory visits to zonal coordinators were there last year? (Check records if 
available).
2. Training:
How many workshops or training sessions did you have for zonal /field 
coordinators  r ?
ii. What is the total number of training/workshops expected for last year?
iii. How many workshops /training sessions are to be done this year?
iv. How many workshops/training sessions have you had so far this year? 
Case containment:
i. How many cases were reported last year? (Check records).
ii. How many of them were contained last year? (Bandaging /extraction)
iii. How many cases of guinea worm have been reported so far this year?
iv. Of the cases this year, how many were contained?
4. Did you run short of Abate (Tomaphos) ? Yes. No.
5. What is the ideal frequency of Abating a dam in a year?
6. i. Did you abate all dams as expected last year? Yes 
records)
ii. If  no, why? (Explain________________________
No. (Check
7. I. Did you use the correct quantities of Abate for each dam at all times?
Yes. _____  No. ____
ii. If  no, why?
Motivation.
8. i. Are there any incentives for zonal and village volunteers? Yes. No.
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ii- If yes, what are they?
iii. Are they regular? Explain.
Political commitment.
i. Have you had any meetings with the presence o f the District Chief Executive or the District
Coordinating Secretary? Yes.
ii. If yes, How many last year?
iii. How many this year?
No.
iv. Does the DCE, Regional Minister, or District Coordination Secretary take advantage of any 
fora to talk about guinea worm? Yes. No.
Inter-sectoral collaboration.
i. Have you had any meetings with representatives from the Ministry of Agriculture, Ministry 
of Education, the Ghana Water Company (formerly Ghana water and Sewage cooperation) or 
NGOs?
Yes. No. Check records (minutes).
ii. What role has each sector played in the GWEP
Imported cases.
i. How many imported cases of Guinea worm were there last year? 
records)
ii. How many imported cases of Guinea worm were there this year? 
Time interview ended.
(Check
Prepared by Reginald Aryee.
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APPENDIX III
FOCUS GROUP DISCUSSION GUIDE
INCREASING NUMBER OF NEW CASES OF GUINEA WORM IN THE 
TAMALE MUNICIPALITY.
General question: why are we not successful in the eradication effort?
Health education.
• Knowledge o f the people about GW and the eradication effort. To what extent is 
it? -  Discuss.
NB. Adults and children, Cause of disease, programme prescribed preventive 
measures -  filtration, abating o f dams, case containment (bandaging, surgical 
extraction, cash incentives).
Beliefs.
• There are some beliefs regarding the cause o f the disease. What are some o f them  
Discuss each?
NB. E.g. It is in the blood, in the soil, given to us by God.
• Do the beliefs affect people’s preventive behaviour and practices? Discuss.
NB. Reporting for treatment, local treatment, filtration o f dam water etc.
Effect of the war:
•  What role has the ethnic conflict played in the eradication o f guinea worm?
NB. Work o f the willage volunteers and zonal coordinators, Abating of dams, case 
reporting, case containment, health education, imported cases o f guinea worm, 
health education etc.
Political commitment.
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• Are the politicians DCE, DCS, district assembly involved? In what ways? -  
discuss.
What do you expect o f them?
Fatigue (loss o f initial zeal)
• Has the duration o f the programme (over 10 years) had any effect? -  Discuss.
NB. Are the expectations o f the people contributory.
Filters.
• Any problem with that? -  Discuss.
NB. Supply, replacement, size, sale o f filters, use o f Vail etc.
Case containment (bandaging before blister opens, or within 24 hours o f worm 
emergence o f the worm).
• Does it take place in all cases? -  Discuss.
NB. What are some o f the difficulties, role o f children, supplies (bandage and 
Tamale oil surgical equipment), early reporting, cash incentive etc.
Imported cases.
• To what extent is the problem? -  Discuss.
Village volunteers and field workers.
• Performance in the different communities
Health education, supply o f filters (? Sale o f  filters), replacement o f filters etc.
• What are some o f the difficulties the face.
Zonal coordinators / district coordinators
•  Supervision o f village volunteers.
• Supplies: filters, Abate, cash reward etc.
Is there any other reason for failure to achieve eradication?
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