SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
 
 
 
MALARIA PREVENTION AND TREATMENT SEEKING PRACTICES AMONG 
MOTHERS OF CHILDREN UNDER FIVE YEARS IN ADENTAN MUNICIPALITY 
 
BY 
 
KINGSLEY IKHUOSHO OJEIKERE 
(10584997) 
 
THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON 
IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF 
MASTER OF PUBLIC HEALTH DEGREE 
 
SEPTEMBER 
2016 
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DECLARATION 
 
I, Kingsley Ikhuosho Ojeikere, declare that except for the other people’s research work which 
have been duly acknowledged, this work is the result of my own original research, either in 
whole or part, has not been presented elsewhere for another degree. 
                             
……………………………………                                                …………………………….. 
Kingsley Ikhuosho Ojeikere                                                            Date 
  Student ID (10584997) 
 
 
………………………………..                                                    ……………………………… 
Prof. Richard Adanu                                                                               Date 
       Supervisor 
 
 
 
 
 
 
 
 
 
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DEDICATION 
I dedicate this work to the Almighty God for the gift of life and strength to complete this work 
successfully. 
I also dedicate it to my late mother, Mrs Felicia Ojeikere, my father Mr Benjamin Ojeikere and 
my siblings. 
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 ACKNOWLEDGEMENT 
 I owe a great deal of gratitude to all who contributed in diverse ways to make this study a 
success. I acknowledge the Almighty God, who endowed me with strength, resilience, 
knowledge and understanding to produce this dissertation.  
I wish to appreciate WHO/TDR and School of Public Health for deeming me fit for this 
postgraduate scholarship. 
I also acknowledge my supervisor and Dean Prof. Richard Adanu, my Head of Department Dr 
Augustine Ankomah and the entire team of lecturers at the School of Public Health. 
My appreciation also goes to the management of Adentan Health Directorate of the Greater 
Accra Region, the Director and the malaria focal person, Mr John Sarsah. 
I also appreciate the work of the Community Health Nurses and volunteers who assisted in house 
numbering and data collection. 
 Finally, I would like to thank all other individuals not listed here who provided diverse support 
for me to complete this study   
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 ABSTRACT 
Background: Malaria is endemic in Ghana, posing serious public health challenge to the 
development of Ghana. Currently, it is ranked number one among the causes of admission of 
children under five years; likewise the number one cause of death of children under five years in 
Ghana. Despite prevention strategies introduced, it maintains its top spot. This study assessed 
knowledge of mothers of children under five years in Adentan Municipality regarding malaria, 
their prevention methods practiced, challenges and their treatment seeking practices. 
Methods: A cross-sectional study assessed malaria related knowledge, prevention, challenges 
and treatment seeking practices in Adentan Municipality of Greater Accra Region in Ghana. A 
structured interviewer-administered questionnaire was administered to 363 mothers of children 
under five years drawn by systematic sampling to collect information on their socio-demographic 
characteristics, malaria knowledge, malaria prevention practices, challenges, and treatment 
seeking practices for their under-five. 
Results: Majority of respondents had good knowledge of malaria, 87.6% prevented their child 
from malaria, the prevention strategies are; use of drugs, repellants, bed nets, insecticide treated 
nets (ITNs), insecticide spray, protective clothing, environment cleaning and use of multiple 
strategies. ITN was the commonest strategy utilized. Challenges included discomfort, cost, 
irritation, skin conditions, allergies, tear and difficulty in tacking ITNs. 74.4% of respondent’s 
child had a positive history of fever, 32.8% had been admitted due to fever, 3.8% had history of 
unconsciousness, 4% had history of convulsion and 0.3% has lost a child after developing fever, 
being unconscious or convulsed. 36.3% tepid sponge their child as first response to fever, 86.2% 
took their child to the health facility on persistence of fever. 41.2% took their first action in less 
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than 24 hours. There was significant association between mothers’ level of education and 
knowledge of malaria, knowledge and prevention of malaria, child’s age and history of fever, 
knowledge of malaria and history of fever, knowledge of malaria and history of death. 
Conclusion: Health information given to mothers during antenatal visits, visits to the infant and 
child clinic and the adoption of the Community-based Health and Planning Services (CHPS) was 
responsible for the high knowledge of malaria. The delay in seeking treatment suggests the need 
for an emphasis of prompt seeking of care. 
 
  
  
  
  
  
  
  
  
  
  
 
 
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 TABLE OF CONTENTS 
 
DECLARATION ............................................................................................................................ ii 
DEDICATION ............................................................................................................................... iii 
ACKNOWLEDGEMENT ............................................................................................................. iv 
ABSTRACT .................................................................................................................................... v 
TABLE OF CONTENTS .............................................................................................................. vii 
LIST OF TABLES .......................................................................................................................... x 
LIST OF FIGURES ....................................................................................................................... xi 
LIST OF ABBREVIATIONS ....................................................................................................... xii 
CHAPTER ONE ............................................................................................................................. 1 
INTRODUCTION .......................................................................................................................... 1 
1.1 Background ...................................................................................................................... 1 
1.2 Problem Statement ........................................................................................................... 3 
1.3 Conceptual Framework .................................................................................................... 4 
1.4 Justification ...................................................................................................................... 5 
1.5 Research Questions .......................................................................................................... 6 
1.6  Objectives ......................................................................................................................... 7 
1.6.1 General Objective ..................................................................................................... 7 
1.6.2 Specific Objectives ................................................................................................... 7 
CHAPTER TWO ............................................................................................................................ 8 
LITERATURE REVIEW ............................................................................................................... 8 
2.1 Knowledge of Malaria ...................................................................................................... 8 
2.2 Malaria Prevention ......................................................................................................... 11 
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2.3 Malaria Treatment .......................................................................................................... 14 
CHAPTER THREE ...................................................................................................................... 18 
METHODS ................................................................................................................................... 18 
3.1 Study Design .................................................................................................................. 18 
3.2 Study Area ...................................................................................................................... 18 
3.3 Variables......................................................................................................................... 19 
3.4 Sampling......................................................................................................................... 20 
3.4.1 Study Population ..................................................................................................... 20 
3.4.2 Sample Size ............................................................................................................. 20 
3.4.3 Sampling Method .................................................................................................... 21 
3.5 Data collection, handling and analysis ........................................................................... 22 
3.5.1 Inclusion criteria ..................................................................................................... 22 
3.5.2 Exclusion criteria .................................................................................................... 22 
3.5.3 Ethical considerations and approval ....................................................................... 22 
3.5.4 Training of interviewers .......................................................................................... 23 
3.5.5 Data collection: ....................................................................................................... 23 
3.5.6 Pre-testing and review of instruments/tools:........................................................... 24 
3.6 Data Handling and Analysis:.......................................................................................... 24 
3.6.1 Data Storage: ........................................................................................................... 24 
CHAPTER FOUR ......................................................................................................................... 25 
RESULTS ..................................................................................................................................... 25 
4.1 Background characteristics of respondents .................................................................... 25 
4.2 Knowledge of malaria .................................................................................................... 28 
4.2.1 Association between socio-demographic characteristics and knowledge of malaria . 28 
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4.3 Prevention of Malaria ..................................................................................................... 31 
4.3.1 Prevention of malaria, ITN ownership and knowledge of malaria............................. 35 
4.3.2 Socio-demographic characteristics and ITN ownership ............................................. 36 
4.4 Malaria treatment practice .............................................................................................. 37 
4.4.1 Child’s age and History of fever ............................................................................. 39 
4.4.2 Knowledge of malaria and history of fever ............................................................ 40 
4.4.3 Knowledge of malaria and duration between fever onset and action ..................... 41 
4.4.4 Knowledge of malaria and fever admission............................................................ 41 
4.4.5 Knowledge of malaria and history of unconsciousness .......................................... 42 
4.4.6 Knowledge of malaria and history of convulsion ................................................... 42 
4.4.7 Knowledge of malaria and history of death ............................................................ 43 
CHAPTER FIVE .......................................................................................................................... 44 
DISCUSSIONS ............................................................................................................................. 44 
5.1 Knowledge of malaria .................................................................................................... 44 
5.2 Prevention of malaria ..................................................................................................... 45 
5.3 Treatment of malaria ...................................................................................................... 46 
CHAPTER SIX ............................................................................................................................. 49 
CONCLUSIONS AND RECOMMEDATIONS .......................................................................... 49 
6.1 Conclusions .................................................................................................................... 49 
6.2 Recommendations .......................................................................................................... 50 
REFERENCES ............................................................................................................................. 51 
APPENDICES .............................................................................................................................. 54 
CONSENT FORM .................................................................................................................... 54 
QUESTIONNAIRE ................................................................................................................... 57 
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  LIST OF TABLES             
Table 1 Sample allocation to communities ................................................................................... 22 
Table 2 Socio-demographic characteristics of respondents .......................................................... 26 
Table 3 Socio-demographic characteristics and knowledge of malaria........................................ 30 
Table 4 Malaria prevention strategies ........................................................................................... 32 
Table 5 Selected prevention parameters and knowledge of malaria ............................................. 36 
Table 6 Association between socio-demographic characteristics and ITN ownership................. 37 
Table 7 Duration between fever onset and action ......................................................................... 39 
Table 8 Association between child’s age and history of fever ..................................................... 40 
Table 9 Association between knowledge of malaria and history of fever .................................... 40 
Table 10 Association between knowledge of malaria and duration between fever onset and action
....................................................................................................................................................... 41 
Table 11 Association between knowledge of malaria and fever admission ................................. 42 
Table 12 Association between knowledge of malaria and history of unconsciousness ............... 42 
Table 13 Association between knowledge of malaria and history of convulsion ......................... 43 
Table 14 Knowledge of malaria and history of death ................................................................... 43 
 
 
  
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 LIST OF FIGURES 
 
Figure 1 Distribution of knowledge of malaria among respondents............................................. 28 
Figure 2 Distribution of mothers who prevent malaria ................................................................. 31 
Figure 3 Reason for the prevention strategy ................................................................................. 32 
Figure 4 Distribution of ITN ownership ....................................................................................... 33 
Figure 5 Distribution of number of ITN(s) owned ....................................................................... 34 
Figure 6 Persons sleeping under an ITN ....................................................................................... 34 
Figure 7 Frequency of ITN change or re-impregnation ................................................................ 35 
Figure 8 History of fever parameters among child of respondents ............................................... 38 
Figure 9 Frequency of occurrence of fever ................................................................................... 38 
Figure 10 Mother's response to child's fever ................................................................................ 39 
   
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LIST OF ABBREVIATIONS 
 
BCC     Behaviour Change Communication 
CHPS     Community-based Health and Planning Services 
IRS     Indoor Residual Spraying 
ITN    Insecticide Treated Net 
SP    Sulphadoxine – Pyrimethamine 
UNDP    United Nations Development Programme 
UNICEF   United Nations Children's Fund 
WHO    World Health Organization 
 
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CHAPTER ONE 
INTRODUCTION 
1.1 Background 
Malaria is caused by the parasite Plasmodium (P) species; there are five species, four are 
human species transmitted from person to person; P. falciparum, P. vivax, P. malariae and 
P. ovale. The fifth, P. knowlesi is spread from monkeys to humans. P. falciparum is the 
most prevalent in Africa (WHO, 2015). 
Malaria poses a serious public health challenge, which impedes the development of any 
nation; as a result of this, a concerted Roll Back Malaria partnership was launched in 1998 
by WHO, UNDP, UNICEF and World Bank to combat the disease and reduce morbidity 
and mortality associated with it. Ghana was committed to the Roll Back Malaria initiative, 
and to the Abuja Declaration on Roll Back Malaria in Africa (Ghana Health Service (GHS), 
2013; WHO, 2000). 
Malaria is endemic in Ghana; it is hypoendemic in the Greater Accra Region, hyperendemic 
in the Upper West Region and mesoendemic in the rest of the country with a parasite 
prevalence of 39%. It affects all population, but worse in children under five years and 
pregnant women due to reduced immunity (Ghana Health Service (GHS), 2013; Ghana 
Statistical Service, 2011). Strategies to control malaria parasite include vector control by use 
of Insecticide Treated Nets (ITN), Indoor Residual Spray (IRS) and Larval control, Seasonal 
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Chemoprophylaxis and Case Management which includes prompt diagnosis and treatment 
(WHO, 2015). 
Efforts and progress in implementation of control programs has yielded significant results. 
Between 2000 and 2015, the incidence of malaria has declined globally by about 37%, 
likewise death from malaria declined globally by 60%. Progress has been witnessed towards 
global elimination as increasing number of countries have moved towards malaria 
elimination (WHO & UNICEF, 2015; WHO, 2014). 
Progress in reaching children under five years has been encouraging. It is estimated that 
68% of under-fives in sub-Saharan Africa are now sleeping under insecticide treated nets 
(ITNs), compared to less than 2% in 2000, and over this period the under-five global 
malaria death rate declined by 65%. However, this progress has been uneven as some 
countries have a disproportionately high volume of the global burden. Fifteen countries 
mainly in sub-Saharan Africa accounts for 80 percent of malaria cases and 78 percent of 
deaths globally (WHO & UNICEF, 2015). 
There are several barriers to effective malaria prevention and treatment, especially for 
children under five years which results in malaria preventable deaths of over four hundred 
thousand individuals yearly, of whom 70% are under-five (WHO & UNICEF, 2015). 
Reduction of these barriers to the barest minimum would make global malaria elimination 
attainable. 
 
 
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1.2 Problem Statement 
About 3.2 billion people worldwide are at risk of malaria. There was an estimated 214 
million new cases and 438 000 deaths from malaria in 2015. Fifteen countries account for 
80% of malaria cases and 78% of deaths globally, of which Ghana is a part. Though, there 
has been a steady decrease in annual deaths from malaria, from 1.2million in 2004 to 
855,000 in 2013 and presently about 438,000 in 2015; these figures are still huge with a 
large percentage of the deaths occurring in children under five years. Majority of the deaths 
(90%) occur in Africa (Murray, 2014; WHO & UNICEF, 2015; WHO, 2015). 
The number of deaths in under-five due to malaria is estimated to have decreased globally 
from 723,000 in 2000 to 306,000 in 2015. The bulk of which occurred in Africa with a 
decline from 694,000 in 2000 to 292,000 in 2015. The decline in death attributed to malaria 
has been due to emphasis on prevention, diagnosis and prompt treatment. Despite this 
progress, it remains an enormous problem. Large number of people still lack access to 
services geared towards effective malaria prevention and treatment, and it still remains a 
major killer of children in Africa responsible for the death of a child every 2 minutes. There 
are 840 million people at risk of malaria in sub- Saharan Africa, with 269 million of them 
residing in households without ITN or IRS (WHO & UNICEF, 2015; WHO, 2015). 
Malaria poses a huge threat to public health in Ghana, it impinges on child survival. It is the 
leading cause of morbidity and mortality among children under five years, ranking number 
one among the causes of outpatient morbidity (47.4%), the number one cause of hospital 
admission of under-five in Ghana (58.1%) and also the number one cause of the death of 
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under-five (20.2%) in Ghana (Ghana Health Service, 2010). This study therefore seeks to 
identify the prevention methods practiced by mothers of children under five years in 
Adentan Municipality, reasons why the methods are not effectively practiced and determine 
their treatment seeking practice for their under-five. 
1.3 Conceptual Framework 
The conceptual framework below outlines the pathways through which malaria prevention 
and treatment practices can be understood. Thus, malaria prevention and treatment is 
dependent on the socio-demographic characteristics (mothers’ age, marital status, ethnic 
group, educational level, family size, occupation, father’s occupation, family income, 
number of children below five years, age of under- five and sex of under – five)  and 
mother’s knowledge of malaria. 
 
 
 
 
 
 
 
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Conceptual Framework 
Source: Authors Own Construct (2015) 
1.4 Justification 
Malaria prevention methods are not effectively practiced. Adequate knowledge of malaria 
transmission, symptoms, and strict practice of prevention methods, and treatment by 
mothers or caregivers are essential in combating the disease. It was revealed only 47% of 
under-five in rural areas sleep under ITNs, while only 24% in the urban areas sleep under 
ITNs. Greater Accra region was revealed to have the lowest percentage (26%) of under-five 
ITN usage in Ghana (Afoakwah, Nunoo, & Andoh, 2015; Ghana Statistical Service (GSS), 
Ghana health Service (GHS), & ICF International, 2015; Osero, Otieno, & Orago, 2006). 
Early detection and commencement of treatment of under-fives curbs progression to severe 
form of the disease, which is responsible for the deaths associated with the disease. Under-
Socio-Demographic 
Characteristics 
 
Knowledge of 
malaria 
 Malaria prevention 
practices 
 Treatment seeking 
practices 
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five mortality would be reduced when malaria prevention methods are effectively utilized 
(Afoakwah et al., 2015; Iloh, Ofoedu, Njoku, Amadi, & Godswill-Uko, 2012; Iloh, Chuku, 
Amadi, & Ofoedu, 2013; WHO, 2015). 
This study would reveal knowledge and treatment practices of malaria by mothers of under-
five. Findings from the study would enable Adentan Health Directorate develop capacity at 
the community levels to control malaria. Training and enlightenment of the mothers can be 
instituted at the district level for them to recognize malaria control strategies, which 
significantly reduces under-five mortality. 
1.5 Research Questions 
1. What is the knowledge level of the mothers regarding malaria and its prevention 
methods? 
2. How do the mothers prevent malaria? 
3. What are the mothers’ malaria prevention challenges? 
4 What treatment method do the mothers opt for when their child has a fever, becomes 
unconscious or convulses? 
 
 
 
 
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1.6  Objectives 
 
1.6.1 General Objective 
To determine the knowledge level of mothers of under-five regarding malaria, their 
prevention practices, challenges to effective prevention and treatment seeking practices. 
1.6.2 Specific Objectives 
1. To measure the level of knowledge of mothers of under-five about malaria. 
2. To identify the prevention methods practiced. 
3. To determine challenges to effective prevention by mothers. 
4. To determine the treatment seeking practices of mothers for their under- five children. 
 
 
 
 
 
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CHAPTER TWO 
LITERATURE REVIEW 
2.1 Knowledge of Malaria 
The highest burden of malaria is in Africa, where an estimated 90% of all malaria deaths 
occur, and children aged less than 5 years account for 78% of all deaths (WHO, 2014). The 
knowledge of malaria by individuals residing where it is endemic is vital and should 
essentially be the first step in curtailing it. 
Paulander and colleagues interviewed 1652 mothers in Tigray, a predominantly rural 
community in Ethiopia, where it was revealed that 92.7% were able to mention at least one 
malaria symptom while 65.3% could mention three or more symptoms. Majority (74.7%) of 
the women believed malaria is a preventable disease, out of which 82.3% were aware of 
environmental management, 46.2% Insecticide treated nets (ITNs), 15.6% Indoor residual 
spraying (IRS) and 15.6% chemoprophylaxis. About 65.9% believed malaria could lead to 
death while almost all women (92.7%) believed malaria could be cured.  Despite the low 
educational level in this community (90.6% had just a single year of schooling), there was a 
relatively good knowledge about malaria in this rural community, but their source of 
knowledge was not revealed (Paulander et al., 2009). 
Study done in Nyamira district, Kenya to assess mothers’ knowledge of malaria and vector 
management revealed only 6.5% of the mothers did not know anything about malaria, 
majority (91.8%) recognized mosquito as a cause of malaria and a large proportion had a 
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good knowledge of basic symptoms. About 80.3% knew about mosquito nets and 
Insecticide treated nets (ITNs). A good knowledge about malaria here despite their low 
educational level was attributed to prior family member attack and health education via the 
radio (Osero et al., 2006). 
In Kuje area council, Abuja, where the knowledge of malaria among mothers of children 
under-five years was assessed in comparison with a similar area council selected as control. 
The mothers in Kuje were given health information on malaria, its mode of transmission, 
prevention and complications with the collection of data prior to health education and after 
twenty weeks. Mothers in the control did not receive health information. It was revealed that 
the mothers in both groups had poor knowledge of malaria and its prevention methods. 
Though there was a remarkable improvement in the knowledge level of the mothers in Kuje 
area council after the intervention, it was still low. There was however, no information 
revealing whether it was exactly the same mothers who were interviewed pre and post 
intervention (Ashikeni M.A, Envuladu E.A, Zoakah A.I, 2013). 
Iloh and colleagues were able to associate socio-demographic data with knowledge of 
malaria complications. The children of mothers who had a low level of education, had 
severe malaria disease more than those who had a high level of education; likewise 
separated mothers, lower family social class, and lower maternal educational attainment was 
associated with severe malaria. Separated mothers were strongly associated with severe 
malaria as under-five children whose parents were not living together were three times more 
likely to have severe disease compared with those living together (Iloh et al., 2013). Adongo 
and colleagues revealed fairly good knowledge of malaria in Kassena-Nankana and Bulsa 
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district of Upper East Region in Ghana. Majority of the respondents mentioned bed nets as a 
malaria prevention method, though it was mainly perceived as a nuisance reduction tool 
(Adongo, Kirkwood, & Kendall, 2005). Another study carried out in thirteen communities 
in the Afram Plains District of the Eastern Region and twenty communities in the Asikuma-
Odoben-Brakwa District of the Central Region in Ghana among mothers of under-five 
revealed majority of respondents were knowledgeable about the mode of transmission of 
malaria, prevention methods and symptoms like fever, vomiting, yellowish discoloration of 
urine, lack of appetite. Only about 27.6% of respondents in Central region and 16% in 
Eastern region associated chills with malaria. The knowledge however did not translate into 
prevention practices as respondents whose children do not sleep under bed nets were more 
knowledgeable about malaria (De La Cruz et al., 2006). This is similar to what Edelu and 
colleagues found, where 80% of mothers who visited the paediatric outpatient department of 
the University of Nigeria Teaching Hospital, Enugu between August 2007 and March 2008 
had knowledge of Insecticide treated net (ITN), only 26.1% of them had their child sleep 
under the net (Edelu, Ikefuna, Emodi, & Adimora, 2010).  
These points to an assumption that knowledge does not translate to practice. Hence there 
should be other factors responsible for this such as the cost, colour and shape of bed net, 
occupation and educational levels, beliefs that certain types of fever are caused by the heat 
from the sun, residence in an urban setting compared to a rural setting, children sleeping 
with mothers, the presence of at least one ITN in the household and sickness of a child in 
the household in the last fourteen days prior to the survey, difficulty in hanging ITN, and 
holes in the ITN. These were among reasons why prevention methods were not practiced 
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(Baume, Reithinger, & Woldehanna, 2009; De La Cruz et al., 2006; García-Basteiro et al., 
2011; Ng’ang'a et al., 2009; Wiseman, Scott, McElroy, Conteh, & Stevens, 2007). 
Knowledge of mothers regarding malaria can be said to be related with level of education, 
geographical area one resides, the type of community and a previous history of malaria in 
the family.  
2.2 Malaria Prevention 
Paulander and colleagues’ study in Ethiopia where a large number of mothers were aware of 
environmental management and ITN, and few of IRS and chemoprophylaxis. Almost all the 
respondents had at least one ITN in their home which was got from the government, a little 
above half had enough to protect every member of the family, nothing was said about the 
other preventive methods (Paulander et al., 2009). 
The study done in Nyamira district, Kenya where about 80.3% of mothers knew about 
mosquito nets and ITNs, most (55.5%) of them do not engage in any preventive methods, 
33.5% use bed nets, 6.8% repellants, 2.8% environmental management, 1.0% use clothes, 
0.5% use chemoprophylaxis, while 0.3% boil drinking water to prevent mosquitoes and 
malaria (Osero et al., 2006). An improvement to this was seen in Ng’ang’a and colleagues’ 
study done in Kirinyaga district of Central Kenya where 48.6% had access to bed nets and 
46.7% slept under bed net the previous night. Suffice it to say bed nets include both 
insecticide treated and untreated nets (Ng’ang'a et al., 2009). According to Ghana 
Demographic and Health Survey (2015), about 48% of under-fives slept under an ITN the 
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night prior to the survey while about 54% either slept under an ITN the night prior to the 
survey or in a dwelling sprayed with IRS in the past twelve months. 
The number of children in stable malaria-endemic conditions in Africa protected by an ITN 
increased from 1.8% in 2000 to 18.5% by 2007. This left about 89.6 million children 
unprotected. In Ethiopia there was an increase from 0% to 30%, 3% to 44% in Kenya, 1% to 
3% in Nigeria and 4% to 22% in Ghana (Noor, Mutheu, Tatem, Hay, & Snow, 2009). 
Within a seven-year period, a significant increase was noticed in some countries while some 
others lagged behind, this points to the fact that there are challenges to effective ITN usage, 
and not until these challenges are surmounted, achieving one hundred percent protection is 
uncertain. 
A study worth mentioning was done by Afoakwah and colleagues who sourced three 
thousand, eight hundred and thirty nine under-five data from Ghana Demographic and 
Health Survey (GDHS 2008), where it was revealed in Ghana 52.1% of under-fives do not 
sleep with nets, 23.1% use ITN while 24.2% use untreated net (Afoakwah et al., 2015) 
 Under-five mortality among children who use ITN in Ghana is about 18.8% lower than 
those who do not (Afoakwah et al., 2015). Achieving a hundred percent protection would 
significantly reduce deaths among under-fives. 
A systematic review which examined beliefs and practices concerning malaria in sub-
Saharan African countries revealed numerous barriers to malaria prevention. Barriers to the 
use of bed nets include the cost and ease of use, notion of increased sweating at night, and 
difficulty to mount it. Beliefs that malaria cannot be prevented or malaria being caused by 
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factors other than mosquitoes and Plasmodium parasites like environmental factors 
(excessive heat, wind, or cold), dietary factors (eating oily foods, certain fruits and grains, or 
too much of the same foods), drinking or bathing in dirty water, and supernatural causes 
(witchcraft, sorcery, and possession by spirits) (Maslove et al., 2009). 
Other barriers include the lack of understanding of the cause and transmission of malaria, 
the use of ineffective prevention measures which includes eating a balanced diet, drinking 
herbal teas, wearing charms or amulets, and vaccinating children (Maslove et al., 2009). 
Rickard and colleagues created and implemented an intervention to improve ITN use in a 
rural community, which involves “providing hands-on instructions and assistance in 
hanging of nets, in-home small group education, and monthly follow-up by trained 
community members. There was an increase in the usage rates for under-fives from 46% at 
the baseline to 95.7% at 6 months and 95.4% at 12 months, (both p < 0.001) (Rickard et al., 
2011). 
Mass distribution of free ITN coupled with massive enlightenment programs and the various 
methods revealed earlier would go a long way to improve malaria prevention methods 
(Diabaté et al., 2014; Terlouw et al., 2010). 
Knowledge of malaria prevention is essential to the adoption and practice of a prevention 
strategy; however, it has been revealed that knowledge does not always translate to practice. 
The prominent prevention strategy is the use of ITN which has some challenges associated 
with its use. 
 
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2.3 Malaria Treatment 
Malaria is endemic in sub-Saharan Africa, as a result appropriate treatment modalities have 
to be put in place. In Tigray where about one-third of the respondents Paulander and 
colleagues interviewed, revealed at least a member of the family had suffered from malaria 
since the last major transmission. Almost all the mothers’ revealed treatment was sought at a 
public health care facility, and tablets was the main type of treatment given which to a large 
extent relieved the symptoms (Paulander et al., 2009; WHO, 2014). 
Ashikeni and colleagues revealed in Kuje and Rubochi (control) area council in Abuja that 
most mothers use chloroquine to treat malaria in their under-five; however, this declined in 
Kuje after they were introduced to health intervention. An increase in the use of 
Artemisinin-based Combination Therapy (ACTs) was noticed in Kuje from 9.3% to 16.5% 
after the intervention (Ashikeni, 2013). 
A cross-sectional study done in the west of Sudan among mothers who attended a health 
facility revealed treatment options includes consulting a health worker, the use of traditional 
medicine, herbs and self-treatment. Self-treatment with chloroquine, aspirin and 
paracetamol purchased from drug stores in nearby villages was common, however, when 
symptoms deteriorates the health worker is consulted (Malik, Hanafi, Ali, Ahmed, & 
Mohamed, 2006). 
In a rural district in Burkina Faso, home treatment is the most frequent and the first action 
taken. 95% of the children received treatment; 72% from modern medication, 18% 
traditional while 5% mixes both. Most medication was given at home which was majorly 
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chloroquine, however, there is availability of other antimalarial medication such as quinine, 
amodiaquine, sulphadoxine-pyrimethamine (SP) in only about 1% of homes, but they were 
available at the health facility whilst no child received ACT. This study may not be a true 
representative for the whole district due to the study design (Tipke et al., 2009). 
In Dodoma region of Tanzania where two hundred and eighty seven under-fives with fever 
were studied, 16.8% sought medical care same day of onset of the fever which increased to 
27.7% after day one and 29.6% after two days. The number decreased to 20.7% after day 
three and 4.8% after day four, only one child (0.4%) sought care after five days. It was 
noticed that children who lived with both parents were less likely to be delayed while those 
from households with two to three under-fives were more likely to be delayed. Children 
who reside at distances greater than or equal to five kilometres from the health facility were 
about twice more likely to be delayed than those from shorter distances (Kassile, Lokina, 
Mujinja, & Mmbando, 2014). 
A study carried out in Kassena-Nankana district located in northern Ghana, which covered a 
period of two key malaria intervention activities ongoing in the district, revealed 67.4% of 
mothers were reported seeking treatment for their children under five years within the first 
24 hours of their child's febrile illness in the year 2000 community survey, which 
significantly improved to 93% in year 2003 survey. Most mothers reported seeking 
treatment for their children from chemical shops and drug vendors (50.5%) and 26.6% 
attended government clinics in 2000. There was an improvement in 2003 as 36.2% sought 
treatment at government clinics (Owusu-Agyei et al., 2007). Ahorlu and colleagues 
conducted a study in Shime sub-district of Keta district in the Volta region of Ghana, where 
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it was revealed that intermittent preventive treatment for children given three times in a year 
combined with timely home treatment for malaria reduces malaria prevalence significantly 
from 25% to 3%. This significantly reduces under-five deaths associated with malaria 
(Ahorlu, Koram, Seakey, & Weiss, 2009). 
In Dangme West District in Greater Accra Region, 75% of fever cases were first managed at 
home by ingestion of medications in the home or tepid sponging and purchase of over the 
counter drugs. The sex of the child was revealed to influence how treatment was sought. 
Female under-five used self-medication, while male under-fives where taken to a public 
health facility. However, it was revealed that the evidence was not strong enough hence the 
need for further study. Families with a higher income tend to use public or private providers 
as against self-medication while those covered in health insurance used public health 
facilities as against over-the-counter. Longer travel, waiting time in health facilities were 
factors favouring self-medication and over-the-counter treatment (Nonvignon et al., 2010). 
 The majority of deaths in under-five Nigerian children associated with malaria are due to 
severe malaria, deaths occur between one to three days after the commencement of the 
severe symptoms hence early detection and commencement of treatment by family members 
especially mothers is key (Iloh et al., 2012; Iloh et al., 2013). 
The children under five years are therefore a high risk group for infectious diseases due to 
the waning of  immunity acquired transplacentally, and the transitional period of 
development of their own immunity (Iloh et al., 2012). The recognition of malaria 
symptoms and prompt treatment curbs progression of malaria to its severe state. Marital 
status, distance to health facility, socioeconomic status influences health seeking behaviour. 
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Adequate knowledge of malaria, effective preventive strategy and prompt treatment affects 
morbidity and mortality of children under five years. 
It is for this reason I aim to determine the knowledge level of mothers of under-five 
regarding malaria, their prevention practices, challenges to effective prevention and 
treatment seeking practices. 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER THREE 
METHODS 
3.1 Study Design 
This study is a community based cross-sectional study in Adentan Municipality to determine 
the knowledge level of mothers of under-five regarding malaria, their prevention practices, 
challenges to effective prevention and treatment seeking practices 
The study adopts quantitative method. Structured questionnaire interviews of mothers of 
children under five years was conducted in selected communities in the four zonal councils; 
Kosee, Gbentanaa, Nii Ashale and Sutsurunaa. 
3.2 Study Area 
This study was performed in Adentan Municipality of Greater Accra Region, Ghana. The 
Municipality has a land area of about 928.4 sq km. It shares boundaries with Ashaiman 
Municipal Assembly and Kpong Akatamanso District Assembly in the east and north, La 
Nkwantanang Municipal Assembly in the west and south. 
It has four zonal councils namely; Koose, Gbentanaa, Nii Ashale and Sutsurunaa. These 
zonal councils have 12 electoral areas. 
The population of Adentan Municipality is 78,215. Males constitute 50.3% and females 
represent 49.7%. About 62.5 percent of the population resides in urban and 37.5 percent in 
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rural areas. There is a total of 9870 under-five in the Municipality, 5024 males and 4846 
females. 
The Municipality has a household population of 76,601 with a total number of 20,478 
households. The average household size in the Municipality is 3.7 persons per household. 
Children constitute the largest proportion of the household members accounting for 35.1%. 
Spouses form about 12.4%. Nuclear households (head, spouse(s) and children) constitute 
26.9% of the household structure in the Municipality. 46.7% have never married, 6.8% are 
in consensual unions, 2.3% is widowed, 2.4% divorced and 6.6% separated. 
Of the population 11 years and older, 91.9% are literate and 8.1% are not literate. Slightly 
more than five out of ten people (54.8%) could read and write in both English and a 
Ghanaian language. Of the population aged 3 years and older 24,740 are currently attending 
school in the Municipality. About 74.1% of the population aged 15 years and older is 
economically active while 25.9% are economically not active. For those who are 
economically not active, a larger percentage of them are students (50.9%), 23.9% perform 
household duties and 2.4% are disabled or too sick to work (Ghana Statistical Service 
(GSS), 2014). 
3.3 Variables 
The variables for this study are categorized into dependent and independent as shown 
below: 
Dependent variables: Prevention practice, Treatment practice 
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Independent variables: mothers’ age, marital status, ethnic group, educational level, family 
size, occupation, father’s occupation, family income, number of children below five years, 
age of under- five and sex of under – five, knowledge of malaria. 
3.4 Sampling 
3.4.1 Study Population  
The population for study is mothers of children under five years who reside within Adentan 
Municipality. 
3.4.2 Sample Size  
Sample size was estimated on the basis of the following: Using a 95% confidence level (Z) 
and the prevalence of malaria among children aged less than five years to be 27% according 
to Ghana Demographic and Health Survey(2015). 
n = sample size = (z2pq)/d2  
Z=1.96 at 95% confident interval (CI) 
d= Desired difference between observed proportion and true proportion= 5% (95% CI) 
n = sample size = 302  
To make for attrition, 20% of the sample size would be added to make up for non-responses. 
Hence, a total of 363 mothers were recruited for the study. 
 
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3.4.3 Sampling Method 
A community from each zonal council was selected by simple random method. In the 
selected community, a systematic sampling method was utilized to recruit mothers of 
children under five years for the study. 
At the first stage, a list of under-five population by community was collected from Ghana 
Statistical Service (2010 Population and Housing Census) to determine the proportionate 
sample size for each of the four selected communities. Sample proportions for the four 
communities were estimated based on under-five population. 
A listing of the houses in each of the communities was done, with the list; a sampling 
interval was calculated for each of the community. The first house was chosen by random 
and subsequent selection was by the calculated sampling interval. Only one mother of a 
child below five years was chosen per house by a simple random method and in situation 
where there is no eligible mother, the very next house was selected.  
Table 1 shows the sampling allocation to communities: 
 
 
 
 
 
 
 
 
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Table 1 Sample allocation to communities 
Zonal 
Council 
Community Total 
Population 
Under-five 
Population 
Proportions Sample size 
Sutsurunaa Adjiringanor 4708 560 0.262418 95 
Koose Amanfro 675 78 0.036398 13 
Gbentanaa Frafraha 6214 721 0.336444 122 
Nii Ashale Ogbojo 5920 784 0.364442 133 
Total   2143  363 
 
 
3.5 Data collection, handling and analysis  
3.5.1 Inclusion criteria 
Mothers of children under five years (less than 60 months) in Adentan Municipality 
3.5.2 Exclusion criteria 
Mothers whose children are aged five years and above. 
3.5.3 Ethical considerations and approval  
Ethical approval was sought from Ghana Health Service Ethical Review Committee.  
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Permission from Adentan Health Directorate, Traditional elders and heads of the households 
before interview. 
Informed Consent 
Written informed consent was sought from all mothers prior to administration of 
questionnaires.  
Confidentiality 
Participant confidentiality was assured throughout the study. 
Risks and benefits 
There are no risks associated with participating in the study and there are no compensations 
as well. 
3.5.4 Training of interviewers 
Data collectors recruited were trained to administer the questionnaires. They were coached 
specifically on ways of administering questionnaires and conducting the interviews for 
quality data collection. 
3.5.5 Data collection: 
 Data was collected using structured questionnaire with questions assessing the knowledge 
level of mothers about malaria, prevention methods practiced, challenges to effective 
prevention and their treatment seeking practices. 
 
 
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3.5.6 Pre-testing and review of instruments/tools:  
Questionnaires were pre-tested at Madina, reviewed with appropriate changes effected 
accordingly. 
3.6 Data Handling and Analysis:  
Data from the study was entered, cleaned and analyzed in Stata version 13. Confidentiality 
was ensured and completed questionnaires were kept under lock and key.  
Demographic characteristics are presented in graphs and tables as appropriate. A chi square 
test was used to determine the association between dependent and independent variables. 
The knowledge of malaria was assessed by the use of questionnaire, which contains 49 
items. Mothers were asked about the transmission of malaria, symptoms, complications, 
most risk group, prevention and treatment strategies. 
A knowledge score was calculated by giving one point for each item answered correctly and 
no point for incorrect answer. The total score ranges from 0 to 49. Mothers with scores 0 to 
24 were considered to have poor knowledge, while those with scores 25 and above were 
considered to have good knowledge. 
3.6.1 Data Storage:  
All manual and electronic data were stored in a secure locked cabinet and access granted to 
only to the investigator. Data held on computers and flash drives was encrypted with a 
password which will be made available only on a need to know basis. 
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CHAPTER FOUR 
RESULTS 
This chapter presents information on the findings of the study. The data was collected from 
four communities in Adentan Municipality namely Adringanor, Amanfro, Frafraha and 
Ogbojo.  
It is organized as follows: Socio-demographic characteristics of respondents, knowledge of 
malaria, prevention methods practiced, challenges to prevention methods and treatment 
seeking practices of the mothers of children under five years.  
4.1 Background characteristics of respondents  
This describes the socio-demographic characteristics of the respondents, a total of 363 
mothers of children under five years who reside in Adentan Municipality were involved in 
this study. Ages of respondents in this study ranges from 17 to 47 years. Table 2 shows that 
majority of the respondents (56.2%) are from the age group 26-35 and this indicates that 
they are the most populated group. Age group 17-25 and 36-47 make up 26.2% and 17.6% 
respectively. 76.3% of the respondents are presently married while 23.7% are either single 
or previously married.  
Majority of the respondents are either Akan (33.3%) or Ewe (33.1%). 44.9% acquired 
secondary school education while 19.8% of the respondents have been to tertiary school. 
40.5% of the respondents are traders while 0.8% are students. 
A large proportion of the respondents’ family income is less than Ghc 1000 (76.3%), while 
13.2% has a family income of GHc 1000 and above. 68.9% had a family size of two to four 
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while 3.6% had a family size of seven to eleven. 68.8% of respondents had only one child 
aged below five years while 0.3% had four children aged below five years. 46.3% of the 
children were aged between one to eighteen months while 16.0% were aged thirty seven to 
fifty nine months. In terms of sex of the child, 52.6% are females while 45.7 were males. 
Table 2 indicates the details below: 
Table 2 Socio-demographic characteristics of respondents 
Variable name Frequency (n=363) Percentage (%) 
Age   
17-25 95 26.2 
26-35 204 56.2 
36-47 64 17.6 
Marital status   
Married 277 76.3 
Unmarried 86 23.7 
Ethnic group   
Akan 121 33.3 
Ewe 120 33.1 
Ga-Dangme 68 18.7 
Others 54 14.9 
Level of Education   
None 31 8.6 
Primary 97 26.7 
Secondary 163 44.9 
Tertiary 72 19.8 
Occupation   
Professional 66 18.2 
Artisan 108 29.8 
Trader 147 40.5 
Housewife 17 4.7 
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Variable name Frequency (n=363) Percentage (%) 
Student 3 0.8 
Unemployed 22 6.0 
Family Income (Ghc)   
Less than 1000 277 76.3 
At least 1000 48 13.2 
Non response 38 10.5 
Family size   
2-4 250 68.9 
5-7 96 26.4 
7-11 13 3.6 
Non response 4 1.1 
Number of U5 in households   
1 250 68.8 
2 103 28.3 
3 5 1.4 
4 1 0.3 
5 2 0.6 
Non response 2 0.6 
Age of child (months)   
1-18 168 46.3 
19-36 134 36.9 
37-59 58 16.0 
Non response 3 0.8 
Sex of child    
Male 166 45.7 
Female 191 52.6 
Non response 6 1.7 
   
   
 
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4.2 Knowledge of malaria 
Out of the 363 mothers enrolled, 95.6% had good knowledge of transmission of malaria, its 
symptoms, complications, most risk group, prevention and treatment strategies as shown in 
figure 1. 
 
Figure 1 Distribution of knowledge of malaria among respondents 
 
4.2.1 Association between socio-demographic characteristics and 
knowledge of malaria 
Chi-squared test was conducted to check association between socio-demographic 
characteristics and knowledge of malaria. A P-value less than 0.05 was considered 
significant. A high proportion of respondents in all age group had good knowledge of 
malaria, 93.7% among respondents aged 17–25, 96.6% among those aged between 26-35 
years and 95.3% among those aged between 36 -47 years. Age was not significantly 
associated with knowledge of malaria (p = 0.524). Knowledge of malaria was higher among 
the unmarried (97.7%) as compared to the married (94.9%). This difference was however, 
not statistically significant (p=0.377).  
4.40% 
95.60% 
Poor
Good
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All mothers with tertiary level of education had a good knowledge of malaria (100%) while 
those with no form of education have the least proportion of those with good knowledge of 
malaria (83.9%). Mother’s level of education has statistical significant association with 
knowledge of malaria (p=0.002). All the mothers with a monthly family income of Ghc 
1000 and above had good knowledge of malaria with 95.3% of those with a monthly family 
income of less than Ghc 1000 having good knowledge of malaria. Mothers in families with 
a size of 7-11 members had the least proportion of those with good knowledge of malaria 
(84.6%). Both family income and family size was not statistically significant with the 
knowledge of malaria. 
Table 3 indicates the details below: 
 
 
 
 
 
 
 
 
 
 
 
 
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Table 3 Socio-demographic characteristics and knowledge of malaria 
         N=363(%)   
Characteristics Poor 
knowledge 
Good 
knowledge 
Total p-value 
Age     
17-25 6(6.3) 89(93.7) 95(100.0)  
26-35 7(3.4) 197(96.6) 204(100.0)  0.524 
36-47 3(4.7) 61(95.3) 64(100.0)  
Marital status     
Married 14(5.1) 263(94.9) 277(100.0) *0.377 
Unmarried 2(2.3) 84(97.7) 86(100.0)  
Level of Education     
None 5(16.1) 26(83.9) 31(100.0)  
Primary 6(6.2) 91(93.8) 97(100.0) 0.002 
Secondary 5(3.1) 158(96.9) 163(100.0)  
Tertiary 0(0.0) 72(100.0) 72(100.0)  
Family Income Ghc     
Less than 1000 13(4.7) 264(95.3) 277(100.0) *0.229  
At least 1000 0(0.0) 48(100.0) 48(100.0)  
Family size     
2-4 9(3.6) 241(96.4) 250(100.0)  
5-7 3(3.1) 93(96.9) 96(100.0) *0.119 
7-11 2(15.4) 11(84.6) 13(100.0)  
*Statistical testing using Fisher’s exact 
 
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4.3 Prevention of Malaria 
A higher proportion of mothers (87.6%) prevented their child from malaria using any of the 
malaria prevention strategies. Majority use multiple strategies to prevent malaria (54.4%), 
33.7% use ITN only while 0.3% clean the environment as the only prevention strategy. 
56.4% of the mothers chose their malaria prevention strategy because they felt it was 
effective while affordability of the method was the reason for 6.4% of the mothers, as 
shown in figures (2, 3) and table 4. 
 
Figure 2 Distribution of mothers who prevent malaria 
 
 
 
 
 
 
 
 
87.60% 
12.20% 
Prevent malaria
Do not prevent malaria
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Table 4 Malaria prevention strategies 
Strategy Frequency (n=318) Percentage (%) 
Drug 3 0.9 
Repellant 9 2.8 
Bednet 3 0.9 
ITN 107 33.7 
Insecticide spray 17 5.4 
Wear protective clothing 5 1.6 
Clean environment 1 0.3 
Multiple 173 54.4 
 
          
Figure 3 Reason for the prevention strategy 
 
Some challenges identified by study respondent in relation to current malaria prevention 
method included discomfort, cost, irritation, skin conditions, allergies, tear and difficulty in 
tacking ITNs. About 29% felt uncomfortable with their current malaria prevention strategy 
while 12.9% perceived cost was a major determinant of malaria prevention strategy. Among 
6.4 
10.9 
12.8 
13.5 
56.4 
0 10 20 30 40 50 60
Affordability
Convenience
Safety
Availability
Effectiveness
Percentage (%) 
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the 318 mothers who prevent their child from malaria, 74.8% (238) own an ITN. 49.2% of 
the 238 mothers own one ITN while 1.7% own more than four ITNs as shown in figures 
(4&5). 
Of the 74.8% mothers who own an ITN, no member of the household sleep under the ITN 
of 2.1% of the mothers while 44.5% revealed a maximum of two members of their 
household sleep under one ITN. 8.8% reveal their ITN is been changed or re-impregnated in 
less than six months while 46% has never changed nor re-impregnated their ITN, as shown 
in figures (6&7). 
 
Figure 4 Distribution of ITN ownership       
 
74.8 
25.2 
Own ITN
Do not own ITN
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Figure 5 Distribution of number of ITN(s) owned 
 
 
 
Figure 6 Persons sleeping under an ITN 
 
49.2 
36.1 
8 
5 
1.7 
0
10
20
30
40
50
60
1 2 3 4 >4
Number of ITN owned
2.1 
8.8 
44.5 
26.1 
14.7 
3.8 
0
5
10
15
20
25
30
35
40
45
50
0 1 2 3 4 >4
Number of people
sleeping under one ITN
in the household
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Figure 7 Frequency of ITN change or re-impregnation 
 
4.3.1 Prevention of malaria, ITN ownership and knowledge of malaria 
A high proportion of mothers who prevent malaria have good knowledge of malaria 
(98.1%). Preventing malaria has statistical significant association with knowledge of malaria 
(p<0.001). A high proportion of both mothers who own and do not own ITN have good 
knowledge of malaria. This however was not statistically significant (p=0.170). 
Table 5 indicates the details below: 
 
 
 
 
 
8.8 
21.8 
23.4 
46 
0 10 20 30 40 50
<6months
6mtn-1yr
>1yr
never
Percentage (%) 
Fr
eq
u
en
cy
  
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Table 5 Selected prevention parameters and knowledge of malaria 
         N=363(%)   
Characteristics Poor 
knowledge 
Good 
knowledge 
Total p-value 
Preventing Malaria     
Yes 6(1.9) 312(98.1) 318(100.0) <0.001 
No 10(22.2) 35(77.8) 45(100.0)  
ITN Ownership     
Yes 3(1.3) 235(98.7) 238(100.0) *0.170 
No 3(3.8) 77(96.2) 80(100.0)  
*Statistical testing using Fisher’s exact 
 
4.3.2 Socio-demographic characteristics and ITN ownership  
From the analysis, 70.7% of respondents with no formal education own ITN, 76.7% of those 
with primary education own ITN, 81.5% of those with secondary education while 60% of 
those with tertiary education own an ITN. This, however was not statistically significant 
(p=0.140). 
Out of the 44 mothers with a monthly family income of Ghc 1000 and above, 86.4% own an 
ITN while 72.6% own an ITN among those with a monthly family income of less than Ghc 
1000, this also was not statistically significant as shown in table 6. 
 
 
 
 
 
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Table 6 Association between socio-demographic characteristics and ITN ownership 
  N=318(%)   
  ITN Ownership   
Characteristics Yes No Total p-value 
Level of Education     
None 58(70.7) 24(29.3) 82(100.0)  
Primary 112(76.7) 34(23.3) 146(100.0) 0.140 
Secondary 53(81.5) 12(18.5) 65(100.0)  
Tertiary 15(60) 10(40) 25(100.0)  
Family Income 
Ghc 
    
Less than 1000 175(72.6) 66(27.4) 241(100.0) 0.054 
At least 1000 38(86.4) 6(13.6) 44(100.0)  
 
4.4 Malaria treatment practice 
Analysis revealed 74.4% of respondent’s child had a positive history of fever, 32.8% had 
been admitted due to fever, 3.8% had history of unconsciousness, 4% had history of 
convulsion and 0.3% has lost a child after developing fever, being unconscious or 
convulsed. 8.5% of the children whose mother were interviewed experience fever regularly 
while 58.5% rarely experience fever. 0.7% visits the laboratory as first action after noticing 
fever in their child while 36.3% tepid sponge. On persistence of the fever, none of the 
mothers use herbs while 86.2% take their child to the health facility. Of the mothers 
interviewed, 41.2% took action in less than 24 hours, while 8.8% took action after three 
days, as shown in figures (8, 9, 10) and table 7. 
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Figure 8 History of fever parameters among child of respondents 
 
 
 
 
Figure 9 Frequency of occurrence of fever           
 
 
74.4 
32.8 
3.8 
4 
0.3 
25.6 
67.2 
96.2 
96 
99.7 
0 20 40 60 80 100 120
History of fever
Admission due to fever
History of unconsciousness
History of convulsion
History of death
No
Yes
8.5 
33 
58.5 
0
10
20
30
40
50
60
70
Regularly Occasionally Rarely
P
er
ce
n
ta
ge
 
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Figure 10 Mother's response to child's fever 
 
Table 7 Duration between fever onset and action 
Duration (days) Frequency n=250 Percentage (%) 
<1 103 41.2 
1 64 25.6 
2 33 13.2 
3 28 11.2 
>3 22 8.8 
 
4.4.1 Child’s age and History of fever  
Children in age group 1-18 months had a 66.1% positive history of fever, 81.3% among 
those between 19-36 months and 84.5% among those between 37-59 months. Age is 
significantly associated with history of fever, as shown in table 8. 
 
1.6 
1.2 
0.4 
3.1 
0 
7.5 
86.2 
1.1 
36.3 
0.7 
35.6 
1.5 
13.3 
11.5 
0 10 20 30 40 50 60 70 80 90 100
Do nothing
Tepid sponge
Visit lab
Medication
Herbs
Visit drug store
Visit health facility
First response to fever
Second response on persistence of fever
Percentage 
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Table 8 Association between child’s age and history of fever 
            History of fever N=360(%)      
Characteristics Positive Negative Total p-value 
Age (months)     
1-18 111(66.1) 57(33.9) 168(100.0)  
19-36 109(81.3) 25(18.7) 134(100.0) 0.002 
37-59 49(84.5) 9(15.5) 58(100.0)  
 
4.4.2 Knowledge of malaria and history of fever 
Of the mothers with poor knowledge of malaria, 12.5% of their child had a positive history 
of fever while 77.2% of the children of the mothers with good knowledge of malaria had a 
positive history of fever. There was significant association between knowledge of malaria 
and history of fever (p<0.001), as shown in table 9. 
Table 9 Association between knowledge of malaria and history of fever 
            History of fever N=363(%)      
Knowledge  Positive Negative Total p-value 
Poor 2(12.5) 14(87.5) 16(100.0)  
Good 268(77.2) 79(22.8) 347(100.0) *<0.001 
*Statistical testing using Fisher’s exact 
 
 
 
 
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4.4.3 Knowledge of malaria and duration between fever onset and action  
A higher proportion of the mothers with good knowledge of malaria (41.5%) took action in 
less than a day. 50% of the mothers with poor knowledge took action two days after onset of 
fever with the remaining 50% taking action three days after onset of fever. There was no 
significant association between mothers’ knowledge of malaria and the duration between 
fever onset and action, as shown in table 10. 
Table 10 Association between knowledge of malaria and duration between fever onset 
and action 
   Duration between fever 
onset and action (days) 
N=250(%) 
    
Knowledge  <1 1 2 3 >3 Total p-value 
Poor 0(0.0) 0(0.0) 1(50.0) 1(50.0) 0(0.0) 2(100.0)  
Good 103(41.5) 64(25.8) 32(12.9) 27(10.9) 22(8.9) 248(100.0) *0.109 
*Statistical testing using Fisher’s exact 
 
4.4.4 Knowledge of malaria and fever admission 
The children of most of mothers with good knowledge of malaria had no history of 
admission due to fever (67.3%), while half of the mothers with poor knowledge had 
experienced hospital admission of the child due to fever. There was no significant 
association between knowledge of malaria and fever admission, as shown in table 11. 
 
 
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Table 11 Association between knowledge of malaria and fever admission 
  Fever admission N=268(%)      
Knowledge  Positive Negative Total p-value 
Poor 1(50.0) 1(50.0) 2(100.0)  
Good 87(32.7) 179(67.3) 266(100.0) *0.550 
*Statistical testing using Fisher’s exact 
 
4.4.5 Knowledge of malaria and history of unconsciousness  
The children of majority of the mothers with good knowledge of malaria (96.5%) have no 
history of unconsciousness while the children of 25% of mothers with poor knowledge have 
a positive history of unconsciousness. There was no association between knowledge of 
malaria and history of unconsciousness, as shown in table 12. 
Table 12 Association between knowledge of malaria and history of unconsciousness 
         History of unconsciousness N=292(%)      
Knowledge  Positive Negative Total p-value 
Poor 1(25.0) 3(75.0) 4(100.0)  
Good 10(3.5) 278(96.5) 288(100.0) *0.143 
*Statistical testing using Fisher’s exact 
 
4.4.6 Knowledge of malaria and history of convulsion 
The children of majority of mothers with good knowledge of malaria (96.1%) have no 
history of convulsion likewise majority of children of mother with poor knowledge (93.3%) 
also have no history of convulsion. There was no significant association between knowledge 
of malaria and history of convulsion, as shown in table 13. 
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Table 13 Association between knowledge of malaria and history of convulsion 
                  History of convulsion N=351(%)      
Knowledge  Positive Negative Total p-value 
Poor 1(6.7) 14(93.3) 15(100.0)  
Good 13(3.9) 323(96.1) 336(100.0) *0.464 
*Statistical testing using Fisher’s exact 
 
4.4.7 Knowledge of malaria and history of death 
All respondents with good knowledge of malaria has not lost a child after developing fever, 
unconsciousness or convulsion while 6.7% of mothers with poor knowledge has lost a child 
after developing fever, unconsciousness or convulsion. Knowledge of malaria was 
statistically significant with history of death, as shown in table 14. 
Table 14 Knowledge of malaria and history of death 
                  History of death N=352(%)      
Knowledge  Positive Negative Total p-value 
Poor 1(6.7) 14(93.3) 15(100.0)  
Good 0(0.0) 337(100.0) 337(100.0) *0.043 
*Statistical testing using Fisher’s exact 
 
 
 
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CHAPTER FIVE 
DISCUSSIONS 
This chapter discusses the findings obtained from the analysis and how they are related to 
other findings. Data was collected from 363 mothers of children under five years in Adentan 
Municipality. The Objectives of the study were to measure the level of knowledge of 
mothers of children under five years about malaria, identify prevention methods practiced, 
determine challenges to effective prevention and their treatment seeking practices. 
5.1 Knowledge of malaria 
With 95.6% of the mothers with good knowledge of malaria transmission, symptoms, 
complications, most risk group, prevention and treatment strategies, awareness of malaria 
was very high. This is similar to studies done by Paulander and colleagues (2009) in 
Ethiopia, Kinung'hi and colleagues (2010) in North-western Tanzani, De La Cruz and 
colleagues (2006) in the Eastern and Central region of Ghana and Ameyaw and colleagues 
(2015) in Kumasi, Ghana. But different from the study in Kuje, Nigeria where mothers 
demonstrated poor knowledge both pre and post health information about malaria (Ashikeni, 
2013). A possible explanation for the high knowledge was health information given to the 
mothers during antenatal visits, visits to the infant and child clinic especially for 
immunization and the adoption of the Community-based Health and Planning Services 
(CHPS) system which brings trained health care workers directly into the communities 
(Ghana Statistical Service (GSS), 2014). Among the socio-demographic characteristics, only 
the level of education was found to be statistically significant with mothers’ knowledge of 
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malaria (p=0.002). Majority of the mothers (91.4%) had at least primary education while 
64.7% had at least secondary education. Education may lead to an increased knowledge of 
malaria, its prevention and control in children under five years as it increases the chances to 
be informed about malaria and better understand information given. This is corroborated by 
Iloh and colleagues’ (2013) where level of education was associated with knowledge of 
malaria and its complications which had an impact on the decision-making process as 
regards health seeking behaviour for malaria. However, there was no significant association 
between level of education and knowledge of malaria in the study done by Appiah-Darkwah 
(2011) in Accra as non-formal and informal forms of education are attributed to play a role. 
5.2 Prevention of malaria 
Mothers’ knowledge of malaria is important for its prevention and control in their children. 
87.6% of mothers prevented their child from malaria. ITN usage was the most common 
prevention strategy; it is usually combined with other strategies. 
Of the respondents interviewed, 65.6% (238) own an ITN while 64.2% (233) use the ITN. 
The free distribution of ITNs to every pregnant woman and mother of a child under five 
years who visits the health facility and distribution to the homes by Adentan Health 
Directorate is a possible reason it is the commonest prevention strategy. This is similar to 
the study by Paulander and colleagues’ (2009) where most households had ITN which was 
gotten from the government . 
The result from this study is higher than the national figure of 48% and that of Greater 
Accra region which has the lowest percentage (26%) in the country (Ghana Statistical 
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Service (GSS) et al., 2015) It meets the Abuja target of 60% which should be replicated to 
the region and entire country (WHO, 2000).  
Of the mothers who own ITN (238), the ITN seem to be insufficient for 44.6% of them who 
have more than two people sleeping in the ITN while 2.1% have ITNs they refuse to use. 
Knowledge of malaria and prevention practice were significantly associated (p<0.001) in 
contrast with the findings of De La Cruz and colleagues (2006) and Edelu and colleagues 
(2010) which revealed that knowledge does not translate into practice. 
Challenges with the use of ITNs include tear, tacking difficulty, discomfort in the form of 
heat, burning of the skin in the initial days used. Mothers prefer the circular ITNs to the 
rectangular one because of the ease in tacking. Insecticide spray was regarded expensive and 
causes some form of allergy likewise coils and repellants. Wearing of overall protective 
clothes and environmental management were perceived ineffective when used alone. 
Maslove and colleagues’ (2009) revealed similar findings; the barriers to effective ITN 
usage were cost and ease of use, notion of increased sweating at night, tacking difficulty, the 
unpleasant side effect of coil smokes, repellants and insecticide spray were among the 
reasons. Ignorance also played a role as the lack of knowledge that mosquitoes causes 
malaria would render the use of ITNs irrelevant. 
5.3 Treatment of malaria 
Malaria in children under five years requires prompt recognition and treatment to prevent 
complications. Mortality occurs only after 24 to 72 hours after commencement of severe 
symptoms. Mothers have a key role to play. 74.4% of respondent’s child had a positive 
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history of fever, 32.8% had been admitted due to fever, 3.8% had history of 
unconsciousness, 4% had history of convulsion and 0.3% has lost a child after developing 
fever, being unconscious or convulsed. 8.5% of the children whose mother were interviewed 
experience fever regularly while 58.5% rarely experience fever. Mothers knowledge of 
malaria and history of fever was significantly associated (p<0.001) likewise child’s age was 
significantly associated with history of fever (p=0.002). Majority of the children in the 37 - 
59 months age group (84.5%) have a positive history of fever compared to those between 1-
18 months. A possible explanation for this is since the prevalence of malaria in the different 
age group was not determined in the study, it is logical that the older child would have had 
more fever experience than the younger ones. Nyarko and Cobblah (2014) study in Ghana 
revealed a 12% prevalence rate in the younger age group compared to 26% in the 12 – 23 
months age group and 24% in the 24-35 months age group. Presence of antibodies acquired 
from their mothers is a possible reason for the protection in the younger age group. 
It was a common practice to tepid sponge, as about 36.3% of the mothers did to reduce the 
child’s body temperature this could be harmful as the fever may worsen to its severe form. 
About 74.4% of the fever cases were first managed at home (tepid sponge, medication, 
herbs) which is similar to the study done in Dangme West District, in the same Greater 
Accra region of Ghana (Nonvignon et al., 2010). This could be due to the average travel 
time of 16 to 30 minutes and an average waiting time of between one to two hours. Majority 
of the mothers take their child to the health facility only on persistence of the fever 
symptoms (86.2%) as against 11.5% who took their child to a health facility as the first 
response. Cost of care could be another possible reason. Of the mothers interviewed, 41.2% 
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took action in less than 24 hours, which is less than the recommended 60% Abuja target 
(WHO, 2000), 25.6% in 24 hours and 13.2% in 48 hours. This is in contrast to a study done 
in Volta and Eastern region of Ghana where significant proportion of under-five children 
receiving treatment after 24 hours with only 11% receiving treatment in less than 24 hours 
(Ahorlu, Koram, Ahorlu, De Savigny, & Weiss, 2006) and to a study done in central 
Tanzania with similar figures (Kassile et al., 2014). There was no association between 
mothers’ knowledge of malaria and duration between fever onset and action (p=0.109), 
however knowledge of malaria was significantly associated with history of death of under-
five due to fever or its complication (p=0.043). Adequate knowledge of malaria 
transmission, symptoms, complications, most risk group, prevention and treatment strategies 
would enable mothers prevent their child from malaria, detect symptoms and promptly 
respond to avoid exacerbation into its severe form hence reducing morbidity and mortality 
of children under five years due to malaria. 
 
 
 
 
 
 
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CHAPTER SIX 
CONCLUSIONS AND RECOMMEDATIONS 
6.1 Conclusions 
Mothers’ of children under five years knowledge of malaria was high which could be 
attributed to health information given to them during antenatal visits, visits to the infant and 
child clinic especially for immunization and the adoption of the Community-based Health 
and Planning Services (CHPS) system which brings trained health care workers directly into 
the communities.   
 The distribution of ITNs to pregnant women and children under five years in Adentan 
resulted in ITN being the most common prevention strategy, which is usually combined 
with other strategies, however the number of ITNs available to 44.6% of the respondents is 
insufficient for their household. Challenges with the use of ITNs include tear, tacking 
difficulty, discomfort in the form of heat, burning of the skin in the initial days used. 
Mothers prefer the circular ITNs to the rectangular one because of the ease in tacking. 
Insecticide spray was regarded expensive and causes some form of allergy likewise coils 
and repellants. Wearing of overall protective clothes and environmental management were 
perceived ineffective when used alone. 
Tepid sponging was the first response to fever while visit to the health facility was mainly 
the response on persistence of symptoms. The proportion of response within first 24 hours 
does not meet the Abuja target of 60%, suggesting the need for an emphasis of prompt 
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seeking of care. Adequate knowledge of malaria, effective preventive measures and prompt 
treatment would in no small measure reduce under-five morbidity and mortality. 
 
6.2 Recommendations 
Malaria control is a concerted effort that involves all stakeholders.  
The following measures are being recommended to the Adentan Health Directorate; 
 The community health nurses and volunteers who are primarily involved in the 
CHPS service should be routinely trained for more effective Behaviour Change 
Communication (BCC) activities as regards mothers’ early recognition of malaria 
symptoms and prompt response. 
 Encourage continued ITN distribution particularly to pregnant women and children 
under five years preferably the circular ITNs. 
To the Ministry of Health and National Malaria Control Programme; 
 The need to sustain the free ITN distribution in antenatal clinics, child welfare 
clinics and community based distribution in order to increase access and use. 
 Continued sustenance of the CHPS service which improves knowledge of malaria 
and encourages the adoption of control strategies.  
 Feedback to the manufacturers of the ITNs to improve on the design and quality of 
their product. 
 Adequate staffing of the community clinics, with an upward review of the working 
hours. 
 
 
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University of Ghana http://ugspace.ug.edu.gh
  
 APPENDICES 
CONSENT FORM 
Malaria prevention and treatment seeking practices among mothers of children 
under five years in Adentan Municipality 
Principal Investigator: Kingsley Ikhuosho Ojeikere 
Address: School of Public Health, College of Health Sciences, University of Ghana.   
Email: kiojeikere@st.ug.edu.gh, kingsley.ojeikere@gmail.com 
Mobile no: +233503268444, +2348184266920 
General information about Research 
Malaria is known to be endemic in Ghana and poses serious public health challenges to 
the development of Ghana. 
It is currently number one among the causes of admission of children under five years 
likewise number one cause of death of children under five years in Ghana. 
This study would determine the knowledge level of mothers of children under five years, 
the prevention method practiced, challenges associated with preventing malaria, and 
treatment seeking practices which would provide relevant information to combat malaria 
in Ghana. 
It would take approximately 15 minutes of your time responding to the questionnaire. 
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Possible Risks 
There is no risk in participating in this research. 
Possible Benefits 
Participation in this research may not benefit you directly. However, results from this 
study will be used to inform decisions in implementation and strengthening of programs 
aimed at controlling morbidity and mortality of children under five years in Ghana. 
Confidentiality 
We will protect information about you taking part in this research to the best of our 
ability. We will neither use your name in any reports nor discuss your participation with 
anyone outside the research team. 
Compensation 
There is no compensation in taking part in this research. 
Additional Cost  
There will be no additional cost for the participant 
Voluntary Participation and Right to Leave the Research 
Your participation in this research is voluntary and you have the right to withdraw 
without any penalty at any point of participating in the research. You also have the right 
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not to answer questions that you are not comfortable with. 
Termination of Participation by the Researcher 
You may leave the research at any time. If you choose not to take part, you can change 
your mind at any time and withdraw. The researcher may also terminate the research if 
the respondent is not co-operating. 
Contacts for Additional Information 
Please call Prof Richard Adanu - 0244 238556 in case you have any problem with 
participation in the research or want some verification about this research. 
Your Right as a Participant 
This research has been reviewed and approved by the Ghana Health Service Ethical 
Review Committee. If you have any questions about your right as a research participant, 
you can contact the GHS research office between the hours of 8am-5pm through Dr 
Hannah Frimpong (233 021 681109) or email address Hannah.Frimpong@hru-ghs.org  
VOLUNTEER AGREEMENT 
I understand all that has been explained to me about the study – objectives, benefits, risks 
and my rights, and I agree to participate in this study. 
  
_____________________________                                                        _______________ 
Signature of respondent                                                                                      Date  
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QUESTIONNAIRE 
 
Zonal Council:……………………………………………        Community:……………………………………………      
A. SOCIO-DEMOGRAPHIC CHARACTERISTICS 
Mother 
1. Age (in years)……………………. 
2. Marital status: Single {   } Married {   } Co-habiting {   } Separated {   } Divorced {   }   
Widowed {   }  
3. Ethnic group :  ……………………………….. 
4. Educational Level: Primary {   } Secondary {   } Tertiary {   } None {   } 
5. Occupation…………………………….. 
6. Husband’s occupation………………….. (skip if unavailable) 
7. Family Income : <100 cedis {   } 100 – 499 cedis {   } 500 – 999 cedis {   } 1000 – 2000 cedis 
{   }                                                                     >2000cedis {   } 
8. Family size ……………………. 
9. Number of Under – five in household………………………. 
 
Child 
1. Age of child (in months)…………………………………… 
2. Sex : Male {   } Female {   } 
 
B KNOWLEDGE 
1. Have you heard about Malaria?   Yes {   } No {   } If No go to section C 
2. How did you hear about Malaria? Radio {   } Television {   } Family member {   } 
Health                               worker {   } Others ……………………………………………………                   
     
3. Have you received any teaching or training on malaria? Yes {   } No {   }   
 
4. How is Malaria transmitted?  
Close contact with malaria patient   Yes {   } No {   } 
Unhygienic practices      Yes {   } No {   } 
Mosquitoes bites          Yes {   } No {   } 
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Exposure to Sunlight    Yes {   } No {   }   
Heat       Yes {   } No {   } 
Cold      Yes {   } No {   } 
Eating contaminated food   Yes {   } No {   }   
Drinking contaminated water   Yes {   } No {   }   
Supernatural     Yes {   } No {   }   
5. Symptoms of Malaria?  Fever    Yes {   } No {   } 
 Headache  Yes {   } No {   } 
 Diarrhoea   Yes {   } No {   } 
 Vomiting              Yes {   } No {   }   
 Body pain  Yes {   } No {   } 
 Coughing   Yes {   } No {   } 
Shivering  Yes {   } No {   } 
Inability to eat  Yes {   } No {   } 
6. Complications of Malaria? Anaemia  Yes {   } No {   } 
Unconsciousness Yes {   } No {   } 
Convulsion  Yes {   } No {   } 
7. Who is most at risk to malaria? 
Males    Yes {   } No {   } 
 Females   Yes {   } No {   } 
Mother   Yes {   } No {   } 
Father    Yes {   } No {   } 
Teenager   Yes {   } No {   } 
Adolescent   Yes {   } No {   } 
Under- fives   Yes {   } No {   } 
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8. Can malaria be prevented?  Yes {   } No {   }  If No go to No. 10 
9. Ways to prevent malaria: 
Wear long sleeve clothing Yes {   } No {   } 
Eat balanced diet   Yes {   } No {   } 
Drinking herbal tea  Yes {   } No {   } 
Use bed nets   Yes {   } No {   } 
Use insecticide-treated nets Yes {   } No {   } 
Use mosquito repellents Yes {   } No {   } 
Drain stagnant water   Yes {   } No {   } 
Trim bushes around the house Yes {   } No {   } 
Clean dark corners in the house Yes {   } No {   } 
Spray insecticide  Yes {   } No {   } 
Take preventive medications Yes {   } No {   } 
    Avoid sunlight    Yes {   } No {   } 
    Wearing charms and amulets Yes {   } No {   } 
    Vaccinate child   Yes {   } No {   } 
10. Can malaria be cured? Yes {   } No {   } If No go to section C 
11. How can malaria be cured? 
 Self-limiting (resolves on its own) Yes {   } No {   }  
Tepid sponge     Yes {   } No {   } 
Taking medications    Yes {   } No {   } 
Taking Herbs    Yes {   } No {   } 
Visit Health facility    Yes {   } No {   } 
 
12. Can malaria cause death?   Yes {   } No {   } 
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C PREVENTION PRACTICE 
1. Do you prevent your child from Malaria?  Yes {   } No {   } If No go to Section D 
2. How do you prevent Malaria?   
Drugs {   }  
Repellants {   }  
Net {   }  
Insecticide Treated Nets {   }  
Indoor Residual Spraying {   }  
Wear the child long sleeves {   }  
Clean the environment {   } 
Others………………………………………………… 
3. Reason(s) for the prevention method practiced and not other methods? 
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4. What are the challenges to prevention method practiced? 
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5. Why are other methods not practiced? 
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6. Do you own an ITN?  Yes {   } No {   } If No go to section D 
 
7. How many ITN(s) do you own? 1 {   } 2{   } 3 {   } 4 {   } >4 {   } 
 
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8. How many people sleep under one ITN in your household? 1 {   } 2{   } 3 {   } 4 {   } >4 {   } 
 
9. How often is the net changed or re-impregnated? 3 months {   } 6 months {   } 1 year {   } 
3 -5 years {   } Never {   } 
 
 
 
D TREATMENT PRACTICE 
1.  Has your child ever had a fever? Yes {   } No {   } 
2. How often does he have fever? Daily {   } Weekly {   } Bi-weekly {   } Monthly {   }  
Every 3 months {   } Others ……………………………………………………………… 
3. What is the first action taken when your child has a fever?  (One response only) 
Do nothing and wait for improvement {   } 
Tepid sponge {   } 
Visit a laboratory {   } 
Give medications {   }, which? ………………………………… 
Give Herbs {   } 
Visit Drug store {   } 
Visit Health facility {   } 
4. Duration between onset of fever and first action? Within 24 hours{   }  1 day {   } 2 days {   }  
3 days {   } 4-7 days {   } others 
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5. If symptoms persists what is the next action taken?  (One response only) 
Do nothing and wait for improvement {   } 
Tepid sponge {   } 
Visit a laboratory {   } 
Give medications {   }, which? ………………………………… 
Give Herbs {   } 
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Visit Drug store {   } 
Visit Health facility {   } 
6. What is the distance (in Km) or time it would take to move from the home to nearest health 
facility? (If applicable)............................................................ 
7. What is the duration of time spent at health facility?  
(If applicable)............................................................. 
8. Has your child ever been admitted due to fever? Yes {   } No {   } 
9. Has your child ever become unconscious? Yes {   } No {   } 
10. If yes, what did you do? 
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11. Has your child ever convulsed? Yes {   } No {   } 
12. If yes, what did you do? 
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13. Ever lost any child after developing fever, being unconscious or convulsed?  Yes {   } No {   } 
 
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