ral
ssBioMed CentMalaria Journal
Open AcceResearch
Self-reported use of anti-malarial drugs and health facility 
management of malaria in Ghana
Kwame O Buabeng*1,2, Mahama Duwiejua2, Alex NO Dodoo3, 
Lloyd K Matowe4 and Hannes Enlund1
Address: 1Department of Social Pharmacy, University of Kuopio, Finland, 2Department of Clinical & Social Pharmacy, Faculty of Pharmacy, 
Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana, 3Centre for Tropical Clinical Pharmacology & Therapeutics, 
University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana and 4Center for Pharmaceutical Management, Management 
Sciences for Health, Arlington, Virginia, USA
Email: Kwame O Buabeng* - ohenebuabeng@msn.com; Mahama Duwiejua - mahama_duwiejua@yahoo.com; 
Alex NO Dodoo - alexooo@yahoo.com; Lloyd K Matowe - lmatowe@msh.org; Hannes Enlund - hannes.enlund@uku.fi
* Corresponding author    
Abstract
Objective: To assess the appropriateness of self-reported use of anti-malarial drugs prior to
health facility attendance, and the management of malaria in two health facilities in Ghana.
Method: A structured questionnaire was used to collect data from 500 respondents who were
diagnosed clinically and/or parasitologically for malaria at Agogo Presbyterian Hospital and
Suntreso Polyclinic, both in the Ashanti Region of Ghana. Collected information included previous
use of anti-malarial drugs prior to attending the health facilities, types of drugs used, how the drugs
were used, and the sources of the drugs. In addition, the anti-malarial therapy given and outcomes
at the two health facilities were assessed.
Results: Of the 500 patients interviewed, 17% had severe malaria, 8% had moderate to severe
malaria and 75% had uncomplicated malaria. Forty three percent of the respondents had taken anti-
malarial drugs within two weeks prior to hospital attendance. The most commonly used anti-
malarials were chloroquine (76%), sulphadoxine-pyrimethamine (9%), herbal preparations (9%) and
amodiaquine (6%). The sources of these medicines were licensed chemical sellers (50%),
pharmacies (21%), neighbouring clinics (9%) or "other" sources (20%) including left-over medicines
at home. One hundred and sixty three (77%) of the 213 patients who had used anti-malarial drugs
prior to attending the health facilities, used the drugs inappropriately. At the health facilities, the
anti-malarials were prescribed and used according to the national standard treatment guidelines
with good outcomes.
Conclusion: Prevalence of inappropriate use of anti-malarials in the community in Ghana is high.
There is need for enhanced public health education on home-based management of malaria and
training for workers in medicine supply outlets to ensure effective use of anti-malaria drugs in the
country.
Published: 2 July 2007
Malaria Journal 2007, 6:85 doi:10.1186/1475-2875-6-85
Received: 21 April 2007
Accepted: 2 July 2007
This article is available from: http://www.malariajournal.com/content/6/1/85
© 2007 Buabeng et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 6
(page number not for citation purposes)
Malaria Journal 2007, 6:85 http://www.malariajournal.com/content/6/1/85
Background
Malaria is a public health problem in more than 90 coun-
tries. Each year, between 300 and 500 million new cases
are reported worldwide [1]. According to the Roll Back
Malaria Campaign of the World Health Organization
(WHO), 90 percent of the more than one million deaths
worldwide caused by malaria every year take place in
Africa, and malaria constitutes 10 percent of the conti-
nent's overall disease burden [1,2]. In Africa south of the
Sahara, malaria accounts for approximately 15% of deaths
in children under five years of age and most of these occur
in rural areas which have poor access to health care serv-
ices [2-4].
In Ghana, malaria is responsible for up to 40% of daily
out-patient consultations at hospitals and clinics and over
23% of deaths in children under five years of age [5-7].
Malaria is also responsible for 38,000 deaths per annum
and over 2,000 deaths in pregnant women, accounting for
9% of all deaths in pregnancy [5,6].
Treatment and prevention of malaria deaths exist if the
condition is promptly diagnosed, treated and/or referred.
Delay in seeking therapy, misuse of anti-malarial drugs,
and resistance of malaria parasites to existing drugs frus-
trate measures to effectively manage the disease in Africa
[4,5,7-10].
In Ghana, most malaria cases are managed at the house-
hold level. Help is usually sought from the community
pharmacist or licensed chemical seller (registered suppli-
ers of specified over-the-counter-medicines) after the ini-
tial therapy has failed. Most patients reporting at clinics
and hospitals facilities would have gone through home-
based treatment or community drug shops/pharmacies
initially. Thus mainly resistant, severe, or recurrent epi-
sodes are seen at clinics and hospitals. There is concern
that community and household management of malaria
is often inadequate, inappropriate and ineffective. The
current study was undertaken to assess the effectiveness
and quality of home based and health facility manage-
ment of malaria in two communities in Ghana.
Methods
Setting
The study was conducted on a cohort of patients diag-
nosed with malaria from Agogo hospital (a 240-bed mis-
sion and referral hospital in the country side, that
provides specialist services in paediatrics, surgery, obstet-
rics & gynaecology and ophthalmology) and Suntreso
Polyclinic in Kumasi City (which has an average attend-
ance of about 150 out-patients per day). Kumasi is the sec-
ond largest city in Ghana.
Institutional approval for the study was obtained from
medical authorities of the health facilities. Patient consent
was sought from either patients or their caregivers in the
case of children after the purpose of the study and guaran-
tees of anonymity and their rights had been explained to
them in either English or one of the local Ghanaian lan-
guages.
Target population and sample
All patients attending the Suntreso polyclinic and Agogo
Presbyterian hospital with a diagnosis/suspected diagno-
sis of malaria were targeted for inclusion in the study. The
sample included 300 patients from Agogo and 200 from
Suntreso polyclinic.
Data were collected consecutively on every other new case
of malaria diagnosed either clinically and/or parasitologi-
cally. In addition, all in-patients and those who had been
detained at the two facilities for further observation were
included in the study. Sampling was done daily for a
period of six weeks in April to May 2002.
Of the 500 patients included in the study, 407 were chil-
dren under 12 years of age, and 93 were adult patients.
Blood film examinations were used to diagnose 315 of the
malaria cases (63%) while 185 (37%) were diagnosed
clinically. Definitions of these diagnosis categories are
given in Table 1.
The Questionnaire
The data collection tool used consisted of sections on
patient details, previous episodes of malaria two weeks
prior to hospital or polyclinic attendance, drugs or herbs
used for the prior treatment of malaria and its appropri-
ateness in terms of dosage, frequency and duration of use,
and current anti-malarial medications given at the health
facilities. In the case of the patients who had had previous
episodes of malaria, the source of drugs or herbs used for
the prior treatment was also recorded. In addition to the
patient interviews, pill identification and evaluation of
previous anti-malarial drug packages were used to assess
the anti-malarial drug history prior to health facility
attendance for malaria treatment. The questionnaire was
then pre-tested on a sample of 20 patients (10 from each
facility) as a pilot, before it was used for the study. Appro-
priateness of drug use (either by prescribers at health facil-
ities or the patients before hospital attendance) was
determined using recommended dosage regimen from the
Ghana National Standard Treatment Guidelines 2000
(STGs).
This study was conducted nearly three years before
Ghana's new malaria policy change was implemented inPage 2 of 6
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January 2005. At the time of the study, the national first
line treatment for uncomplicated malaria was chloro-
Malaria Journal 2007, 6:85 http://www.malariajournal.com/content/6/1/85
quine monotherapy with amodiaquine and/or sul-
phadoxine-pyrimethamine being used as second line.
Under the current policy, a combination of amodiaquine
plus artesunate is the first line recommendation for
uncomplicated malaria. Quinine was, and still is the rec-
ommended drug for severe malaria. Definitions of terms
used in the study are presented in Table 1.
Data analysis
The information was entered into a database by a single
data entry clerk using SPSS, Version 11. Discrepancies
were resolved by cross checking with the hard copy of the
data collection instruments. Data analyses were per-
formed using the same software.
Results
Use of antimalarials and patient-reported knowledge of 
malaria
Of the 500 patients interviewed, a total of 85 (17%) had
severe malaria, 38 (8%) were cases of moderate to severe
malaria and 377 (75%) had uncomplicated malaria
(Table 2). The majority of severe malaria cases (89%) were
children aged five years or less, indicating the vulnerabil-
ity of this group to severe or complicated malaria.
Two hundred and thirteen (43%) of the patients had
taken an anti-malarial drug within two weeks prior to
attending the hospital or polyclinic. Of these, one hun-
dred and sixty-two (76%) had used chloroquine, 19 (9%)
sulphadoxine/pyrimethamine, 13 (6%) amodiaquine
while 19 (9%) had used a variety of herbal preparations.
One hundred and seven (50%) obtained their medica-
tions from licensed chemical sellers and 45 (21%)
obtained their drugs from pharmacies. Nineteen (9%)
had been treated at a health facility (neighbouring clinic)
before and 42 (20%) used leftover drugs from their
homes, relatives or friends.
Altogether, 163 patients (77 %) did not know how to use
from licensed chemical sellers used the medicines inap-
propriately while twenty four (53%) of the 45 patients
who sourced anti-malarial drugs from pharmacies used
the drugs inappropriately. Seven (37%) of the 19 patients
who received their medicines from neighbouring clinics
used the medicines inappropriately. All but two of the 42
patients (95%) who used left-over medicines from their
homes and from friends or relatives used the medicines
inappropriately (Table 3).
An assessment of respondents' knowledge of what malaria
was indicated some knowledge of uncomplicated malaria.
All study participants associated mosquito bites and fever
with malaria but only 24 % of participants knew the dan-
ger signs of malaria and when to refer. The participants
could not identify the signs of complicated malaria. There
was no significant difference in the knowledge of partici-
pants with low educational (junior secondary education
and below) attainment and those with higher educational
attainment in their knowledge of malaria.
Facility-based malaria treatment
Out of the 500 study participants only 253 could be fol-
lowed up to assess treatment outcomes. The rest could not
be traced because they lived at distances too far from the
facilities or the contact details they provided were incor-
rect or non existent. However, all the cases of severe and
moderate to severe malaria were followed up because the
patients were detained or admitted at the institutions.
Quinine, often used in combination with sulphadoxine/
pyrimetahmine, was the preferred anti-malarial drug for
severe malaria at Agogo Hospital. Fifty-one patients of the
85 with severe malaria were put on quinine with a 98%
cure rate achieved (one patient died). Artemisinin deriva-
tives were the preferred choice for severe malaria at Sun-
treso polyclinic. Artemisinin derivatives were prescribed
for 34 patients with severe malaria. All of the patients on
this regimen were successfully treated. Artesunate was
Table 1: Definitions of terms used in the study
Clinical diagnosis Diagnosis based on clinical assessment of the patient by a medical practitioner
Laboratory diagnosis Diagnosis based on the presence of plasmodia parasites in the blood film of patients.
Correct dosage Standard dosage of the anti-malaria drug recommended for complete treatment of the disease, based on mg/kg body 
weight or that recommended in the STGs*
Wrong or inappropriate use Wrong dosage, wrong frequency and/or wrong duration of therapy
Uncomplicated malaria Mild to moderate malaria without complications
Moderate to severe malaria Malaria with symptoms leading to the patient being detained or admitted but without complications
Severe malaria Malaria with complications and evidence of high parasitaemia
Clinical cure Rapid resolution of signs and symptoms of malaria associated with improved well being of the patients
Treatment failure Worsening of fever and other symptoms or death after initiation of therapyPage 3 of 6
(page number not for citation purposes)
and/or had used the medicines inappropriately. Ninety-
two (86%) of the 107 who obtained their medications
used in 26 (80%) of the cases. None of the patients were
put on a regimen of artemisin-based combination ther-
Malaria Journal 2007, 6:85 http://www.malariajournal.com/content/6/1/85
apy. Of those 38 patients with moderate to severe malaria
in both institutions, all of them received amodiaquine
with a cure rate of 84%.
Chloroquine was prescribed in both institutions for 88 of
the 130 patients with uncomplicated malaria who were
followed-up. In these patients a clinical cure rate of 85%
was achieved. Also in this group of patients with uncom-
plicated malaria, Sulphadoxine/pyrimethamine was used
by 30 patients with a cure rate of 67%. In addition 12
patients used amodiaquine with a 100% clinical cure rate.
Discussion
This study showed that inappropriate use of anti-malarial
drugs was high among patients attending two major
health facilities in the Ashanti region of Ghana. Inappro-
priate use was highest among those who used left-over
drugs and those who obtained their drugs from licensed
chemical sellers. Such inappropriate use could be due to
poor training for medicines dispensers, limited public
health campaigns on medicines use, or poor regulation of
the pharmaceutical distribution system in the country.
Interventions to improve the use of anti-malarial medi-
cines in Ghana could include public campaigns on use of
anti-malarial drugs among the general public, training
health workers on the management and appropriate use
of anti-malarial drugs, or more stringent regulation of
licensed chemical sellers' shops. In Tanzania, licensing,
regulation, and franchizing of chemical shops signifi-
cantly reduced the inappropriate use of medicines [15].
Environmental sanitation, the use of insecticide-treated
bed nets and other aspects of the Roll Back Malaria initia-
tive [1,2,5,7,11], must also be properly and efficiently
implemented.
The use of anti-malarial drugs by those who obtained
them from pharmacies and clinics was more rational than
by those who obtained their medicines from chemical
sellers, and those who treated themselves with leftover
medicines. Still, inappropriate use rates of 54% and 37%
in pharmacies and clinics respectively are high and inter-
ventions to improve use of anti-malarial medicines
should target these outlets as well.
In this study 35% of the cases were diagnosed clinically.
In a previous study in Ghana, Dunyo and colleagues
established that children diagnosed with malaria by care-
takers in the household were as likely to have malaria par-
asitaemia as those diagnosed with malaria in health
facilities [17]. This fact dismisses inaccurate diagnosis as
the cause of inappropriate use of anti-malarial medicines
in Ghana.
Quinine was the preferred anti-malarial drug for severe
malaria at Agogo hospital, which is located in a rural area,
about 85 km from Kumasi. Quinine has been and is still
reserved for severe malaria treatment in Ghana, because it
has retained its efficacy. This may be due to the fact that
quinine is not easily available and routinely used like
chloroquine and sulphadoxine/pyrimethamine in the
homes and drug retail outlets in the communities in
Ghana [12,14,18]. It is mostly available in the health facil-
ities like hospitals and clinics, and is usually given as an
injectable for severe malaria. In Agogo hospital, it was
used in combination with sulphadoxine/pyrimethamine
with good outcomes, rather than used as monotherapy as
stated in the national treatment guidelines. Further inves-
tigation is required to ascertain whether the combination
treatment is more effective than quinine alone. The artem-
isinin derivatives were preferred at the polyclinic in the
Table 2: Severity of malaria according to age of participants
Severity of malaria Age of patient
5 years or less
n (%)
Over 5 years
n (%)
Total
n (%)
Uncomplicated 211 (67) 166 (90) 377 (75)
Moderate to severe 29 (9) 9 (5) 38 (8)
Severe 76 (24) 9 (5) 85 (17)
Total 316 (100) 184 (100) 500 (100)
Table 3: Sources of anti-malaria drugs and the percentage of inappropriate use
Source of antimalaria drug Inappropriate use
n (%) n % 95% CI
Licensed Chemical Shop 107 (50) 92 (86) 79 – 93
Pharmacy 45 (21) 24 (54) 39 – 69
Other sources at home 42 (20) 40 (95) 88 – 100
Neighbouring clinics 19 (9) 7 (37) 15 – 59Page 4 of 6
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Total 213 (100) 163 (77)
Malaria Journal 2007, 6:85 http://www.malariajournal.com/content/6/1/85
city for management of severe malaria. This was also a
deviation from the national treatment guidelines at that
time, which recommended quinine. But most clinicians
were more comfortable prescribing preparations that were
easy to administer. The preference for artemisinin deriva-
tives could also have been due to aggressive marketing of
the products by pharmaceutical company representatives
which was going on at the time of the study.
Treatment failure observed with common anti-malarial
drugs in both institutions may be due to drug resistance.
There is evidence that about 40% and 15% respectively of
parasitological and clinical treatment failure associated
with chloroquine in sub-Saharan Africa is due to drug
resistance [12-14,18]. This study did not ascertain the pre-
cise reasons that accounted for the over 30% treatment
failure to sulphadoxine/pyrimethamine observed. It
could be due to quality of the drugs or drug resistance.
Like chloroquine, there are also reports of resistance to
sulphadoxine/pyrimethamine in sub-Saharan Africa
[12,18].
The most commonly used anti-malarial drug reported for
treating previous episodes of malaria before attending the
health facilities was chloroquine. Chloroquine was the
first line drug for uncomplicated malaria, and the recom-
mended drug for home-base management of malaria in
Ghana at the time of the study. Various published studies
in the late 90s showed that appropriate use of chloro-
quine was associated with good patient outcomes,
whereas inappropriate or inadequate use was associated
with treatment failure as was observed in this study [1-
3,8,11,13]. In most endemic countries in Africa, including
Ghana, increasing reports of widespread resistance to
chloroquine and other common antimalarial drugs has
necessitated a change in policy to Artemisinin Combina-
tion Therapy (ACT) as first line treatment for uncompli-
cated malaria. In Ghana, the recommended ACT is
artesunate-amodiaquine. This has huge economic impli-
cations for most poor patients in sub-Saharan Africa, since
the ACTs are comparatively more expensive. There are sev-
eral legitimate concerns about the sustainability of this
policy but the change is necessary for effective manage-
ment of malaria in Ghana, due to the widespread multi-
drug resistant strains of malaria parasites in the West Afri-
can sub-region and Ghana in particular. In addition to the
financial burden to be incurred as a result of this change,
it is important to ensure appropriate usage of these medi-
cines to prevent development of resistance to the artemisi-
nins and related combination products, and to reduce
cost associated with treatment failures. A national health
insurance scheme has been instituted in Ghana supported
by an act of parliament that allows the public to access
institution or paying for drug prescriptions. Effective
implementation of this scheme may provide respite eco-
nomically for use of ACT for uncomplicated malaria in
Ghana.
Limitations of this study include the fact that 247 patients
(49% of the study participants) were lost to follow-up for
outcomes assessment at the health facilities. These were
all outpatients whose addresses were not traceable. This in
itself is not surprising considering the very high migration
rate within the community studied and the nation at
large. Furthermore, the lack of a proper address system in
the study areas leads to huge inevitable loss of patients in
such study designs which happen to be the most prag-
matic. However, all the patients with moderate to severe
and complicated malaria, were followed up for outcomes
assessment in the health facilities. It is strongly recom-
mended to health policy makers and local governments to
put in place systems for effective follow up of patients
treated at OPD units of health facilities in Ghana, for ther-
apeutic outcomes evaluation. Another limitation is target-
ing only one region in the country and only two facilities
within that region. The reported results may, therefore,
not fully represent the country as a whole but most likely
to serve as a fair estimate of the situation in Ghana.
Conclusion
The study has shown that there is a high prevalence of
anti-malarial drug usage in the community prior to hospi-
tal attendance and that in most cases these drugs are used
inappropriately. Effective and pragmatic strategies must
be adopted to enhance public health education on safe
and effective use of anti-malaria drugs in the community.
In particular it is strongly recommended that appropriate
training be provided for staff in the pharmacies, licensed
chemical shops and other dispensers in health care facili-
ties in Ghana, on the need to advice clients or patients on
adherence to appropriate treatment regimen for malaria
and other interventions for malaria control to reduce mor-
bidity and mortality.
Authors' contributions
KOB, the corresponding author was the principal investi-
gator for this project, played an active role in data collec-
tion, data analysis and drafting of the manuscript.
LM, ANOD and MD were all actively involved in the
design of the project and contributed to the drafting and
reviewing of the manuscript. HE was the Project supervi-
sor, and was involved with the drafting and reviewing of
the manuscript. All the authors read and approved the
final manuscript.Page 5 of 6
(page number not for citation purposes)
health care for diseases of public health concern without
making an out-of-pocket payment for attending a health
Acknowledgements
The financial support provided by Ernest Chemists Ltd and Kama Health 
Service, local Pharmaceutical companies in Ghana for the study is hereby 
Publish with BioMed Central   and  every 
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Malaria Journal 2007, 6:85 http://www.malariajournal.com/content/6/1/85
acknowledged. We also acknowledge the contribution and support from 
the PhD students of the department of Social Pharmacy of Kuopio Univer-
sity, and from Mr Alex N. Kesse of Agogo Presbyterian hospital in Ghana.
An abstract of this paper was presented at the 65th Congress of the Inter-
national Pharmaceutical Federation (FIP) in Cairo, Egypt in September 2005 
with sponsorship from the Procurement and Supply Directorate of the 
Ministry of Health, Ghana.
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