SCHOOL OF PUBLIC HEALTH 

COLLEGE OF HEALTH SCIENCES 

UNIVERSITY OF GHANA 

 

 
 

 

ADHERENCE TO THE ADMINISTRATION GUIDELINES OF SEASONAL MALARIA 

CHEMOPREVENTION BY CAREGIVERS IN THE TAMALE CENTRAL DISTRICT 

 

 

MOHAMMED SHAMSUDEEN FUSEINI 

(10937085) 

  

 

THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON 

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE 

MASTER OF PUBLIC HEALTH (MPH) DEGREE 

 

 

JANUARY 2023

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DECLARATION 

I Mohammed Shamsudeen Fuseini declare that this dissertation is my own research work 

conducted under supervision. Other people’s work used in this study has been acknowledged duly. 

I equally state that this dissertation has neither been submitted in whole nor in part for any other 

degree.  

 

 

                                                                              31/01/2023 

……………………………..      ……………………………… 

Mohammed Shamsudeen Fuseini     Date 

(Student) 

 

 

                                                                            31/01/2023 

……………………………..      ……………………………… 

Dr. Priscillia Nortey       Date 

(Supervisor) 

 

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DEDICATION 

I dedicate this work to Almighty Allah, my family, my friends, and those who have a hand in my 

upbringing. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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ACKNOWLEDGMENTS 

Praise and thanks be to Allah, Lord of the Worlds, for His favor and grace that has kept me this 

far.   

I am grateful to my supervisor Dr. Priscillia Nortey for her patience in guiding me through this 

project. Her valuable contributions are very much appreciated.  

My sincere appreciation goes to the Mayor of Tamale, Honorable Sule Salifu, his aid, Mr. Amadu 

Hamdawey, and the entire coordinating council for their swift response in permitting me to conduct 

this research in the Tamale Central area. I appreciate the caregivers who consented to be part of 

this study. 

I thank my research assistants for their excellent work in the data collection process.   

I appreciate my wife Hafsah for her support, love, and care for me and our little child throughout 

my studies.  

Finally, I want to thank my friends from the university of Ghana especially Michael, Lawrence 

Mensah, Isaac Naab, John Tetteh, and Shin, for their support and encouragement, and the entire 

2022 MPH cohort.   

 

 

 

 

 

 

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Table of Contents 

DECLARATION ........................................................................................................................ i 

DEDICATION ........................................................................................................................... ii 

ACKNOWLEDGMENTS ......................................................................................................... iii 

LIST OF FIGURES ................................................................................................................ viii 

LIST OF TABLES .................................................................................................................... ix 

LIST OF ACRONYMS ...............................................................................................................x 

ABSTRACT ............................................................................................................................. xi 

CHAPTER ONE .........................................................................................................................1 

1.1. Background ......................................................................................................................1 

1.2. Problem Statement............................................................................................................3 

1.3. Conceptual Framework .....................................................................................................5 

1.4. Narration of Conceptual Framework .................................................................................5 

1.5. Justification of the Study ..................................................................................................6 

1.6. Research Questions ..........................................................................................................7 

1.7 Research Objectives ..........................................................................................................7 

1.7.1 General Objective ................................................................................................................. 7 

1.7.2 Specific Objectives ................................................................................................................ 7 

CHAPTER TWO ........................................................................................................................8 

LITTERATURE REVIEW .........................................................................................................8 

2.1. Epidemiology of Malaria ..................................................................................................8 

2.2. Malaria Control Strategies ................................................................................................9 

2.3. The Concept of the Seasonal Malaria Chemoprevention ................................................. 11 

2.3.1. Administration of the SMC ................................................................................................ 13 

2.3.2. Delivery of the SMC drug .................................................................................................. 13 

2.3.3. Contraindications ............................................................................................................... 14 

2.4. Seasonal Malaria Chemoprevention in Ghana ................................................................. 15 

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2.5. Factors Associated with the Effectiveness of the SMC in Ghana ..................................... 16 

2.5.1. Adherence ........................................................................................................................... 16 

2.6.2. Maternal Literacy .............................................................................................................. 17 

2.6.3. Community Health Volunteer Factors .............................................................................. 18 

6.3.5. Reasons for non-adherence to SMC .................................................................................. 19 

CHAPTER THREE ................................................................................................................... 21 

METHODS ............................................................................................................................... 21 

3.1. Study Design .................................................................................................................. 21 

3.2. Study Area ..................................................................................................................... 21 

3.3.2. Study Population ................................................................................................................ 22 

3.4. Inclusion Criteria ............................................................................................................ 23 

3.5. Exclusion Criteria ........................................................................................................... 23 

3.6. Study Variables .............................................................................................................. 23 

3.7. Sampling ........................................................................................................................ 26 

3.7.1. Sample size determination ................................................................................................. 26 

3.7.2 Sampling Method ................................................................................................................ 27 

3.8. Data Collection Methods, Tools, and Techniques. .......................................................... 30 

3.9. Data Collection Procedure .............................................................................................. 31 

3.10. Quality Assurance ........................................................................................................ 31 

3.11. Data Processing and Analysis ....................................................................................... 32 

3.12. Ethical Consideration.................................................................................................... 33 

3.12.1. Ethical Clearance ............................................................................................................. 33 

3.12.2. Voluntary Participation ................................................................................................... 33 

3.12.3. Risk / Benefits ................................................................................................................... 33 

3.12.4. Right to Refuse or withdraw from study. ........................................................................ 34 

3.12.5. Conflict of Interest ........................................................................................................... 34 

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3.12.6. Funding ............................................................................................................................. 34 

3.12.7. Confidentiality .................................................................................................................. 34 

3.13. Data storage and Usage................................................................................................. 35 

CHAPTER FOUR ..................................................................................................................... 36 

RESULTS ................................................................................................................................. 36 

4.1 Distribution of study participants. .................................................................................... 36 

4.2 Sociodemographic characteristics .................................................................................... 37 

4.3 Knowledge of malaria ..................................................................................................... 38 

4.4 Awareness of the benefits of SMC. .................................................................................. 43 

4.5 Adherence to SMC .......................................................................................................... 44 

4.5.1 Adherence to SMC administration guidelines by caregivers ............................................. 46 

4.5.2 Adherence by Subdistricts .................................................................................................. 46 

4.6 Community health volunteers’ factors ............................................................................. 47 

4.7 Bivariate analysis of the adherence to SMC ..................................................................... 48 

4.7.2 Sociodemographic characteristics and adherence .............................................................. 48 

4.7.3 Knowledge on malaria and adherence................................................................................ 50 

4.7.4 Adherence and awareness of the benefits of SMC ............................................................. 52 

4.7.5 Adherence to SMC and Community health volunteer factors ........................................... 53 

4.8 Multivariate binary logistic regression analysis for adherence to SMC. ............................ 54 

CHAPTER FIVE ................................................................................................................... 56 

5.0 Discussion ....................................................................................................................... 56 

5.1 Adherence to SMC .......................................................................................................... 56 

5.2 Sociodemographic characteristics .................................................................................... 57 

5.3 Knowledge of caregivers on malaria ................................................................................ 58 

5.5 Source of information on SMC ........................................................................................ 60 

5.6 Community health volunteer factors ................................................................................ 61 

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5.7 Reasons for non-adherence to SMC ................................................................................. 61 

5.8 Strengths ......................................................................................................................... 62 

5.9 Limitations ...................................................................................................................... 62 

5.10 Conclusion .................................................................................................................... 63 

5.11 Recommendation ........................................................................................................... 64 

References ................................................................................................................................ 66 

APPENDICES .......................................................................................................................... 73 

APPENDIX 1: Research Timelines ....................................................................................... 73 

APPENDIX 2: Budget ........................................................................................................... 74 

APPENDIX 3: PARTICIPANT’S INFORMATION SHEET AND CONSENT FORM ......... 75 

APPENDIX 4: QUESTIONNAIRE ....................................................................................... 81 

 

 

 

 

  

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LIST OF FIGURES 

Figure 1: Conceptual Framework illustrating factors influencing adherence to SMC. .................5 

Figure 2: Map of the Tamale Metropolitan Area and surrounding districts. .............................. 21 

Figure 3: Distribution of study participants by communities and Subdistrict of residence ......... 36 

Figure 4: Overall knowledge assessment of caregivers on malaria ............................................ 39 

Figure 5: knowledge of caregivers on causes of malaria ........................................................... 40 

Figure 7: Adherence to SMC by caregivers. ............................................................................. 46 

Figure 8: Adherence to SMC by subdistricts ............................................................................ 47 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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LIST OF TABLES 

Table 1: Study Variables .......................................................................................................... 23 

Table 2: Ghana’s estimated population, 2021 ........................................................................... 29 

Table 3: Estimated sub-district population of women aged 15-54 ............................................. 29 

Table 4: The required sample size for each Sub-District ........................................................... 30 

Table 5: Characteristics of study participants by Subdistrict ..................................................... 37 

Table 6: Caregivers’ knowledge on causes, signs and symptoms, effects, and prevention of malaria 

by Subdistrict. ........................................................................................................................... 42 

Table 7: Awareness of caregivers on the benefits of SMC medication ...................................... 43 

Table 8: Adherence to SMC among caregivers ......................................................................... 45 

Table 9: Community health volunteers’ factors by Subdistricts ................................................. 48 

Table 10: Association between adherence to SMC and sociodemographic characteristics of 

caregivers .................................................................................................................................. 49 

Table 11: Association between adherence to SMC and knowledge of caregivers on causes, signs 

and symptoms, effects, and prevention of malaria ..................................................................... 51 

Table 12: Association between adherence and awareness of the benefits of SMC ..................... 52 

Table 13: Association between adherence to SMC and community volunteers related factors. .. 53 

Table 14: Multivariable binary logistic regression model of factors associated with adherence to 

SMC among caregivers. ............................................................................................................ 53 

 

 

 

 

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LIST OF ACRONYMS  

AIDS  ----------          Acquired Immune Deficiency Syndrome 

CHPS  ----------          Community-Based Health Planning and Services  

CHWs  ---------- Community Health Workers  

CHVs  ---------- Community Health Volunteers  

CWC  ---------- Child Welfare Clinic  

DHMT  ---------- District Health Management Team  

DOTS  ---------- Directly Observed Treatment Short-Course  

IPTi  ---------- Intermittent Preventative Treatment in Infant  

IPTp  ---------- Intermittent Preventative Treatment in Pregnant woman  

IPTc  ---------- Intermittent Preventative Treatment in Children  

IRS  ---------- Indoor Residual Spray  

ITNs  ---------- Insecticide Treated Nets  

NMCP  ---------- National Malaria Control Program  

PMI  ---------- President Malaria Initiative  

PMC  ---------- Perennial Malaria Chemoprevention  

RA  ---------- Research Assistants  

SMC  ---------- Seasonal Malaria Chemoprevention  

SP+AQ ---------- Sulphadoxine-Pyrimethamine + Amodiaquine  

TBA  ---------- Traditional Birth Attendant  

UNICEF ---------- United Nations Children’s Fund  

WHO  ---------- World Health Organization 

 

 

 

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ABSTRACT 

 

Background: In developing countries including Ghana, malaria continues to be a major cause of 

morbidity and mortality, especially in children below five years. The World Health Organization 

(WHO) introduced Seasonal Malaria Chemoprevention (SMC) as an additional strategy to 

strengthen malaria control. The intervention is very effective in the prevention of clinical episodes 

of malaria in children but not without adherence to the administration protocols. This study 

examines the factors that are associated with adherence to SMC among caregivers in the Tamale 

Central District. 

 

Objective: To assess the factors influencing adherence to Seasonal Malaria Chemoprevention 

(SMC) administration guidelines by caregivers in the Tamale Central District. 

 

Methods: The study approach used was cross-sectional, conducted in four (4) subdistricts in the 

Tamale Central District. Eight (8) communities were selected through simple random sampling. A 

total of 471 caregivers from households were randomly sampled by balloting to participate in the 

study. Knowledge of malaria and awareness of the benefits of SMC was assessed by scoring 

correct answer questions from multiple choice questions related to malaria and SMC. We used 

close-ended questions to assess community health volunteer factors. Pearson Chi-square test was 

used to test the association between adherence to SMC and the predictor variables. Multiple 

logistic regression analysis was performed to examine the strength of the associations between 

adherence to SMC and the predictor variables and the results were interpreted at a 95% confidence 

level.  

 

Results: The study obtained an SMC adherence rate of 90.9%. Forgetfulness (62.5%) was the 

main reason for missing SMC doses. Overall knowledge of caregivers on malaria was low at 

71.1%, moderate at 26.5%, and high at.3%. About 85% of respondents were aware of the benefits 

of SMC. The factors that were significantly related to adherence in the multiple logistic regression 

model were educational background, knowledge of malaria, source of information on SMC, and 

satisfaction level of caregivers.  

 

Conclusion: The adherence rate of SMC in the Tamale Central District is 90.9%. The result from 

the study reveals that having secondary and tertiary education, those who reported the child refused 

to play as the effects of malaria, those who use mosquito coil as a way of preventing a child from 

malaria, those whose source of information on SMC is from friends, and those who are happy with 

SMC, were significantly associated with adherence to SMC.  

 

Keywords: Adherence, seasonal malaria chemoprevention, malaria, Children under five 

Sulfadoxine Pyrimethamine Amodiaquine,  

 

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CHAPTER ONE 

1.1. Background 

Malaria is a life-threatening disease and a public health priority to the global community. It is 

mostly endemic in the tropical and sub-tropical countries of the world with about 90% of the global 

burden recorded in sub-Saharan Africa (Attu et.al., 2018). Malaria is transmitted to humans by 

five plasmodial species. Plasmodium falciparum is the most significant in terms of fatalities. P. 

vivax causes most of the illnesses across the world. P. knowlesi, P. ovale, and P. malariae, cause 

less significant disease (Cowman et al., 2016) 

Intervention programs and measures of effective malaria control have been put in place, but the 

poor implementation in the affected areas makes the disease a ubiquitous killer in the subregion 

(Cowman et al., 2016) including Ghana. Indoor Residual Spraying (IRS), insecticide-treated bed 

nets (ITNs), early detection and treatment of malaria cases with artemisinin combination therapies 

(ACTs), intermittent preventive treatment of malaria in pregnant women (IPTp) and infants (IPTi), 

vaccination are currently the prevention and control programs in Ghana, (Stelmach et al., 2018). 

In 2012 the World Health Organization (WHO) recommended seasonal malaria chemoprevention 

(SMC) for the control of malaria infections in children under five years in regions with seasonal 

malaria transmission. SMC involves the intermittent administration of full treatment courses of 

antimalaria medicine (Amodiaquine plus Sulfadoxine-Pyrimethamine), to children below 5 years 

during the malaria season to avert malaria infections and maintain therapeutic antimalarial drug 

concentration levels in the blood throughout the period of greatest malaria risk. In sub–Saharan 

Africa, countries like Niger, Nigeria, Mali, Chad, Gambia, Guinea, and Burkina Faso adopted 

SMC in 2014 as a new tool for malaria control, and by 2015 and 2016, 3.6 million and 7.6 million 

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children (aged 3-59 months) respectively in areas of the Sahelian Sub-region were targeted and 

received SMC (Orok et al., 2021). The WHO also reported that in 2017 15.7 million children in 

countries implementing SMC were protected against malaria. Sylla et al., 2017,  and  Baba et al., 

2020 in their studies showed that SMC is effective, cost-effective, and safe for the prevention of 

malaria. 

In Ghana, SMC was incorporated as an additional malaria control intervention in the vision 2014-

2020 Strategic Plan for Malaria Control. Malaria is endemic in Ghana and varies from season to 

season. There are two major transmission patterns, dependent on geographical location and 

duration of the dry season - December to March, at which time transmission is less. A larger part 

of the north has about a 6–7-month transmission season and a shorter 3–4-month transmission in 

the upper part of the North, with the highest number of cases of malaria occurring between July 

and November. In the South, transmission season can exceed 9 months, it peaks a little from May 

to June and a larger peak from October to November. The Northern Region is the major hotspot 

for malaria cases in the country, recording about 40% of malaria cases in children below 5 years.  

Piloted in the Upper West Region in 2015, SMC implementation extended to Upper East Region 

in 2016, Northern Region in 2019, and Bono East and Oti regions in 2021 (Severe Malaria 

Observatory, 2021).  

In 2020, nearly 700,000 children under 5 years received the SMC drug in three Northern Regions 

from the community health workers (USAID, 2021). Meanwhile, malaria cases reported in the 

region persist among these age groups. This study will assess the factors influencing adherence to 

the administration guidelines of SMC by caregivers in the Tamale Central District. 

 

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1.2. Problem Statement 

In sub-Saharan Africa, the majority of malaria morbidities and mortalities occur during and after 

the short rainy season (Baba et al., 2020). As recommended by the WHO, SMC has been included 

in the strategic plan for malaria control by many countries. Transmission of the disease is highly 

seasonal in the Sahelian regions including Ghana. SMC involves administering a full malaria 

treatment course of sulfadoxine-pyrimethamine + amodiaquine to children aged 3-59 months 

during the malaria season to prevent infections and to maintain a therapeutic concentration of anti-

malaria drug levels in the blood (Ansah et al., 2021a) 

The Ghana national malaria control program implemented the SMC tool as an additional measure 

for the prevention and control of malaria in children under 5 years in 2015. But there exists limited 

information with regard to whether caregivers strictly adhere to the administration guidelines. 

SMC involves a three-day consecutive administration of full treatment doses of sulfadoxine-

pyrimethamine (SP) and amodiaquine (AQ) to these children at monthly intervals, beginning at 

the start of the malaria transmission season (rainy season). This is supposed to be done for a 

maximum of four months. Community Health Volunteers visit every household to administer the 

drug to eligible children under Directly Observed Treatment Short-course (DOTS) and the 

remaining two days doses of the drug are given to the caregivers to be administered the next 

consecutive days.  

Evidence suggests that some caregivers do not adhere to the administration guidelines of SMC 

(Antwi et al., 2016; Doumbia, C. O., 2021). Earlier studies have identified seasonal factors that 

may influence adherence, Chatio et al., 2019 identified farm demands and forgetfulness as causing 

non-adherence to SMC. Other studies have also shown that sociodemographic characteristics, 

household past experiences, drug distributors-related factors, individual factors, community 

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leaders, awareness of the benefits of SMC, knowledge about malaria, the media, and drug-related 

factors influence adherence to SMC ( Ansah et al., 2021a;  Chatio et al., 2019; Druetz et al., 2018) 

Studies on SMC have analyzed the impact, coverage, effectiveness, and accessibility of seasonal 

malaria chemoprevention but few studies have examined the pertinent individual, 

sociodemographic, seasonal, and operational factors within households that can promote or 

prevent adherence to SMC (Doumbia O. C., 2021). Children who miss SMC doses show lower 

protection against malaria attacks. Therefore, caregivers are expected to adhere strictly to the 

administration guidelines to maximize the level of protection of the drug and minimize the capacity 

of the malaria parasites’ to become resistant to SP+AQ. Ding et al., 2020 revealed in their study 

that a randomized placebo-controlled trial of SMC elsewhere in Ghana showed close to 100% 

adherence to the 3-day administration protocol when self-reported. Some caregivers, however 

were found to have the remaining medicines of SMC in the blister packs not administered, albeit 

not in the SMC setting. 

The issue of non-adherence by caregivers calls for attention, to identify the factors associated. This 

will propel and encourage the design and implementation of measures to avert the prevalence, 

morbidity, and mortality of malaria in children below 5 years. It is imperative to understand why 

children under 5 still get malaria while there have been many interventions put in place vis-a-vis 

the high coverage of the SMC implementation. This study will assess adherence to the 

administration guidelines of SMC by caregivers in the Tamale Central District 

 

 

 

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1.3. Conceptual Framework 

 

 

 

 

 

 

 

 

 

   

 

 

  

 

 

 

 

 

Figure 1: Conceptual Framework illustrating factors influencing adherence to SMC. 

 

1.4. Narration of Conceptual Framework 

Adherence to Seasonal Malaria Chemoprevention guidelines can be affected by several factors. 

These independent variables include sociodemographic factors like age, marital status, number of 

children, household size, place of residence, level of education, ethnicity, and religion. Low 

Knowledge of Malaria 

• Cause of malaria 

• Signs and symptoms 

• Effects of Malaria 

• Prevention of malaria 
 

 Socio-

demographic 

factors 

• Age 

• Marital Status 

• Occupation 

• Household size 

• Place of 

residence 

• Education 

• Religion  

Awareness of the benefits of 

SMC 

 

Adherence to SMC 

administration 

guidelines 

Community Health Volunteer 

factors   

• Number of re-visits 

• Observing DOTs 

• Education on Side effects 

of drug 
 

 

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educational background is said to be related to an individual’s understanding and reactions towards 

health intervention programs, like SMC. Those with little or no education might not adhere to 

SMC. In a large household with a higher number of caregivers and a small household with only 

the principal caregiver in charge of decision-making on the child’s wellbeing and medication, 

adherence will surely differ in these two households. We assume that caregivers who have 

knowledge of malaria are more likely to adhere to the SMC program. An individual’s 

understanding of malaria, its causes, and effects on children will embrace an intervention like SMC 

compared to someone with little or no Knowledge of the condition. We also assume that awareness 

of the benefits of SMC will affect the level of caregiver’s adherence. Individual’s perceptions will 

influence the adherence to SMC, the perceptions caregivers hold about SMC - whether they see 

the need for SMC will directly influence adherence. In addition, those who report satisfied with 

the program are more likely to adhere and cause others to adhere, on the other hand, side effects 

following drug administration might nurture negative perceptions, believes, and attitude towards 

SMC.  

Community Health Volunteers or the drug distributors are very instrumental in the success of the 

SMC program. They move door-to-door to administer these medicines under DOT and are to 

revisit household to ensure the subsequent days medicines are administered. It’s reported that some 

of the CHVs do not perform these duties well and this can have influence on caregiver’s adherence.  

 

1.5. Justification of the Study 

The study is focused on caregiver’s adherence to the administration guidelines of SMC in the 

Tamale Central District and the factors associated with same. Identifying these factors that 

influence adherence will be a useful information for the District Health Authorities in planning 

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towards addressing these factors. The results of the study will also be a useful information to 

consider in the execution of future SMC programs and other malaria campaigns in these age 

groups. The findings will provide a reference source of information for future research in Malaria 

in the Tamale Metropolis and beyond. 

 

1.6. Research Questions 

1. Are caregivers adhering to the administration protocols of SMC?  

2. What is the association between knowledge of malaria on adherence to SMC? 

3. Does awareness of the benefits of SMC affect adherence? 

4. What sociodemographic factors influence adherence to SMC?  

5. What are the community health volunteer factors that influence adherence? 

 

1.7 Research Objectives 

1.7.1 General Objective 

To assess the factors influencing adherence to Seasonal Malaria Chemoprevention administration 

guidelines by caregivers in the Tamale Central District. 

 

1.7.2 Specific Objectives 

1. To assess caregivers’ adherence to the administration protocols of SMC. 

2. To examine the association between knowledge of malaria and adherence to SMC. 

3. To determine whether awareness of the benefits of SMC affect adherence.  

4. To determine the sociodemographic factors influencing adherence to SMC. 

5. To examine community health volunteer factors that influence adherence.  

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CHAPTER TWO 

LITTERATURE REVIEW 

2.1. Epidemiology of Malaria 

Malaria is a protozoan infectious disease caused by the plasmodium parasites and transmitted in 

humans through the bite of the Anopheles female mosquito (Varo et al., 2020). Malaria has been 

with man for decades, causing substantial economic, social and health consequences. Each year 

thousands of lives are lost to this curable and preventable disease. The disease still has a 

considerable impact on public health in Sub-Saharan African and is responsible for about 10% of 

all fatalities despite a significant decline in the disease’s burden over the past two decades (Ansah 

et al., 2021b).  

Although the worldwide burden of malaria has significantly decreased since 2000 (WHO, 2016), 

morbidity and mortality caused by malaria are still unacceptable, with 200 million new cases 

reported each year (WHO, 2018). In 2016, 91 countries worldwide reported 216 million malaria 

cases - 5 million more cases than in 2015, and an estimated 445,000 deaths, which is roughly in 

line with the 446,000 deaths reported in 2015 (WHO, 2017). In 2017, cases again rose above the 

2016 figures. The years saw and increased of about 3 million more cases, and 10, 000 decrease in 

the death rate relative to 2016. The WHO has indicated that the decrease in deaths in the past ten 

years is rather happening at a very slow rate (WHO, 2018). Similarly, there were 241million 

malaria cases recorded in 85 countries with high endemicity of malaria in the year 2020, more than 

the 2019 figure of 227 million cases (World Health Organization, 2021). The World Health 

Organization (WHO) African region alone had 228 million cases in 2020, representing 95% of the 

Global figure (WHO, 2021).  

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Malaria deaths in the WHO African Region also saw an increase from 534 000 in 2019 to 602 000 

in 2020. The mortality rate also increased, rising from 56 per 100 000 at-risk population in 2019, 

to 62 per 100 000 in 2020, and children under 5 years old made up about 80% of all the malaria 

mortalities in the region. (WHO, 2021). About 720 deaths occurs in children under five years 

everyday due to malaria (WHO,2018). This age group is vulnerable because of the incomplete 

development of their immune system. Though it is known that breastmilk provides some form of 

immunity to infants, they eventually become vulnerable after three months. 

Malaria appears to be the main contributing factor to mortality and morbidity in Ghana (NMCP, 

2013). About 10.4 million persons were reported to have malaria in various health care facilities 

in 2016, representing 39% of OPD cases in the country. This represents a 2.5% increase in cases 

when compared to the same time in 2015. (GHS, 2017) with 1,264 malaria-related deaths, of which 

590 were children under five. Over 4.9 million cases and 11,000 deaths were reported in 2019 

(PMI Fact Sheet, 2020). The northern region is the major hotspot for malaria cases in the country, 

recording about 40% of malaria cases in children under 5. 

2.2. Malaria Control Strategies 

Malaria prevalence and transmission is an interactive process involving the environment, the 

vector and man. Control and elimination programs will only be successful if it targets the forces 

that exists in these interactions, (Orok et al., 2021). 

Vector control 

Vector control is one of the strategies in place for malaria control. It includes environmental 

hygiene and sanitation, insecticide-treated mosquito bed nets and drying irrigation channels. This 

will reduce the vector human contact and break the transmission path (“WHO | Core Vector 

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Control Methods,” 2020). The 2 core interventions are insecticide-treated nets (ITNs) and indoor 

residual spraying (IRS). Chemicals are also used in indoor and outdoor spraying. Mineral oil mixed 

with 1% DDT or Dihedron is spread on the surface of stagnant or standing water to destroy 

mosquito larvae (“WHO | Environmental Management for Vector Control,” 2016). At the 

individual level, the use of mosquito repellants, insecticide tablets and sprays, wearing of 

protective clothing, and the use of ITNs are encouraged. In the period between 2010 and 2019, 78 

countries reported mosquito resistance to at least 1 of the 4 widely used pesticides classes, 

according to the most recent World Malaria Report. Mosquito resistance to all pesticides classes 

was observed in 29 different countries. Churcher et al., (2016) opines that the adoption, 

distribution, and use of vector control products save lives. 

Preventive Chemotherapy 

This is the practice of using medications to stop malaria infections and its effects. Perennial malaria 

chemoprevention (PMC), seasonal malaria chemoprevention (SMC), intermittent preventive 

treatment of malaria in pregnancy (IPTp) and school-aged children (IPTsc), post-discharge malaria 

chemoprevention (PDMC), and mass drug administration (MDA), according to WHO (2022), are 

all effective methods of preventing malaria. Sulphadoxine-pyramethamine (SP) is the drug 

recommended for use in Africa as prophylaxis for pregnant women (IPTp). The NMCP of Ghana 

currently recommends the administration of SP to every pregnant woman starting from 16 weeks 

of gestation and one month apart until delivery. 

The WHO also recommends chemoprevention therapies for children under five years in both 

endemic and non-endemic countries. It is known as SMC, previously called intermittent preventive 

treatment in children (IPTc). It is very effective in regions where the transmission period for 

malaria is short (Cairns et al., 2012). It involves the administration of antimalaria medicines to 

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children under five years when the transmission period is usually high (rainy season) (WHO, 

2020). 

Vaccine 

Since October 2021, WHO has recommended widespread vaccination against malaria with the 

RTS, S/AS01 malaria vaccine in children residing in areas with moderate to high P. 

falciparum malaria transmission. The vaccine has been shown to significantly reduce malaria, 

including severe malaria among young children. 

Other interventions include Diagnostic testing and treatment. The WHO recommends that all 

suspected cases of malaria be confirmed through testing using microscopy or the RDT before 

treating. Integrated Community Case Management (iCCM) has been adopted by 26 countries that 

have established policies to train and equip health facilities and community health workers 

(CHWs) on the integrated management of the top three life-threatening conditions in children- 

malaria, diarrhea, and pneumonia. 

 

2.3. The Concept of the Seasonal Malaria Chemoprevention  

According to the World Health Organization (WHO), the epidemiology of malaria is changing, 

and this requires progressive attention which is a shift from the “one size fits all” approach to 

malaria control (WHO, 2012). In effect, the WHO recommended Seasonal Malaria 

Chemoprevention (SMC), as a new preventive measure against the Plasmodium falciparum, in 

2012. SMC is defined as “the intermittent administration of full treatment courses of an 

antimalarial medicine during the malaria season to prevent malarial illness and to maintain 

therapeutic antimalarial drug concentrations in the blood throughout the period of greatest malarial 

risk” (WHO, 2012). Particularly, preventive chemotherapy is connected with the use of medicines 

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in combination or alone, for the prevention of malaria infections and its consequences. The SMC 

was previously known to be the Intermittent Preventive Treatment in children (IPTc).  

The SMC is identified to be among the three (3) malaria prevention strategies recommended by 

the WHO. The others are perennial malaria chemoprevention (PMC – previously known as 

intermittent preventive treatment in infants, or IPTi) and intermittent preventive treatment of 

malaria in pregnancy (IPTp) (WHO, 2022). The chemoprevention therapy is administered to 

pregnant women and young children identified as being prone to and vulnerable to malaria. 

Furthermore, the SMC is administered on a community basis, typically delivered door-to-door 

either by volunteer community distributors or community health workers. In 2020 the SMC was 

implemented in 13 countries in the Sahel, which targeted about 22 million children (WHO, 2020). 

The target children are between the ages of 3 to 59 months of age to receive the dose, especially 

during the intense malaria season (Coldiron et al., 2017). 

Before the scaling up of the SMC, several other chemoprevention strategies (IPTp, IPTi, IPTc, 

etc.) had been adopted and used in health care centers for antenatal visits and routine childhood 

vaccination, (WHO, 2012). Afterward, from 2012 when the SMC was scaled up and introduced, 

there has seen a tremendous impact as about 12 million children received the intervention in 2016 

(Coldiron et al., 2017). York (2017) adds that the impact was greatly driven by the UNITAID 

funding and the Access-SMC by provided SMCs to 4 million children in 2016. Also, the World 

Bank and UNICEF funded the implementation. These supports and commitments have prevented 

10 million malaria cases and 60,000 deaths over the period from 2013 to 2017 since the 

commencement of the program in countries like Cameroon, Ghana, Senegal, Togo, and Guinea-

Bissau.  

 

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2.3.1. Administration of the SMC 

WHO has recommended two antimalarial medicines for use. The drugs used in the sub-Sahara are 

amodiaquine plus sulfadoxine-pyrimethamine (AQ+SP). In comparison to the other drug 

combinations, the SP+AQ provides better protection (“WHO | World Malaria Report 2012,” 

2014). The combination also lowers the risk of developing resistance to SP+AQ in comparison to 

using these drugs as monotherapy. The combination SPAQ does not contain artemisinin-based 

derivatives, which are reserved for the treatment of malaria. The protocol of the NMCP for SPAQ 

administration in Ghana is provided below. 

The drug is presented in two forms: 

1. Sulfadoxine 500mg-Pyrimethamine 25mg (SP), and Amodiaquine 150mg (AQ) 

2. Sulfadoxine 250mg-Pyrimethamine 12.5mg (SP), and Amodiaquine 75mg (AQ) 

The dose and dosage are dependent on age. Infants 3 to 11 months of age are given one tablet of 

SP 250/12.5mg in a single dose and 75mg tablets of AQ daily for 3 days. For children aged 12 to 

59 months, one tablet of SP 500/25mg tablet in a single dose and 150mg tablet of AQ once daily 

for 3 days. 

It is important to note that a total of four (4) or five (5) doses are given at monthly intervals over 

the season WHO (2012). 

 

2.3.2. Delivery of the SMC drug 

Different methods for the delivery of the SMC drug have been proposed. Giving the SMC drug at 

the child welfare clinic (CWC), combining SMC with community case management, organizing 

community gatherings to deliver SMC drug, community kiosks permanently stationed in the 

community to give SMC medicine to passing caregivers, household delivery where CHWs makes 

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announcements for caregivers to assemble and collect SMC and delivered SMC to children in 

homes where carers are not present. However, field tests conducted have showed such methods 

are less effective (Antwi et al., 2016; Doumbia, C. O. 2021). In Ghana SMC is delivered door-to-

door. Flexible point distribution has been suggested to improve uptake (Antwi et al., 2016). 

 

2.3.3. Contraindications  

There are some contraindications to the administration of the SMC drug which includes the 

following: 

1. Children who have a severe acute illness are unable to take their medication orally. 

2. Children who have been diagnosed to be allergic to the drugs (both AQ and SP). 

3.  Children who have received the drug in the previous month. 

4. Any child that is HIV positive and is receiving co-trimoxazole (WHO, 2012), 

Aside from these outlined restrictions on giving the drug, in the earlier recommendation from the 

WHO (2012), the AQ and SP were not to be given to countries within Southern and Eastern Africa, 

according to the WHO. This follows that the eligibility of the SMC may only apply to certain 

endemic areas in those countries. However, in the most recent WHO recommendations for malaria 

chemoprevention among children and pregnant women, the drug is no more geographically 

restricted. This recommendation was against the backdrop that in 2021, 13 African countries in 

the Sahel sub-region, having implemented the SMC acknowledged its worth and so believed that 

it could be implemented elsewhere in Africa. In concordance, those countries that are associated 

with highly seasonal variation in their malaria burden also have the chance to be a beneficiary of 

the SMC program (WHO, 2022). This hereby calls for new drugs that are more viable for malaria 

prevention.  

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Also, the dosage has been reviewed, and SMC should be given advisably during the peak times of 

the transmission season without any binding specific monthly cycle. Regarding age-based risks in 

children, more flexibility has been introduced. Children who are older than the stipulate age 

bracket and are at high-risk levels of severe malaria can be administered the drug other than only 

those below 6 years. This introduction of flexibility will enable countries like Cameroon to tailor 

their strategies, according to Dr. Dorothy Achu, manager of the Cameroonian Ministry of Health 

for the National Malaria Control Programme. She added that “this will enhance the impact of SMC, 

especially when used with other interventions such as bed nets and the new malaria vaccine”. 

 

2.4. Seasonal Malaria Chemoprevention in Ghana 

Following the WHO recommendation of the SMC program, Ghana implemented it in the Upper 

West Region in 2015 (Chatio et al., 2019). The piloting in the Upper West Region was a result of 

the prevalence of under 5 malaria mortality and morbidity in all the regions in the country. 

Considering the significant variation of malaria transmission in Ghana, especially between the 

northern savannah and southern coastal regions, authorities pushed for the implementation in the 

north. The program was then extended to the Ashanti Region as a trial for over five months (Antwi 

et al., 2016), in a predominantly rural area, Ejisu-Juabeng Municipality. Under the programme in 

the region, the incidence of malaria was reduced by about 40 percent, indicating its significant 

public health impact. Tagbor et al. (2016) identified that several studies confirm the effectiveness 

of the seasonal malaria chemoprevention among Ghanaian children. 

 

 

 

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2.5. Factors Associated with the Effectiveness of the SMC in Ghana 

Higher impacts could be badged, however, due to factors of maternal literacy, some perceived 

influence of the SMC, inadequate understanding of the chemoprevention, trust in caregivers, and 

lack of access to medication, method of distribution, coverage, and adherence (Antwi et al., 2016; 

Doumbia, 2021).  

 

2.5.1. Adherence 

A significant factor, probably the most important factor to the effectiveness of the SMC program 

is adherence (Koko et al., 2022). That is, compliance with the mode of administering the drug and 

the guidelines associated with it ought to be strictly followed. Compliance and adherence are major 

terms commonly used synonymously in public health (Doumbia, 2021). Ding et al., (2020a) 

explain that non-adherence to the SMC medication guidelines may fail the disease from being 

prevented, this will also result in the spread of drug-resistant parasites and in effect, make the drug 

ineffective in the future against the parasites. Under this factor, several types of research have been 

done to ascertain the compliance level of the drug (Pell et al., 2017; Roschnik et al., 2019; Somé 

et al., 2020). Okuboyejo & Eyesan (2014) opine that the adherence of patients to malaria medicines 

can be related to their awareness, access to information on the medicines, benefits of the drugs, 

and the perceived treatment obstacle. This confirms the challenges of the inadequate information 

associated with the SMC. The adherence level and participation are lower in the rural areas as 

compared to the urban and peri-urban centers (Doumbia, C. O. 2021). 

In the Northern Region of Ghana, most mothers reported giving the drug and completing the 

dosages. Others reported their inability to complete the entire dosage for their children (Chatio et 

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al., 2019). Some did twice, others thrice out of the four required. Excuses such as forgetfulness 

due to farming in such season, and children resisting the bitter taste of the medicine among others. 

 

2.6.2. Maternal Literacy 

Poor maternal literacy has a substantial impact on how well their wards receive medication. A 

significant number of the mothers did not appreciate the purpose of the drug in the study by Chatio 

et al., (2019), although some stakeholders, mothers, parents, guardians, or caretakers acknowledge 

that the drug was given to protect their children from contracting malaria. Some reported that they 

perceive the drug to enable their lads to eat well and become healthy whiles others said the drug 

was for diarrhea and polio. Antwi, et al., (2016) explains that there is even a varied understanding 

of the malaria disease in itself. Some believe when the child walks under the sun, they could get 

sick with malaria. Furthermore, the knowledge of malaria was then seen not to be an important 

determinant in taking the SMC. In Rwanda, Asingizwe et al., (2015) reported that, the level of 

education, knowledge, and attitudes exhibited a statistically significant association with adherence. 

They noted that respondents with low educational background were more likely to have poor 

practices towards the disease and adherence to the use of medication for healing it, same for 

negative attitudes compared to those with high education. Education is hereby an important factor 

that positively influences the level of adherence in the administration of the SMC and even for 

general health decisions, especially female education according to Amu et al., (2018).  

 

 

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2.6.3. Community Health Volunteer Factors 

The WHO (2021) identifies community health workers (CHWs) to be healthcare providers who 

are known to reside in the communities they serve and get less formal education and training than 

professional workers. They are recognized for the provision of healthcare assistance services to 

vulnerable group in the communities or among the population. The target group for the CHWs is 

the population in remote areas, the marginalized in society, deprived, to give them the necessary 

health care aid in their scope acceptable. Following the SMC administration, these play a 

significant role, with support from what we call the “community health volunteers (CHV).” They 

are essential to the delivery of primary healthcare (Kuule, 2017). As such several countries are 

known to rely on the services of these CHVs for primary health care and first aid, especially in 

low- and middle-income countries (Kok, 2015). In some instances, the two are used 

interchangeably. Community members like the traditional birth attendants (TBA) have historically 

filled some gaps. However, the healthcare system is formally integrating laypeople with varied 

levels of training (Lehman and Sanders, 2007). These laypeople, who typically go by the name 

community health volunteers (CHVs) participate in small-scale community-based projects to 

national programmes. These are non-specialist healthcare providers and village gents among the 

common terms (Van Ginneken et al, 2013). Their range of activities includes anything from 

immunization to the distribution of bed nets to the administration of medication, prenatal care, and 

care for chronic illnesses like AIDS and Tuberculosis (Koon et al., 2013). Several studies have 

reported that community health volunteers (CHV), including lay health workers, offer a number 

of advantages in comparison to their professional colleagues. (Gilmore and McAuliffe, 2013). 

Gaining the trust of their patients and interacting with the community might be simpler for them. 

In this regard, CHV’s are often seen as a bridge connecting communities and the formal health 

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system. They are considered as a way to ‘reach the last mile’ when implementing programmes, 

reducing obstacles to healthcare in the community (Berthold, 2016).  

For the SMC, these personnel are integral in the administering and adherence of the medicines to 

children and caregivers. They receive training prior to the start of the SMC program on how to 

administer the drug- under DOT, and to educate mothers on possible adverse drug reactions and 

how to manage same. They are also required as part of their mandate to revisit the household on 

the second and third day to ensure the caregiver administers the rest of the medication. According 

to Antwi et al., (2016), the CHWs make announcements for the caregivers to commute to a place, 

gather and receive the drug or have it delivered to them if they are unable to report for collection. 

In some cases, caregivers were constantly not available to take the drugs when delivered to them, 

they added. The reasons that afforded the frequent absence were associated with farm workers and 

traders. Owing to the intense work done by these, they lauded themselves for being more suitable 

administrators than the Child Welfare Clinics (CWC). Some challenges are also associated with 

the CHWs where some mothers, though few complain of having adverse events with the CHWs 

(Tagbor, 2016).  

 

6.3.5. Reasons for non-adherence to SMC 

Patients’ perceptions, awareness, access to information on medications, the benefits of the drugs, 

and the perceived treatment obstacle, are found to influence adherence (Okuboyejo & Eyesan 

2014).  In Ghana, Doumbia, C. O. (2021), found that forgetfulness by caregivers, child refusal to 

take medication, vomiting, and child falling ill were the reasons for non-adherence to the SMC 

medicine. In Niger Ding et al., (2020) found that some children spit out the medication even after 

it had been dissolved, some caregivers saved the medication for future use by another member of 

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the family who will suffer malaria, some fathers refusing the medication for their children, sub-

optimal instructions from health workers, were the reasons for non-adherence. Elsewhere in 

Africa, caregivers responded their children would not accept the medicine if they are to administer 

it themselves and preferred that the volunteers administer it (Ward et al., 2022). Somé et al., 2022 

also reported low proportions of non-adherence in Burkina Faso, Mali, and Niger. The factors 

associated with non-adherence include travel of parents, illness of child, vomiting, child refusing 

to swallow medicine, and forgetfulness.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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CHAPTER THREE 

METHODS 

3.1. Study Design 

The study employed a cross-sectional design and collected data from caregivers within households 

in the Tamale central district. Face-to-face interviews were conducted using a standardized 

questionnaire to collect relevant data with regard to the study subject.  

 

3.2. Study Area 

The study was conducted in the Tamale Central District in the Northern Region of Ghana. Tamale 

Central is the biggest Sub-District in the Tamale Metropolis, with almost half of the entire 

District’s population, according to the District Health Management Team (DHMT) profile. 

   

 

 

 

 

 

 

 

 

 

 

 

Figure 2: Map of the Tamale Metropolitan Area and surrounding districts. 

 

Source:  Fuseini & Kemp, (2016). 

 

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3.3. Description of Study Site 

Tamale Central District is an urban community made up of 23 communities. The district is majorly 

occupied by Dagombas. The language commonly spoken is Dagbani and Islam is the predominant 

religion. The people are mainly traders and farmers, the majority of the population are also 

employed in the public sector while others are entrepreneurs owing their own shops and 

businesses. The district shares boundaries with Vitting at the East, Bilpeila at the South, Nyohini 

Sub-Metro at the West, and the Sagnerigu Municipal at the North.  

Tamale is located 600km north of Accra and covers a total land area of 750 square kilometers. The 

Tamale Teaching Hospital, which is the third largest in the country, is located 2 km south to the 

Tamale Central District. Other hospitals within the district include the Tamale Central Hospital, 

Tamale West Hospital, and the SDA Hospital. The Tamale Central Health Center, Moshie Zongo 

Health Center, One Heart Medical Center, Changli clinic, Prisons clinic, Police clinic, Rabito 

clinic, and Tamale NMTC Prestige Hospital are all health facilities within the Tamale metropolitan 

area. There are also seven (7) Community-Based Health Planning and services (CHPS) zones and 

20 outreach points. 

 

3.3.2. Study Population 

The study included all caregivers of children under five years in the Tamale Central District where 

SMC has been taking place since 2019. The projected population from the 2021 population and 

housing census was 138,821 people, according to the DHMT profile. 

 

 

 

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3.4. Inclusion Criteria 

Caregivers were selected to take part in the study based on the following: 

1. Has at least one or more children under 5 years under his or her care at the time of the 

study. 

2. Has been a resident in the district for at least six months. 

3. Has been in the community during the first round of SMC in 2022. 

 

3.5. Exclusion Criteria 

Caregivers who were absent at the time of the study. 

Caregivers who do not want to participate.  

 

3.6. Study Variables 

Table 1: Study Variables  

VARIABLE OPERATIONAL 

DEFINITION 

SCALE OF 

MEASUREMENT 

LABEL SOURCE OF 

INFORMATION 

DEPENDENT VARIABLE 

Adherence to 

SMC 

Child under 5 

years who has 

received and 

completed the 3 

days medication 

during the last 

round of SMC in 

October 2022. 

Dichotomous Yes  

No 

Interview  

INDEPENDENT VARIABLES 

Age  Age of Caregiver 

at last birthday 

Continuous 

 

Age in years Interview 

Highest 

Level of 

Education 

Level of education Ordinal 1. No 

education 

2. Primary 

3. JHS 

4. Secondary 

5. Tertiary 

Interview 

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VARIABLE OPERATIONAL 

DEFINITION 

SCALE OF 

MEASUREMENT 

LABEL SOURCE OF 

INFORMATION 

Marital status Being married or 

otherwise 

Nominal • Single 

• Married 

• Divorced 

• Widowed 

• Interview 

Religion A system of 

worship or faith 

Nominal • No Religion 

• Islam 

• Christianity 

• Traditional 

religion 

• Other 

• Interview 

Occupation Current 

employment status 

Categorical  • Housewife  

• Unemployed  

• Trader  

• Formal Work 

• Others 

• Interview 

Residence 

location  

Name of sub-

district 

Nominal • Tishegu zone  

• Gumbihini 

zone 

• Lamashegu 

zone 

• Changli zone 

• Interview 

Household 

size 

Number of people 

currently living in 

the household at 

the time of the 

survey  

Discrete  Raw number Interview 

Number of 

children 

below 5 

years in the 

household 

The total number 

of children below 

5 years living in 

the household at 

the time of the 

survey  

Discrete  

Categorical 

Raw number 

3-11 months 

12-59 

months 

Interview 

Knowledge 

on the cause 

of malaria  

Does respondent 

know these cause 

of malaria 

Binary 

1. Infected mosquito 

bites 

2. Dirty environment 

3. Ancestors 

4. Other 

Yes 

No  

Interview 

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VARIABLE OPERATIONAL 

DEFINITION 

SCALE OF 

MEASUREMENT 

LABEL SOURCE OF 

INFORMATION 

Knowledge 

on the signs 

and 

symptoms of 

malaria 

Do respondents 

know these signs 

and symptoms of 

malaria  

Binary 

1. The body feels 

warm 

2. Headache  

3. Poor appetite 

4. Vomiting 

5. Diarrhoea  

6. Other  

 

Yes  

No  

 

Interview  

Knowledge 

on the effects 

of malaria 

Do respondent 

know these are 

effects of malaria 

Binary 

1. Child refuse to eat 

2. Child cannot go to 

school 

3. Child refuse to 

play 

4. Convulsion  

5. Anemia  

6. Death 

7. Other  

Yes  

No  

interview 

Knowledge 

on 

prevention of 

malaria 

Do respondents 

know these are 

methods of malaria 

preventing 

themselves and 

their children from 

malaria 

Binary  

1. Use of ITNs  

2. Through SMC 

3. Use of mosquito 

sprays and coils  

4. Wearing protective 

clothing 

5. Don’t know 

6. Other  

Yes  

No  

interview 

Overall 

Knowledge 

on malaria 

 

Percentage score 

of participants 

knowledge on 

causes, signs and 

symptoms, effects, 

and prevention of 

malaria.  

Ordinal Low (<50%) 

Moderate 

(50-69%) 

High (≥70%) 

Interview 

Awareness of 

the benefits 

of SMC 

Respondents’ 

awareness of the 

benefits of SMC 

Binary 1. Yes 

2. No 

3. Interview 

Caregivers’ 

satisfaction 

and 

perception of 

Community 

Whether 

Respondents are 

happy with the 

work of the 

volunteers. 

Binary  • Yes  

• No  

• Interview 

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VARIABLE OPERATIONAL 

DEFINITION 

SCALE OF 

MEASUREMENT 

LABEL SOURCE OF 

INFORMATION 

Health 

Volunteers 

Community 

health 

volunteers 

administering 

SMC drug 

under DOT 

Whether 

Volunteers 

administer day one 

medication under 

observation   

Binary  • Yes 

• No 

• Interview 

Number of 

revisits by 

Volunteers 

Numbers of times 

volunteer revisits 

the house after 

administering the 

initial dose of 

SMC 

Discrete Raw number Interview 

Education on 

how to 

manage side 

effects of 

drug 

Whether 

caregivers are 

educated by 

Volunteers on the 

possible side 

effects of the drug 

and how to 

manage them 

Binary • Yes 

• No 

• Interview 

 

3.7. Sampling 

3.7.1. Sample size determination 

The Cochran formula was used to calculate the sample size given the large size of the sample 

population. 

No= 
𝑧2𝑝𝑞

𝑒2  

 

No = The estimated sample size  

Z = Standard deviation of 1.96 at 95% confidence level 

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p = Since the proportion of caregivers who adhere to SMC in the Tamale Central District is 

unknown, we assume p=50% by default.  

q = 1 – p (1 – 0.5) 

e = Margin of error at 5% or 0.05  

Imputing the figures into the Cochran formula, the estimated sample size was: 384. 

 

𝑛0 =
1.962 X 0.5(1−0.5)

0.052  
 

A non-response rate of 5% was used and the final sample size was 400. 

 

3.7.2 Sampling Method 

Multi-stage sampling was used to sample multiple units at various stages, from the community 

level to the household level and the study participants. 

Sub-district level sampling  

The Tamale Central District has four Sub-Districts (Tishegu, Changli, Gumbihini, and Lamashegu 

Sub-Districts) and all were included in the study to ensure that the population is fairly represented. 

A simple random sampling by non-replacement balloting was used to select eight (8) communities, 

two each from the four (4) Sub-Districts. Names of the communities were folded in pieces of paper 

and placed in a bowl for balloting. The researcher with his eyes closed dipped his hand in the bowl 

and whichever communities he picked represented the study sites where caregivers were recruited 

to participate in the study. The eight communities selected included Changli, Dagbandabi fong, 

Gumbihini North, Warizehi, Lamashegu North, Zogbeli, Tishegu, and Salamba. A proportionate 

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sampling technique was utilized in determining how many participants are included in each 

community. 

Community Level  

Each of the communities selected was stratified into four- north, south, east, and west. Starting 

from a notable landmark in the community, the researcher randomly selected the direction to move, 

and went house to house until he exhausted all four directions in that community. This was 

repeated in all the selected communities where the study took place. 

Household Level 

At the household level, a caregiver who was 18 years and older and residing in the house, met the 

criteria and was willing to participate in the study was interviewed. In houses with more than one 

household, balloting was done to randomly select one of them to complete the questionnaire. The 

researcher continued the interview process from house to house until the targeted sample size of 

that community is met before moving to the next community. In a case where the required sample 

size for a community was not met, the data collection continued in the next candidate community 

until the final sample size was achieved. We used the World Bank demographic distribution of age 

by sex groups (World Development Indicators, 2022), (Table 2) to compute for the proportion of 

women of reproductive age for each sub-district (Table 3). This estimated proportion of women 

was then used to determine the number of interviews to be conducted in each sub-district (Table 

4). In this study, we target women between the ages of 18-49 as the primary caregivers for 

programs like SMC and selected our sample population to be the 15-54 years group. 

 

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Table 2: Ghana’s estimated population, 2021 

Age Group Proportion of 

Total 

population 

Male Population  Female population Population of 

females age 15-54 

0-14 36.90% 5,976,570 5,728,786  

15-24 19.22% 3,117,818 2,982,639                    

8,504,351 

 
25-54 35.35% 5,697,556 5,521,712 

55-64 5.32% 825,178 863,267  

65+ 3.21% 468,726 549,874  

 

The total population (Male + Female) = 31,732,128.  

It implies, therefore that the proportion of female population aged 15-54 = 
8,504,351

31,732,128
X 100 = 

26.8% 

Table 3: Estimated sub-district population of women aged 15-54 

Sub-district Estimated population Estimated population of women aged 15-54 

in sub-district 

Changli 36,500 36,500 (26.8%) =   9,782 

Gumbihini 28,700 28,700 (26.8%) =   7,691.6 

Lamashegu 40,710 40,710 (26.8%) =   10,910.28 

Tishegu 32,911 32,911 (26.8%) =   8,820.148 

Total 138,821 138,821 (26.8%) =   37,204.028 

 

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Table 4: The required sample size for each Sub-District 

Sub-districts Estimated population 

of women aged 15-54 

Sample size calculation Required 

sample size 

Changli 9,782 400 (9,782÷37,204.028) = 105.17 105 

Gumbihini 7,691.6 400 (7,691.6÷37,204.028) = 82.69 83 

Lamashegu 10,910.28 400 (10,910.28÷37,204.028) = 117.3 117 

Tishegu 8,820.148 400 (8,820.148÷37,204.028) = 94.8 95 

Total 37,204.028  400 

 

The required sample size for each sub-district was divided by two to determine the number of 

interviews to be conducted in each of the two communities randomly selected from the sub-district.  

 

3.8. Data Collection Methods, Tools, and Techniques. 

This study used Interviewer administered questionnaire, semi-structured, to collect data from the 

400 participants in the Eight (8) selected communities. The questionnaire was written in simple 

English which reflected the study variables. For participants who could not speak English, data 

collectors asked questions in local dialects Dagbani, Hausa, Twi, Zabarima, Mossi languages for 

them to understand and respond appropriately. The questionnaire is in different sections with 

questions focused on specific demographic characteristics of respondents, their knowledge on 

malaria, their awareness of the benefits of SMC, adherence to SMC, and community health 

volunteer factors.  

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The questionnaire was pre-tested in Bulpela Sub-district with 25 respondents in 15 households. 

The feedback gathered helped finetune the tool before administering it to participants in the study 

area. 

3.9. Data Collection Procedure 

Upon entry into a household, a self-introduction was done, and the purpose of the visit explained 

to the household head and other members of the house present. A brief presentation on the risks 

and benefits of participation were clearly explained and caregivers were invited to voluntarily 

participate. There were consent forms for those who agree to participate. Each participant filled 

two forms one for the research assistant and the other for the respondent in addition to one copy 

of the participant information sheet. The questions covered the demographic characteristics of 

respondents, knowledge of malaria, awareness of the benefits of SMC, community health 

volunteer factors, and adherence to SMC. In total participants answered 40 questions which took 

an average time of 20 minutes to complete. 

  

3.10. Quality Assurance  

Research assistants (RA) were used in the data collection process. They were trained for two (2) 

days on basic communication skills and how to interpret and administer questionnaires, as well as 

how to translate questions in the local language. The RAs were also trained on ethical issues and 

the need to seek for informed consent before conduction any interview. Pretesting of the tool was 

done with the RAs before final deployment for the actual data collection. There was constant 

supervision by the Principal Investigator during the process to ensure data collected passed through 

quality control checks to scrutinize and validate data. All questionnaires had unique codes to avoid 

repetition.  

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3.11. Data Processing and Analysis  

After the end of the data collection process, the questionnaire which was entered in Kobo collect 

toolbox, was exported into Microsoft excel and downloaded before it was imported to STATA 

version 16 for the statistical analysis. All subsequent analysis were performed using STATA IC 

version 17 (Stata Corp., College Station, TX, US). The frequencies of all variables were run to 

ensure completeness and correct coding of variables. Descriptive statistics was performed on the 

sociodemographic characteristics of respondents. The results were presented in tables, charts, and 

graphs using frequencies and percentages for categorical variables. Median and quartiles for 

continuous and discrete variables.  

Overall knowledge of study participants was assessed using a composite score of participants 

knowledge of causes, symptoms, prevention, and effects of malaria. Scores were rescaled to a 

percentage scale and categorized such that those scoring below 50% were considered to have low 

knowledge, those scoring 50% to 70% were considered to have moderate knowledge and those 

scoring above 70% were considered to have high knowledge on malaria.  

Bivariate analysis was performed using the Pearson chi-square test to compare proportions and 

test associations between the dependent variable (adherence to SMC) and the independent variable 

(sociodemographic factors, knowledge of malaria, awareness of the benefits of SMC, Community 

volunteer factors). The binary logistic regression model was used to estimate the crude and 

adjusted odds ratio of adherence to SMC drug administration. The 95% confidence interval and 

the corresponding p-values of the factors associated adherence to SMC drug administration. For 

the multivariable binary logistic regression model, variables with p-values less than 0.20 were 

considered to determine the effects of covariates on adherence to SMC and the strength of the 

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associations between the independent and dependent variables. All statistical analysis were 

considered significant at an alpha of 0.05. 

 

3.12. Ethical Consideration 

3.12.1. Ethical Clearance  

Ethical clearance was sought from the Ghana Health Service Ethical Review Board. The approval 

letter was presented to the Metropolitan assembly to seek their Permission before the data 

collection. Due processes were equally followed at the community and household levels to seek 

approval from Chiefs and other gate keepers before data collection started.  

 

3.12.2. Voluntary Participation  

Caregivers’ decision to participate in this study were entirely voluntary, those who refuse to 

participate were not in any way coerced as to why they did not participate. Their decision did not 

affect other members in the house who wish to take part in the study. 

 

3.12.3. Risk / Benefits  

There is minimal risk to study participants in this study. COVID 19 safety protocols were observed 

by research assistants and participants, hand washing, use of face mask, and the use of alcohol-

based hand sanitizer. Participants were offered facemask before interviews and were educated on 

the need to maintain the COVID 19 protocols.  At the end of the study, participants were 

appreciated for their time and energy but there are no direct benefits for participation.  

 

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3.12.4. Right to Refuse or withdraw from study. 

It is within the rights of participants to withdraw at any point in time of the study or refuse to 

participate at all without any consequences. There was informed consent form for all participants 

written in simple English for respondents to understand and agree to participate by signing. 

Participants who could not read nor write had a witness present who read the consent form to them 

in a language they understand before signing, or thumb printing the form to accept participation. 

A copy of the form was given to them to keep. 

 

3.12.5. Conflict of Interest 

No known conflict of interest by the Principal Investigator, his supervisor and research assistants 

to declare.  

 

3.12.6. Funding  

There is no known external source of funding for the research project other than from the personal 

savings of the Principal Investigator. 

 

3.12.7. Confidentiality  

To ensure confidentiality, names and household details of participants will not be disclosed to a 

third party. Information collected is solely to be used for research and academic purposes and 

participants are identified through code numbers assigned to them. This information is encrypted 

and stored safely in a laptop. 

 

 

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3.13. Data storage and Usage 

Questionnaire from this study is kept safe under lock and key, with limited access by only the 

principal investigator and his supervisor to that information. A secured laptop with restricted 

access is used to store data collected from the study. 

 

3.14. Dissemination of Results 

Duplicates of the findings of the research will be presented to the School of Public Health and the 

University of Ghana, Legon, in partial fulfillment for the award of a Master of Public Health 

degree. It will also be made available to the Regional and Metropolitan Health Directorates and 

will be published in peer-review journals. 

 

 

 

 

 

 

 

 

 

 

 

 

 

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CHAPTER FOUR 

RESULTS 

In October 2022, 471 caregivers of children under five years were randomly sampled from eight 

(8) communities in the Tamale Central District. The last round of SMC had just finished a month 

that proceeded the survey. Research assistants visited households and conducted interviews using 

a structured questionnaire to assess adherence to the three-day dose of the SMC drug.   

4.1 Distribution of study participants. 

The proportion of caregivers according to communities and subdistricts of residence is shown in 

Figure 4 below. We exceeded the required sample size of 400 for this study. Gumbihini sub-district 

had the highest representation of 31.9% (150/471) whilst Tishegu had the lowest representation 

with 16.7% (79/471). The response rate in Tishegu fell short of the required sample size (95) for 

the sub-district because eligible respondents were usually not at home during the visits, and some 

caregivers were reluctant to participate. However, the overall response rate was 100%.   

  
Figure 3: Distribution of study participants by communities and Subdistrict of residence 

% of respondents (N=471) 

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4.2 Sociodemographic characteristics 

The median age of the caregivers was 36 years (13) IQR. About 7% (34/471) of participants were 

cohabiting, 9.1% (43/471) were widowed, 9.8% (46/471) were divorced, 15 % (73/471) were 

single parents and the majority 58.4% (275/471) were married. Among the 275 respondents who 

were married, 71.3% (196/275) were in monogamous marriages, 25.5% (70/275) in polygamous 

marriages, and 3.3% (9/275) were in open relationships. Close to 18% (84/471) did not have any 

form of formal education. Most participants were either housewives (25.3%) or unemployed 

(17.6%), whilst 16.1 % were employed in the formal sector and the rest had some other forms of 

occupation. Dagombas formed 53.9% of the study participants and 66.5% were practicing Islam 

religion. As shown Table 1 below, 181 out of 471 caregivers had one child under 5 and the rest of 

the 290 caregivers had two or more. 

Table 5 below shows the distribution of the characteristics of the study participants in each of the 

4 districts.  

 

Table 5: Characteristics of study participants by Subdistrict 

 Subdistricts  

 Lamashegu Changli Tishegu Gumbihini Total 

Characteristics N=121 N=121 N=79 N=150 N=471 

Age of respondent; median (IQR) 32 (28-39) 38 (31-43) 33 (27-36) 41 (29-51) 36 (29-42) 
Age of respondent      
   <20 years 0 (0.0) 0 (0.0) 3 (3.8) 4 (2.7) 7 (1.5) 
   20-29 years 39 (32.2) 23 (19.0) 22 (27.8) 34 (22.7) 118 (25.1) 
   30-39 years 56 (46.3) 57 (47.1) 43 (54.4) 32 (21.3) 188 (39.9) 
   40-49 years 22 (18.2) 22 (18.2) 7 (8.9) 38 (25.3) 89 (18.9) 
   50-59 years 3 (2.5) 9 (7.4) 4 (5.1) 35 (23.3) 51 (10.8) 

   60+ years 1 (0.8) 10 (8.3) 0 (0.0) 7 (4.7) 18 (3.8) 
Marital status      
   Single 9 (7.4) 28 (23.1) 16 (20.3) 20 (13.3) 73 (15.5) 
   Married 99 (81.8) 74 (61.2) 57 (72.2) 45 (30.0) 275 (58.4) 
   Cohabiting 0 (0.0) 0 (0.0) 0 (0.0) 34 (22.7) 34 (7.2) 
   Divorced 8 (6.6) 9 (7.4) 2 (2.5) 27 (18.0) 46 (9.8) 
   Widowed 5 (4.1) 10 (8.3) 4 (5.1) 24 (16.0) 43 (9.1) 
Type of marriage      
   Monogamous 59 (59.6) 74 (100.0) 41 (71.9) 22 (48.9) 196 (71.3) 
   Polygamous 40 (40.4) 0 (0.0) 13 (22.8) 17 (37.8) 70 (25.5) 
   Open relationship 0 (0.0) 0 (0.0) 3 (5.3) 6 (13.3) 9 (3.3) 

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 Subdistricts  

 Lamashegu Changli Tishegu Gumbihini Total 

Characteristics N=121 N=121 N=79 N=150 N=471 

Educational status      
   No formal education 11 (9.1) 12 (9.9) 14 (17.7) 47 (31.3) 84 (17.8) 
   Primary 8 (6.6) 15 (12.4) 15 (19.0) 34 (22.7) 72 (15.3) 
   JHS 19 (15.7) 28 (23.1) 18 (22.8) 23 (15.3) 88 (18.7) 
   Secondary 30 (24.8) 54 (44.6) 26 (32.9) 29 (19.3) 139 (29.5) 
   Tertiary 53 (43.8) 12 (9.9) 6 (7.6) 17 (11.3) 88 (18.7) 
Occupation      
   Housewife 17 (14.0) 50 (41.3) 17 (21.5) 35 (23.3) 119 (25.3) 
   Unemployed 20 (16.5) 10 (8.3) 13 (16.5) 40 (26.7) 83 (17.6) 

   Farmer 4 (3.3) 1 (0.8) 3 (3.8) 34 (22.7) 42 (8.9) 
   Formal work 33 (27.3) 9 (7.4) 5 (6.3) 29 (19.3) 76 (16.1) 
   Trader 32 (26.4) 50 (41.3) 40 (50.6) 8 (5.3) 130 (27.6) 
   Other 15 (12.4) 1 (0.8) 1 (1.3) 4 (2.7) 21 (4.5) 
Religion      
   Islam 104 (86.0) 102 (84.3) 55 (69.6) 52 (34.7) 313 (66.5) 
   Christian 17 (14.0) 19 (15.7) 24 (30.4) 35 (23.3) 95 (20.2) 
   African Traditional religion 0 (0.0) 0 (0.0) 0 (0.0) 38 (25.3) 38 (8.1) 

   No Religion 0 (0.0) 0 (0.0) 0 (0.0) 25 (16.7) 25 (5.3) 
Ethnicity      
   Dagbani 79 (65.3) 67 (55.4) 45 (57.0) 63 (42.0) 254 (53.9) 
   Hawsa 7 (5.8) 37 (30.6) 10 (12.7) 46 (30.7) 100 (21.2) 
   Twi 6 (5.0) 16 (13.2) 19 (24.1) 41 (27.3) 82 (17.4) 
   Other 29 (24.0) 1 (0.8) 5 (6.3) 0 (0.0) 35 (7.4) 
Household size: median (IQR) 5 (4-6) 5 (3-6) 4 (3-5) 5 (4-6) 5 (3-6) 
Household size      
   <4 members 29 (24.0) 33 (27.3) 38 (48.1) 36 (24.8) 136 (29.2) 

   4-6 members 63 (52.1) 74 (61.2) 34 (43.0) 80 (55.2) 251 (53.9) 
   7+ members 29 (24.0) 14 (11.6) 7 (8.9) 29 (20.0) 79 (17.0) 
Children <5 years; median (IQR) 1 (1-2) 1 (1-2) 2 (1-2) 3 (3-5) 2 (1-3) 
Children <5 years      
   One child 73 (60.3) 65 (53.7) 30 (38.0) 13 (8.9) 181 (38.8) 
   Two children 37 (30.6) 53 (43.8) 33 (41.8) 20 (13.7) 143 (30.6) 
   Three children 10 (8.3) 3 (2.5) 15 (19.0) 48 (32.9) 76 (16.3) 
   >Three children 1 (0.8) 0 (0.0) 1 (1.3) 65 (44.5) 67 (14.3) 

Relationship to the child(ren)      
   Parent 111 (91.7) 106 (87.6) 62 (78.5) 74 (49.3) 353 (74.9) 
   Uncle/Aunt 6 (5.0) 0 (0.0) 10 (12.7) 29 (19.3) 45 (9.6) 
   Grandparent 3 (2.5) 14 (11.6) 7 (8.9) 11 (7.3) 35 (7.4) 
   Sibling 1 (0.8) 1 (0.8) 0 (0.0) 23 (15.3) 25 (5.3) 
   Others 0 (0.0) 0 (0.0) 0 (0.0) 13 (8.7) 13 (2.8) 

 

 

 

4.3 Knowledge of malaria    

Knowledge of study participants were assessed using a composite score of participants knowledge 

of causes, symptoms, prevention, and effects of malaria. Scores were rescaled to a percentage scale 

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and categorized such that those scoring below 50% were considered to have low knowledge, those 

scoring 50% to 70% had moderate knowledge and those scoring above 70% had high knowledge 

on malaria. As shown in Figure 4 below, overall, the knowledge level of caregivers was low for 

71.1% (335/471), moderate for 26.5% (125/471) and high for 2.3% (11/471). 

 

Figure 4: Overall knowledge assessment of caregivers on malaria  

 

 

More than 80% (383/471) of respondents correctly reported malaria is caused by the bite of an 

infected mosquito (Fig. 5). 

 

 

 

 

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On the signs and symptoms of malaria, 85.6% (403/471) mentioned the body feels warm, over 

40% mentioned vomiting (204/471), headache (198/471), poor appetite (194/471) respectively 

(Fig. 6A). When asked about the effects of malaria, 87.7% (413/471) reported their children 

refused to eat, 15.9% (75/471) mentioned convulsion, 12.3% (58/471) mentioned death and 6.8% 

(32/471) mentioned malaria can cause anaemia (Fig. 6B).  

Only 1.7% said they do not know what ways to prevent themselves from getting malaria. Of the 

471 respondents 401 (85.1%) mentioned the use of insecticide-treated nets as a malaria preventive 

method for themselves (Fig. 6C). 

Only 2 respondents said they do not know what ways to prevent their children from getting malaria. 

Most (81.7%) of respondents mentioned the use of insecticide treated-nets as a malaria preventive 

method for their children and 62% (292/471) of them mentioned SMC (Fig. 6D).  

Figure 5: knowledge of caregivers on causes of malaria 

 

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Figure 6: Knowledge of caregivers on signs and symptoms, effects, and prevention of malaria 

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Table 6: Caregivers’ knowledge on causes, signs and symptoms, effects, and prevention of malaria 

by Subdistrict. 
 Subdistricts  
 Lamashegu Changli Tishegu Gumbihini Total 

 Variables N=121 N=121 N=79 N=150 N=471 

Knowledge level on malaria      
   Low 62 (51.2) 114 (94.2) 11 (13.9) 148 (98.7) 335 (71.1) 
   Moderate 59 (48.8) 7 (5.8) 57 (72.2) 2 (1.3) 125 (26.5) 
   High 0 (0.0) 0 (0.0) 11 (13.9) 0 (0.0) 11 (2.3) 
Cause of malaria      
   By infected mosquito bites 115 (95.0) 119 (98.3) 58 (73.4) 91 (60.7) 383 (81.3) 
   Dirty environment 2 (1.7) 2 (1.7) 21 (26.6) 45 (30.0) 70 (14.9) 
   Ancestors 0 (0.0) 0 (0.0) 0 (0.0) 14 (9.3) 14 (3.0) 
   Other 4 (3.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (0.8) 

Signs and symptoms of malaria known 
(M)      
The body feels warm 114 (94.2) 112 (92.6) 69 (87.3) 108 (72.0) 403 (85.6) 
Vomiting 80 (66.1) 19 (15.7) 53 (67.1) 52 (34.7) 204 (43.3) 
Headache 53 (43.8) 57 (47.1) 68 (86.1) 20 (13.3) 198 (42.0) 
Poor appetite 93 (76.9) 75 (62.0) 18 (22.8) 8 (5.3) 194 (41.2) 
Diarrhoea 10 (8.3) 13 (10.7) 40 (50.6) 5 (3.3) 68 (14.4) 
Other 23 (19.0) 0 (0.0) 0 (0.0) 0 (0.0) 23 (4.9) 

Effects of malaria on children (M)      
Child refuse to eat 113 (93.4) 121 (100.0) 79 (100.0) 100 (66.7) 413 (87.7) 
Child cannot go to school 45 (37.2) 19 (15.7) 53 (67.1) 53 (35.3) 170 (36.1) 
Child refuse to play 34 (28.1) 23 (19.0) 66 (83.5) 29 (19.3) 152 (32.3) 
Convulsion 25 (20.7) 5 (4.1) 22 (27.8) 23 (15.3) 75 (15.9) 
Can cause anaemia 3 (2.5) 4 (3.3) 12 (15.2) 13 (8.7) 32 (6.8) 
Death 28 (23.1) 9 (7.4) 17 (21.5) 4 (2.7) 58 (12.3) 
Other 38 (31.4) 0 (0.0) 0 (0.0) 0 (0.0) 38 (8.1) 

Ways one can prevents themselves from 

getting malaria (M)      
Use of Insecticide Treated Nets 113 (93.4) 121 (100.0) 77 (97.5) 90 (60.0) 401 (85.1) 
Use of mosquito sprays 87 (71.9) 27 (22.3) 63 (79.7) 43 (28.7) 220 (46.7) 
Use of mosquito coil 89 (73.6) 11 (9.1) 57 (72.2) 37 (24.7) 194 (41.2) 
Wearing Protective clothing 3 (2.5) 0 (0.0) 40 (50.6) 28 (18.7) 71 (15.1) 
Don't know 0 (0.0) 0 (0.0) 0 (0.0) 8 (5.3) 8 (1.7) 
Other 11 (9.1) 0 (0.0) 2 (2.5) 0 (0.0) 13 (2.8) 

Ways one can prevents child(ren) from 

getting malaria (M)      
Use of Insecticide Treated Nets 118 (97.5) 117 (96.7) 76 (96.2) 74 (49.3) 385 (81.7) 
Use of mosquito sprays 70 (57.9) 37 (30.6) 53 (67.1) 55 (36.7) 215 (45.6) 
Use of mosquito coil 72 (59.5) 17 (14.0) 48 (60.8) 35 (23.3) 172 (36.5) 
Through SMC 109 (90.1) 91 (75.2) 54 (68.4) 38 (25.3) 292 (62.0) 
Wearing Protective clothing 6 (5.0) 1 (0.8) 28 (35.4) 8 (5.3) 43 (9.1) 
Don't know 0 (0.0) 1 (0.8) 0 (0.0) 1 (0.7) 2 (0.4) 
Other 11 (9.1) 0 (0.0) 0 (0.0) 0 (0.0) 11 (2.3) 
(M): Multiple choice responses 

 

 

 

 

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4.4 Awareness of the benefits of SMC. 

In Table 7 below, 80% (377/471) respondents reported their source of information on SMC was 

from the community volunteer, followed by TV (45.2%), radio (40.1%), and health worker 

(27.2%). Others mentioned friends (21.4%) and place of worship (10.4%) as their source of 

information on SMC. Almost all 94.5% (445/471) respondents know SMC is given in the rainy 

season, but only 38% (177/471) correctly stated the minimum age requirement for the SMC drug. 

About 85% (400/471) of the respondents were aware of the benefits of SMC and mentioned it 

prevents malaria, whiles 13.4 % (63/471) said it treats malaria. Only 2 respondents said they did 

not know the benefits of SMC. About 26% (124/471) of respondents answered yes when we asked 

if there are any problems with the SMC drug. They cited adverse drug reactions like fever, 

vomiting, diarrhoea, and weakness. But overall, about 97.7% (460/471) of respondents were happy 

with SMC (Table 7).  

Table 7: Awareness of caregivers on the benefits of SMC medication 

 Subdistricts  

  Lamashegu Changli Tishegu Gumbihini Total 

Characteristics N=121 N=121 N=79 N=150 N=471 

Source of information on SMC (M) 1 (0.8) 100 (82.6) 10 (12.7) 102 (68.0) 213 (45.2) 
TV 1 (0.8) 100 (82.6) 10 (12.7) 102 (68.0) 213 (45.2) 
Radio 15 (12.4) 77 (63.6) 63 (79.7) 34 (22.7) 189 (40.1) 
Community volunteer 115 (95.0) 99 (81.8) 73 (92.4) 90 (60.0) 377 (80.0) 
Health worker 25 (20.7) 33 (27.3) 26 (32.9) 44 (29.3) 128 (27.2) 
Friends 29 (24.0) 29 (24.0) 25 (31.6) 18 (12.0) 101 (21.4) 

Worship place 0 (0.0) 37 (30.6) 2 (2.5) 10 (6.7) 49 (10.4) 
Other 4 (3.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (0.8) 
What season of the year is SMC given      

   Rainy season 111 (91.7) 120 (99.2) 72 (91.1) 142 (94.7) 445 (94.5) 
   Dry season 0 (0.0) 0 (0.0) 0 (0.0) 5 (3.3) 5 (1.1) 
   All year round 2 (1.7) 0 (0.0) 4 (5.1) 1 (0.7) 7 (1.5) 
   Don't know 8 (6.6) 1 (0.8) 3 (3.8) 2 (1.3) 14 (3.0) 
What are the benefits of SMC      

   Prevent malaria in children under 5 years 115 (95.0) 120 (99.2) 42 (53.2) 123 (82.0) 400 (84.9) 
   Treat malaria in children under 5 years 2 (1.7) 0 (0.0) 37 (46.8) 24 (16.0) 63 (13.4) 
   Don't know 0 (0.0) 1 (0.8) 0 (0.0) 3 (2.0) 4 (0.8) 
   Other 4 (3.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (0.8) 
Minimum age required for SMC 

medication (in months) 
     

   1 0 (0.0) 114 (94.2) 1 (1.3) 7 (4.8) 122 (26.2) 
   2 0 (0.0) 0 (0.0) 0 (0.0) 25 (17.0) 25 (5.4) 

   3 109 (90.1) 5 (4.1) 39 (50.6) 24 (16.3) 177 (38.0) 

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 Subdistricts  

  Lamashegu Changli Tishegu Gumbihini Total 

Characteristics N=121 N=121 N=79 N=150 N=471 

   4 2 (1.7) 0 (0.0) 2 (2.6) 23 (15.6) 27 (5.8) 
   5 2 (1.7) 0 (0.0) 2 (2.6) 29 (19.7) 33 (7.1) 
   6 6 (5.0) 0 (0.0) 3 (3.9) 5 (3.4) 14 (3.0) 
   7 0 (0.0) 0 (0.0) 0 (0.0) 6 (4.1) 6 (1.3) 
   8 0 (0.0) 0 (0.0) 0 (0.0) 6 (4.1) 6 (1.3) 
   9 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.7) 1 (0.2) 
   12 1 (0.8) 0 (0.0) 2 (2.6) 5 (3.4) 8 (1.7) 
   24 0 (0.0) 0 (0.0) 1 (1.3) 5 (3.4) 6 (1.3) 

   36 1 (0.8) 2 (1.7) 3 (3.9) 5 (3.4) 11 (2.4) 
   48 0 (0.0) 0 (0.0) 5 (6.5) 1 (0.7) 6 (1.3) 
   60 0 (0.0) 0 (0.0) 19 (24.7) 5 (3.4) 24 (5.2) 
Are there any problems with the SMC 

drug that you know 
     

   Yes 35 (28.9) 17 (14.0) 16 (20.3) 56 (37.3) 124 (26.3) 
   No 86 (71.1) 104 (86.0) 63 (79.7) 94 (62.7) 347 (73.7) 
Are you happy with the SMC      

   Yes 115 (95.0) 121 (100.0) 76 (96.2) 148 (98.7) 460 (97.7) 
   No 6 (5.0) 0 (0.0) 3 (3.8) 2 (1.3) 11 (2.3) 
Will you advise people to let their 

child(ren) take the SMC medicine 
     

   Yes 115 (95.0) 121 (100.0) 79 (100.0) 150 (100.0) 465 (98.7) 
   No 6 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 6 (1.3) 
(M): Multiple choice responses 

 

 

4.5 Adherence to SMC 

Adherence is defined as those caregivers who administered both the second-day and third day 

doses of the SMC drug to their children after receiving the first day dose from the CHVs during 

the last round of the 2022 SMC campaign. In this study, adherence to SMC was assessed using 

several questions as shown in Table 8 below. About 97.4% (455/471) correctly recognized the 

SMC drug is taken 3 days in a month, whiles 57.7% (266/471) correctly recognized the SMC drug 

is given 4 times in a year. About 95.3% (449/471) reported they administered the drug on the 

second day whiles 91.7% (432/471) reported they administered the drug on the third day. 

Forgetfulness (65.2%), side effects of drug (27.8%), bitter taste of the drug (10.4%), child refusing 

to take drug (43.5%), were the reasons caregivers gave for missing doses of the SMC drug. 

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Table 8: Adherence to SMC among caregivers 

 Subdistricts  

  Lamashegu Changli Tishegu Gumbihini Total 

Variables N=121 N=121 N=79 N=150 N=471 

How many times is SMC drug given in a year      

   1 0 (0.0) 2 (1.7) 1 (1.3) 1 (0.7) 4 (0.9) 
   3 9 (8.0) 34 (28.1) 26 (32.9) 122 (81.9) 191 (41.4) 
   4 103 (92.0) 85 (70.2) 52 (65.8) 26 (17.4) 266 (57.7) 
How many days is the SMC drug taken in a 

month 
     

   1 0 (0.0) 1 (0.8) 2 (2.5) 0 (0.0) 3 (0.6) 
   2 0 (0.0) 0 (0.0) 2 (2.5) 0 (0.0) 2 (0.4) 
   3 120 (99.2) 119 (98.3) 73 (92.4) 143 (97.9) 455 (97.4) 
   4 1 (0.8) 1 (0.8) 2 (2.5) 3 (2.1) 7 (1.5) 
How many of your child(ren) received the 

SMC during the last exercise this year 
     

   0 4 (3.3) 0 (0.0) 0 (0.0) 2 (1.4) 6 (1.3) 
   1 73 (60.3) 67 (55.4) 27 (34.2) 11 (7.5) 178 (38.1) 
   2 35 (28.9) 51 (42.1) 35 (44.3) 23 (15.8) 144 (30.8) 

   3 8 (6.6) 3 (2.5) 16 (20.3) 49 (33.6) 76 (16.3) 
   4 1 (0.8) 0 (0.0) 1 (1.3) 49 (33.6) 51 (10.9) 
   5 0 (0.0) 0 (0.0) 0 (0.0) 12 (8.2) 12 (2.6) 
How many of your child(ren) completed all 

the SMC doses 
     

   0 12 (9.9) 1 (0.8) 0 (0.0) 6 (4.0) 19 (4.0) 
   1 72 (59.5) 66 (54.5) 31 (39.2) 12 (8.0) 181 (38.4) 
   2 33 (27.3) 51 (42.1) 32 (40.5) 25 (16.7) 141 (29.9) 

   3 4 (3.3) 3 (2.5) 16 (20.3) 43 (28.7) 66 (14.0) 
   4 0 (0.0) 0 (0.0) 0 (0.0) 50 (33.3) 50 (10.6) 
   5 0 (0.0) 0 (0.0) 0 (0.0) 12 (8.0) 12 (2.5) 
   6 0 (0.0) 0 (0.0) 0 (0.0) 2 (1.3) 2 (0.4) 
How many of your child(ren) did not 

complete the SMC doses 
     

   0 97 (80.2) 119 (98.3) 60 (75.9) 127 (84.7) 403 (85.6) 
   1 21 (17.4) 1 (0.8) 18 (22.8) 4 (2.7) 44 (9.3) 

   2 3 (2.5) 1 (0.8) 1 (1.3) 7 (4.7) 12 (2.5) 
   3 0 (0.0) 0 (0.0) 0 (0.0) 6 (4.0) 6 (1.3) 
   4 0 (0.0) 0 (0.0) 0 (0.0) 5 (3.3) 5 (1.1) 
   5 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.7) 1 (0.2) 
Did you administer the SMC medicine to 

your child(ren) on the second day 
     

   Yes 111 (91.7) 120 (99.2) 70 (88.6) 148 (98.7) 449 (95.3) 
   No 10 (8.3) 1 (0.8) 9 (11.4) 2 (1.3) 22 (4.7) 

Did you administer the SMC medicine to 

your child(ren) on the third day 
     

   Yes 109 (90.1) 120 (99.2) 56 (70.9) 147 (98.0) 432 (91.7) 
   No 12 (9.9) 1 (0.8) 23 (29.1) 3 (2.0) 39 (8.3) 
Do you sometimes miss administering the 

SMC drug to your child 
     

   Yes 18 (14.9) 3 (2.5) 55 (69.6) 39 (26.0) 115 (24.4) 
   No 103 (85.1) 118 (97.5) 24 (30.4) 111 (74.0) 356 (75.6) 
Reasons for missing SMC medication 

(N=115) (M) 
     

Forgetfulness 5 (27.8) 0 (0.0) 46 (83.6) 24 (61.5) 75 (65.2) 
Side effects of drug 13 (72.2) 3 (100.0) 2 (3.6) 14 (35.9) 32 (27.8) 
Bitter taste of the drug 0 (0.0) 0 (0.0) 6 (10.9) 6 (15.4) 12 (10.4) 
Child refuse to take drug 0 (0.0) 0 (0.0) 45 (81.8) 5 (12.8) 50 (43.5) 
Other 1 (5.6) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.9) 
(M): Multiple choice responses 

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4.5.1 Adherence to SMC administration guidelines by caregivers 

The study identified adherence rate of 90.1% to SMC among caregivers in the Tamale Central 

District with a 95% confidence interval estimate from 87.9% to 93.3% (Figure 7).  

 

  

Figure 7: Adherence to SMC by caregivers.   

 

 

4.5.2 Adherence by Subdistricts 

Adherence was lowest in the Tishegu Subdistrict (68.4%) whilst Lamashegu Subdistrict had 90.1% 

adherence rate, Gumbihini recorded 96.7% adherence rate and Changli recorded the highest 

adherence rate of 99.2% (Figure 8). 

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Figure 8: Adherence to SMC by subdistricts 

 

4.6 Community health volunteers’ factors 

Nearly all (97%) (457/471) respondents said they were comfortable with the volunteers coming to 

their homes to administer the SMC medicine. They reported identifying the volunteers through 

several means like wearing SMC T-shirts (51%) (240/471), volunteer self-introduction (48.8%) 

(230/471), wearing identification tags (47.8%) (225/471), and 43.9% (207/471) said SMC 

volunteers are members of the community. Only 5.3% (25/471) of respondents reported the 

volunteers did not observe the child take the first dose of the SMC drug. Some 8.3% (39/471) of 

respondents said the volunteers did not educate them o the adverse effects of the drug and how to 

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manage them, and 13.4% (63/471) also said the volunteers did not visit their homes again after the 

initial dose of the SMC drug. Generally, respondents were happy with the work of volunteers 

(91.9%) (433/471), as shown in Table 9 below. 

Table 9: Community health volunteers’ factors by Subdistricts 

 Subdistricts  

  Lamashegu Changli Tishegu Gumbihini Total 

Characteristics N=121 N=121 N=79 N=150 N=471 

Are you comfortable with volunteers 

coming to administer SMC to your child 
     

   Yes 118 (97.5) 121 (100.0) 68 (86.1) 150 (100.0) 457 (97.0) 
   No 3 (2.5) 0 (0.0) 11 (13.9) 0 (0.0) 14 (3.0) 

How do you identify SMC volunteers 

when they visit the house (M) 
     

They are members of the community 71 (58.7) 90 (74.4) 32 (40.5) 14 (9.3) 207 (43.9) 
They wear SMC T-shirts 102 (84.3) 2 (1.7) 43 (54.4) 93 (62.0) 240 (51.0) 
They wear ID tags 26 (21.5) 11 (9.1) 55 (69.6) 133 (88.7) 225 (47.8) 
Volunteer self-introduction 26 (21.5) 39 (32.2) 19 (24.1) 146 (97.3) 230 (48.8) 
Other 120 (99.2) 121 (100.0) 79 (100.0) 150 (100.0) 470 (99.8) 
Did the volunteer observe the child take 

the first dose of the drug 
     

   Yes 108 (89.3) 121 (100.0) 71 (89.9) 146 (97.3) 446 (94.7) 
   No 13 (10.7) 0 (0.0) 8 (10.1) 4 (2.7) 25 (5.3) 
Did the volunteer educate you on the 

adverse effects of the drug and ho