O ? © M A * A U B M A R V UNIVERSITY OF GHANA THE BALME LIBRARY HAI.MI LIBRARY THESES 1. Balme Library theses are available for consultation in the Library. They are no! normally available for loan, and they are never lent to individuals. 2. All who consult a thesis must not copy or quote from it without the consent of the Author and of this University. 3. Any copying or quotation permitted should be duly acknowledged. RM868.5 M91 bite C.l G374448 TH E BALM E LIBRARY 3 0 6 9 2 1 0 0 7 3 4 0 9 2 University of Ghana http://ugspace.ug.edu.gh LOCAL M ANAGEM ENT OF CH ILDHOOD MALAR IA IN THE MANYA K RO BO DISTR ICT OF GHANA HY IDDRISU MUMUNI THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF M. PHIL SOCIOLOGY DEGREE. 24"' July 2004 University of Ghana http://ugspace.ug.edu.gh {( j § / 4448 y> \ k, c / c* i University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that this thesis is the result o f my own research work carried out, under the supervision of Dr. K.A. Senah and Dr. K. Yeboah both of the Department o f Sociology, University o f Ghana, Legon. I also affirm that to the best o f my knowledge, this work has not been submitted in part or in whole for the award o f a university degree anywhere. IDDRISU MUMUNI (STUDENT) DR. K.A. SENAH (MAIN SUPERVISOR) DR. K. YEBOAH (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh DEDICATION Dedicated to my parents: Habiba Mahama and Mumuni Alhassan University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT All thanks and praises be to Almighty Allah for making it possible for me to have finally completed this study. I owe a debt o f gratitude to my Principal Supervisor, Dr. K.A. Senah for his keen and efficient supervision without which this work would not have been a success. Special thanks also go to Dr. K. Yeboah for his useful advice and suggestions. Indeed, I appreciate the suggestions from the entire teaching staff o f the Sociology Department as well as the support I enjoyed from the non-teaching staff. I wish to acknowledge my thanks to the many scholars whose work I have cited in this study. Special thanks go to Dr. (Mrs.) Constance Bart Plange, Programme Manager of the National Malaria Control Programme in Ghana and Ms. Ngalame, the Coordinator o f the Partnership for Social Science in Malaria Control (PSSMC) for providing me with useful database and information on malaria research. Also Professor Twumasi, a consultant at the WHO Office in Ghana deserves to be mentioned for his keen interest and insightful comments. I also wish to express appreciation to Mrs. Faustina Anyetei for the patience exhibited while typing this write up. University of Ghana http://ugspace.ug.edu.gh It is impossible to mention the names of all the people who helped me in diverse ways during my studies. However, my indebtedness cannot be complete without expressing my profound appreciation to Mr. Ali, an Economics Officer o f the Ministry o f Finance for his tremendous support. My good friends Garba, BBC and Awal deserve mentioning. I cannot forget the cooperation and support of all my course mates particularly Kafui, Asare and Sasu. Finally, I wish to express my special gratitude to my parents Ummah Habiba and Baba Mumuni as well as my siblings for their patience and encouragement. I, however, take full responsibility for any error or shortcomings in this thesis. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Page Declaration ... ... ... ii Dedication ... ... ... iii Acknowledgement ... ... ... iv Table o f Content vi List o f Tables ... ................ .... .... xii List o f Figures ... ... ... xiii Acronyms ... ... ... xiv Abstract ... ... ... xv CHAPTER ONE: INTRODUCTION ... 1 Background o f the study ... ... ... 1 Statement o f the Problem ... ... ... 6 Objectives ... ... ... 11 Definition o f Key Concepts ... ... ... 12 Significance o f the Study ... ... ... 13 CHAPTER TWO: LITERATURE REVIEW ... 14 Introduction ... ... ... 14 Disease Burden ... ... ... 14 Knowledge/Perception o f the Cause o f Malaria ... 15 Signs and Symptoms of Malaria ... ... 18 vi University of Ghana http://ugspace.ug.edu.gh Treatment Seeking Behaviour ... ... ... 18 Home Care Treatment ... ... ... ...2 3 Decision Making Process ... ... ... ... 25 Preventive Measures ... ... ... ... 26 Literacy and Health ... ... ... ... 27 Conclusion ... ... ... ... 29 Conceptual Framework ... ... ... ... 30 Hypotheses ... ... ... ... 32 CHAPTER THREE: MALARIA CONTROL IN GHANA: A POLICY OVERVIEW ... ... ... 34 Introduction ... ... ... ... 34 Segregation Policy ... ... ... ... 34 Sanitary Reforms ... ... ... ... 35 Health Education ... ... ... ... 36 Chemoprophylaxis ... ... ... 37 Control o f Larvae and Adult Mosquito ... ... ... 3 8 Global Attempt at Malaria Eradication ... ... ... 3 8 Global Malaria Control Strategy ... ... ... 39 Accelerated Malaria Control Programme ... ... ... 39 Roll-Back Malaria ... ... ... ... 40 Summary ... ... ... ... 42 CHAPTER FOUR: BACKGROUND OF STUDY AREA ............... 43 Introduction 43 University of Ghana http://ugspace.ug.edu.gh Physical Characteristics 43 Historical Origin ... ... ... ... 46 Demographic Structure ... ... ... ... 48 Socio-Economic Formation ... ... ... ... 49 Education ... ... ... ... 50 Health, Water and Sanitation ... ... ... ... 51 Development Project ... ... ... ... 52 Political Organisation ... ... ... ... 53 Traditional Values and Practices ... ... ... 54 Social Change ... ... ... ... 57 CHAPTER FIVE: RESEARCH METHOD 59 Study Population ... ... ... ... 59 Sample Size ... ... ... ... 60 Sampling Technique/Method .... .... 60 Method o f Data Collection ... ... ... ... 62 Pretesting ... ... ... ■ • • ... 63 Training o f Field Assistants ... ... ... ... 64 Ethical Consideration ... • • • • • ■ ... 64 Fieldwork Procedure ... ... ... ... 65 Data Processing and Analysis Procedure ... ... ... 66 Field Experience ... ... ... ... 66 Study Limitations ... ... ... ... 67 vm University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX: DATA ANALYSIS AND INTERPRETATION Introduction 69 69 Respondents Category ... ... ... ... 69 Socio-Demographic Characteristics o f Respondents ... ... 70 Age o f Respondents ... ... ... ... 71 Religious Affiliation ... ... ... ... 72 Education ... ... ... ... 73 Principal Occupation ... ... ... ... 74 Marital Status ... ... ... ... 74 Income Level ... ... ... ... 75 Conclusion ... ... ... ... 76 Morbidity Patterns in the Communities ... ... ... 77 Perceived Causes o f Malaria ... ... ... 79 Convulsion ... ... ... ... 83 Education and Perceived Cause(s) o f Malaria ... ... 85 Age and Perceived Cause(s) o f Malaria ... ... ... 87 Perception o f Malaria Parasite Transmission ... ... 89 Literacy Level and Knowledge o f Malaria Parasite Transmission ... 90 Signs and Symptoms o f Childhood Malaria ... ... 92 Perceived Vulnerability o f Children to Malaria Infection ... ... 95 ix University of Ghana http://ugspace.ug.edu.gh Treatment Seeking Behaviour ... ... ... 96 Treatment Action ... ... ... ... 96 Medications Administered ... ... ... ... 98 Knowledge/Perception of the Cause of Malaria and First Treatment Action Taken ... ... ... ... 99 Others Factors Influencing Management of Childhood Malaria ... 101 Education and First Treatment Action Taken ... ... 101 Age and First Treatment Action Taken ... ... ... 103 Income and First Treatment Action Taken ... ... 105 Income Level and Health Care Facility Visitation ... 107 Distance and the Desire to Seek Treatment ... ... 108 Reasons for Choice o f Treatment Outlets ... ... ... 109 Home Treatment ... ... ... ... 109 Health Care Facilities Treatment ... ... ... 112 Treatment at Pharmacy/Chemical/Drug Stores ... ... 114 Treatment from Traditional Healers ... ... ... 115 Seeking Treatment from Faith Healers/Spirituals ... ... 117 Decision Making ... ... • • ■ ... 117 Malaria Prevention ... ... ... 121 Prevention o f Childhood Malaria ... ... ... 122 Knowledge and Use o f Insecticide Treated Mosquito Net (ITMN) ... 124 CHAPTER SEVEN: CONCLUSION ANI) RECOMMENDATIONS 126 Conclusion ... ••• 126 Recommendations ... ... ... 131 References ••• 136 Appendix A: Interview Schedule ... ... 153 x University of Ghana http://ugspace.ug.edu.gh Appendix B: Focus Group Discussion Guide ... 164 Appendix C: Sample Size Calculation ... ... 165 xi University of Ghana http://ugspace.ug.edu.gh Table LIST OF TABLES Page I Malaria Cases and Deaths in Selected hospitals ... ... 7 2. Schools and Enrolment in the Manya Krobo District ... ... 50 3 Socio-demographic Characteristics o f Respondents ... ... 70 4 Common Childhood Illnesses in Manya Krobo ... ... 78 5 Perceived Cause(s) o f Childhood Malaria ... ... 82 6 Perceived Cause(s) o f Convulsion ... ... 84 7 Education and Perception o f the Cause(s) o f Malaria ... 86 8 Age Group and Perceived Cause o f Malaria ... ... 87 9 Literacy Level and Knowledge of Malaria ... ... 91 10 Perceived Signs and Symptoms of Malaria in Children ... 93 II Knowledge/Perception o f the Cause of Malaria and First Treatment Action Taken 100 12 Education and First Treatment Action Taken ... ... 102 13 Age and First Treatment Action Taken ... ...104 14 Income Level and First Treatment Action Taken ... ... 105 15 Income Level and Flealth Care Facility Visitation ... 107 16 Distance and Desire to Seek Treatment ... 108 17 Measures taken to prevent childhood Malaria ... 123 Xll University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure Page 1 Health Belief Model showing interrelationship among factors influencing mothers management o f childhood malaria 33 2 A Map Showing the location of Manya Krobo District and Sampling Sites within the district ... ... 45 3 Reasons for opting for home treatment ... ... 110 4 Considerations for taking a sick child to a health care facility ... 113 5 Consideration for seeking treatment from a traditional healer ... 116 xiii University of Ghana http://ugspace.ug.edu.gh ACRONYMS OTC Over-The-Counter ITMN Insecticide Treated Mosquito Net GICHS Ghana Integrated Child Health Survey MKD Manya Krobo District HBM Health Belief Model WHO World Health Organization UNICEF United Nations Children’s Education Fund GDHS Ghana Demographic and Health Survey MOH Ministry o f Health RBM Roll Back Malaria STD Sexually Transmitted Diseases KAP Knowledge, Attitude and Practice ARI Acute Respiratory Infection TBA Traditional Birth Attendant FCUBE Free Compulsory Universal Basic Education NGO Non-Governmental Organisation EA Electoral Areas FGD Focus Group Discussion OPD Out-Patient Department MCH Maternal and Child Health HIV/AIDS Human Immune Virus/Acquired Immune Deficiency Syndrome PHC Primary Health Care University of Ghana http://ugspace.ug.edu.gh ABSTRACT Malaria has been identified as the single most important infectious disease in children, being responsible for the death of about one million children per year or 25 percent o f all childhood deaths worldwide. Most clinical cases o f the disease occur in sub-Saharan Africa. Malaria may also contribute to the severity o f other childhood diseases and repeated infections can be a cause o f chronic anaemia in children due to their relatively weak immune system. About one million children under five suffer from malaria in Ghana; malaria leads to 45 deaths of children under five every day (MOH, 2003). The health burden o f malaria has far-reaching implications for child health and survival. Apart from the morbid and socio-economic impact o f the disease on children and their carers, death o f children under five resulting from malaria has been increasing in Ghana over the years. This is reflected in the infant and under five mortality rate for Ghana from 1999-2003 (GDHS, 2003). Adoption of new strategies to combat malaria based on increased participation o f all stakeholders and improved case management requires in-depth appreciation of carers perception and management of childhood malaria episode. The main thrust of the thesis is to investigate how mothers/carers perceived and managed childhood malaria. In furtherance o f this main objective, the study xv University of Ghana http://ugspace.ug.edu.gh assessed mother’s perception/knowledge o f the aetiology and transmission of malaria; investigated actions taken during episodes of childhood malaria; examined factors influencing choice o f treatment outlets and ascertained practices on malaria prevention. The study combined both quantitative (survey) and qualitative (Focus Group Discussion) methods in collecting necessary data. A sample size o f 230 was used in the survey. Manya Krobo District was selected for the study not only for the endemicity o f malaria in that area but also for the fact that it has a very high disease burden including HIV/AIDS. Results o f the study show that although respondents are familiar with common signs and symptoms o f malaria in children, they generally do not consider childhood convulsion as a manifestation o f severe malaria. Regarding the aetiology o f childhood malaria, the study found that some respondents attribute it to mosquito bite only while others attribute it to both mosquito bite and other natural and environmental factors such as exposure to excessive heat, playing or walking in the sun, eating oily food, poor nutritional intake and exposure to cold weather condition. Concerning choice o f treatment outlet, the majority prefers reporting their child’s conditions to operators o f drug retail outlets for appropriate. Accessibility and lower cost o f drugs were some o f the consideration for consulting drug retail University of Ghana http://ugspace.ug.edu.gh outlets. Treatment sought is also influenced by individual characteristics such as level o f education, income, access to health care and advice from lay referrals. It was also found that the majority o f respondents believed that malaria could be prevented by avoiding mosquito bites, avoiding oily foods and protecting oneself from the heat o f the sun, among others. The use o f Insecticide Treated Mosquito Nets (ITMN) was found to be very low. Malaria control effort should, therefore, take into account the multi-dimensional human contexts that create and support varying notions o f malaria and its prevention, treatment and control. In this context; • Public health education on malaria should be intensified by relevant agencies, especially, at the community level. • Stakeholders at all levels must also be included in the malaria control programme. • The exemption policy for treatment o f malaria in children under five must be fully implemented to facilitate assess to health care facilities. • Government and other stakeholders should subsidize the cost of the ITMN. • District Assemblies must endeavour to support the implementation of malaria control programmes, provide necessary human and material resources for effective waste management while ensuring the enforcement o f sanitary regulations and by-laws. xvii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION Background of the Study The focus o f this thesis is to investigate mothers’ or carers’ modes o f managing childhood malaria in the Manya Krobo District (MKD). Essentially, the study is concerned with local perceptions and beliefs about the cause(s) and transmission o f malaria in children and the choice of treatment outlets. Generally, it has been recognized that every society has folk beliefs about illnesses and diseases. Twumasi (1988) has observed that in traditional societies, illness is mostly associated with external forces such as evil spirits whereas in modem societies it is perceived as having a physical cause, resulting from the infestation of a germ in the body or other physical disturbances. Illness behaviour, therefore, depends on the cultural ideas about health and disease, so that treatment and prevention follow logically from beliefs about causation (Hannay, 1988). Other external factors, which directly or indirectly influence carers’ readiness to take specific health actions when a child is ill, include socio-demographic characteristics, health education and perceived benefits from taking a particular action. University of Ghana http://ugspace.ug.edu.gh The desire to protect children against illness and disease to ensure that they are healthy is not the exclusive concern of the family since it has a broader implication for society’s development and general well-being. It is instructive to also note that health is a complex phenomenon. As defined by the World Health Organisation, health is “a state of complete physical, mental and social well-being and not merely the absence o f disease or infirmity” (WHO, 1978). Despite this broad definition, observing mortality and morbidity rates over a period o f time traditionally assesses health. Therefore, the presence o f disease becomes a prime indicator o f health. The United Nations Children Fund (UNICEF) for instance, uses the under-five mortality rate as a principal indicator for measuring the level of child well being and also as a major index in the assessment o f a nation’s level of socio-economic development and quality o f life. In this vein, nations the world over, including Ghana, have over the years instituted various measures aimed at improving the health status o f their citizens, especially children. International agencies such as the World Health Organization (WHO) and the UNICEF supported and continue to support such health programmes resulting in the steady decline in the infant and child mortality rates globally. Infant mortality in Ghana, for instance, has decreased steadily from 133 per 1000 live births in 1957 to 66 per 1000 in 1993 and 57 per 1000 live births in 1998 (GDHS, 1998). The rate for under five mortality follow similar trend over the period. However, what is disturbing is that, preliminary report o f the 2003 GDHS shows increasing rates for both the infant and under five mortality rates. The data show a 12 percent increase in infant mortality rate from 57 deaths per 1000 live birth in 1998 to 64 in 2003. Similarly, the under five mortality rate 2University of Ghana http://ugspace.ug.edu.gh increased by 3 percent from 108 death per 100 live births in 1998 to 111 in 2003 (GDHS, 2003 Preliminary Report). The trend may depict deterioration in the general quality o f life among Ghanaian population and in particular an upsurge in childhood illnesses. Patterns o f morbidity and mortality remain virtually unchanged as the majority of children in the country are still afflicted by preventable diseases such as malaria, diarrhoea, whooping cough, tuberculosis, tetanus, measles, acute respiratory infection, malnutrition in the form o f pneumonia and now the HIV/AIDS pandemic. Malaria is one o f the most prevalent infectious diseases worldwide and recognized as an endemic problem in the tropics. It is also one of the ancient infections and noted in some o f the earliest records in the 5th Century BC when Hippocrates differentiated types of fever and described the disease in detail (Russel, 1955). Over 40 percent o f the world’s population now lives in malaria endemic areas. African countries account for more than 90 percent o f the total malaria incidence and the great majority o f deaths. An estimated 300-500 million cases o f malaria each year result in one million deaths, mainly children under 5 years in Africa. Thus, children under 5 continue to constitute one o f the most vulnerable groups (WHO, 2000). Malaria is a serious, acute and chronic relapsing infection in humans, characterized by periodic chills and fever, sleepiness, anaemia and often fatal complications. Treatment and control o f the disease is becoming increasingly difficult and the epidemiological situation is likely to continue to deteriorate for 3University of Ghana http://ugspace.ug.edu.gh some years to come (WHO, 1993). Recent reports indicate widespread resistance o f the malaria parasite to drugs such as chloroquine which is still the first line drug adopted by the Ghanaian Ministry O f Health (MOH) for the treatment of malaria (Daily Graphic, Jan. 24, 2003). Earlier attempts at malaria eradication launched by the WHO have largely failed to achieve the desired result. The strategy adopted in the 1990s, therefore, emphasized early diagnosis and prompt and efficient treatment o f the disease (WHO, 1993). Following the world declaration on the survival, protection and development of children at the World Summit for Children in 1990, political leaders committed themselves to give every child a better future. This was against the background that many children around the world are exposed to dangers that hamper their growth and development. Being the first country to ratify the Convention on the Rights o f the Child, Ghana has demonstrated that it can rise to the challenge of the summit. Since then, the Government of Ghana, through the MOH, has undertaken a number o f programmes within the National Programme of Action (NPA) to help improve the health status o f children in the country. These include the intensification o f its Primary Health Care (PHC) activities, expanding health care facilities and training more health personnel throughout the country to help combat childhood diseases. In order to promote the utilization of biomedical health care facilities for mothers and their children the government has, since 1996, introduced a policy to provide 4University of Ghana http://ugspace.ug.edu.gh free four antenatal visits for mothers and free medical care for children under 5 years. As will be discussed in greater detail in Chapter Four various policies and programmes have been instituted since the colonial era in an attempt to combat the malaria menace in the country. Major attempts during the colonial administration include residential segregation policy, environmental management such as larviciding o f water bodies, inspection of household drinking water and health education programmes. After the attainment o f political independence a malaria eradication programme was also instituted in 1961 but could not be sustained and was subsequently abandoned in 1968 (Addae, 1996). Following the adoption of a Global Malaria Control Strategy, a 5-year national malaria control programme was instituted from 1993-1997. An accelerated malaria control programme followed this from 1997 and piloted in 30 districts in Ghana. This programme is being extended to cover all the 110 districts in the country under the Roll Back Malaria (RBM) programme adopted in 1999 (MOH, 2001). Despite all these initiatives malaria continues to be a major public health problem in Ghana. The slow success rate may be attributed to a combination of factors such as poor local knowledge of the disease and its treatment, non-adherence to therapeutic regimen and preventive measures, inadequate health education about the disease and its biomedical treatment, high cost o f treatment, lack o f access to health care, inadequate health personnel and the general world view of mothers and carers. Therefore, the cultural background and socio-economic status of mothers and carers o f children are critical for the effective implementation of child 5University of Ghana http://ugspace.ug.edu.gh health promotion programmes such as in the malaria control programmes since such factors influence actions towards the management o f the disease. Statement of the Problem Malaria has been identified in a number o f reports as the single most important infectious disease in children, being responsible for the deaths o f about one million children per year or 25 percent of all childhood deaths worldwide (TDR/WHO, 2002; RBM/WHO, 2000; WHO,2003; Bloland et al, 2000; Baume,2000; Wellcome,2002). The malaria health burden has an important morbidity as well as mortality component, with the severe forms o f the disease being the main reasons for hospital admissions of young children in malaria endemic areas (Global Forum for Health Research, 2003).Although malaria has a wider global distribution, most clinical cases per year occur in sub-Saharan African. Malaria may also contribute to the severity o f other childhood diseases and repeated infections can be a cause o f chronic anaemia in children. In Ghana, Malaria accounts for 42 percent o f all Out-Patients Department (OPD) Cases and 38 percent o f all hospital admissions. Between 950,000 and 970,000 cases in children under five suffer from malaria with 45 deaths of children under five every day (MOH, 2003).A special data collection exercise carried out by the Ministry o f Health in 66 selected hospitals countrywide depicts increasing prevalence o f malaria as shown in Table (1). 6University of Ghana http://ugspace.ug.edu.gh Table (1): Malaria Cases and Deaths in 66 Selected Hospitals in Ghana Age Group 2000 2001 2002 Cases Deaths Cases Deaths Cases Death Under Five 269,815 1952 282,783 1,717 279,967 1917 Five Years and above 500,516 2,102 495,783 1.441 543,628 1.360 Total 770,331 4,054 778,566 3,158 823,595 3,277 Source: National Malaria Programme (MOH, 2003). Table (1) shows that, cases o f malaria have been increasing over the past 3 years for all age groups. What is even more serious is the fact that malaria death rates among under five year is increasing while it is declining for the other age group. Correspondingly, incidence of malaria cases is also on the ascendancy in the Manya Krobo District. In 1998, a total o f 19,617 cases o f malaria were recorded from health institutions in the district. The figure went up by about 1.6 percent to 19,934 in 1999 and further shot up by 36 percent to 31,071 cases in 2000 (MOH 2002). The profile o f malaria cases in the district confirms the national malaria prevalence situation. It is worth noting that these statistics represent only cases reported at selected health institutions and records obtained from sentinel surveillance. However, those which are not accounted for should be enormous in view o f the problems o f accessibility to modern health care facilities and the University of Ghana http://ugspace.ug.edu.gh general tendency towards home-based treatment o f malaria and non-reporting of cases o f malaria-related deaths. Although the prevalence rate for malaria in the Manya Krobo district is not so different from those of other districts in Ghana, the impression one gets is that the Manya Krobo District has a particularly heavy disease burden given the high incidence and prevalence o f HIV/AIDS and many other nosocomial infections such as diarrhoea, tuberculosis and sexually transmitted diseases (STDs) in the district. In the case o f HIV/AIDS, for instance, the district is rated second in terms o f reported cases o f the disease in the Eastern Region and it is noted as one of the E1IV/AIDS endemic areas in Ghana. The argument here is that since there is no known cure for the HIV/AIDS and in a situation where most victims cannot afford the cost o f the newly developed anti-retroviral drugs, it is reasonable for stakeholders in the health sector to try and at least control the incidence of opportunistic infections such as malaria which can be easily prevented and treated at a relatively cheaper cost so as to promote the health of individuals and society in general. Despite all the malaria control initiatives mentioned earlier and the huge financial outlay committed so far, a high incidence of malaria specific morbidity and mortality still persists in the country. A total o f about US$2.3 million from both domestic and external sources was earmarked by the MOH for malaria control activities in Ghana for the year 2003 (MOH, 2003). The problem with the control of malaria in Ghana can, to some extent, be attributed to the fundamental issues o f folk beliefs and perceptions of illness and University of Ghana http://ugspace.ug.edu.gh disease, which invariably influence decisions and actions towards seeking help from the appropriate quarters. Preliminary interviews conducted by the researcher revealed that mothers or carers in the Manya Krobo District generally rely on their traditional knowledge and views in identifying cases o f suspected malaria in children and consequently seek treatment they consider appropriate under the circumstance. The process o f seeking treatment when malaria is suspected is often delayed by socio-economic and cultural factors prevailing within the area. Another aspect o f the problem is the lack o f access to modem health care facilities for the majority of the population living in the rural areas that incidentally are more prone to malaria and other illnesses. Philip (1990) noted that relatively few people, especially in the poorer Third World countries, have access to, or contact with a modem “western” health centre. He reiterated that about 70 percent o f the population o f poorer Third World nations does not have access to basic modem medicines or health care; and it is widely assumed that most health care received in such countries must either be from a traditional source or by self-treatment. In a report on a national rural community survey in Ghana (GSS 1993) it was indicated that only about 3 percent of rural households in Ghana live in communities where there is a medical practitioner. For a further 36 percent o f rural households, the nearest medical officer is less than 10 miles away. On the other extreme about 18 percent o f rural households travel at least 30 miles to get to a doctor. This unfortunate state of affairs can be traced to Ghana’s colonial and post­ colonial experiences, poor linkage within the health system and budgetary 9University of Ghana http://ugspace.ug.edu.gh constraints for health care delivery resulting from the fragile nature o f the national economy. Consequently, emphasis on health delivery has concentrated on the provision o f biomedical health care facilities mostly in the urban and peri-urban communities. For instance, all the three hospitals in the Manya Krobo District, (one o f which is a mission hospital) are all located in the urban and more developed towns while the majority o f the rural communities in the district are provided with few ill-equipped health facilities. Thus, even for those in the urban and peri-urban areas, hospitals and other modern health care facilities are financially inaccessible to most people. The alternative is for people to resort to other health care outlets such as buying drugs from peddlers and consulting a traditional/spiritual healer whose services are relatively cheaper. In view o f all these difficulties the issues o f concern are: To what extent are the target populations involved in the implementation of the various malaria control programmes? What is the impact o f health education on mothers/carers perception o f the aetiology, treatment and prevention of childhood malaria? How accessible are modern health care facilities to mothers/carers? This study, therefore, seeks to investigate some o f the concerns raised and then make necessary recommendations to stakeholders for effective management o f malaria not only in the Manya Krobo District but also in other districts with similar health problems. 10University of Ghana http://ugspace.ug.edu.gh OBJECTIVES General Objectives In furtherance o f the questions raised, the study generally seeks to assess mothers/carers practices associated with childhood malaria management in the Manya Krobo District o f Ghana. Specific Objectives Specifically, the study seeks to address the following issues: a. assess mothers/carers perception/knowledge o f the cause(s) and modes of transmission o f childhood malaria; b. investigate actions taken when children are perceived to have developed malaria; c. examine factors that influence the choice o f health care outlets; and d. ascertain local malaria prevention practices. 11University of Ghana http://ugspace.ug.edu.gh Definition of Key Concepts a. Management: For the purpose o f this study, management involves the identification o f signs and symptoms o f malaria infection and the choices made in seeking treatment. b. Childhood Malaria: This refers to the severe illness in children resulting from the bite of a mosquito causing fever, chill, vomiting, loss of appetite, unusual sleepiness, weaknesses, convulsion and sometimes death. c. Perception/knowledge: The two concepts may be defined differently but for the purpose o f this study they are considered within the same context and used interchangeably. Knowledge or perception is the depth of one’s understanding and awareness of issues related to childhood malaria in terms o f its cause(s), symptoms and application of appropriate treatments and preventive measures. d. Belief: It is defined as a person’s strong feeling about the cause(s) of malaria and the efficacy of a particular treatment option. e. Health seeking Behaviour: It refers to the sequence o f actions that an individual undertakes to rectify perceived ill health in a given situation. 12University of Ghana http://ugspace.ug.edu.gh 13 Significance of the Study Malaria is considered a major health problem in Ghana. As reports indicate childhood morbidity and mortality due to malaria are on the increase despite on­ going interventions (MOH, 2001). The prevalence of malaria in the Manya Krobo district may not be significantly different from other parts o f the country. However, it has a particularly high disease burden and rated as one of the highest in terms o f the HIV/AIDS infections countrywide. In view o f such prevailing health hazard in the district, it is necessary to urgently put measures in place to control the scourge o f malaria and other opportunistic diseases to help prolong the life o f HIV/AIDs victims including children in the district while looking forward to the development o f a potent vaccine against malaria and the HIV/AIDs. This situation also calls for urgent and continuous biomedical and social research to ensure successful implementation o f interventions since the focus o f ensuring child health is shifting from treatment o f disease to prevention of illness. Unfortunately, few studies focus attention on socio-cultural aspects of managing childhood malaria even though differences exist in socio-cultural background. Thus, this study seeks to focus on the socio-cultural response to childhood malaria by carers within the context o f a particular social setting. Apart from adding to the existing literature on management of childhood malaria, it is expected that the intended outcome o f the study will be useful to policy makers and other stakeholders. The findings can also be used to assess aspects o f the Roll Back Malaria Control Programme in the country University of Ghana http://ugspace.ug.edu.gh 14 CHAPTER TWO LITERATURE REVIEW Introduction This chapter reviews some literature on malaria, treatment seeking behaviour and other related issues. The review is set to provide a general background of the study and lay the basis for understanding discussions in subsequent chapters. A conceptual framework to put the study in perspective discussed. Disease Burden Malaria is acknowledged to be by far the most important tropical parasitic disease, causing great suffering and loss o f life to humans. It is usually due to the infection o f the red blood cells with plasmodium faciparum. Malaria is spread from person to person from the bites o f an infected female anopheles mosquito (Nevill, 1990). Malaria also undermines the health and welfare o f families, endangers the survival o f children and debilitates the active population. Control is becoming increasingly difficult and the epidemiological situation is likely to continue to deteriorate in the coming years (WHO, 1993). Some of the severe malaria epidemics in recent years have taken place in highland areas in Africa, the most serious being the epidemic that claimed about 25,000 lives in Madagascar in 1988 (WHO, 1993). As noted earlier, an estimated 300-500 million cases o f malaria each year result in about one million deaths, most o f them in Africa and South Asia (WHO, 2000). University of Ghana http://ugspace.ug.edu.gh Malaria is hyper-endemic in most parts o f Ghana and it is also identified as the leading cause o f morbidity and mortality in children under five years (MOH, 2000 ). Malaria is one o f the major killer diseases in rural tropical Africa, taking the life of one out o f twenty children before the age o f five years. The cost of this disease is a drain on both the individual and the state. In 1987, the estimated annual direct and indirect cost o f malaria in Africa was US$800 million and this figure was expected to rise above US$1800 million by 1995 (WHO 1993). A study by Asenso-Okyere (1997) shows that the cost per episode of malaria in Ghana was $8.67 or 5 days o f work at the minimum wage. Brinkman and Brinkman (1991) also found that on the average, a person with uncomplicated malaria would be unable to work for 3.5 days and that the duration o f sickness will be 5 days while 2 days o f an adult’s time is usually lost to care for a malarous child. Knowledge/Perception of the Causes of Malaria Studies in Ghana and elsewhere have given inconsistent account o f people's perception o f the causes and transmission o f malaria and other diseases. Bamikale (1997), for instance, studied the impact o f cultural beliefs on a mother’s management o f childhood diseases in among Yoruba in Nigeria. The study revealed that only 4.4 percent of mothers had adequate knowledge o f the cause(s) o f measles, 55.8 percent o f diarrhoea, and 66.4 percent o f malaria. It was also found that 56.2 percent of mothers believed in the existence of spirit children, while 30.6 percent did not. Mothers who believed in “abiku” indicated that 15University of Ghana http://ugspace.ug.edu.gh repeated deaths, deformity and frequent indisposition of children are some evidence o f the existence of spirit children (abikus). Doe (1987) studied mother’s knowledge of the etiology, diagnosis, prevention and management o f diarrhoea in children under 5 years in the Ashanti Akim District of Ghana. The study revealed that most o f the mothers identified diarrhoea as the frequent passage o f watery stools, three or more times a day. The list of the causes o f diarrhoea mentioned included; teething, crawling, eating soil and unclean food and infections among others. The study further revealed that many o f the mothers already knew o f the simple preparation of ORT and believed in giving liquids to replace lost fluids. Fayorsey (1988) noted that a Ghanaian woman’s perception of diseases and sickness is greatly influenced by societal beliefs and practices, which usually attribute diseases to the powers of the supernatural world. Thus, in a traditional society, supernatural causation seems to be the only plausible explanation for disease and deaths. Such assertion or observation about the Ghanaian woman perception on disease causation in traditional societies is often cited in earlier anthropological studies in Ghana. However, the situation is changing due to improvement in access to education and girl’s enrolment, urbanization, migration, technological development and access to primary health care. Diseases and deaths are mostly explained in terms of both natural and supernatural causation among Ghanaian women following recent studies. In a comparative study o f five West African countries including Ghana, Aikins et al. (1994) found that only 50 percent o f Ghanaians associate mosquito bites with malaria. An earlier study by Agyepong 16University of Ghana http://ugspace.ug.edu.gh (1992) in a Dangme community in Ghana revealed that 37 percent o f adolescent girls perceived excessive sun/heat as causing malaria (asra) while only 2 percent attributed the cause to mosquitoes. Mensah-Quainoo et al. (1995) also found that many respondents thought malaria was caused by the heat o f the sun, overworking one’s self, undue tiredness, heat from fire and eating starchy foods. Adongo and Hudelson (1995) revealed that some respondents attributed the cause o f the disease to God and heredity. Similarly, Kendall et al. (1999) noted that respondents’ lack knowledge o f the cause(s) o f convulsion as they failed to link the manifestation o f severe malaria (cerebral malaria) to the onset o f convulsions; it was thought to be caused by the shadow o f nocturnal bird, a caterpillar, bad food, constipation and sores in the anus. According to the Integrated Child Health Survey conducted in four districts of Ghana none o f the women interviewed had heard about malaria transmission (ICHS, 2001). This revelation is in line with the findings by Dukurugu (1997). Even though the majority o f the people believe that mosquito causes malaria, they have very little knowledge about its transmission. On the other hand, Nieto et al. (1999) noted that in Colombia respondents knew that malaria transmission occurred through mosquito bites. Ntow et al. (1999) in a study on childhood malaria in rural communities in Ghana revealed that there is a great deal o f misunderstanding about the causes o f malaria. In children, participants indicated 17University of Ghana http://ugspace.ug.edu.gh that excessive heat and over-crowding in a room and constipation can all bring about malaria. From the findings o f the studies cited above one can conclude that scientific knowledge about the aetiology and transmission o f malaria and other diseases is generally low, especially, among illiterates and rural dwellers and perception about the causes and transmission of malaria differ. Signs and Symptoms of Malaria The different terminologies used to describe a combination o f signs and symptoms among different ethnic groups in various studies are close to a clinical diagnosis of malaria. A study in a Southern Ghana revealed that malaria is often associated with malaria signs and symptoms such as hot body, vomiting, headache and chill (Ahorlu et a l l 997). Diallo et al. (2001) in a study conducted in rural Guinea where large populations of children are infected by malaria found that mothers rarely identify fever and diagnose malaria. Agboada (1999) in a study in the Kintampo District found that some mothers (21%), however, were aware o f the major signs and symptoms of childhood anaemia. Treatment Seeking Behaviour A number o f studies in the developing world show that most people seek treatment at home during an episode o f malaria. According to the 1998 Ghana Demographic and Health Survey, one out o f four households reported that a child (under five years) had fever two weeks preceding the survey. However, only 40 percent were 18University of Ghana http://ugspace.ug.edu.gh taken to a health facility for treatment (GDHS, 1998). Brinkman and Brinkman (1991) in a study on malaria and health in Africa concluded that between 8 and 25 percent o f persons with malaria visit health centres with self-treatment being common in urban than in rural communities. Hussain et al. (1997) studied perceptions and management of acute respiratory infections (ARI) among the people of Karachi in Pakistan. The main objective was to consider variations in the treatment outlets. They found that between 10 and 99 percent o f patients used clinics and hospitals for treatment o f ARI while 4.87 percent auto-medicated. The study also revealed that exclusive reliance on traditional methods was extremely rare; traditional remedies were often combined with orthodox medicine. The main reason for self-medication was the perceived high cost o f treatment at the clinics and hospitals. Asenso-Okyere et al. (1995) observed that health financing reforms that culminate in the introduction o f user charges and cost-recovery for drugs in health care facilities often make it very difficult for many people to access modem health care and often cause a delay in reporting illness to biomedical health care providers. During these periods certain home management practices are adopted as cost saving measures. Other studies in Ghana confirmed that there was a drop in utilization o f health care facilities immediately after user fee was introduced (Vogel, 1988). For the instance, Waddington and Enyimanyew (1989) reported on the attendance behaviour o f outpatients at health centers in the Ashanti-Akim District o f Ghana after user fees were introduced in 1985. According to them, 19University of Ghana http://ugspace.ug.edu.gh within the first six months o f the introduction o f user fees, attendance at the health centers declined by 50 percent. Ruebush et al. (1995) found that in western Kenya, 60% o f fever episodes were treated at home with only 18 percent resorting to a clinic or a hospital. The rest sought no treatment. Similarly, Mwenesi et al. (1995) reveal that 23 percent of mothers in coastal Kenya who reported that a child had malaria in the two weeks prior to the interview had sought care from a health care facility. Ahorlu et al. (1997) also found that a visit to a health center was the last resort after failure of home treatment. The above studies show that most mothers seek treatment at home and would only visit a health care facility when the illness persists. Since mothers are the first source of treatment for their children, identifying factors that influence their treatment seeking behaviour could facilitate behaviour modification through educational interventions and policy changes. Slusker et al. (1994), in a study on the treatment of malaria among children in Malawi revealed that 52 percent o f malaria episodes resulted in a visit to a clinic. In that study, higher socio-economic status was found to be positively correlated with clinic attendance. Twumasi (1986) found that traditional healers were not frequently consulted when modern hospitals were available in the area. Nieto et al. (1999) also indicated that participants in the focus groups identified two ways o f coping with the disease: they either go to the health center or to the traditional healers, or both. In the case of health services utilization once malaria was suspected, the study found that people tended to avoid health care facilities 20University of Ghana http://ugspace.ug.edu.gh because of the distance from home, time spent in awaiting treatment, quality of service and delay in the diagnosis. Physical distance acts as a barrier or a disincentive to attendance at almost any facilities for practical reasons. Most studies have identified a negative relationship between distance and utilization (Philips, 1986b; Stock 1987.) although some show this relationship may vary according to the nature o f illness. Income is another major factor affecting treatment-seeking behaviour. Chermichovsky and Meesook (1986), analyzing household utilization data for Indonesia (covering urban and rural areas, and different socio-economic groups), found low income to be a strong barrier to the utilization o f modern primary medical facilities even when publicly provided. The relatively well-to-do were spending more, and relying heavily on the services o f trained physicians. The poor segments o f the Indonesian population (the poor in Java) were mostly treated at home by family members or at a traditional medical practitioner’s home. Very few o f the urban upper income group, according to the survey, received treatment from traditional medical practitioners. Owusu and Ablordey (1993) noted that low utilization o f health services has been the result o f people’s satisfaction and preference for herbal medicines as against the orthodox ones. Principally, this is due to the belief that some ailments are incurable at the hospital. Waddington and Enyimayew (1989) equally observed the use o f herbal medicines in the Volta Region o f Ghana and concluded that the 21University of Ghana http://ugspace.ug.edu.gh practice was prevalent because in the opinion o f the people, concoctions from herbalists tended to be better. Religion is another significant determinant o f how people perceive and treat diseases. This attitude may probably be influenced by the desire from an individual to use a particular mode o f treatment for illness due to the individual’s religious beliefs (Senah et al. 1994). Fosu (1981) also argues that people’s beliefs in the cause of illness affect their choice o f health care. Where people consider the causes o f illness as natural they most probably seek care at the health facilities, but where illnesses are considered as supernatural, they most probably, go to traditional healers. Boerman and Baya (1990) noted that in the coastal province of Kenya, Christians use modem health care services more than Muslims and traditional believers. Mwenesi et al. (1995) also found that the use o f health facilities for treatment of malaria was low, and the use o f traditional healers was non-existent except for the treatment o f convulsions. Management o f convulsions at hospitals kept mothers away because it is not in accordance with the cultural expectation of how therapy should be administered. There seems to be some disagreement in the results o f the various studies concerning the type o f treatment sought during childhood malaria episodes and the predisposing factors. For instance, some studies indicate high service utilization while others show low utilization. Findings on traditional medicine utilization 22University of Ghana http://ugspace.ug.edu.gh were also not consistent. This confirms that differences do exist in various societies when it comes to health-seeking behaviour. Home Care Treatment The 1998 Ghana Demographic and Health Survey (GDHS) show that 40 percent o f children with fever did not receive any anti-malaria treatment; 30 percent received anti malaria treatment at home and only 30 percent received anti-malaria treatment after consulting a health professional. This is perhaps due to the fact that most child illnesses in many Ghanaian communities are perceived, defined and first treated at home. It is only when the situation begins to worsen that carers turn to either a modem health facility or traditional sources o f treatment. The Ghana ICHS (2001) revealed that three out o f four children with fever in the two weeks before the survey received some professional care while 38 percent received home care. It further noted that children with fever for whom some action was taken were most likely to have received chloroquine, either as a combination therapy with panodol or on its own. Thus the majority o f children were said to have received the recommended chloroquine either from the home, a drug vendor, or from any public/private health facilities. However, children who received medicine from home are the least likely to receive the recommended chloroquine. This study shows that there is a lack o f knowledge among mothers about the correct application o f chloroquine. Mensah-Quainoo et al. (1995) in a baseline study on improving malaria control in Ghana revealed that a large percentage o f the respondents were found to have used University of Ghana http://ugspace.ug.edu.gh home treatment including herbs, drugs or a combination o f both as the first treatment action for episodes of malaria. A reason for use o f home treatment was lack o f money to attend clinics. Health facilities are visited only when people do not get better in spite o f home treatment or when the illness gets worse. However, one significant finding o f the study was that respondents maintained that traditional healers can not treat malaria. Diallo et al. (2001) in a study conducted in a rural area in Guinea concluded that only a small population o f children affected by malaria received chloroquine at home. Not unexpectedly, the study found that failure to use chloroquine was associated with mothers’ lack o f access to health services. Thus, mothers living closer to health care facilities were more likely to consult and give chloroquine earlier than mothers living far from health centres. Mothers give various types o f medication to malarious children at home. Gyapong et al. (1998) noted two options that caregivers adopt in caring for a sick child in the Dangbe West district. The first option is to smear garlic paste on the child’s body to help reduce body temperature. In the second option, the child is sponged with cold water and also given paracetamol and chloroquine syrup. Agyepong (1992) and Ahorlu et al (1997) also found that home treatment of malaria involves herbal preparations or biomedicines or both. Asenso-Okyere (1992) similarly found that most people resort to herbal remedies and that almost every household in the four communities studied in Ghana is aware o f one herbal preparation or another for the treatment o f malaria. The neem tree (Adzadirachta 24University of Ghana http://ugspace.ug.edu.gh Indica) was commonly used as a home therapy for malaria. The studies show a significant adoption o f home-based treatment for malaria in the study areas. The type o f therapy used for such home-based treatment is either bio-medical or traditional herbal medicine depending on predisposing socio economic and cultural factors. Decision Making Process The decision to seek care and the type of treatment sought is determined not only by knowledge about the cause and signs o f the disease but also by other socio cultural factors. Studies have shown that social roles and responsibility determine mothers’ decision-making process. Tanner and V lassoff (1998) found that “Although women (carried) the major share of responsibility for the well-being of the household in Benin, this responsibility was rarely matched by autonomy to make decisions or by access to necessary resources” (Tanner and Vlassoff, 1998:526). Adongo and Hudelson (1995), in a study o f rural communities in northern Ghana stated that when a mother notices that her child is ill, she must first report the illness to her husband, compound head or mother-in-law. She must obtain permission and money from her husband or compound head before taking the child for treatment. In most cases, husbands or compound heads will consult the ancestors through a sooth sayer to ascertain the cause o f the disease first and to determine what rituals need to be performed. A decision is made regarding where to send the child for treatment based on the outcome o f the consultation with 25University of Ghana http://ugspace.ug.edu.gh soothsayers. Browne (1999) also found that mothers o f sick children consult family members such as father, husband, mother and sisters. Mwenesi et al. (1995) revealed that almost all mothers regardless o f marital status, age and educational level, reported that they would seek advice before taking an ill child to a health facility. Preventive Measures The Ghana ICHS (2001) survey found that knowledge and use of preventive strategies against malaria are very minimal. For instance, only 14 percent of children had slept under treated bednets and only 54 percent o f the women had heard about the bednets. Chinbuah (1999) indicates that knowledge about insecticide treated bednets is very low (8.7 percent). The proportion o f respondents sleeping in bednets is also low (0.8 percent). However, the proportion willing to sleep in the net is high (96.3 percent). Similarly, Dukrugu (1997), in a study, found that many people do not use bednet but few burn mosquito repellent. Other studies show that children’s lives can be saved by bednet treated with insecticides. One such study in Gambia found that the use o f such nets reduced malaria deaths among children to between 60-70 percent (WHO, 1995). On the other hand Agyepong (1992) noted that the prevailing opinion among the studied population is that there is very little the community can do by itself to prevent “asra” (fever) and that it is in a way an unavoidable fact o f life. The belief is that the sun causes “asra” and one cannot refuse to work in the sun if one has to eat. 26University of Ghana http://ugspace.ug.edu.gh Literacy and Health Illiteracy has been described as a major barrier for those seeking improvement in the socio economic condition o f vulnerable populations (Mulholland et al. 1999). Illiteracy is not only a barrier to communication, understanding and knowledge, but also prevents exposure to the world beyond the immediate surroundings. In spite o f the significant progress made in improving school enrolment and infrastructure since the attainment of Ghana’s independence, the rate o f illiteracy is still high. A summary report o f the Ghana 2000 population and Housing Census indicate that 45.9 percent o f Ghanaians are not literate; 34.2 percent are literate in English and a Ghanaian language while 12.7 percent are literate in English only. It is significant to know that women and rural dwellers form the majority of the illiterate population in Ghana. In developing countries, including Ghana, the education o f females has always lagged behind that o f males (Dolphyne 1991; Summers 1992). Assimeng (1981) also indicated that educating women was initially not encouraged. Thus many people did not give much attention to the education o f girls. Mulholland et al. (1999) noted that while illiteracy is common to both men and women, it is more noticeable among women. Thus, there is a relationship between an increase in a woman’s educational level and reduction in infant and child mortality as well as fertility. Likewise, functional literacy has been shown to make a significant difference in parent and child relationship, and in decision­ making relating to choice o f food and medicine. For instance, in the developing 27University of Ghana http://ugspace.ug.edu.gh countries participating in the World Fertility Survey, women with more years of schooling were more likely to use a modern family planning method and to have a smaller family size (GDHS, 1988). Ankobiah (1986) investigated the extent to which the educational attainment of women affected their attitude toward maternal and child care practices in the Bekwai area in Ghana. It established a relationship between the educational level o f a woman and her preference for modern or traditional methods o f maternal and child health care. The study further considered whether such factors as place of residence, occupation and access to health care do affect women’s attitude towards modem or traditional methods of health care. The study revealed that the level and content o f education was essential for the utilization of health services and that the choice between traditional and modem health care system was dictated mostly by availability, accessibility and suitability, and that both systems may be resorted to indiscriminately. There is a growing consensus that mother’s education influences her choice and increases her knowledge and skills in health care practices related to nutrition, hygiene, preventive care and disease treatment, which suppress infant and child mortality rates (Caldwell, 1979; Farah and Preston, 1982). King and Hill (1993) indicate that education can even substitute for community health programmes by informing women about health care and personal hygiene, and it can complement such programmes by raising income and promoting greater recognition of the value o f these services. 28University of Ghana http://ugspace.ug.edu.gh 29 Balcher (1975), in an evaluative study of an anti-malaria programme for children in Danfa near Accra, indicate that although almost all mothers mentioned fever in children as a commonplace ill health, only 11.9 percent felt that it could lead to death. Agyei (1985) carried out a study at the Winneba Hospital to determine the effect o f some selected socio-economic variables on the health o f a population which utilizes the services o f the hospital. The study revealed that the educational background o f a mother had a significant impact on the health o f the child. It concluded by recommending the intensification of health education among others. A study in India has demonstrated that higher female education and wider availability and use o f medical services are two crucial factors associated with lower infant mortality in the state o f Kerala (Jain, 1985). In Malaysia, mothers’ education was found to have a marked effect on infant mortality rates, especially, in the sixth month o f life (Butz, et al. 1984).Caldwell (1979) hypothesized that in West Africa a mother’s education enabled her to exploit local public health care more effectively. Conclusion There were considerable differences in the type, design and methods o f the studies reviewed so far. However, the literature reviewed has shown interesting and far- reaching findings on local perception and knowledge about disease causation, symptoms identification and response to treatment and prevention practices. University of Ghana http://ugspace.ug.edu.gh Some studies revealed that while most people could easily identify symptoms of malaria, knowledge about the aetiology and transmission was generally low. Results concerning treatment-seeking pattern varies depending on the study areas and target groups. There seems to be agreement in other studies that health care facilities utilization was low while resort to home or self-treatment for malaria was high. Relationship between accurate knowledge o f aetiology and transmission of malaria and treatment seeking behaviour has not been adequately dealt with. A few studies recorded multiple treatment o f malaria. However, it is useful to examine this question in terms o f hierarchy o f resort since categories of self­ treatment, use o f health care facilities or herbal medicine are not mutually exclusive. This current study is an attempt at directing attention to some of the gaps and inadequacies noted in the literature reviewed. Conceptual Framework This study primarily aims at investigating mothers’ management o f childhood malaria and how it relates to their health seeking behaviour. The study is essentially based on the Health Belief Model (HBM), which is one o f the most widely used conceptual frameworks on health behaviour. The HBM was developed initially in the 1950s by a group o f social psychologists in the US Public Health Service to explain the widespread failure o f the people to participate in programmes to prevent and detect diseases (Hochbaun, 1958; Rosenstock, 1960, 1974). Since then the theory has evolved gradually in response to very practical concerns. It is now extended to explain people’s responses to 30University of Ghana http://ugspace.ug.edu.gh 31 symptoms and behaviour and particularly adherence to medical regimens. It further extends beyond screening behaviour to include preventive actions, illness behaviours and sick-role behaviour (Janz and Becker, 1984). Consequently, it has been used both to explain change and maintenance o f health related interventions. The HBM is a value-expectancy theory and is based on the assumption that mothers place value on the desire to prevent illness as well as control disease among their children. Mothers also believe that any specific health care action taken in the management o f childhood disease would prevent or ameliorate illness. Thus, external factors such as the socio-demographic characteristic o f a mother directly or indirectly influence her state o f readiness to take a specific health action when a child is ill (Refer to Figure 1). Other external factors that influence mothers on the choice o f health-care outlet include cues that trigger action in the form o f media publicity, health education and significant others. These factors can adequately inform mothers on the threats to a child’s health as well as barriers to the health seeking decision to the management o f childhood diseases. Specific health care actions by mothers in seeking health for their children in the form o f going to hospital or clinic, consulting a traditional healer, spiritualist, delay o f action or taking no action, depend on the perceived benefits they hope to derive from such an action. It is, therefore, believed that mothers will take action to prevent or to control ill-health conditions if they regard children to be susceptible to the condition, believe it would have potentially serious University of Ghana http://ugspace.ug.edu.gh consequences, and believe that a course o f action would be beneficial in reducing either the anticipated barriers to (or cost of) taking action are outweighed by its benefits. Like all explanatory models, the HBM also has its deficiencies. Essentially, it assumes that every health seeking behaviour adopted will always yield the intended result, that is, to get well. Consequently, it does not give an alternative health seeking behaviour outlet (Glanz, et al. 2002). In spite o f its shortcomings, the model is still relevant for this study. This is because it shows the interrelationships between the factors, which influence a mother’s decision to take specific health care action. The model also uses social and psychological variables to determine relationships between the construct and the behaviour o f mothers regarding health care intervention for their sick children. Hypotheses a. There is no relationship between level of education and the perception/knowledge of the cause(s) o f malaria; b. There is no relationship between distance o f mother/carer’s residence from a health care facility and seeking treatment from a health care facility c. There is no relationship between size o f mother’s income and seeking treatment for a sick child from a health care facility 32University of Ghana http://ugspace.ug.edu.gh FIGURE 1. : HEALTH BELIEF MODEL SHOWING THE INTERRELATIONSHIP AMONG FACTORS INFLUENCING MOTHERS MANAGEMENT OF CHILDHOOD MALARIA Individual perceptions Modifying factors Likelihood of Action Age, sex, ethnicity, socio­ economic background Perceived susceptibility to, severity o f malaria illness on the child . Perceived threat of malaria Cues to Action Mass media Health education Social pressures Perceived benefits minus Perceived barriers to behaviour change Likelihood Action Biomedical facilities Hospital Clinic Health post Pharmacist./chemist Drug store Home treatment - Self treatment Drug dealers - Herbal medicines - Traditional healer Spiritualist Source: G lam et al (2002) Health Bahaviour and Health Education Theory, Research and Practice l ' d Ed Jossey - Bass. San Francisco University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE MALARIA CONTROL IN GHANA: A POLICY OVERVIEW Introduction This Chapter discusses malaria policies and control strategies in Ghana over the years. Until recently, Ghana had no clear-cut malaria control policy even though many programmes on malaria control were pursued since the colonial era. The approach in this chapter is to briefly outline and discuss the major malaria control policies and programmes in Ghana from a historical perspective. Such an approach is necessary as it enables us to know and appreciate past and present efforts at malaria control to ensure successful planning and implementation of future interventions. Segregation Policy One o f the earliest official anti-malaria measures in Ghana was the introduction of a segregation policy. Separate quarters were provided for Europeans in order to protect them from contracting malaria and to safeguard their general health. This followed concern over the high death rate among the Europeans, which was principally attributed to malaria (Addae, 1996). Although the residential segregation policy showed positive results in terms of reducing death and invalidity for segregated Europeans within its few years o f implementation, it University of Ghana http://ugspace.ug.edu.gh 35 became a huge cost burden to the colony’s treasury (Government o f Gold Coast Report on the Medical and Sanitary Department [GCGRMSD], 1932-1933). Despite the scientific justification for such policy it was not fully complied with by some o f the Europeans whose activities brought them in close contact with the Africans. Such a policy was considered rather discriminatory and insensitive to the local black Africans. Sanitary Reforms Various sanitary reforms were carried out in the colony following the outbreak of the Bubonic plague in 1908 with the aim of ensuring good sanitation to reduce the high incidence o f diseases like malaria and yellow fever (Addae, 1996). A Sanitary Branch o f the Medical Department was established in 1910 to carry out such reforms. Generally, its functions included general sanitation; refuse disposal; the construction and proper maintenance o f drains, lagoon reclamation and mosquito control among others. In order to facilitate the implementation of measures aimed at malaria prevention, mosquito brigades were formed under the Sanitary Branch. Reports, however, indicate that initial attempts at promoting voluntary participation of both Europeans and Africans in the brigade activities failed due to general apathy from both groups. Following the setback in attracting voluntary membership of the mosquito brigades, professional mosquito brigades led by Sanitary Inspectors and Mosquito Headmen were established to seek, identify and completely destroy all breeding places for mosquitoes in townships and their immediate vicinity University of Ghana http://ugspace.ug.edu.gh (GCGRMSD, 1910). This group was givien legislative empowerment through the passing o f the Mosquito Ordinance in 1911 which required private dwellings in certain towns to submit to authorized entry and larval and general inspection by Sanitary Inspectors and their crew between 6.00 a.m. and 6.00 p.m. every day. The Mosquito Ordinance became very effective due to its vigorous prosecution of offenders although there were instances o f resistance. By 1960, the house-to- house inspection and prosecution o f sanitary offenders became less effective due to budgetary constraints and the lack of commitment by some inspection teams to vigorously carry out their duty without favouritism. Health Education Besides destroying mosquito breeding sites and prosecution of sanitary offenders, health education remains an important activity o f anti-malaria initiative. Thus, between 1910 and 1920, one major step at promoting health education was the introduction o f the teaching o f hygiene and sanitation in schools (Addae, 1996). The main issues then were the prevention o f malaria and yellow fever. In realizing this objective, every teacher and pupil was expected to understand the life cycle of the mosquito. This was achieved through the practical demonstration of the various stages o f the mosquito’s life cycle with large pictures exhibited on classroom walls. Sanitary Inspectors were also actively involved in disseminating health education to the adult population at home. According to Addae (1996), in keeping with this policy, Governor Guggisberg introduced Health weeks and Health Days to whip 36University of Ghana http://ugspace.ug.edu.gh up public awareness and active participation in sanitation issues. It must be stressed here that health education can help change the behaviour o f a people toward better sanitation only if the socio-cultural aspects o f their life is taking into consideration. Chemoprophylaxis Another approach o f malaria control was the distribution o f quinine as a chemoprophylaxis against malaria to school children following the high parasitaemia rate o f malaria infections. According to Patterson (1981), school children were given regular doses of quinine in chocolate candy. However, this experiment failed, as children were reluctant in taking the quinine due to its bitter taste in spite o f the fact that it was coated with chocolate candy. Quinine was also distributed to the general public and sold at post offices in the country from the mid-1950s until the outbreak o f the Second World War with the hope o f reaching out to all people, especially, those in the rural areas with no access to health services. Unlike the residential segregation policy, the chemoprophylaxis programme sought to embrace all groups o f people although it ended up reaching only a fraction o f the population. Drug non-compliance was also said to have characterized the programme. Again, the quinine programme was discontinued due to the lack of funds and abuse. 37University of Ghana http://ugspace.ug.edu.gh Control of Larvae and Adult Mosquito Knowledge o f the breeding habits o f Anopheles sambiae led to a variety of anti- larval measures in larger towns and administrative stations in Ghana. Holes, puddles, borrow pits, and ponds were filled, oiled or treated with arsenicals like Paris green; vegetation was trimmed; larvaceous fish were introduced into coastal lagoons; and elaborate drainage systems were constructed (Patterson, 1981). Unfortunately, such laudable larvae control measures had little success mainly due to unsustained funding of the programmes. Spraying to kill adult anophelines became practical following the introduction of Dichlor-Diphenyl-Trichlorethane (DDT) and other insecticides during the Second World War. Although DDT was considered a very effective chemical against mosquitoes it was not extensively used in Ghana during that period (Patterson, 1981). Global Attempt at Malaria Eradication A malaria eradication programme of the WHO was embarked upon in the country between 1957 and 1968 as part o f the global strategy adopted to control malaria. In this respect, a Malaria Control Unit was set up at Ho in the Volta Region in 1957 to oversee the malaria eradication programme. Activities include the conventional vector control using insecticides to interrupt the life cycle of mosquitoes in the Volta region. As part o f the eradication programme, mass chemoprophylaxis with pyrimethamine and chloroquine medicated salt were tried in the Upper Region in 1960 (Pinotti Project). Aerial spraying of mosquitoes was University of Ghana http://ugspace.ug.edu.gh started in Accra in i 964, but towards the end o f 1967 it was found to be unsustainable (Patterson 1981). The malaria eradication project was, however, abandoned in 1968 on the advice of the WHO due to lack o f funds and the development o f resistance to insecticides. Global Malaria Control Strategy Following the failure o f the malaria eradication programme in the late 1960s, the WHO came up with a Global Malaria Control Strategy in the early 1990s. Ghana adopted the strategy in 1992 with the setting up o f a National Advisory Board on Malaria and the development o f a Malaria Action Plan (1993-1997) by the Ministry o f Health (MOH, 2001). The main objective o f the Action Plan was to reduce malaria-related mortality amongst risk groups such as pregnant women and children under five years. Strategies adopted included Improved Case Management, Vector Control and Health Education. Inadequate laboratory support and finance were some o f the constraints faced in the implementation of the Action Plan. Health legislation and vector control were also not well addressed. Such setbacks could be traced to inadequate involvement o f other key stakeholders in the programme. Accelerated Malaria Control Programme An Accelerated Malaria Control Programme was instituted in 1997 by the WHO to strengthen the foundation for further development and implementation of 39University of Ghana http://ugspace.ug.edu.gh sustainable malaria control in the African Region in order to prevent mortality and morbidity due to malaria. Strategies adopted under this programme include Improved Case Management, vector control, and community-based malaria control, strengthening o f Health Information System, strengthening of programme management and sustainable monitoring and evaluation system. Some structural, management and technical bottlenecks also hampered the implementation o f the programme. Roll-Back Malaria The Roll-Back Malaria (RBM) initiatives was introduced by the WHO in 1998 with the general objective o f helping to, reduce, significantly the global malaria burden, especially, in the high transmission areas o f Africa. Following the launch of the RBM. an African Summit on Malaria was held in Abuja, Nigeria where heads o f state o f 53 countries in Africa met and adopted a plan to cut the number o f malaria deaths by 50 percent by the Year 2010. Specific objectives of the RBM by the year 2010 are that: * 80 percent o f caretakers will recognize early symptoms o f malaria in children <5 years old and respond appropriately. ■ Quality o f management of malaria/fever will be improved in 80 percent o f health facilities. ■ Increase number o f children under five years and pregnant women sleeping under treated bednet to 70 percent. 40University of Ghana http://ugspace.ug.edu.gh 41 * 80 percent o f pregnant women should be on appropriate chemoprophylaxis by 2010. A key purpose o f the RBM is to make malaria control a truly developmental issue and to increase participation o f key stakeholders in malaria control (Ghana Roll Back Malaria Strategic Plan, 2001-2010). Ghana has committed itself to the RBM initiative and had already developed a strategic framework to guide its implementation. A National Malaria Control Programme is now in place to facilitate the implementation of the RBM strategies. On the whole, Ghana’s RBM puts emphasis on strengthening health services and making effective prevention and treatment strategies more widely available through sensitization and consensus building among various stakeholders at all levels (MOH, 2000). Other strategies include focused/evidence-based research, pursuing and promoting multiple prevention and improving case management at all levels (from household to heath facility). These strategies, if well implemented, can actually result in rolling back the burden o f malaria within the given period. However, it appears that targets set are not likely to be achieved within the given period in view o f the financial and technical bottlenecks facing the health sector. So far, not much is being done in the area o f environmental management, which requires active inter-sectoral cooperation. It should also be remembered that malaria control measures cannot be separated from the socio­ economic realities o f life confronting the people. University of Ghana http://ugspace.ug.edu.gh Summary An assessment o f the major malaria control programmes in Ghana since the colonial era was highlighted in this chapter. A segregation policy introduced by the colonialist could not be sustained in view of the huge financial burden associated with its implemtation. Other strategies introduced by the colonial administration included sanitary reforms health education, chemoprophylaxis and the control o f larvae and adult mosquito. Global strategy for malaria eradication adopted since 1957 was also abandoned in 1968 on the advice o f the WHO due to lack of funds and the occurrence of resistance to insecticides. A Malaria Action Plan (1993-1997) was also developed for Ghana in accordance with the Global Malaria Control Strategy. However, its implementation was hampared by certain structural, management and technical setbacks. Ghana has since 1998 adopted the R B M initiative with the aim of reducing significantly the malaria burden in the country through increase participation of key stakeholders. 42University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR BACKGROUND OF THE STUDY AREA Introduction This Chapter presents a description o f the physical characteristics, demographic structure and socio-economic situation of the Manya Krobo District. Aspects of the social structure o f the Manya Krobo people including their historical origin, political organisation, traditional values and practices and social change are also discussed. It is important to present a background o f the study area in order to provide a deeper understanding o f the socio-economic and cultural life o f the people concerned in the study. This would make it possible to relate some o f the variables to the incidence o f malaria and treatment seeking behaviour as one’s social position determine one’s social consciousness. Physical Characteristics Manya Krobo is one o f the seventeen (17) districts in the Eastern Region of Ghana. It is located in the eastern part o f the region along the south-western comer o f the Volta River. It lies between the latitudes 6°05S and 6°30N and longitude 0°08E and 0°20w. The district shares common boundaries with the Afram Plains in the north-east, Fanteakwa District in the north-west, Yilo Krobo District in the west, Dangbe West District in the south-west, North Tongu District in the south-east and University of Ghana http://ugspace.ug.edu.gh Asuogyaman District in the east. The district covers an area o f 1479 square kilometers. The major towns in the district include Krobo-Odumase, which is the district capital, Kpong, Asesewa, Sekesua, Akuse, Agormanya, Akateng and Otrokper (Figure 2). The topography o f the district can generally be described as undulating. The highest peak in the district is a little over 660 meters above sea level. The north­ eastern and south-eastern parts o f the district are generally low lying with some isolated hills such as the Krobo Hill in the extreme south-eastern parts, which rises 350 meters above sea level. Prominent rivers in the district include the Volta, Ponpon, Krum, Dawado, Ayermesudo, Anyaboni, Fefedo and Aboaa. With the exception o f the Volta River, almost all these rivers are seasonal with most of them overflowing their banks during the rainy season. The district also lies within the semi-equatorial climatic belt with mean annual rainfall ranging between 900mm to 11500mm. Relative humidity is high during the wet season ranging between 70 and 80 percent and low in the dry season (55 to 60 percent). The district experiences two major seasons, namely the wet and dry seasons. The wet season occurs between April and October whereas the dry or warm season is experienced from November to March. Temperatures are generally high with average temperature ranging between 26°C and 32°C. The vegetation in the district is generally semi-deciduous and a dried savannah zone. Trees commonly found on such vegetation are palm, mango, ceibo, neem and acasia. Human activities on the vegetation have resulted in scattered patches o f secondary or broken forests. The predominant soils in the district can be 44University of Ghana http://ugspace.ug.edu.gh F IG . 2 A M A P OF M A N Y A K R O B O D I S T R I C T SHOWING T HE L O C A T IO N OF S A M P L I N G S I T E S Seseaman -r / X \/ M A N \Y A cq ; AsesewcM A buasa / Adwensu I Anyabon i j °KROBO ( Sekesua DISTRICT N Otrokper 0 ° 2 0 ' W 0 ° 0 0 ' S O U R C E : S U R V E Y D E P T . , A C C R A . I N S E T M A P OF G H A N A S H O W I N G T H E L O C A T I O N OF M A N Y A k R O B O D I S T R I C T W H E R E T H E S A M P L I N G S I T E S A R E L O C A T E D A C C R A 5° 0 0 - 0 10 20 KM L E G E N D S A MP L I N G S I T ES R e g i o n a l B o u n d a r y Di s t r i c t B o u n d a r y R o a d s University of Ghana http://ugspace.ug.edu.gh grouped into four, namely sandstone, buem, acidic gneiss and basic gneiss and pyroxenite. Soils in the district are generally good for the cultivation o f crops such as maize, cassava, rice, sugarcane and vegetables. The geology comprises rocks of Precambian age (Togo series). Large deposits o f limestone are found at Younquase, Popotia, Oborpa and Odugblage. Large clay deposits are also found at Amedika and Okwenya. The large deposit o f rocks around the district is a great potential for the mining industry (Manya Krobo District Assembly Annual Report, 2001 ). Historical Origin The Manya Krobos, like their neighbours in the Yilo Krobo District, are from a large ethnic group among the Dangbe people o f Ghana. Very little has been written about the traditional, social and religious life o f the Krobo as compared with that o f the Ashantis. One of the most authoritative and detailed accounts about the Krobo was written by Hugo Huber (1993). The Krobos were said to have migrated from Sameh, an island on the River Ogun in Northern Nigeria following Moslem invasions, slave raids and constant inter­ tribal wars. From Sameh, they moved on to Lalovor where they crossed over to Dahomey (Benin), then to Togoland and finally settled on the Krobo Mountain, which they found uninhabited, under the leadership o f Akro-Manse or Akro- Nadebi. According to Azu (1926), the first settlers and original Krobo are the three Dzebiam Clans namely Nam, Agbom and Yokunyonya who were shortly afterwards followed by the Manya-Lomodze group. Some Denkyera groups who 46University of Ghana http://ugspace.ug.edu.gh were refugees later joined the Krobo on the mountain after being dispersed following their defeat by the Ashantis around 1700. The first Konor, according to historical tradition was the late Odue. Odonko Azu occupied the stool around 1830 after other chiefs. His son Nene Sakite succeeded him after his death in September 1867. New farmlands were purchased from the Akwapim, Begoro and Jakiti people under the leadership o f Nene Sakite. In spite of the acquisition o f new farmlands where they now settled for farming activities, they still maintained the Krobo Hill as their ancestral home where they buried their dead, kept their shrines and their gods and where their daughters passed their initiation into womanhood (Hugo, 1993). Following rumours o f ritual cruelties and murders by the Krobo in connection with the worship o f their war gods "Nadu" and "Kotoklo", the British authorities imposed severe sanctions and punishment on anyone who would further promote or take part in human sacrifices or who would further organise "fetish" festivals on the mountain. Again, burial o f their dead on the hill and performance of Customary Puberty rituals for their daughters were henceforth forbidden. A further serious aspect o f the declaration was that within three days the people had to remove all their belongings from their mountain home. The people were, therefore, forced to move away from the mountain to settle in the plains, which subsequently developed into towns where new centers o f worship were built. Odumase became the permanent residence o f the Paramount Chief o f Manya and it is currently the capital of the Manya Krobo District Assembly. University of Ghana http://ugspace.ug.edu.gh Demographic Structure According to the 2000 Population and Housing Census, the total population of the Manya Krobo District stands at 154,301 with a 1.0 percent growth rate. The Census shows that females number 79,047 (50.7%) whiles male number 75,254 (49.3%). This situation is however, not much different from the national situation. The female dominance in the district may be attributed the rural-urban migration among young male adults. The average household size in the district is 7.5. The figure is higher than both the regional and national averages o f 4.6 and 5.1 respectively (Ghana Statistical Service 2002). The high average household size in the district suggests that the dependency ratio is quite high since there are more mouths to feed. Unless and until adequate measures are found to curtail the average family size in the district, the living standard may continue to decline if parents are unable to raise sufficient income to cater for the basic needs o f their family. The district has a youthful and active population. Children less than five years represent 13.8 percent o f the population while those within the age group 15-44 years constitute 51.5 percent (MKDHS, 2000 ). The people in the district consist of various ethnic groups with different religious inclinations. The Krobo are the dominant tribe constituting about 70% o f the district’s population. Other ethnic groups include the Ewe, Akan and Hausa among University of Ghana http://ugspace.ug.edu.gh others. Most o f the people profess Christianity while the rest are either Moslems or followers o f the African Traditional Religion. Socio-Economic Formation Traditionally, the people of Manya Krobo are basically agrarian. They are, however, engaged in other activities such as trading, craftwork, fishing and hunting. Animals such as cattle, sheep and goats are also reared while poultry are kept in many households for domestic consumption. In recent times the people o f the district are engaged in new economic activities although farming and trading activities still remain the two major occupations. These new activities, which came as a result o f technological advancement and rural electrification among others, include machine repairing, driving, hairdressing, tailoring and dressmaking and electrical works. Education There are quite a number o f schools in the district ranging from nursery to senior secondary schools (SSS) as shown in the Table below. 49University of Ghana http://ugspace.ug.edu.gh 50 Table (2): Schools and Enrolment in the Manya Krobo District (MKD) Level Number Enrolment Boys (%) Girls (%) Nursery 88 2,637 50.2 49.8 Primary 134 19,620 54.0 46.0 J.S.S(Junior Secondary School) 41 5,920 56.0 44.0 S.S.S. 5 1,457 65.0 35.0 Source: MKD Report, 2001. Table 2 shows the existing number o f schools and their enrolment in the Manya Krobo District as at 2001. It can be seen from the table that as pupils move from primary to SSS, the drop-out rate increases. There is a further drastic decline from J.S.S. to S.S.S., thus, contributing to a high school dropout rate. It can also be inferred from the table that at every level of the educational ladder, the enrolment of girls is less than that o f boys. This confirms the low attention given to girl child education among members of the society. As noted by Dolphyne (1991), in developing countries, including Ghana, the education o f females has always lagged behind that o f males. This trend may be explained by the reluctance of parents, especially, those in the rural areas to send their female children to school as well as the general lack o f access to schools in those areas. Many hold the view that traditionally the proper place for the woman is the husband’s house where her University of Ghana http://ugspace.ug.edu.gh main task is to perform house chores, which do not necessarily require formal education. Health, Water and Sanitation Modem health service delivery in the district is the primary responsibility o f the public sector health institutions with support from the private sector including non­ governmental organisations (NGOs) and religious organisations. The district has two Government hospitals and one Mission hospital all o f which are located in the lower and more developed part o f the district. There is only one health center and few MCH/FP centers in the northern part o f the district where the majority o f the people live. In addition to these health facilities, people in the district seek health care from traditional medical practitioners such as the herbalists, spiritualists and diviners and traditional birth attendants (TBAs). Other sources o f treatment include the pharmacy, chemical shops, drugstores and herbal centers. Apart from the infrastructural problems associated with modem health delivery in the district, indiscriminate selling o f drugs by unlicensed dealers and inappropriate self- medication are major handicaps. As mentioned earlier, malaria is the first o f the top ten diseases reported by all health institutions in the district. Diarrhoeas, STIs, TB and HIV/AIDS are some of the common diseases in the district. Currently, the district is ranked second after the New Juaben Municipality in terms of reported cases o f HIV/AIDS in the Eastern Region o f Ghana. Water is obtained mainly from pipe bome water, boreholes, hand dug wells and streams. However, pipe bome water is enjoyed mostly by the urban population, 51University of Ghana http://ugspace.ug.edu.gh especially, those in the lower parts o f the district. Communities in the middle belt and upper parts o f the district depend mainly on non-portable sources such as boreholes, wells with and streams. The problem with this non-potable water is that most people do not often boil the water before drinking. Thus, it poses a major hazard to the health o f the rural people. Environmental sanitation and waste management have also become major concerns in the district. Development Project The completions of the Akosombo and Kpong hydro-electric dams have no doubt had important economic and ecological effect in the district and in the nation at large. Apart from the industrial and domestic benefits derived from the electricity generated by the two hydro-electric dams, water from the Volta Lake is being used for irrigation purposes in parts o f the district and elsewhere. It is also significant to note that such water development projects always have the potential to alter local disease environments as they affect parasite and vector populations. Chinery has observed that the creation of dams, whether large or small, produces a multiplicity o f vector-borne and parasitic diseases, but bigger dams pose more serious problems because o f the significant changes they impose on the ecosystem (Chinery, 1990). He also noted that such important vectors o f malaria, filariasis and arbo viruses like Anopheles gambiae s. I. and Anopheles funestus s.I. breed profusely on the Volta Lake in association with the hydrophyte-dependent mansomia africana. Thus, the rice plantation projects in the environs o f Akuse and Kpong constitute fertile ground for mosquito breeding. 52University of Ghana http://ugspace.ug.edu.gh Political Organisation The Paramount Chief (Konor) together with his council exercise political and judicial authority over Manya Krobo. The Manya Krobo Traditional area is divided into six divisions each o f which is headed by a divisional chief. These divisional chiefs known as "Wetsomatsemei" are the military leaders as well as heads o f clans and sub-tribes. Under the divisional chiefs, there are sub-chiefs called "Asafoatsemei" and "Dadematsemei". Manya Krobo has a traditional central organisation as practiced among other ethnic groups in Ghana. This is because they have chiefs who exercise jurisdiction over a wide area with clear-cut boundaries within which operates well-developed administrative, legislative and judicial institutions for the governance of the territories. A series o f hierarchical levels o f authority exists in the traditional political system o f the Manya Krobo. This operates from the family units through the lineage to the final authority, the Paramount Chief (Konor). The important levels include the household, the compound, the lineage, village, town, the divisions and the paramouncy. The position of the Queenmother is an integral part o f the traditional political system. Among other roles, the Queenmother has great influence in the selection o f the Chief (Hugo, 1993). The political and judicial functions, which in the past were exclusively exercised by the Konor, the Council and the sub-chiefs, are subsequently taken over by the new form o f local government vested in the Manya Krobo Local Council (now the District Assembly). The concept o f local government allows people in the various communities and towns to elect representatives at the unit levels to form unit University of Ghana http://ugspace.ug.edu.gh committees and also to elect an assemblyman or woman to represent their interest at the District Assembly. Although the traditional leaders still play some roles and exercise some authority over their subjects, their power and authority have been reduced by the new political organisation. Traditional Values and Practices Traditional values are embedded within the network o f social relations that arise among people. Therefore, human behaviour is largely shaped by the groups to which they belong and by the social interaction that takes place within groups. For instance, kinship relationship permeates all aspect o f traditional social life including religious practices, economic organization and political institutions. Thus, kinship system prescribes status and roles to people who are in a particular relationship and therefore determines the rules, duties and obligations o f individuals and groups in all aspects o f life in which these individuals and groups interact (Nukunya, 1992). The Krobo society, like other Adangbe societies in general, is patrilineal and based on lineage organisation whereby members of smaller units trace descent through the male line from a common ancestor. This means a child belongs to, and enjoys first rights and owes first duties to paternal agnatic kin. Among the Manya Krobo, every individual belongs to one o f the three social groupings namely, “wetse’V’kasi” and “we”. The “wetso” which literally means “family tree” is the largest unit within the Krobo society. According to Hugo, the University of Ghana http://ugspace.ug.edu.gh Manya Krobo are divided into six main clans namely, Djebian, Manya, Akwonor, Dorm, Suisi and Piengua. Residence is almost invariably patrilocal or virilocal. That is to say, a couple will either live in the compound of the bridegroom’s father or in a house built by the bridegroom him self (Hugo, 1993). The basic domestic groups or households in a Krobo village are either monogamous or polygynous. Such groups in the villages may includes the husband, his wife or wives, unmarried children, and sometimes his unmarried brothers and sisters or one or two o f his married sons and their wives and children. In the towns, however, close patrilineal relatives generally share houses. Parent-child relationship among the Krobo is deeply felt and experienced within the nuclear family, that is, between the child and its legitimate parents. The father bears major responsibilities and duties towards his children though he may occupy a subordinate position in the structure of his own kin group. A strong bond of affection exists between the mother and the child especially during the early years when the child is biologically dependent on the mother. Marriage constitutes the very basis o f new ties o f relationship defined in terms of specific rights, duties and customary behavior and is protected by peculiar ritual sanctions. Among the Krobo, both endogamous and exogamous marriage is permitted. Marriage is largely considered as a bond between two kin groups rather than between two individual persons. The Krobo parent, like in other similar 55University of Ghana http://ugspace.ug.edu.gh traditional societies, used to have a greater influence in the choice o f partners for their children. The relationship between husband and wife is generally harmonious and cordial, provided each party performs his or her duties and acts within the confines of tradition and social norms. The husband is expected to provide the needs o f the wife and children especially during sickness. The wife is also expected to reciprocate with obedience and respect towards her husband. Decisions regarding their children are often discussed between the two even though the husband often has the final authority. The people o f Manya Krobo like other ethnic groups in Ghana are highly religious. This is manifested in their traditional beliefs and relationship with the Supreme God, small gods, magic, witchcraft, oracles as well as practices associated with the dead and ancestors. The main annual festival of the Krobo is the “ngmayemi” or yam festival. It is usually celebrated in the month of October. During the period o f the celebration they visit their ancestral home on the Krobo Mountain to pay homage and perform rituals. In recent times this festival attracts a number of people including foreign tourists. The “Dipo” ritual or initiation to womanhood is the most cherished initiation rite among the Krobo. An important feature o f the dipo ritual is the attainment of the girl’s physical and social maturity. The initiation, which used to take place on the Krobo Mountain and lasting one year or more, is now reduced to some few weeks. 56University of Ghana http://ugspace.ug.edu.gh Perhaps one o f its significance is the fact that it provides a unique opportunity each year to generally revive ancient tradition and also reaffirm kinship and other social relationships. The Krobo also believe in a variety o f causes o f illnesses and diseases affecting both children and adults. Such sicknesses or deaths are often attributed to natural factors and supernatural forces. In seeking treatment or cure for illness related to supernatural forces, they normally consult spiritualists or herbalist for help. It is significant to note that such traditional views about illnesses and local cures still exist in most communities especially in the rural areas. Social Change Over the past decades, Ghanaian societies have come under different influences from both internal and external factors resulting in rapid and significant alterations in the patterns o f culture, social structure and behaviour. Apart from the socio­ cultural effects o f pre-colonial social interaction and military confrontations among the various ethnic groups, changes in the size, composition and distribution o f the population as well as colonial experiences, Christianity, formal education, urbanization, the mass media, technological advancement and changes in the physical environment all affected the lives of Ghanaians, For instance, through the influence of formal education and Christian doctrines, many Ghanaians are shying away from traditional values and cultural norms. Indeed, formal education and science have brought about enlightenment and provided answers to critical issues, which hitherto were given simple and University of Ghana http://ugspace.ug.edu.gh superstitious explanations. The aetiology and treatment o f diseases is now based on scientific perceptions to a large extent. Thus, the people’s mindset is gradually drifting away from superstitious beliefs to scientific knowledge. For instance, a number o f Krobos, especially the educated ones have, in recent times, attached less importance to the performance o f the dipo rituals and similar customary practices. They consider such practices to be outmoded and therefore irrelevant. However, in spite o f the changes taking place some traditional and cultural values are still respected. 58University of Ghana http://ugspace.ug.edu.gh 59 CHAPTER FIVE RESEARCH METHOD In this chapter, the researcher describes the target population, sample size, sampling technique/method and method of data collection. The research study is both descriptive and cross-sectional. It is based on a systematic collection and presentation of data as well as observation at a single point in time with the aim o f describing relationships between variables. Data for this study were obtained from two main sources, primary and secondary. The primary data were obtained through the structured interview schedule, focus group discussions, key informant interview and participant observation. The use o f primary sources o f data made it possible to obtain the exact information required. It also ensured the integrity and reliability o f the study. Secondary data were also drawn from existing literature such as books, journals, published and unpublished research works and other historical sources such as reports and archive documents. Study Population The target population consists of mothers/carers o f children under five years in the Manya Krobo District o f the Eastern Region o f Ghana. It is obvious that mothers by their nature and traditional roles are the predominant carers o f children. 6 * - • University of Ghana http://ugspace.ug.edu.gh However, the inclusion o f other carers stems from the fact that children are also cared for by other members o f the family. Sample Size A sample size o f 384 was initially arrived at. This figure was based on calculations with an estimate o f 50 percent o f respondents from the target population expected to seek treatment for children with malaria from a health care facility using a design effect o f 1.0 with a confidence interval o f 95 percent (Refer to Appendix C). However, due to time and financial constraints the researcher used a sample size o f 230, which is considered sufficient for the analysis of variable(s) (See Appendix C). Sampling Technique/Method Sampling is fundamental to the conduct of research and interpretation o f its results (Osuala, 1993). In this respect, the study employed different sampling techniques and method for each data collection instruments. A multi-stage Cluster Sampling technique was used to draw sample for the quantitative data. The employment o f this method was based on the envisaged difficulties o f compiling an exhaustive list o f elements comprising the target population. In spite of the risk of disproportionate selection o f samples and the element o f sampling errors, cluster sampling is highly recommended for its efficiency (Babbie, 1992). University of Ghana http://ugspace.ug.edu.gh At the initial stage o f sampling, four (4) out o f the six (6) Sub-Districts of the MOH in the District were sampled using a simple random sampling approach. The sampled Sub-Districts were Odumase, Kpong/Akuse, Sekesua and Otrokpe. At the second stage, a list o f Electoral Areas (EAs) in each of the sampled areas was obtained from the Office o f the Manya Krobo District Electoral Commission. A proportionate number o f EAs within each o f the selected Sub-Districts were sampled by means o f a simple random sample method. After that, all houses within the sampled EAs were numbered and the total number o f houses o f each EA obtained. A Systematic Sampling approach with interval based on the number o f houses and the number o f interviewees required for each sampled EA was employed to select a respondent from selected houses. Where there were more than one qualified respondent in a house, balloting was used to select one of them. In the case o f the Focused Group Discussion (FGD), three different groups in three communities within the study area (namely Sekesua, Otrokpe and Atua) were selected for the discussions. Each o f the selected groups consisted o f seven (7) mothers/carers selected on the basis o f age. Thus Group A consisted of mothers/carers between the ages of 15 to 29 years; Group B 30 to 44 years and Group C 45 to 60. This approach not only ensured that members of the group freely expressed their views but also brought out different perspectives on the issues from the various age groups during the discussion. FGD is a qualitative technique adopted to explore more on the range o f knowledge, beliefs and practices among the group about the topic. It also acts as a validity check on responses from the survey. University of Ghana http://ugspace.ug.edu.gh Method of Data Collection The selection o f a particular method o f data collection must be decided upon in the light o f the problem under consideration. Such decision must also be informed by the type o f people, the nature of the situation and the mood of the social environment and the psychology o f the people (Twumasi, 2001). A combination of both quantitative and qualitative methods o f data collection was, therefore, employed by the researcher in this study to obtain different perspectives of information on the subject matter. This also helped in the evaluation of data sources and the detection o f inconsistent answers. A structured interview schedule was the main instrument used for the quantitative method o f data collection. The schedule consists o f both close-ended and open- ended questions. The questions were based on the objectives of the research and focused on topics such as the socio-demographic characteristics of mothers or carers, perception and knowledge about the cause(s) and transmission of malaria, malaria prevention, local management of malaria and treatment seeking behaviour, choice o f health care outlet and sources of information about malaria (See Appendix A). Although the structured interview schedule was written in English, the researcher with his two assistants communicated with respondents in the language they understand better. The employment o f the interview schedule ensured high response rate and completeness in the interview due to the physical presence o f the interviewer. It was also considered appropriate in view o f the high illiteracy among the respondents. However, some o f its shortcomings were that it was costly and time-consuming. Again, the way structured questions are asked subtly biases the responses given. University of Ghana http://ugspace.ug.edu.gh In-depth and informal interviews were also held with key informants such as medical officers, nurses, other health workers, chemical sellers, traditional medical practitioners, chiefs, assembly members and other opinion leaders to obtain information on their views, perceptions and experiences about childhood malaria and its management in their various communities. The researcher also observed participants while gathering data in the study areas. Informal visits were made to the hospitals and traditional healing centers to interact with patients especially carers who brought their children for treatment. As mentioned earlier, focused group discussions were used to explore further on the topic so as to check for validity or contradiction in responses gathered from the survey. Three focused group discussions were held with groups o f 7-8 mothers or carers o f children under 5 years selected o f different age groups in three communities within the study area. An interview guide was prepared as an outline to direct the discussions (see Appendix B). The researcher served as the facilitator in all the three discussions while one o f the field assistants acted as a recorder of proceedings. Discussions were essentially carried out in Krobo. Each discussion lasted a maximum o f one hour at a secured place to avoid unnecessary interference. The main investigator at the end o f each discussion then transcribed the recordings. Pretesting In order to ensure that questions in the interview schedule and the discussion guide were meaningful and easily understood by respondents, a pretesting o f the tools 63University of Ghana http://ugspace.ug.edu.gh was conducted at Somanya. This town comprises people with similar socio­ cultural background as those in the study area. This enabled the researcher to reword, rephrase, change the sequence o f questions and in some cases removed completely irrelevant questions. Training of Field Assistants The investigator recognized the need to employ field assistants in view o f time constraints and scope o f the fieldwork. In this respect, two field assistants, a national service personnel and a health worker at the District Assembly were recruited. They underwent two-day training on how to conduct a successful interview. They were also briefed on the objectives and nature of the research. The interview guide was discussed in detail together with possible answers. Since the interview was largely conducted in the local dialect, an agreed translation of the various questions, concepts and common terminology in the local language was arrived at to ensure uniformity. A practical session was, also organized before the actual fieldwork to ascertain the competence level o f the assistants. Ethical Consideration The need for ethical consideration is paramount in the conduct of social research. In conducting this study, permission was sought first from the political and health authorities in the district. Chiefs, assembly members and other opinion leaders in the communities were also visited. They were all briefed on the nature of the studv and its objectives. Before an interview or discussion, the consent o f University of Ghana http://ugspace.ug.edu.gh respondents and groups was sought by assuring them o f confidentiality and anonymity. Also, questions that may cause embarrassment, guilt or discomfort to the respondents were avoided as much as possible and where necessary the respondents were accordingly informed at the onset o f the interview. This notwithstanding, the researcher encountered some ethical problems. Respondents sometimes felt uncomfortable when asked to reveal certain personal characteristics and behaviour such as income level, marital status and why certain actions were taken during episode o f childhood malaria. Fieldwork Procedure The main fieldwork exercise began from 18th June and ended on 15th July 2003. The rainy season was chosen for the fieldwork in order to obtain high response on the phenomenon as available information indicated that reported malaria cases in the district are highest during such period. The researcher was, however, mindful o f the fact participants engaged in farming and may not be available during most part o f the day. After initial introductory formality with the administrative authorities and local opinion leaders, the researcher sought accommodation at Odumase in the family house o f a former schoolmate for the duration o f the fieldwork. This served as a base for visiting other communities. The researcher, with the two field assistants visited selected EAs and carried out a house numbering exercise. Subsequently, the research team undertook an interview o f sampled respondents from selected 65University of Ghana http://ugspace.ug.edu.gh houses. The FGDs were conducted after gathering the quantitative data. Interviewing o f key informants and participant observations were done along side. Data Processing and Analyses Procedure Data processing and analyses constitute very important stages in a research exercise. Hence data collected using the structured interview schedule was field- edited to check for completeness and also as a quality control measure. This exercise ensued a quick follow up field checks where necessary. The data were also post-edited to check for consistency o f response. All coded interview schedule were electronically inputted into a computer software programme for analysis by a computer expert. The software used was the Statistical Package for Social Sciences (SPSS). Both quantitative and qualitative data were analysed. In the univariate (descriptive) analyses, data were represented in the form o f frequency tables and mean (averages). At the bivariate analysis, cross tabulation, chi-square and Pearson Correlation were used to identify the relationship between variables. Field Experiences The absence o f some respondents during the day led to the postponement of the interviews to the evenings as most o f them were engaged in farming and trading activities during the day. Working in the field during the rainy season was quite challenging as rain usually disturbed the daily routine work schedule and normal social interaction. University of Ghana http://ugspace.ug.edu.gh Another interesting field experience was that most respondents were initially reluctant to participate in the interview as they felt that this research like earlier ones would not bring any change in their socio-economic situation. However, the researcher managed to persuade them to cooperate as the findings o f the study would be forwarded to the appropriate authorities and stakeholders for prompt action to improve their children’s health condition and theirs in general as well. It was also difficult conducting exclusive interviews with one person as other relatives often intruded in the process. Under such circumstances the responses may be biased by those intrusions. The researcher, however, tried as much as possible to politely request for privacy to secure unbiased responses. Study Limitation The following factors may place some limitation on the conclusions o f the study and their general application to other situations. Although the selection o f respondents was based on the probability sampling technique, a proportionate representation o f respondents from rural and urban locations in selected areas could not be attained. Also, the combination of both qualitative and quantitative methods of investigations is based on assumption that it will reflect different perspectives on the subject being studied rather than attempting to capture the absolute truth. The methods and instruments used cannot guarantee the respondents truthfulness in answering the questions. University of Ghana http://ugspace.ug.edu.gh Recall o f treatment sought during episode of malaria in children posed some difficulties due to the one month lapse. 68University of Ghana http://ugspace.ug.edu.gh 69 CHAPTER SIX DATA ANALYSIS AND INTERPRETATION Introduction This chapter deals with the analysis o f data. As mentioned earlier, the study sought to identify how mothers/carers perceived childhood malaria and their social and cultural responses in terms o f treatment seeking behaviour. The chapter has, therefore, been arranged under four main sections relating to the specific objectives o f the study. They include the following: (a) socio-demographic characteristics o f respondents; (b) perceptions/knowledge about the causes, signs and symptoms of malaria; (c) treatment seeking behaviour; and (d) preventive measures. Respondent Category The majority o f the respondents in the survey were biological mothers of children under five years. They constitute about 70 percent of the respondents’ category. Another category o f carers interviewed included the following: father, grandmother or grandfather, aunt, uncle, stepmother and sister. However, the initial categorisation o f respondents was only meant to provide information about the types o f respondents. In subsequent analysis of data, respondents, “mothers” or “carers” will be used interchangeably. University of Ghana http://ugspace.ug.edu.gh 70 Socio-demographic Characteristics of Respondents This section seeks to present a description o f the socio-demographic characteristics o f respondents relevant to the objectives of the study. The variables considered as shown in table (3) below include: age, religion, education; occupation; marriage; and income. In a sociological analysis, one needs to know the background of the people to make a meaningful analysis of their responses on the management o f childhood malaria. Table 3 presents the socio-demographic characteristics of respondents. Table 3:______Socio-Demographic Characteristics of Respondents (N = 230) BACKGROUND CHARACTERISTICS FREQUENCY PERCENTAGE Age Group Below 20 years 18 7.9 20-24 33 14.3 25-29 28 12.2 30-34 35 15.2 35-39 55 23.9 40-44 28 12.2 45-49 19 8.3 50 and above 14 6.0 Total 230 100 Religious Affiliation Christian 200 87 Moslem 24 10.4 Traditional Religion 2 0.9 No religion 4 1.7 Total 230 100 Educational Attainment No education 46 20 Non-formal education 9 3.9 Primary (Complete) 16 7.0 Primary (Incomplete) 38 16.5 JSS/Middle (Complete) 56 24.3 JSS/Middle (Incomplete) 12 5.2 SSS/Secondary (Complete) 30 13 Tertiary (complete) 23 10 University of Ghana http://ugspace.ug.edu.gh 71 Total 230 100 Principal Occupation Trading 99 43 Public/Private Service 41 17.8 Dressmaking/Tailoring/Hairdressing 37 16.1 Farming 26 11.3 No occupation 14 6.1 Mechanic (Fitting) 8 3.5 Apprenticeship 5 2.2 Total 230 100 Marital Status Married 164 71.3 Single 37 16.1 Divorced 4 1.7 Separated 11 4.8 Widowed 14 6.1 Total 230 100 Monthly Income No Income 21 9.1 Less than 0100,000 60 26.1 0100,000-0200,000 50 21.7 0200,000-0300,000 40 17.4 0300,000-0400,000 14 6.1 0400,000-0500,000 10 4.3 0500,000 and above 35 15.2 Total 230 100 % Age of Respondents Age is a very important variable as it allows us to identify the target population and the likely behaviour o f a particular age group. The data in Table 3 show, that age o f respondents ranged between 17 and 58 years with a mean age of 34 years. The majority o f respondents, 169 (73.5 %) were less than 40 years; 18 (8 %) were below 20 years while only 14 (6 %) were beyond 50 years. The age distribution and mean age of 34 years suggest that the majority of respondents are in their early adulthood and hold great autonomy and responsibility in terms o f decision making. It is also interesting to note that in University of Ghana http://ugspace.ug.edu.gh view o f the changing traditional norms and expectations, age is gradually losing many o f its customary meanings. As a result, we may be witnessing what sociologist Neugarten (1979) called an “age irrelevant society” in which there is no single appropriate age for taking on given roles. Religious Affiliation It is important to note that religion occupies a central position in the lives o f a people, especially those in traditional societies. Frazer considers religion as beliefs and act which aim at “the propitiation or conciliation o f powers superior to man which are believed to direct and control the course of nature and human life” (Frazer 1890: 222). However, Nukunya gave a simple definition of religion as “beliefs and practices associated with the supernatural” (Nukunya 1992:53). Such beliefs and practices associated with the supernatural are important aspects of the Ghanaian traditional religion long after the advent o f Christianity and Islam in the country. Table 3 shows that the majority, 200 (87 %) o f the respondents were Christians; Muslims constituted, 24 (10.4 %) while the followers of traditional religion were only, 2 (1 %). Those with no particular religion represented 1.7 %. Clearly, it can be concluded that the dominant religion is Christianity. Such dominance o f Christianity, which started in the 19th Century, has led to the alienation o f Christians from their traditional beliefs and practices. Nukunya (1992), noted that any major change in the religious attitude and beliefs of any group o f people is bound to have repercussions elsewhere. The Christian doctrine did not only oppose traditional religious practices but also anything traditional is 72University of Ghana http://ugspace.ug.edu.gh considered as pagan. This obviously has far reaching implications for the practice and use o f traditional medicine, which naturally relies on traditional methods of healings. Education Many studies have established some relationship between education and other variables. Education can have strong influences on behaviour, knowledge and attitude. Thus, it is considered an important variable in this study. From table 3, 55 (24 %) o f the respondents have had no formal education out o f which only 9 (4 %) have attended non-formal literacy classes. For those who have had formal education, 16 (7 %) completed the primary level while 38 (16 %) dropped out at that level. However, there was a decline in the drop out rate at the JSS/Middle School Level with a high completion rate of 24 %. Only 30(13 %) and 23 (10 %) had completed SSS/Secondary and Tertiary levels, respectively. It is noteworthy that the school drop out rate was high especially at the primary level. The implication o f the high illiteracy level among the people in the area is that it can have a negative impact on their socio-economic status in terms o f their worldview, income and general well being. In contrast, the attainment of literacy through formal education has the potential o f improving the socio-economic status of a person. As noted by Nukunya (1992), one o f the main effects o f formal education on the individual is its impact on the in general. The acquisition o f literacy and knowledge gained from the school environment widens one’s entire world view. It is, therefore, believed that a relationship exists between the literacy level of 73University of Ghana http://ugspace.ug.edu.gh mothers/carers and their perceptions about the causes o f malaria as well as treatment seeking behaviour as would be discussed further in the analysis. Principal Occupation The type, o f occupation one is engaged in is an important determinant of one’s socio-economic status. As shown in table 3, 99 (43 %) of respondents are engaged in trading as their principal occupation. 41 (18 %) are in either the public or private sectors and in jobs such as teaching, nursing, security services and clerical duties. Thirty-seven (16 %) are in vocational occupations such as dressmaking, tailoring and hairdressing and only 26 (11 %) engaged in fanning. Fourteen (6 %) have no occupation while 5 (2 %) are engaged in apprenticeship. The gradual shift from farming as a major occupation to commercial, vocational and clerical activities is a manifestation of the changing employment status of women in the Ghanaian society. This emerging trend has profound implications and far-reaching consequences for the authority structure within the family. Under such circumstances individuals, and for that matter women could earn their living quite independently o f their lineage and kin groups. This situation has the potential o f weakening the traditional control husbands and in-laws have over wives. Thus, the entry o f women into the labour force has implications for child care from care. Marital Status Marital status o f respondents is another key variable in this study. Marriage confers a higher social status on a person in view o f the roles and responsibilities associated with it. According to Nukunya (1992), marriage creates new social 74University of Ghana http://ugspace.ug.edu.gh relationships and reciprocal rights between spouses, between each spouse and the kin o f the other, and establishes what will be the right and status of the children when they are born. From table 3, majority, 164 (71 %) o f respondents are married; 37 (16 %) are single parents. Fifteen (7 %) are either divorced or separated while only 15 (6 %) are widowed. It is significant to note that though women in marital relationship may receive support from their spouses in contrast to the others, their subordinate positions in relation to the opposite sex in a traditional set up is similar. Nukunya (op cit), also noted that in many Ghanaian societies, the traditional position is that women are not wholly independent. It is generally accepted that a woman must always be under the guardianship o f a man, and even after she marries, her original guardian hands over some or all o f his responsibility for her to her husband. Such a situation will obviously have implication for decisions on child health issues. Income Level The amount o f money people earn is another important factor in determining one’s socio-economic status. A person’s wealth, measured in terms o f income, puts him in a position to acquire good and services. From table 3, 150 (65 %) o f respondents earn less than 0300,000 monthly; only 35 (15 %) earn 0500,000 or more. It is instructive to note that the current minimum daily wage in Ghana is about 010,000 (US$1). Thus, given the present cost of living, the average income will not be enough to provide nutritionally adequate diet for a family assuming all of it is used for food. Such general low income situation has implication on maintenance of good health for the family in terms of University of Ghana http://ugspace.ug.edu.gh intake o f balance diet and ability to seek immediate and appropriate health care should a family member falls sick. It is also worth mentioning that the estimation o f the monthly income cannot be wholly relied upon. This is due to difficulties o f getting accurate response on earnings from respondents partly due to the nature o f their jobs and the deliberate underestimation o f earnings. The validity o f income estimates, therefore, depends on the degree o f accuracy o f income reporting. Conclusion The socio-demographic characteristics of the respondents give the impression that the respondent population is fairly literate and young. Income levels are generally low. The majority o f the people are engaged, in petty trading and few in farming activities. Christianity is the principal religion. Relationship between respondents’ characteristics and treatment seeking behaviour will be examined in subsequent analysis. University of Ghana http://ugspace.ug.edu.gh 77 Morbidity Patterns in the Communities Before enquiring about what they perceived to be the cause(s) of malaria, respondents were first asked to identify or mention common diseases affecting children in their communities. The target group identified malaria/fever locally termed “assla” as the commonest illness affecting children in the communities. Table 4 shows responses about the common childhood illnesses in Manya Krobo. University of Ghana http://ugspace.ug.edu.gh 78 (N = 230) Table 4: Common Childhood Illnesses in Manya Krobo Type of Disease Frequency of Responses Percentage of Responses Malaria/Fever (Assla) 217 94.3 Diarrhoea (Plemi) 152 66.1 Measles (Gbidimi) 133 57.8 Coughing 91 35.2 Boil 64 26.1 Skin Rashes 56 24.3 Stomach Ache 51 22.2 Convulsion (Hiowe) 35 15.2 Asthma 16 5.2 Malnutrition (Kwashiorkor) 11 4.8 Headache 11 4.8 Worms 10 4.3 Constipation 8 3.5 HIV/AIDS 6 2.6 Polio 6 2.6 Typhoid Fever 6 2.6 Warm body (Hedola) 5 2.2 Cholera 4 1.7 Eye infection 4 1.7 Epilepsy 2 0.9 T O T A L 890 378.3 % Multiple Responses University of Ghana http://ugspace.ug.edu.gh As shown in Table 4, 217 of the total 230 respondents representing 94.3 percent of respondents mentioned malaria/fever or “assla” as the most common disease affecting children in their communities. Sixty-six percent mentioned diarrhoea whilst 57.8 % mentioned measles. Other important childhood diseases mentioned include coughing, boil, skin rashes, stomachache, convulsion and HIV/AIDS. The morbidity pattern outlined in Table 2 is typical o f the epidemiology o f childhood diseases at the district and national level (MOH, 2001). Also, information from FGDs and interviews with key informants on prevailing childhood diseases in the area corroborated the findings in the survey. The findings show that the district has a high disease burden for children. Even though the diseases mentioned by respondents may not necessarily be the same in standard medical practice, mothers/carers could be trusted to know the nature and type o f childhood illnesses affecting children. Perceived Causes of Malaria It is believed that perception about the cause o f a disease can influence therapeutic action. Different views and beliefs about the cause(s) and transmission of malaria are held in various societies with direct bearing on treatment-seeking behaviour and prevention o f malaria. Thus, understanding people’s perceptions of malaria and the factors that influence such views are very essential for any malaria intervention and control. Studies by Ahorlu et al. (1997) and Bradley et al. (1991) also support this view. University of Ghana http://ugspace.ug.edu.gh The concept o f causality has been found to influence disease behaviour and consequently therapeutic choices (Fosu, 1977). Under normal situations, it is expected that diseases believed to be caused by natural forces are likely to be remedied through natural means and those believed to have been caused by supernatural forces are also likely to be dealt with by forces o f the same nature. It is significant to note here that indigenous categorization o f illnesses are recognized in terms o f both symptoms and causes which serve as a flexible idiom for evaluating and responding to illness (Hushie, 1994). However, Heggenhougen and Draper (1990) are o f the view that in most medical systems, it is not so much the underlying pathology but the underlying cause. Hence, in this study, the idea o f “cause” is an important aspect in the evaluation and assessment of treatment seeking behaviour in relation to childhood malaria. It is worth noting that earlier anthropological studies on disease causation in Africa presented a narrow perspective o f the Africans nosological notions about disease causation. For instance, Field (1960) and Evans-Pritchard (1937) discovered causality as the basis o f disease classification but failed to recognize the natural/supernatural dichotomy. These earlier anthropologists thought that Africans or preliterate people classify diseases only in supernatural terms. In the case o f Evans-Pritchard, he observed that “The Azande attribute sickness whatever its nature to witchcraft and sorcery” (Evans-Pritchard, 1937: 479). Field, in her writing also stated that “According to the African dogma, sickness and health are ultimately o f supernatural origin” (Field, 1960: 112). Present day anthropologists have, however, identified three main categories of etiological perceptions namely University of Ghana http://ugspace.ug.edu.gh natural, supernatural and natural-supernatural representations o f cause (Twumasi, 1972; Nukunya and Twumasi, 1976; Fosu, 1977, Foster, 1978; Senah, 1993). Illnesses that are thought to emanate from physical conditions such as cold, eating oily food, heat from the sun, etc., are attributed to natural forces. Diseases or illnesses believed to be caused by some human or non-human factors are attributed to supernatural forces. Illnesses go through a diagnostic process in the third category o f a natural-supernatural cycle; the cause is initially attributed to natural forces and at a later stage to supernatural forces. It is therefore essential to relate perceived aetiology to therapy seeking behaviour to enhance a deeper insight and broader assessment o f the situation. In this study, respondents were asked about the perceived cause(s) of malaria. Table 5 presents responses on the perceived cause(s) o f childhood malaria. University of Ghana http://ugspace.ug.edu.gh 82 Table 5: Perceived Cause(s) of Malaria in Children Perceived Cause(s) of Malaria Frequency of Responses Percentage of Responses Mosquito bites 128 55.7 Walking/playing in the sun 82 35.7 Poor diet 57 24.8 Over eating 26 11.3 Exposure to cold weather conditions 25 10.9 Playing in filthy environments 18 7.8 Diarrhoea/Worms 11 4.8 Hereditary 6 2.6 Loss o f Blood 5 2.2 Drinking Dirty Water 4 1.7 Transferred through Breastfeeding 3 1.5 Housefly 2 0.9 No idea 4 1.7 TOTAL 371* 161.6 Multiple responses As shown in Table 5 malaria (assla) is perceived to come about mainly through a number o f natural causes. It was observed from the data that, 55.7 percent o f the respondents attributed malaria to mosquito bite while 35.7 percent associate it to walking and playing in the sun. Other causal responses included poor diet (24.8 percent), over eating (11.3 percent), exposure to cold weather (10.9 percent), University of Ghana http://ugspace.ug.edu.gh playing in filthy environment (7.8 percent), diarrhoea/worms (4.8 percent) and others such as hereditary, loss of blood, intake o f diity water transmitted through breastfeeding and houseflies. It is significant to note that about 56 percent o f the total respondents identified mosquito bites with other natural factors as the cause(s) o f malaria. However, only a few attributed malaria solely to mosquito bites. It is. thus, possible and indeed common for people to accept biomedical explanations for disease causation and hold this view concurrently with other understanding o f the disease. Information gathered from FGDs on perceived aetiology o f malaria was similar to those from the survey. The tendency to provide causal explanations for malaria by associating it with natural forces is a common issue in malaria studies. Thus, earlier studies conducted in Ghana by Agyepong (1992); Aikins et al. (1994) and Owusu-Agyei et al. (1999) confirm the result o f this study. The result, therefore, has enormous implication for treatment seeking behaviour as well as malaria prevention and control programmes. For example, lack o f scientific knowledge about the cause o f malaria can result in wrong approach to its treatment and prevention. Thus, it is possible that health education programmes on malaria has not gone down well with the people. Convulsion Although the focus o f this study was not on childhood convulsion, the investigator was interested in finding out how mothers/carers perceived convulsion locally referred to as “hiowe”. This is because there is a medical link between severe or cerebral malaria and convulsion in children. Cerebral malaria in children often 83University of Ghana http://ugspace.ug.edu.gh leads to convulsion which is a fatal condition requiring prompt treatment. The attributed cause often determines treatment sought. According to Winch et al. 1996:1058 “cerebral malaria is commonly classified as a distinct condition attributable to supernatural forces” . Table 6 shows the perceived cause(s) o f convulsion. 84 Table 6: Perceived Cause(s) of Convulsion Perceived Cause(s) Frequency of Responses Percentage of Responses No idea 50 21.7 Stomach Ache 36 15.7 Severe Malaria 44 19.1 Very high body temperature 75 32.6 Nasal Congestion 6 2.6 Taking too much sugar 11 4.8 Flying bird 22 9.5 Evil spirit/witchcraft 23 10.0 Bad Air 18 7.8 Thunder and Lighting 8 3.5 TOTAL 293* 127.3 Multiple responses As shown in Table 6 about 31 percent o f respondents relate convulsion with supernatural forces such as “flying bird”, evil spirit/witchcraft, “bad air”, thunder and lightening. Only 19 percent attribute it to severe malaria/fever while 32.6 percent link it to very high body temperature. From the aetiological explanation and responses given for malaria/fever in this study, it was observed that “assla” is University of Ghana http://ugspace.ug.edu.gh 85 perceived in highly naturalistic terms in the Manya Krobo District. In the case of cerebral malaria or convulsion, however, it is perceived in the natural-supernatural category. One implication is that respondents may not seek prompt treatment at biomedical facility when their children develop convulsion and will more likely seek spiritual help first. Education and Perceived Cause(s) of Malaria As discussed earlier, it is believed that one’s level o f education can influence ones knowledge and perceptions about the disease and how the individual manages it. In this vein, the interrelationship between educational level and perception about the cause o f malaria was analysed to examine the effects o f the relationship. Table 7 below shows relationship between level o f education and perception about the cause o f malaria. It show that 78 percent o f those who completed JSS and at least have “correct” knowledge about the cause of malaria compared to 32.7 percent of those with no formal education. “Correct” perception/knowledge of the cause of malaria in this context refers to when a respondent shows that malaria is caused by mosquito bites only while, “incorrect” perception/knowledge refers to views held that malaria is caused by other natural factors such as eating oily food and exposure to the heat o f the sun. University of Ghana http://ugspace.ug.edu.gh Table 7: Education and Perception about the Cause of Malaria Cause of Malaria Level of Education No formal Education Below JSS JSS and above Correct 32.7 36.4 78 Incorrect 67.3 63.6 22 Total (N=55) 100 (N=66) 100 (N=109) 100 The value o f the correlation coefficient (r) (-0.618) indicates a moderate negative correlation between level o f education and perception about the cause of malaria. This implies that an increase in the level of education will invariably lead to a decrease in the “incorrect” perception about causes of malaria. The Coefficient of Determination (r2), which shows the extent o f the correlation between the two variables, is 0.381 or 0.38. This means only 38 percent o f the variation between the two variables can be explained from the data. Thus, 62 percent o f the variation may be due to other factors. It may, therefore, be concluded on the basis o f the “r” alone that there is a significant relationship between carer s level of education and perception about the cause of malaria. One o f the hypotheses for this study is that there is no relationship between level of education and perception/knowledge about the cause of malaria. In testing this hypothesis, the Chi-Square statistic (x2) was applied. The value of the computed x2 was 43.48. From the Table x2 critical at 95 percent confidence level and 2 degree o f freedom was 0.103. Comparing x2 computed with x_ critical, we reject the null hypothesis that there is no relationship between level o f education and perception/knowledge about the cause of malaria because x2 computed is greater University of Ghana http://ugspace.ug.edu.gh than x2 critical. We, therefore, accept the alternative hypothesis that a relationship exists between level o f carer’s education and perception/knowledge about the cause o f malaria. Age and Perceived Cause(s) of Malaria Age is another socio-demographic variable found to have some relationship with perception/knowledge about the cause o f malaria in children. Table 10 below shows relationship between Age and perceived cause(s) of malaria. 87 Table 8: Age Group and Perceived Cause(s) of Malaria Perceived Cause(s) of Malaria Age Group Below 34 years 34 years and above Correct 48 % 62% Incorrect 52 % 38 % Total (N=114) 100 (N=116) 100 In Table 8, the age o f respondents is seen to be related to perception about the cause o f malaria irrespective of level o f education. The responses show that the older the individual, the more likely his/her perception about the cause of malaria in children will be correct. It will be seen from the table that 62 percent o f all those above 34 years have a correct perception about the cause of malaria compared to 48 percent for those below 34 years. Conversely, 52 percent of all those below 34 years have an “incorrect” perception about the cause of malaria University of Ghana http://ugspace.ug.edu.gh compared to 38 percent for those above 34 years. The majority o f those below the 34 age group are generally of the view that malaria in children is caused by other natural factors apart from mosquito bites. Some explanations may be offered for this kind o f association between age and perception about the cause o f malaria. One would have thought that younger persons are more likely to perceive the cause o f malaria more correctly as they are expected to be more exposed to modernizing factors like formal education and access to media information than the older ones. Again, they are perceived to have higher propensity to migrate from rural to urban areas where they easily come into contact with modern values than the older people who, as indicated earlier, are more entrenched in the traditional beliefs and practices o f their ancestors. However, a possible explanation o f the rather unexpected findings from the data in table 8 is that the older persons may have availed themselves more of public health educational programmes while the younger ones have the tendency of acquiring information about childhood illnesses from the elderly and their peers instead. Most often, such ideas turn to be incorrect due to misinformation. An interesting observation made by the investigator during the fieldwork, regarding the participation of the folks in such exercises, which coincided with the Malaria Awareness Week in the district may perhaps give an indication about the attitude o f the youth. During one such campaign meeting at Kpong, to launch the use o f Insecticide Treated Mosquito Net (ITMN) and to also educate people on malaria and its control, it was observed that most o f the mothers/carers who turned up at the meeting were generally older in spite of the widespread publicity given University of Ghana http://ugspace.ug.edu.gh by the health workers prior to the programme. When the investigator enquired afterwards from one o f the health workers, the explanation given was that the younger ones are often apathetic towards such public health educational programmes. The timing of such programmes during week days may not be convenient to the youth to participate as they may be busy going about their economic activities Perception of Malaria Parasite Transmission As indicated elsewhere in this study, the natural transmission o f malaria depends on a complex interaction between host, vector and the environment. The anopheles mosquito vector is infected through blood from an infected host. The parasite then matures to the sporozoite stage in the vector, and invades its salivary glands. The mosquito infects other people by injecting sporozoites in the saliva while feeding on their blood. In the process, the host’s liver and the red blood cell is invaded and destroyed. It is important for people to know and understand the correct transmission of malaria so as to take appropriate measures towards its control and prevention. In this regard, the views o f respondents on malaria transmission were sought. Respondents were first asked whether they could tell how the malaria parasite was transmitted. Those who answered in the affirmative were further asked to explain how the parasite was transmitted. It is important to remark here that respondents were not required to give detailed scientific explanations on how the parasite is transmitted. A simple explanation given by a respondent to the effect that the 89University of Ghana http://ugspace.ug.edu.gh parasite is transmitted from an infested person to another person through a mosquito bite is considered adequate and correct explanation about the mode of transmission. Significant number o f the respondents (62 %) admitted they could not explain how the parasite is transmitted. This obviously implies that knowledge about malaria transmission is limited. It also has an implication on the management of childhood malaria by carers. The lack o f knowledge of the malaria parasite transmission may be attributed to the generally high illiteracy level in the area and traditional views about malaria among women. Literacy Level and Knowledge of Malaria Parasite Transmission As explained earlier, a significant relationship exists between the level o f literacy and knowledge o f the transmission of the malaria parasite. Table 9 below shows relationship between literacy level and knowledge about malaria parasite transmission. 90University of Ghana http://ugspace.ug.edu.gh 91 Transmission Table 9: Literacy Level and Knowledge About Malaria Parasite Knowledge of Parasite Transmission Literacy Level Can Easily Read Read with difficult}' Cannot Read at all Yes 73 % 38% 20% No 27 % 62 % 80% Total (N=59) 100 (N=60) 100 (N = ll l ) 100 Table 9 shows that 73 percent o f those who can easily read claimed they know how the malaria parasite is transmitted compared with 38 percent of those who can read with difficulty and 20 percent o f those who cannot read at all. Conversely, 80 percent o f the illiterate population, that is, those who cannot read at all admitted they do not know how the parasite is transmitted compared to only 27 percent of those who are literate (that is, those who can read and understand easily). It can, therefore, be concluded that knowledge o f transmission has a strong positive relationship with the level o f literacy and that the literate have better knowledge of the transmission o f the malaria parasite. This conclusion is confirmed by the value of the correlation coefficient (r) (0.659) which shows a positive moderate relationship between the level o f literacy and knowledge o f the transmission of the malaria parasite. University of Ghana http://ugspace.ug.edu.gh 92 Signs and Symptoms of Childhood Malaria Knowledge o f the signs and symptoms o f malaria in children like its cause and transmission is very essential if mothers/carers are to act in a timely fashion in seeking appropriate treatment for affected children to avoid possible health complications and death. Respondents were therefore, asked to mention some of the signs and symptoms o f “assla” in children. Table 10 shows a distribution of responses in this regard. University of Ghana http://ugspace.ug.edu.gh 93 Table 10: Perceived Signs and Symptoms of Malaria in Children Responses on Signs and Symptoms of Malaria Frequency Percentage (%) Vomiting 125 54.3 Yellow Urine 121 52.6 Warm body (hedola) 115 50.0 Yellow Eyes 111 48.3 Loss o f Appetite 99 43.0 General body weakness 85 36.9 Feverishness 51 22.1 Chill 33 14.3 Diarrhoea 24 10.4 General discomfort 19 8.3 Yellow Eyes 11 4.8 Stiff Neck 4 1.7 Nasal Congestion 4 1.7 Convulsion 4 1.7 Frequent Crying 2 0.9 Sore Mouth 2 0.9 Change in Urine Odour 2 0.9 Nasal Congestion 1 0.4 T O T A L 813* 353.2 * Multiple Responses Table (12) above shows the major signs and symptoms o f childhood mentioned by respondents. About 55 percent of the respondents mentioned vomiting, 52.6% mentioned yellow urine and 50 % warm body or “hedola” among others. It is University of Ghana http://ugspace.ug.edu.gh significant, however, to note that only a small number (1.7 percent) recognized convulsion as one of the signs and symptoms of malaria in children. This situation would have implications for treatment sought during episode of childhood convulsion. Responses by discussants in the FGDs were similar to those in the survey. During one o f the FGDs, a 40-year-old mother captured some o f the views o f discussants on signs and symptoms o f childhood malaria in the following way: "As fo r me there are a number o f changes I see in my child which tells me that he is being attacked by “assla One o f the things I notice is that, the child may refuse to eat regularly and would also vomit almost anything he takes. Other signs include high body temperature (hedola), general discomfort and paleness. ’’ Generally, the various responses given in both the survey and FGDs are close to clinical diagnosis o f malaria in children which seems to suggest that the majority o f mothers/carers can easily identify signs and symptoms o f malaria in children. Findings in a study by Owusu-Agyei et al. (1999) on knowledge o f signs and symptoms o f childhood malaria are confirmed by the results of this study. However, studies by Agboada (1999) and Diallo et al. (2001) came out with contrary findings indicating that most mothers were not aware of the major signs 94University of Ghana http://ugspace.ug.edu.gh and symptoms o f malaria. Such findings have implications for treatment seeking behaviour since the ability to recognize signs and symptoms o f malaria in children is an important step to seeking timely and appropriate treatment. The increase in the reported cases o f under five malaria may be attributed to general high knowledge about its signs and symptoms by mothers/carers in the area. Perceived vulnerability of Children to Malaria Infection Even though majority (63 percent) of the respondents agreed that malaria/fever affects both adults and children, 30 percent were o f the view that children are the most affected while only 7 percent thought that it mostly affects adults. Responding to a question on whether they consider malaria/fever to be a fatal illness, 95 percent acknowledge that it is fatal or that it can result in a child’s death. Hence children are generally thought to be vulnerable by majority of the respondents. The consensus in the FGDs conforms to the findings in the survey. However, this finding is in sharp contrast with findings in an evaluative study of an anti-malaria programme for children in Danfa near Accra. In this study, Balcher (1975), observed that although almost all mothers mentioned fever in children as a common place ill health, only 11.9 percent felt that it could lead to death. Awareness o f the fact that malaria is a major health risk to children can influence action taken by mothers/carers to prevent it or seek prompt action when children are suspected o f contracting malaria. University of Ghana http://ugspace.ug.edu.gh 96 Treatment Seeking Behaviour In this section, results relating to treatment action sought by respondents during episode o f childhood malaria and reasons for taking such actions would be discussed. This would help provide some insight into the pattern of treatment seeking behaviour o f the study community. Respondents were first asked whether any o f their children under five years had suffered from malaria/fever in the last one month preceding the interview. About 66 percent o f mothers/carers indicated that at least one of their children under five years had suffered from malaria/fever in the one month preceding the interview. This result is higher than the finding in the 1998 GDHS which indicate that one in four o f all households reported having a child under five years with fever in the two weeks preceding the survey. This shows the degree o f endemicity of malaria in the area. Treatment Action As indicated in the literature review, the sequence o f remedial actions taken by mothers/carers during episode of childhood malaria can be influenced by the perception about the cause o f the disease, knowledge of the signs and symptoms and other socio-economic and cultural factors. Consequently, the first treatment action taken by mothers/carers when they notice signs o f malaria/fever in their children is indicative of how they perceive childhood malaria. This in turn determines treatment or action they consider most appropriate under the University of Ghana http://ugspace.ug.edu.gh circumstance. In this regard, respondents who reported that their children had been sick with malaria in the preceding month were asked about the first treatment action. As the results show 35 percent o f those who reported having a child with malaria during the period went to a pharmacy/chemical/drug shop while 34 percent said they treated the sick child themselves using either left-over drugs or herbal preparation or a combination of both. Only 26 percent o f respondents claimed they sought treatment at a health facility. About 3 percent and 2 percent consulted drug peddlers and traditional healers, respectively. The results, therefore, indicate that the first point o f seeking treatment by the majority o f respondents when malaria is suspected is the pharmacy/chemical/drug shop. A similar proportion o f the respondents treated their child at home using either herbal preparation or leftover drugs or both. Ahorlu et al. (1997) reported similar results in their study. Those who sought treatment at a health facility as a first action are relatively few. The study also found that consulting traditional healers is the least o f options considered when a child is suspected o f being attacked by malaria/fever. This pattern of treatment behaviour was found in many studies (GDHS 1998; Brinkmann and Brinkmann 1991; Mwenesi et al. 1995; Mensah-Quainoo et al. 1995). The implication of this trend o f treatment seeking behaviour is the likelihood o f drug abuse, which also has the potential ol worsening the child’s health condition. 97University of Ghana http://ugspace.ug.edu.gh When symptoms persist after failure of first treatment, 71 percent of respondents indicated that they would send their untreated child to a health care facility while 14 percent indicate that they would resort to herbal preparations. This result shows that the majority o f people will take their sick children to a health care facility after the failure o f the first treatment action. It should be noted, however, that failure of first treatment option may be due to the effect o f drug resistance, patient non-compliance with drug prescription and the fact that symptoms shown may be as a result o f other illnesses. Medications Administered When asked about the type o f medication administered to their sick children during episode o f malaria, 77 percent o f the respondents claimed to have given chloroquine and paracetamol syrups or tablets. These drugs were usually bought from the pharmacy/chemical/drug store. Some indicated that they bought them from a hospital’s dispensary while others made use o f home stock of drugs. About 11.9 percent said they used herbal preparations such as concoction or decoction from boiled orange leaves, neem tree leaves and unriped pineapple while 11.3 percent could not remember the medication used. From the FGDs it came to light that some mothers/carers used both biomedical drugs and herbal medicine at the same time. The results show that the common medication used to treat childhood malaria was chloroquine with paracetamol in either syrup or tablet form. The use of herbal preparations are less pronounced while in some cases a combination of the tw'o is used to ensure effective treatment. 98University of Ghana http://ugspace.ug.edu.gh 99 It is significant to note that 68 percent o f respondents have little idea about the correct application o f the chloroquine tablet to children (under one year or those between 1-5 years). Knowledge/Perception of the Cause of Malaria and First Treatment Action Taken As indicated earlier, knowledge or perception of the cause of childhood malaria may have some direct consequence on the management option in seeking remedy. If a person believes or knows that a natural force such as mosquito bite causes malaria then he/she is more likely to seek first treatment from a biomedical source. On the other hand, if a person believes that malaria is caused by supernatural forces he/she is likely to resort to traditional or other spiritual healing sources he/she consider appropriate. In this regard a cross-tabulation of knowledge o f the cause o f malaria and first treatment action taken was done to assess their relationship. Table 11 shows relationship between knowledge of cause of malaria and first treatment action taken. University of Ghana http://ugspace.ug.edu.gh Treatment Action Taken Table 11: Knowledge/Perception of the Cause of Malaria and First First Action Taken Knowledge/Perception of Cause of Malaria Correct Wrong Pharmacy/Chemical/Drug Store 31 % 38 % Health Care Facility 27% 26% Drug Peddler 3 % 3 % Traditional Healer 3 % 3 % Home Treatment (drug or herbs) 1 % 3 % T O T A L (N =71)100 (N=78) 100 Table 11 reveals that a relationship exists between knowledge of the cause of malaria and the first treatment action taken. The table shows that 27 percent of those who have correct knowledge o f the cause of malaria sought treatment at a health facility compared to 26 percent o f those who did not have correct knowledge. Another 38 percent o f those who have correct knowledge would first resort to home treatment o f the disease compared with 30 percent o f those who have incorrect perception about malaria. Again, 38 percent o f those with correct knowledge about the cause o f malaria will first seek treatment at a pharmacy/chemical/drug store compared with 31 percent of those who have correct knowledge. It should be noted that the value o f the correlation coefficient (r) of -0.055 suggests little correlation between perception o f the cause of malaria and the first University of Ghana http://ugspace.ug.edu.gh treatment action taken during an episode o f childhood malaria. This means that knowledge/perception o f the cause of malaria does not determine the first treatment action to be taken by carers during episodes o f childhood malaria. The relationship between the two variables is not significant (5 percent). First treatment action taken may, therefore, be determined by other factors. From the data, it may be concluded that there is a slight relationship between knowledge/perception about the cause of malaria and the first treatment option sought by carers during episodes o f childhood malaria. Other Factors Influencing Management of Childhood Malaria As noted earlier, the management of an illness is not just a consequence of knowledge/perception o f the cause of the disease. Other socio-economic determinants such as level o f education, age, income level and access to a health care facility may also play a significant role. A critical analysis o f each of these factors may throw some light on their relationship with first treatment action during episode o f childhood malaria. Education and First Treatment Action Taken It is likely that a relationship may exist between educational background of carer and the first treatment action taken during episode o f childhood malaria. Table 12 looks at the relationship between education and first treatment action taken. 101University of Ghana http://ugspace.ug.edu.gh 102 Table 12: Education and First Treatment Action Taken First Action Taken Level of Education No Formal Education Belov JSS JSS and Above Health Care Facility 31 % 19% 28% Pharmacy/Chemical/Drug Store 35 % 41 % 31 % Drug Peddler 5% 5 % - Traditional Healer - 7 Home Treatment (Drug or Herbs) 29 28 41 Total (N =42 )100 (N=42) 100 (N=65) 100 Table 12 reveals that 31 percent o f those with no formal education are more likely to seek first treatment at a health care facility than those with formal education. On the other hand, 41 percent of those went beyond Junior Secondary School (JSS) are more likely to seek home treatment as a first line of action during episodes o f childhood malaria compared to 29 percent of those with no formal education. It is also significant to note that those below JSS level ot education have the tendency to consult traditional healers during episodes of childhood malaria. The value o f the correlation coefficient (r = 0.115) is indicative of a rather weak relationship between level of education and the first treatment action taken during episodes o f childhood malaria. The relationship is also not significant at 5 percent. It may be concluded that there is no relationship between level o f education and first treatment action taken during episodes of childhood malaria. University of Ghana http://ugspace.ug.edu.gh The data presented in Table 12 is rather surprising as one would have thought that those who attained higher levels o f education will rather seek first treatment at a health care facility due to their expected high socio-economic status. A contrary result in a study on treatment o f childhood malaria in Malawi by Slusker et al. (1994), however, found socio-economic status to be positively correlated with hospital attendance. A possible explanation of the finding in this study is that those who have formal education are generally informed about the correct treatment o f malaria and therefore would prefer first treatment at home. It should be noted also that treatment action may depend on perceived severity of the sickness, accessibility to health care facility, and the quality o f health care services at such facilities. Further studies may be needed on health care utilization by mothers/carers to enable a more detailed analysis on this issue. Age and First Treatment Action Taken Age is an important socio-demographic characteristic used to determine level of maturity and experience in life. Older people are expected to have broader knowledge on issues such as health and would therefore be expected to take appropriate measures in seeking better treatment when their children become sick. In table 13, we look at the relationship between age and first treatment action taken. 103University of Ghana http://ugspace.ug.edu.gh 104 Table 13: Age and First Treatment Action Taken First Action Taken Age Group Below 35 years 35 years and above Health Care Facility 28 % 25 % Pharmacy/Chemical/Drug Shop 39% 31 % Drug Peddler 3 % 2% Traditional Healer 1 % 2 % Home Treatment 29% 40% T O T A L (N = 72) 100 (N = 77) 100 In Table 13 the age o f respondents seems to have some relationship with the first treatment action taken during episode of childhood malaria. The responses generally show that the younger the individual the more he/she is likely to seek first treatment from a health care facility or a pharmacy/chemical/drug store. It can be seen from Table 13 that 28 percent o f all those below 35 years sought first treatment at a health care facility compared to 25 percent o f all those who are 35 years and above. Again 39 percent of all those who are below 35 years of age sought first treatment from a pharmacy/chemical/drug shop compared with 31 percent o f all those 35 years and above. Conversely, 40 percent of all those 35 years and above indicate that the first action they took was to treat the sick child at home compared to 29 percent o f all those below 35 years. It is also interesting to observe that 2 percent of all those above 35 years first consulted a traditional healer compared to only 1 percent o f all those below 35 years. However, the value University of Ghana http://ugspace.ug.edu.gh of the correlation coefficient (0.053) indicated a weak relationship between age and first treatment action taken by carers during episodes of childhood malaria. It may, therefore, be concluded that there is little correlation between age and first treatment action taken during episode o f childhood malaria. Income and First Treatment Action Taken The choice o f a particular treatment outlet depends not only on one’s confidence in it but also on how much it costs to access that particular source, and also on the level o f one’s income. It is, thus, assumed that one’s income level may influence the type o f treatment option to be sought during episodes o f childhood malaria. Table 14 shows relationship the between income level and first treatment action taken. 105 Table 14: Income Level and First Treatment Action Taken First Action Taken Income Level (Monthly) No Income Less than £300,000 0300,000 and above Health Care Facility 36% 29% 13 % Pharmacy/Chemical/Drug Store 46% 39% 16% Drug Peddler - 4% - Traditional Healer - 2 % 3 % Home Treatment 18 % 26% 68 % Total (N = 11) 100 (N= 107) 100 (N = 31) 100 Table 14 shows that 36 percent o f respondents with no income visited a health care facility as a first treatment action compared to 1 j percent o f those who earn University of Ghana http://ugspace.ug.edu.gh 0300,000 and above. The data show that a relationship exists between level of income and first treatment action taken during episodes o f childhood malaria. Table 14 also shows that most (68 percent) o f those who earn over 0300,000 a month are likely to resort to home treatment compared to 26 percent o f those who earn less than 0300,000 and 18 percent o f those who do not earn any income. Interestingly, the data also reveal that those who earn income are more likely to consult traditional healers for treatment. A possible reason why the poor or for that matter those with no income have a greater tendency to seek first treatment from either a retail outlets or a health care facility is because they consider those outlets to be accessible, cheaper and more effective. The fact that home treatment is the preferred option for those with higher income is not strange. Indeed, a number o f studies in Ghana and elsewhere in the developing world has shown that home based treatment as a first option is a common practice (GDHS, 1998; Ghana ICHS, 2001; Mensah-Quainoo, et ai. 1995; McCombie, 1996). A possible explanation for this behaviour cannot be far-fetched. Those with higher income levels are more likely to have higher socio-economic status. Hence, with their relatively higher level o f education they are more likely to have better knowledge about the application o f recommended drugs for the treatment o f malaria and would, therefore, treat their children at home. Also, the demands of their occupations in terms o f time, may not encourage sending a sick child to a health care facility as a first option during episode of malaria. 106University of Ghana http://ugspace.ug.edu.gh A number o f studies have established a relationship between income and treatment seeking at a health care facility (Hussein, et al., 1997; Assenso-Okyere, et al, 1995; Vogel, 1988, Waddington, et al, 1989). As such, in order to find out whether any such relationship exists, it was hypothesized that there is no relationship between size o f income o f mothers/carers and treatment seeking for a child from a health care facility. Chi-square (x~) statistic was, therefore, applied to test the above hypothesis. Table 15 shows the relationship between income level and health care facility visitation. 107 Income Level and Health Care Facility' Visitation Table 15: Income Level and Health Care Facility Visitations Visit Income Level No Income Less than 0300,000 0300,000 and above Total Health Care Facility 5 31 5 41 Other Health Care Outlet 6 76 26 108 T O T A L 11 107 31 149 Table 15 indicate the value of the computed Chi-Square (x2)as 3.89. The x2 critical at 95 percent confidence level and 2 degrees of freedom with probability value less than 0.05 was 0.103. Comparing x2 computed with x2 critical, we reject the null hypothesis that there is no relationship between size of income of mothers/carers and seeking treatment for a sick child from a health care facility because x~ computed is greater than x critical. Therefore, we accepted the University of Ghana http://ugspace.ug.edu.gh alternative hypothesis that there is a relationship between size o f mothers/carers income and treatment seeking for a sick child from a health care facility. Distance and Desire to Seek Treatment Studies have shown that a relationship exists between distance from one’s residence to a health care facility and treatment seeking from a facility. Nukunya and Twumasi (1978) found that the use o f a hospital is dependent on its accessibility. This could be attributed to time taken to reach the hospital and the treatment cost associated with it. In this study, a hypothesis was stated to the effect that there is no relationship between distance o f mothers/carers residence from a health care facility and use of such facilities. Chi-Square (x2) Statistic was again used to test the stated hypothesis. Table 16 shows the relationship between distance and desire to seek treatment from a health care facility. 108 Table 16: Distance and Desire to Seek Treatment Visit Distance from Residence to a Health Care Facility Less Than 1 km 1-5 km 6-20 km Total Health Care Facility 23 % 14% 5 % 42 Other Health Care Outlet 46% 39% 22% 107 Total 69 53 27 149 From Table (16) above, the value of the computed Chi-Square was 2.21. The x2 critical at 5 percent significant level and 2 degrees o f freedom was 0.103. University of Ghana http://ugspace.ug.edu.gh Comparing x2 computed with x2 critical, we reject the null hypothesis that there is no relationship between distance o f mothers’/carers' residence from a health care facility and the desire to seek treatment from such facilities because x2 computed is greater than x2 critical. Fherefore, we accept the alternative hypothesis that there is a relationship between distance of mothers/carers residence from ;i health care facility and the desire to seek treatment for a sick child from such facilities. Reasons for Choice of Treatment Outlets In the previous section we have examined the behaviour of mothers/carers in managing suspected cases o f childhood malaria and the factors that may influence such behaviour. In this section, we shall assess the reasons for choosing a particular treatment outlet in a hypothetical case. Such insight will give a broader perspective about the enabling and predisposing factors influencing treatment seeking behaviour. Home Treatment As observed earlier, home treatment o f childhood malaria with either drug or herbal medicine has been the most frequently subscribed treatment option. In a hypothetical situation, about 75 percent o f the respondent said they would treat their children at home when they suspect malaria. Deming et al. (1989) in a study in Togo, found similar results. Figure 3 shows reasons given by carers for opting for home treatment when a child is sick. 109University of Ghana http://ugspace.ug.edu.gh 110 FIGURE 3: REASONS FOR OPTING FOR HOME TREATM ENT Sickness usually occurs during Boiled herbs are the weekend very effective 2% 7% Convenient buying OTC drugs 7% Have left over drugs 13% Health workers not friendly 9% too much time spent at hospital 17% No money for hospital/clinic 37% Hospital/Clinic too far8% From figure 3, financial consideration featured as the most significant reason why respondents will opt for home treatment. For 37 percent o f the respondents this was the case. Other considerations include: the long time spent at health care facilities (17.4%); poor attitude of health workers (9.3 %); distant location of health facility (8.1 %); availability of left-over drugs (12.8 %); convenience of buying OTC drugs (7 %); confidence about the effectiveness of herbal preparations (7 %); and finally, the period illness usually occurs (2.3 %). It is obvious from the above findings that lack o f money and perceived poor quality of University of Ghana http://ugspace.ug.edu.gh care are the two most important considerations. This is not surprising given the fact that most of the respondents are below the poverty line. It is also common knowledge that every now and then, people express their dissatisfaction with services provided at the health care facilities. Discussants in the FGDs expressed similar views as to why they sometimes opt for home treatment. In one of the FGDs, a 37-year-old mother explained what she normally does when her child has malaria: “As fo r me, whenever, I notice that my child has fever, that is, when her body becomes very warm and she refuse to eat, fo r instance, I will fir s t use some water to sponge her after which I will give her some chloroquine/paracetamol syrup which I always have in stock at home and the child will get better in two or three days time. It is cheaper to treat my child at home this way than going to the hospital where I would spend more money and time. ” Such expressions show that mothers/carers will usually try to treat childhood malaria at home in view o f the fact that malaria is regarded as a common and regular childhood illness, which can easily be treated with prescribed medication. It should be noted, however, that there are many potential dangers for engaging in home/self medication. As noted by Menon et al. (1988), self-medication may lead to delays in seeking treatment in cases of severe malaria. Given the current situation, most people are likely to continue resorting to home/self treatment for curing childhood with malaria. It is also significant to note that the existing health care facilities are incapable o f providing the necessary health care to the people. It will be chaotic if all the people should decide to visit I l lUniversity of Ghana http://ugspace.ug.edu.gh 112 health care facilities during episode of illnesses. Foster (1952:32) aptly remarked that ‘'patients are actually doing the health services a financial favour by self- medicating” . Thus, under the present circumstances, home/self medication may be encouraged for common ailments such as malaria provided it is done with correct prescription. We should also not lose sight of the fact that some herbal preparations have been found to be efficacious. For instance, herbal concoction of neem tree and pawpaw leaves is commonly used in many communities in Ghana. New herbal preparations are now bottled and sold in most drug retail outlets. Health Care Facility Treatment As discussed earlier, decisions to seek treatment from a health care facility is influenced by various considerations. Figure 4 shows carers considerations for taking a sick child to a health care facility. University of Ghana http://ugspace.ug.edu.gh 113 FIGURE 4: CONSIDERATIONS FOR TAKING SICK CHILD TO A HEALTH CARE FACILITY 59.8 It is the best When I have When sickness Accessibility If own treatment place to seek sufficient money becomes fails treatment severe Considera tion As shown in Figure 4. about 60 percent of respondents would consider going to a health care facility for treatment because “it is the best place to seek treatment”. Twenty-one percent would consider such outlets when sickness becomes severe. Other considerations include accessibility and failure of self-treatment. A number o f studies have come up with similar findings (McCombie, 1996; Forster, 1991; Mwenesi et al. 1995). Responses from the FGDs were generally similar to those in the survey. What is clear here is that people have more confidence in seeking University of Ghana http://ugspace.ug.edu.gh treatment at health care facilities. However, the decision to access such facilities would also depend on other considerations discussed earlier. Treatment at Pharmacy/Chemical/Drug Stores It is a common practice for people to seek treatment by consulting pharmacists or attendants at retail outlets during episodes of childhood malaria as revealed earlier in this study. About 71 percent of the respondents indicate that they will consult and buy OTC drugs from such retail outlets if they suspect their children to be suffering from malaria. The study revealed that the most important consideration for seeking treatment from retail outlets is that they provide first aid services. Other considerations include accessibility, lower cost o f drugs and the fact that they also dispense ethical drugs (Senah, 1997). Views expressed during the FGDs were not so different from the survey. In one o f the discussion, a 48-year-old mother at Otrokpe observed: “Since the opening o f a drug store in this community about eight years ago, I always go there fo r medication whenever I or any o f my children is sick. The “doctor” at the shop is very good as he takes his time to ask you about your problems. I will continue to seek treatment there because the drugs are cheaper and even i f you do not have 114University of Ghana http://ugspace.ug.edu.gh 115 sufficient money, he is prepared to give you some on credit. ” The above statement shows that retail outlets serve a very useful purpose, especially in communities where there are no health care facilities. Apart from that, the retail outlet operators are able to satisfy the peculiar needs o f the people by taking their socio-economic and cultural situations into consideration. In a study in Maiduguri, Nigeria, it was found that immediate attention for both consultation and treatment was the single most important reason for patronizing retail pharmacies rather than health clinics (Igun, 1987). Mwenesi et al (1995) also found that 67 percent o f mothers purchased drugs in the two days before the survey. They also noted that the type o f retail outlet used depended on distance from home and availability of required medication. Treatment from Traditional Healer As will be recalled, earlier findings revealed that traditional healers are less patronized during episodes of childhood malaria. Nonetheless, some people still consider them a useful and reliable treatment option. As expected, only 28 percent o f all respondents expressed the desire to seek treatment from a traditional healer. Their reasons are captured in figure 5: University of Ghana http://ugspace.ug.edu.gh 116 FIGURE 5: CONSIDERATION FOR SEEKING TREATMENT FROM A TRADITIONAL HEALER When condition fails to improve after taking drugs 9% Illnesses that are best treated through herbal medicine 66% When child develops convulsion 17% Herbal medicine are less expensive 8% As shown in Figure 5, the most important consideration why carers would opt for traditional medicine is when it is considered that the illness is best treated using herbal medicine, especially in cases of convulsion. Another obvious consideration is that it is relatively less expensive. Similar considerations were found in many studies (Ruebush et al. 1995; Silva, 1991, Tona et al. 1999). University of Ghana http://ugspace.ug.edu.gh Seeking Treatment from Faith Healers/Spiritualists There are different categories of Faith healers/spiritualist found in both local and urban communities where they provide various kinds of services besides healing. In response to a hypothetical situation, only 25 percent o f the respondents indicated that they would sometimes consult faith healers or spiritualists when their children are sick. The considerations for seeking treatment from such outlets were not so different from reasons for consulting traditional healers. The most important consideration was that certain diseases require spiritual intervention and that not all sickness are adequately cured through orthodox means. The fact that some respondents would consider seeking treatment from such traditional sources is an indication that they have trust in them. As noted earlier, such treatment outlets are very significant in the general health delivery system as they fill in a vacuum created by lack of access to modern health facilities, especially in the rural areas. Another significant aspect o f their operation is that their healing processes seem to be rather appealing to their clients as they do not only provide therapy for physical disorders but also provide psychological and spiritual healing. Decision-Making Apart from the socio-demographic characteristics of mothers/carers, the decision to seek treatment for a sick child from a particular source depends on a complex social network. Such decisions may be made by the individual alone, the husband, mother-in-law, elderly person, health worker or other lay references. It was, therefore, not surprising that 67percent o f the respondents reported that they normally sought advice from someone before seeking treatment for a sick child. 117University of Ghana http://ugspace.ug.edu.gh The data show that advice is mostly sought from close family members. Husbands were consulted most frequently (51 percent). Other lay referrals include mother/father, sister, elderly person and mother-in-law. It is significant to note that only few would seek advice from community health workers (2.6 percent). Other studies show similar results (Mwenesi et al, 1995; Adongo and Hudelson, 1995; Browne, 1999). It is essential to note also that social relation and roles are significant in the decision-making process especially in societies where an idea about who “owns” the child is an important. Such ideas about who has more control or “ownership” o f the child is important consideration in assessing treatment-seeking behaviour especially in patrilineal traditional societies. Castle (1995) observed that although women may be the main caretakers in a residential family unit, they may not be the principal decision makers. He explained further that depending on family structure and residential organization, others, particularly senior males or mothers-in-law might be consulted on therapeutic options. Excerpts from the FGDs throw more light on decision-making in seeking treatment for a sick child. A 38-year-old illiterate mother made the following statement regarding what she often does when her child is sick: “Whenever I detect that my child is sick, I f irs t inform my husband about it early in the morning. He would then tell me what to do and also give me some money to pay fo r the cost o f treatment. ” The above statement shows that apart from the traditional expectation that wives will normally seek advice on certain intended actions from their husbands, University of Ghana http://ugspace.ug.edu.gh financial considerations seem to be another obvious reason for seeking advice from husbands. Another discussant recounted the following: "My husband is the firs t person I consult whenever any o f my children fa ll sick because he is the “wetse” (house-head) and “bitse ” (child-father) as well. I do this because it is the proper thing to do in our tradition. I f I go ahead to administer any medicine to the sick child on my own accord or take the child somewhere and there is a problem , I will be in trouble. But in the absence o f my husband, I will seek advice from an elderly person in the house ”. This also emphasizes the traditional pattern o f life and the fact that wives are expected to obey their husband and to consult them on issues that border on the welfare o f their family. Respect for the views o f elders is another cultural value considered sacrosanct. This situation has far-reaching implications for managing suspected cases o f childhood malaria. Even though such practices may be useful, in some cases it is likely to cause unnecessary delays in seeking prompt treatment for children who suddenly show severe signs o f malaria. It is possible, however, that those with higher socio-economic status would show relative independence when it comes to taking such decisions. These expectations found expression in the views o f a 35-year-old literate mother in one o f the FGDs as follows: 119 University of Ghana http://ugspace.ug.edu.gh " I f I notice that my child is ill I do not hesitate to give her some medication immediately or send her to the hospital fo r treatment i f symptoms persist. However, i f my husband is around, I would inform him about the poor state o f our ch ild ’s health fo r us to collectively take a decision. ” Unlike the case o f the illiterate mother, here the literate mother is able to take decisions alone in the absence of the husband. She does not need to wait for instructions from the husband before taking the necessary action even though she recognizes the husband’s position in the family and will inform him about the child’s condition for a collective decision. This shows that mothers with higher socio-economic status are able to take decisions alone in seeking treatment for their sick children without necessarily consulting their husbands or other lay references. A research in Ethiopia found that treatment-seeking was usually made jointly by both parents (Yeneneh et al. 1993). The process of decision making as noted earlier in this study has implications for treatment option sought and how promptly this is done to save the sick child from further suffering or possible death. This is because most o f the carers are mothers with low socio-economic status who are also firmly attached to traditional values and practices. University of Ghana http://ugspace.ug.edu.gh This section explores the views of respondents on malaria prevention and in particular, the specific measures taken by them to prevent children from malaria attack.Anti-malarial drugs and herbal medicine for the treatment of malaria abound in most localities. However, it is better to prevent malaria attack since the continuous reliance on such drugs has been proven to be potentially dangerous to health. Aside this, some of these drugs are becoming ineffective in the treatment o f malaria. As mentioned earlier, the malaria parasite is becoming resistant to chloroquine which ironically is still considered by the MOH as the first line drug for the treatment o f malaria. Thus, until a vaccine against malaria is discovered, the best control measure against the disease is through preventive measures. It is probably in this light that the Roll Back Malaria Programme places emphasis on prevention through the use of I.T.M.N. As indicated earlier, one of the specific objectives o f this study was to ascertain local malaria prevention measures. It was found that the majority (73 percent) o f the respondents agreed that malaria can be prevented. Views o f respondents as to what can be done to prevent malaria were sought. This was intended to examine their perception and practices concerning malaria prevention. The data show that sleeping under mosquito net is the most common view (19.5%) in this regard. Other responses include maintaining a clean environment (16.5%); eating balanced meals (15%); avoiding heat from the sun (12.7%); burning mosquito repellant (8.2 percent) and others, such as taking Malaria Prevention University of Ghana http://ugspace.ug.edu.gh medication, desilting of stagnant waters and destruction of mosquito breeding sites. Indeed, similar views were expressed in the FGDs. A general assessment of the responses on malaria prevention is that respondents are well aware o f what should be done to avoid mosquito bites. It is, however, significant to note that although responses such as “avoiding heat from the sun", "taking balanced meals" and “avoiding oily foods” may not have direct relation with malaria transmission, they may yet have important medical implications. For instance, poor diet can weaken the immune system and therefore prolong the effect o f malaria infection even under strict medication. However, few respondents think that malaria cannot be prevented. As one discussant puts it “it is in our blood and can only be suppressed through taking regular medications and avoiding heat”. This assertion is similar to findings in a study o f a Dangme community where most o f the respondents felt that malaria cannot be prevented because it is endemic, a way o f life (Agyepong, 1992). Such views expressed views by a section o f the public about malaria prevention may have some implication for on-going preventive strategies against the disease. Prevention of Childhood Malaria The investigator was not only interested in the views o f respondents concerning malaria prevention in general but what mothers/carers specifically do to protect their children from malaria attack. Such information will give an in-depth understanding regarding what mothers/carers do in practice to protect their 122University of Ghana http://ugspace.ug.edu.gh children against malaria. Table 17 shows measures taken by mothers/carers to prevent childhood malaria. 123 Table 1.7: Measures Taken to Prevent Childhood Malaria Measures Taken Frequency Percentage Provision o f Balanced Diet 77 23.7 Use o f Mosquito Nets 43 13.2 Burning Mosquito Repellants 38 11.7 Avoid Playing/loitering in the Sun 36 11.1 Giving Medication 33 10.2 Maintaining Hygienic Environments 32 9.8 Spraying Room with Repellants 21 6.5 Avoiding Mosquito Bites 12 3.7 Regular Bathing o f Children 9 2.8 Giving Herbal preparations occasionally 8 2.5 Prayers 6 1.8 Breastfeeding the Child 6 1.8 Installing Trap doors/window fitted with nets 4 1.2 T O T A L 325 100 As shown in Table 17 the most important measure taken by respondents to protect children against malaria was through the provision of balance diet (23.7 percent). Another important measure was through the use o f mosquito nets (13.2 percent). Other measures include burning o f mosquito repellants and preventing children from playing or loitering in the sun. It was generally observed that mothers/carers take necessary measures to protect their children from malana attack. However, University of Ghana http://ugspace.ug.edu.gh emphasis seemed to be placed more on the provision o f balanced diet. This may be due to the general health related education communities receive through health workers and the media. Knowledge and Use of Insecticidc Treated Mosquito Net (ITMN) As indicated elsewhere in this study, the use o f ITMN is one of the most effective means o f protecting children and adults as well from malaria attack. The use of ITMN has been extensively encouraged in the past few years through the RBM initiative. Evaluative studies have indicated that it has resulted in the reduction of malaria reported cases in some countries (Bradley et al, 1986). Whilst mosquito nets have been used for many years in the country, the treatment of nets with insecticides is a relatively new innovation. Ghana has, over the years, been promoting the use o f the ITMN especially among nursing mothers. It was, therefore, deemed important to ascertain the level o f awareness and the extent of usage o f the ITMN among respondents. In this study, 67 percent o f the respondents indicated that they have heard about the ITMN. The Ghana ICHS 2001 Survey shows a 54 percent awareness level. Thus, it can be said that the level o f awareness has been increasing over the past few years probably due to improvement in the promotion strategy. Further questioning on the sources of information about ITMN revealed that respondents heard about it from various sources. The most important source wf information was through Health Workers/Hospital (34%). Other major sources 124 University of Ghana http://ugspace.ug.edu.gh include television, relatives and friends, radio, NGOs, pamphlets/posters and the market. Health workers and hospitals have been the most important source because mothers/carers who regularly visit health care facilities for treatment are encouraged to use the ITMN. The television is another important source because it offers a visual picture o f the ITMN which serves as a regular reminder. Relatives and friends have the tendency to share information with each other about new things such as the ITMN, which is said to kill the insect upon contact. The data also show that some NGOs such as Plan International are working to popularize and encourage the use of ITMN in the district. In response to a question on whether they have ever used ITMN, a significant number o f the respondents (92%) indicated they have never used the ITMN. This result is similar to findings o f earlier studies in Ghana (Chinboah, 1999; Dukurugu, 1997; Ghana ICHS, 2001). The result o f this study clearly reveals that use o f ITMN is very low in the study area and there seem to be no appreciable improvement over the years. Reasons given for not using the ITMN include lack o f money, non-availability, lack of information and high cost of ITMN. Others expressed the view that they do not feel comfortable using it. In one of the discussions, doubts were expressed about its efficacy. Some were of the view that the chemical in the net can cause irritation in case o f body contact. Such views have implication for the use o f ITMN and indeed malaria prevention. Introduction o f a new product, especially, in traditional societies, should take the social structure and worldview o f the people into consideration. 125University of Ghana http://ugspace.ug.edu.gh 126 CHAPTER SEVEN CONCLUSION AND RECOMMENDATIONS Conclusion Malaria constitutes nearly 25 percent o f all child mortality in African and a major factor in the continent’s high rate o f infant and child morbidity and mortality (WHO, 2000). Previous malaria control programmes at global and national levels have often been unsuccessful or unsustainable. This may be partly due to lack of adequate consideration given to social and behavioural aspects o f malaria control. This study, therefore, focused on the modes of managing suspected cases of childhood malaria by mother/carers in the Manya Krobo district. The study also sought to assess mothers/carers perception about the aetiology and modes of transmission o f childhood malaria, investigate actions taken when children are perceived to have developed malaria and to examine factors that influence malaria and related factors that influence choice o f treatment outlets as well as local practices toward malaria prevention. The study was conceptualized within the framework o f the Health Belief Model which is based on the assumption that mothers will take action to prevent or control ill-health condition if they regard children to be susceptible to the University of Ghana http://ugspace.ug.edu.gh condition, believe it would have potentially serious consequences and also believe that a course o f action would be beneficial in reducing the anticipated barriers. To achieve this, two complementary methods were used in the data collection. These were the interview schedule and Focus Group Discussions. The target group was mothers/carers o f children under five years within the study area. An assessment o f the various malaria control strategies in Ghana over the years revealed lack o f financial sustainability and inadequate consideration of attitudinal and behavioural factors in different communities. The choice o f control methods appropriate for a specific community or region requires an understanding o f how various factors affects the local epidemiology of malaria. This is because, local perception of the aetiology of malaria and its causes, the manner in which the people decide whether a given treatment or preventive measure is efficacious and the pattern o f treatment seeking behaviour during episodes o f childhood malaria are very important in planning, implementing and evaluating malaria control programmes. It should be noted that individuals are not just passive observers when it comes to issues that concern their general well being and health in particular. They would like to be part o f the solution and in most cases their informed opinion can be very useful in addressing the problems more effectively. The study revealed the following results University of Ghana http://ugspace.ug.edu.gh Regarding perception/knowledge o f the aetiology, transmission and symptoms o f childhood malaria, the study found that most carers perceived malaria in children as caused by both mosquito bites and other environmental factors such as exposure to bad weather and the heat of the sun as well as the eating o f oily and poor food. Local perception about the aetiology o f malaria is generally not so different from that o f biomedical knowledge on which malaria control is based. It was also found that a significant number o f respondents have no knowledge o f the transmission process of the malaria parasite. However, the results show that the majority o f carers/mothers, irrespective of their socio-economic status could easily identify the common signs and symptoms o f childhood malaria similar to those o f clinical diagnosis. Conversely, convulsion (hiowe) which is a complication associated with malaria is still attributed it to super-natural forces. It was established that a relationship exists between carers’ level of education and knowledge of the cause o f malaria. Also, a fairly strong correlation has been found to exist between literacy level and knowledge o f the “correct” cause o f malaria. Concerning treatment seeking behaviour and indeed the choice of treatment outlets, the study showed that the majority of carers would prefer consultation and purchasing of drugs from drugs retail outlets as the first option. The most significant reasons given by respondents include the 128University of Ghana http://ugspace.ug.edu.gh need for immediate consultation and treatment, and easy accessibility and availability o f cheaper drugs. Some carers also opt for home-based treatment using either leftover drugs or herbal preparations or a combination o f both. Here, financial consideration is the most important reason given. Other reasons include lack o f easy access to health care facilities and dissatisfaction with services at health centers. It was also found that a number o f carers would prefer visiting a health care facility during episodes o f childhood illness because such an outlet is considered the best place to seek treatment. It was also found that most people seek first treatment from drugs retail outlets or at home and move on to the health care facilities when such treatment fails. Significantly, neither traditional healers nor spiritualist were routinely used by carers as first option for treating childhood malaria. However, reasons assigned by those who patronize such outlet are that they sometimes cure certain ailments including severe malaria which could not be treated effectively by modem medicine and that their services are perceived to be relatively cheaper and adaptive. Convulsion is among the conditions which the people believe cannot be cured by modern medicine. The data further indicate that the choice o f a treatment outlet is influenced by a combination of socio-economic and cultural factors such as level o f education, income, access to health care facilities and socio-cultural relations. 129University of Ghana http://ugspace.ug.edu.gh Level o f education and income of carers was found to have little correlation with the type o f treatment sought during episode of childhood malaria. The study also established that a relationship exists between distance of mothers/carers residence from a health care facility and seeking treatment from a health facility. Thus, people leaving closer to a health care facility are more likely to seek treatment from such a facility. It was found that decision making with regards to treatment seeking for sick children lies mainly with close family members, especially, husbands. This implies that targeting women alone for intervention programme will not obtain the intended results. It was also shown that a correlation exists between mothers’ education and income level on the one hand and seeking advice on treatment for a sick child on the other. Those with lower education and or income are more predisposed to seeking advice from close family members before seeking treatment for their sick child. On malaria prevention, the majority believes that avoiding mosquito bites, keeping clean environment and eating well balanced diet can help prevent malaria. Other views include avoiding the heat from the sun and the eating o f oily foods. However, others still believe that it is difficult to prevent malaria/fever due to the natural environment and the general pattern of social life. In terms of actual practices, the most important step mentioned by majority o f carers to protect children against malaria is the provision of well 130University of Ghana http://ugspace.ug.edu.gh balanced diet, protection against mosquito bites and ensuring that children do not play or loiter in the hot sun. ❖ The awareness level about the Insecticide Treated Mosquito Net (ITMN) was found to be fairly high in the district. Its use was, however, very low. Reason assigned for not using the ITMN is poverty. ❖ Most important sources of information about ITMN include Health Workers/Hospitals, T.V. relatives and friends. ❖ Some respondents attribute the increase in the vector population to the development o f irrigation dam and rice plantation in the area. ♦♦♦ Poor environmental sanitation, waste management practices, drainage and non-enforcement o f sanitary regulations were mentioned as reasons for the upsurge o f malaria problem in the area. ♦> Chloroquine tablet/syrup was found to be the most popular drug purchased and administered to sick children. However, knowledge of the correct application o f chloroquine tablets to children under-five years is generally low in the area. Recommendations The findings o f the study have important implications for health policy makers and all other stakeholders including District Assemblies and NGOs. The following recommendations are, therefore, put forward with the hope that their implementation in the short and long term will give practical meaning to on-going efforts at malaria control in the Manya Krobo District and in areas with similar health conditions and socio-cultural environment. *♦* Public health education on general health issues to create higher awareness and to improve knowledge of the various aspects of malaria and its control 131University of Ghana http://ugspace.ug.edu.gh should be pursued vigorously by District Health Management Team (DHMT). Such campaigns should involve opinion leaders at the community levels and should not be limited to durbars, seminars and workshops but should extend to meetings at churches and mosques, and at the household level as well. Also, the electronic media in particular should be encouraged by the M inistry o f Communications to provide free airtime as part of their social responsibilities to enable health professionals and other stakeholders disseminate information on health-related matters to the people. In this respect, the radio health programme dubbed Healthy Happier Home’ (HeHaHo) which features regularly on Radio Ghana in the English Language should be translated into local languages and replicated on other local Radio/stations for the benefit o f the rural listeners. Efforts at providing health care facilities to the communities should be given priority. Such facilities should be well-resourced with necessary drugs, equipment and in particular trained health professional to ensure easy access and prompt treatment of common diseases. Again, government policy on providing free medical services to children under-five years should be actualized to encourage the utilization o f health care facilities during episodes o f childhood illnesses. In this regard the Ministry of Health should liaise effectively with the Ministry o f Finance for timely release o f funds. The training and retraining of drug retail outlet operators on the correct management o f malaria episodes and the application of approved drugs University of Ghana http://ugspace.ug.edu.gh should be given paramount attention by the Ghana Health Services as they represent the first point of contact by carers during episodes of child illnesses. Here, government, NGOs and indeed pharmaceutical companies should pool resources to organize such training programmes. Since herbal medications still offer useful alternative sources o f treatment, it is important to streamline the operations o f traditional healers and to assist them in providing better sendees. Although government has in various ways shown concern to develop and promote traditional medical practices in Ghana through the establishment o f the Traditional and Alternative Medicine Directorate (TAMD) within the MOH and the enactment o f the Traditional Medicine Practice Act (575) which was gazetted as far back as March 2000, to date its governing council is yet to be constituted. With the establishment o f the National Health Insurance Scheme (NHIS) it is suggested that government and indeed the Ministry of Health should hasten to constitute the Traditional Medicine Practice Council to promote traditional medicine in Ghana. Education was found to be an important factor that influences carers knowledge/perception of childhood malaria and treatment seeking behaviour. It is, therefore, recommended that all children of school going age particularly the girl-child should be supported to gain easy access to attain at least basic education. In this respect, the government’s Free Compulsory Universal Basic Education (FCUBE) policy and the District Assemblies’ support to needy but brilliant pupils as well as other education University of Ghana http://ugspace.ug.edu.gh funds set up by traditional leaders and NGOs should be vigorously pursued. The Non-Formal Education Programme o f the Ministry of Education which started some years back should be reorganized and resourced to assist school drop-outs and non-literates to become functionally literate. Teaching o f health science should be encouraged at the pre-university level o f education. Vocational Training should be given to the unskilled especially the young girls who are out o f school to make them employable. In line with the poverty reduction programmes being embarked upon by government and other stakeholders, credit facilities should be made more accessible to people who may want to enter into income generating activities. At the same time such identified individuals and groups should be organized and equipped with basic business techniques to enable them succeed in their various vocations. It is envisaged that such measures will raise the income levels o f individuals to access better health care and other basic necessities in life. District Assemblies and NGOs should play key role in this direction. Attention should also be focused on the provision of good drainage systems and ensuring proper disposal o f both liquid and solid waste. Larviciding mosquito breeding sites and residual spraying o f houses must be encouraged to serve as both medium and long term solution. Recent policy directive by government to use a percentage o f the Dislrict 134University of Ghana http://ugspace.ug.edu.gh Assemblies Common Fund for malaria control can be used for this purpose. Finally, a holistic intersectoral approach, which has proved successful in the control and prevention of parasitic infections in some parts of the world, should be assessed and adopted by the Ministry o f Health. In this direction, it is suggested that a Mosquito Task Force should be constituted at town and village levels and resourced to deal with controlling the vector as well as helping to enforce environmental sanitation regulations in the various communities. Authorities at the District Assemblies should ensure that sanitary workers and inspectors are more proactive in their work. Other health related agencies and stakeholders should work in unison towards improving environmental sanitation to curb the high incidence of malaria in the area. University of Ghana http://ugspace.ug.edu.gh REFERENCES Acquah I. (1958). Accra Survey. London: University o f London Press. Addae Stephen (1996). Evolution o f Modern Medicine in a Developing Country 1880-1960. Durham: Durham Academic Press. Adongo P. and Hudelson P. (1995). The Management o f Malaria in Young Children in Northern Ghana. The Report o f a Rapid Ethnographic Study (Unpublished). Agboada J. (1999). Mother’s Knowledge, Attitude, Beliefs and Practices related to Childhood Anaemia in the Kintampo District (Unpublished Thesis, University o f Ghana). Agyei S. K. (1985). “Factors Influencing Primary Health Care: a look at a Paediatric Unit at Winneba: Department of Community Health, University of Ghana Medical School” : Ardayfio-Schandorf and Kwafo-Akoto (ed.) Accra: WOELI Publishing Services. Agyepong I.A. (1992). Malaria, ethnographical perceptions and practice in an Adangbe farming community and implications for control. Social Science & Medicine 35(2): 131-137. University of Ghana http://ugspace.ug.edu.gh 137 Agyepong I.A. and Manderson. L. (1994). The diagnosis and management of fever at Household level in the Greater Accra Region, Ghana, Acta. Tropica 58: 317-330. Ahorlu C.K., Dunyo, S.K. Afari, E.A. Koram, K.A. Nkrumah, F.K. (1997). Malaria related beliefs and behaviour in Southern Ghana: Implications for Treatment, Prevention and Control. Tropical Medicine and International Health, 2, 488-499. Aikins M.K. Pickering H, Greenwood. B.M. (1994). Attitudes to malaria, traditional practices and bednets (mosquito nets) as vector control measures: a comparative study in Five West African countries. Journal o f Tropical Medicine and Hygiene, 97, 81-86. Ankobiah M. (1986) Educational level and Attitude o f Women towards Maternal and Child Care practices. A Case Study of Bekwai of Ghana (Unpublished Thesis, University o f Ghana). Asenso-Okyere W. K , Dzato J. A., Osei-Akoto S. (1995). The Behaviour toward Malaria Care. A Multinomial Logistic Approach. Health Social Science Research Unit o f ISSER, University o f Ghana, Monograph Series No.5. University of Ghana http://ugspace.ug.edu.gh Asenso-Okyere W. K. and Osei-Akoto 1 (1997). The Role of Man in Promoting more equitable relations in Malaria and Health Care. Health and Social Science Research Unit-ISSER. University o f Ghana. Monograph series No. 7. Assimeng J. M. (1981). Social Structure of Ghana: A Study in Persistence and Change. Tema: Ghana Publishing Corporation. Azu N.A. (1926). “Adangme History” Gold Coast Review. Is It Gold Coast? Vol. l l ,N o .2 , 39-70. Babbie Earl (1992). The Practice of Social Research (6th Edition) Balmont: Wadsworth Publishing Company. Bamikale, M. (1997). Mothers Management o f Childhood diseases in the Yurobaland. The Influence o f Cultural beliefs, Health Transition Review, Vol. 7, No. 1, pp 221-234. Baume, C., Helitzer, D„ Kachur, S.P. (2000). Patterns of Care for Childhood malaria in Zambia. Social Science and medicine, 51:1491-1503 Beland I.L. and Passos, J.Y. (1975) Clinical Nursing Pathophysological Approaches. New York: Macmillan Publishing Co. Inc. 138University of Ghana http://ugspace.ug.edu.gh Belcher D.W. (1975). “Factors influencing utilization of malaria prophylaxis programme in Ghana.” Social Science, and Medicine. Vol. 9. 1975: 241-48. Bledsoe C.H. and Gouband M.H. (1985). The Reinterpretation of Western Pharmaceuticals among the Mende o f Sierra Leone. Social Science and Medicine 21 (3): 275-282. Bloland, P.B., Ettling, M., Meek, S. (2000). Combination Therapy for Malaria in Africa: Hype or Hope? Bull, o f World Health Organisation. 78:1378-1388. Bradley D. (1991). Malaria-When and Whitter: In: Target G.A.T. (ed.) Malaria: Waiting for the vaccine. New York: John Wiley & Son. Bradley, A.K., Greenwood, B.M. (1986) Bednets (Mosquito nets) and morbidity from malaria. Lancet 2,204-207 Brinkman, U., Brinkman, A. (1991). Malaria and Health in Africa: The Present Situation and Epidemiological trends. Tropical Medicine Parasite. 42, 204-213. Caldwell J.C. (1979). “Mass Education as a Determinant o f Mortality Decline” In: Caldwell and Santow, (eds.) Selected Readings in the Cultural, Social ad Behavioural Determinants o f Health. Canberra: Australia Health Transition Centre, The Australian National University. University of Ghana http://ugspace.ug.edu.gh Castle S.E. (1995). Child Fostering and Children’s Nutritional Outcomes in Rural Mali: The Role o f Female Status in Directing Child Transfer. Social Sciences & Medicine 40 (5): 679-693. Chermichovsky D., Meesook, O.A. (1986). Utilization of Health Services in Indonesia. Social Science and Medicine 23 (6): 611-20. Chinbuah M.N.A. (1999) Knowledge, Acceptability and Use of Insecticide Treatment Bednets in the Cape-Coast Municipality. Unpublished Thesis, University o f Ghana. Chinery W.A. (1990). Impact o f Socio-Economic Development on Populations of some parasites and Vectors in Ghana. Its medical implications. Accra: Ghana Universities Press. Daily Graphic, Wednesday, July 16, 2003, pp. 1-3. Deming M.S., Gayibor, A. Murphy, K. Jones, T.S., Karsa, T. (1989). Home Treatment o f Febrile Children with antimalarial drugs in Togo. Bulletin of the World Health Organisation, 67, 695-700. Diallo A.B., De Serres G., Beavogui, A.H., Lapointe, C. Viens, P. (2001) Home Care o f Malaria Infected Children o f less than 5 years of age in a rural area in the Republic o f Guinea. Bulletin of WHO, 2001, 79:28-32. 140University of Ghana http://ugspace.ug.edu.gh 141 Doe P.T. (1987) Knowledge, Attitude and Practices o f mothers in the Ashanti Akim District on Diarrhoea diseases in children under 5 years. (Unpublished Dissertation, Dept, o f Community Health, School of Medical Services, University o f Science and Technology, Kumasi). Dokurugu M ijirah Yusif (1997). Local Perception and Treatment of Malaria. A case study o f Medina. Unpublished Dissertation, Dept, o f Sociology, University of Ghana. Easmon Committee Report (1968). Report of the Committee Appointed to Investigate the Health Needs of Ghana. Govt, of Ghana. Espino F. and Manderson, L. (1997). Perception o f Malaria in a Low Endemic Area in the Philippines: Transmission and Prevention o f Disease. Acta Tropica 63, 221-239. Evans-Pritchard E.E. (1937). Witchcraft, Oracles and Magic Among the Azande. London: Oxford Clarendon Press. Fayorsey Clara (1988). The Ghanaian Women’s Perception o f Disease and Sickness and Cultural Practices that affect Maternal/Infant Child University of Ghana http://ugspace.ug.edu.gh Morbidity and Mortality. (Unpublished, Dept, of Sociolog)'. University o f Ghana, Legon). Field, M.J. (1960).Search for Security: an ethno-psychiatric study of rural Ghana. London, Faber. Foster, S. (1978). Disease Etiologies in Non-Western Medical Systems. American Anthropologist, 78, 773-782. Forster S. (1991). Pricing, distribution and use o f antimalarial drugs. Bulletin of World Health Organisation, 69, 349-363. Fosu G.B. (1977). The Folk Classification of Diseases and its effects on the U tilization o f Health Care Facilities. A Case o f an Akwapim Village. Unpublished Thesis, University o f Ghana, Legon. Frazer J.G. (1890). The Golden Bough. New York: Macmillan. Gale Thomas S. (1995). “The Struggle Against Disease in the Gold Coast: Early Attempts at Urban Sanitation Reform in Transactions of the Historical Society o f Ghana, Vol. XXI, 2 New Services, No.l, Legon, Jan. 1995, pp. 185-204. 142 GDHS (1998).Ghana Demographic and Health Survey, Accra, Ghana Statistical Sendee. University of Ghana http://ugspace.ug.edu.gh GDHS (2003), Ghana Demographic and Health Survey (Preliminary Report). Accra, Ghana Statistical Service 143 Ghana Statistical Service (1993), Ghana Living Standards Survey 1991/92. Accra, Ghana Statistical Service. Glanz K. Rimer, B.K., Lewis, F.M. (2002) Health Behaviour and Health Education. Theory, Research, and Practice, San Francisco, 3rd Ed. Jossey-Bass. Gold Coast Correspondence on outbreak o f Bubonic Plague 1908-1909, National Archives of Ghana, ADM 11/1/1747, Accra. Gold Coast Government Statement on the Report o f the Commission of Enquiry into the Health Needs o f the Gold Coast, Accra, 1955. Government o f Gold Coast Report on the Medical and Sanitary Department, 1898- 1952, University o f Ghana Medical School, Accra. Government o f Gold Coast Report, Annual Reports, Accra laboratory 1911-1938, University o f Ghana Medical School, Accra. University of Ghana http://ugspace.ug.edu.gh Gyapong, M. (1998). Report on Pretesting o f Roll Back Malaria Needs Assessment Instruments in Dangbe West District, Accra. Ghana Health Services Hannay R. David (1988). Lecture Notes on Medical Sociology. Oxford, Blackwell Scientific Publications. Heggenhougen H.K. and Draper, A.D. (1990). Medical Anthropology and Primary Health Care. EPC (LSHTM) Publication No.22. Helman C.G. (2001) Culture, Health and Illness, London: Arnold. 144 Hugo Huber (1993). The Krobo Traditional, Social and Religious Life of a West African People. Fribourg: University Press. Hushie M. (1994). Management of Childhood Diarrhoea in Ghana. The Case of Pute in the Dangbe-East District, Unpublished Thesis, University of Ghana, Legon. Hussain. R.; Lobo, M.A.; Inam, B.; Khan, A.; Qureshi A.F.; Marsh. D. (1997) Pneumonia Perceptions and Management. An Ethnographic Study in Urban Squatter Settlement in Karachi, Pakistan. Social Science and Medicine Vol. 45, NO. 7, pp 991 - 1004. University of Ghana http://ugspace.ug.edu.gh Igun, U.A. (1987). Why we seek treatment here: retail pharmacy and clinical practice in Maiduguri, Nigeria. Social Science & Medicine, 24 689-695. Janz, N.K., Becker, M.H. (1984) The Health Belief Model: A Decade Later. Health Education Quarterly, 10, 1 -47 145 Janzen, J.M. (1978). The Quest for Therapy: Medical Pluralism in Lower Zaire. Los Angeles: Univ. o f California Press. King, M.E. and Hill, M.A. (ed.) (1993). Womens Education in Developing Countries - Barriers, Benefits and Policies. Baltimore: Johns Hopkins University Press. Manya Krobo District Assembly (2001): Manya Krobo District Assembly 2000 Annual Report. Odumase Krobo, Ghana. McCombie, S.C. (1996). Treatment seeking for Malaria: a review of recent research. Social Science & Medicine, 43, 933-943. Menon, A. Joof, D. Rowan, K.M., Greenwood, B.M. (1988). Maternal Administration of Chloroquine: an unexplored aspect of malaria control. Journal o f Tropical Medicine and Hygiene, 91, 49-54. University of Ghana http://ugspace.ug.edu.gh Mensah-Quainoo, E.; Odai, E.; Agyepong, I. (1995). Improving Malaria control in the context o f Health Sector Reforms in Ghana. Dangbe West Research Report Pre Intervention Baseline Study MOH Ghana/WHO. Ministry o f Health (2001), the Health of the Nation: Reflections on the First Five- Year Health Sector Programme o f Work 1997-2001, Accra, Ministry o f Health Ministry o f Health (2001). Old Enemy: New Strategies. Accra, Sonlife Press. Ministry o f Health (2001). Ministry o f Health Annual Report, 2001, MOH, Accra. Ministry o f Health (1998) Health Sector 5-Year Programme of Work, Accra, Ghana. M inistry o f Health (2000): Roll Back Malaria Strategic Plan.Accra, Ghana. Modeste Naomi, N. (1996). Dictionary o f Public Health Promotion and Education: Terms and Concepts, New York, Sage Publication. Mwenesi, H., Harpham, T. Snow, R.W. (1995). Child malaria treatment practices among mothers in Kenya. Social Science & Medicine, 40, 1271- 1277. Neugarten Bernice, L. (1979). Time, age and the life cycle. American Journal of Psychiatry 136: 887-894. University of Ghana http://ugspace.ug.edu.gh 147 Nieto, T. Mendez, F. Carrasquilla, G., (1999). Knowledge, beliefs and practices relevant for malaria control in an endemic urban area of the Colombia Pacific. Social Science & Medicine 49 (15) 601-609. Nevill, C. G (1990) Malaria in Sub-Saharan Africa. Social Science & Medicine, 31(6): 667-669 Ntow, K (1999). A study of Knowledge Attitudes, Practices and Behaviour that influence Response to Perceived Childhood Malaria in Rural Communities. Implications for Health Promotion Strategy and Policy in Ghana. Nukunya, G.K. (1992). Tradition and Change: An Introduction to Sociology. Accra: Ghana Universities Press. Osuala, E.C. (1993). Introduction to Research Methodology. Onitsha: Africana FEP. Publishers Limited. Philips. D.R. (1990). Health and Health Care in the Third World. New York, John Wiley & Sons, Inc. Radcliff-Brown (1952). Structure and Function in Primitive Society: Essays and Addresses. London: Cohen and West. University of Ghana http://ugspace.ug.edu.gh 148 Report o f Commission o f Enquiry into the health needs of the Gold Coast, Accra, 1952. Ruebush, T.K. Weller, S.C. Klein, R.E. (1992). Knowledge and Beliefs about Malaria o f the Pacific Control Plain o f Guatemala, American Journal Tropical Medicine and Hygiene 46, 451-459. Ruebush, T.K., Kern, M.K. Campbell, C.C. Loo, A.J. (1995). Self-Treatment of Malaria in a Rural Area o f Western Kenya. Bulletin o f the World Health Organization 73, 229-236. Russell. P. F. (1955). M an’s Mastery of Malaria.London, Oxford University Press. Sarantakos, S. (1993). Social Research. London: Macmillan Press. Senah, K.A. (1989). Problems of the Health Care Delivery System In: Hansen, E. and Ninsin, K.A. (ed.), The State, Development and Politics in Ghana. London: CODESRIA Book Series. Senah. K.A. (1993). The Logic of “rational” drug use. The Case o f a Rural Ghanaian Community. In Essential Drugs Monitor, No. 14, (1993). Senah. K.A. (1997) Money Be Man. The Popularity o f Medicines in a Rural Ghanaian Community. Amsterdam: Het Spinhuis. University of Ghana http://ugspace.ug.edu.gh Silva, K.T. (1991). Ayurveda, malaria and indigenous herbal tradition in Sri Lanka: Social Science & Medicine, 33, 153-160. Slustker, L., Chritsulo, L. Macheso, A. Steketee, R.W.(1994) Treatment of Malaria among children in Malawi: results o f a KAP survey. Tropical Medicine and Parasitology 45: 61-65. Somuah. H. (2001). Improving Utilization of Health Care in Dangbe West District - Is Community Health Insurance the Answer? Unpublished dissertation. Tabi, A.K. (1989). Socio-economic Groups and Health Care Utilisation, Unpublished dissertation, Department o f Sociology, University of Ghana, Legon. Tanner. M. and V lassoff C. (1998) Treatment-seeking behaviour for malaria: a typology based on endmicity and gender. Social Science & Medicine, 46 (4-5):523 Tona. L. (1999). Antimalarial activities of 20 crude extracts from nine African medicinal plants used in Kinshasa, Congo. Journal of Enthnopharmacology, 68 (1-3): 193-203. 149 Twumasi. P.A. (1972). Ashanti Traditional Medicine Transition, 8 (IV): 50-63. University of Ghana http://ugspace.ug.edu.gh 150 Twumasi, P.A. (1975). iMedical Systems in Ghana. A study of Medical Sociology, A ccra-1 ema, Ghana Publishing Corporation. Twumasi, P.A. (1986). Comparative Analysis o f Child Care Practices in Traditional and Modem Health Institutions. Unpublished Report. Twumasi, P. A. (1988). Social Foundation of the Interplay between traditional and Modem Medical System. Inaugural Lecture, University of Ghana. Twumasi, P.A. (2001). Social Research in Rural Communities (2nd Twumasi, P.A. (2002). Belief system and the control o f FIIV/AIDS infection. Unpublished Research Report to National AIDS control programme. UNICEF (2000). Situation Analysis of Children and Women in Ghana, Accra. Van der Guest, S. (1987). Self-Care and the Informal Sale o f Drugs in South Cameroon. Soc. Sci. Med. 25, 293-294. Vogel, R.J. (1988). Cost Recovery in Health Care Sector: Selected Country Studies in West Africa, World Bank No. 85, Washington D.C. Ed).Accra.Ghana Universities Press. University of Ghana http://ugspace.ug.edu.gh Waddington, C. and Enyimayew, K.A. (1990). A Price to Pay Part II, The Impact o f user charges in the Volta Region o f Ghana. International Journal o f Health Planning and Management: 5:2 89 - 312 Wellcome News (2000): Research Directions in Malaria. Supplement 6, London Winch, P.J., Makemba A.M., Kamazima, S.R., Lwhihula, G.K., Lubega, P., Mingas J.N., Shiff C.J. (1994). Seasonal variation in the perceived risk o f malaria; implication for the promotion o f insecticide impregnated bednets. Social Science and Medicine 39, 63-75. World Health Organisation (1978): Declaration o f Alma Ata. Report on the International Conference on Primary Health Care, Alma Ata, Geneva. World Health Organisation (1993): 1991-92 Progress Research Report on Tropical Diseases. Geneva. World Health Organisation (2003): The African malaria Report. Geneva. WHO/CDS/MAL/2003. World Health Organisation (1997): World Malaria Situation, 1994. Weekly Epidemiological Recod, 72 (36): 269-276 World Health Report (1998), Life in the 21st century: a vision for all. Geneva, World health Organisation, 1998: 90-104 University of Ghana http://ugspace.ug.edu.gh World Health Organisation (WHO) Report, 1993. A Global Strategy for Malaria Control. Geneva. Yeneneh. H., Gyorkos, T.W., Joseph, L. Pickering, J. Tedla. S. (1993). Antimalarial drug utilization by Women in Ethiopia: a knowledge - attitude-practice study. Bulletin of the World Health Organisation, 71, 763-772. 152University of Ghana http://ugspace.ug.edu.gh APPENDIX A DEPARTMENT OF SOCIOLOGY UNIVERSITY OF GHANA INTERVIEW SCHEDULE ON THE LOCAL MANAGEMENT OF CHILDHOOD MALARIA INTRODUCTION This study is an academic exercise being conducted to find out your views and practices as mothers and carers concerning some illnesses affecting children in this district. The information you provide will be useful in coming up with appropriate solutions to your children health problems and also be treated in confidence and in Trust. We shall be grateful if you could spare us a little time to interview you. SECTION A: IDENTIFICATION 1. Interview N o :....................................................... Date: 2. Town/Village:.......................................................................................................... 3. Respondent Category: Parent | | Carer | | University of Ghana http://ugspace.ug.edu.gh 4. Do you care for a child under five years? 1. Yes I I 2. No 5. What is your relationship to the Child? 154 SECTION B SOCIO DEMOGRAPHIC DATA 6. Could you please tell me your age?.............................................................................. 7. Which religious group do you belong to? 1. Christian CHI 4. No Religion d U □ 2. Moslem 5. O ther:.............................................................. 3. Traditional |-----1 8. What is your highest level of education? 1. Primary: Complete I 1 4. Tertiary: Complete □ Incomplete Incomplete |---- 1 2. JSS/Middle School: Complete □ 5. No education □ Incomplete 6. Other (specify) 3. SS S/Secondary /Technical/Voc.: Complete □ Incomplete I 1 9. Can you indicate below how you can read and understand a letter or a newspaper? 1. Easily |--1 2. With difficulty | | 3. Not at all | | University of Ghana http://ugspace.ug.edu.gh 155 10. What is your principal occupation?...................................... 11. What is your marital status? 1. Married q 4. Separated |— ] 2. Single □ 5. Widowed □ 3. Divorced I 1 12. About how much is your monthly income? 1. Less than 0100,000 a month 2.0100.000 - 0200,000 a month I I 3.0200.000 - 0300,000 a month j---- j 4.0300.000 - 0400,000 a month | | 5 .0400.000 - 0500,000 a month I I □ 6.0500.000 - plus SECTION C: PERCEPTION /KNOWLEDGE OF THE CAUSES AND TRANSMISSION OF MALARIA 13. What do you think are the common diseases affecting Children in this community? (Please rank them in order of importance) 1................................................................................................ 2 .................................................................................................... 3 .................................................................................................................... 4 .................................................................................................................... 5.................................................................................................................... *14. Have you heard o f Malaria/Fever? 1. Yes CHI 2. No I I *skip question 14 if malaria/fever is mentioned in question 13 University of Ghana http://ugspace.ug.edu.gh What other name(s) if any, does malaria/fever have in the local language? How common is malaria/fever in this community? 1. Very common CZH 2. Common □ □ 3. Not Common □ □ □ 4. Don’t know Which group of people does it attack most? 1. Children I I 2. Adults I I 3. Both I I Generally, what cause(s) malaria in adults? What in your opinion cause(s) malaria/fever in children? How can you tell whether a child has malaria/fever (signs and symptoms)? Please list them. 1......................................................... 2 ......................................................... 3 .................................................................. 4 .............................................................. 5 .................................................................. 6..................................................... Do you think malaria can lead to the death of a child? 1. Yes □ 2. No □ Can you explain why? University of Ghana http://ugspace.ug.edu.gh 23. Can you explain how the malaria parasite is transmitted? 1. Yes 2. No 24. If yes, how? ..................................................................................... SECTION D: MALARIA PREVENTION 25. Do you think malaria can be prevented? 1. Yes □ 2. No D 3. Don’t □ Know 26. If yes, in what ways can malaria be prevented? List 27. If no, why? 28. What do you do to prevent your child from getting malaria? 29. Have you heard about the insecticide treated mosquito net? [ ^ Y e s | | 2.No 30. If yes from where/whom did you hear about it? 31. Have you ever used the insecticide treated mosquito net? 1. Yes CD 2. No C D University of Ghana http://ugspace.ug.edu.gh 32. Are you now using the insecticide treated mosquito net? 1. Yes 2.No. ^ 33. If no, why? SECTION E.: LOCAL MANAGEMENT OF MALARIA AND TREATMENT SEEKING BEHAVIOUR 34. Did any o f your children under five years have malaria/fever anytime in the past Month? 1. Yes ^ ^ 2. No. ^ ^ 3. Don’t Know ' ' 35. If yes, how did you know that the sick child had malaria? 36. What did you do first? Tick only one answer 1. Went to hospital □ 2. Went to Flealth Center/MCH Clinic/Post □ 3. Went to private hospital/clinic □ □ 4. Went to pharmacy/chemist/drug 5. Went to village health worker □ 6. Went to drug peddler □ □ 7. Went to traditional healer □ 8. Went to traditional birth attendant 9. Treated child myself □ □ 10. Sought advice from relatives/friends 11. Did nothing □ University of Ghana http://ugspace.ug.edu.gh 159 specify)....................................................................... 37. Which medication did you administer to the child? 12. O ther 38. Was the sick child cured after your first action? l .Y e s d D 2. No □ □ 39. If no, what did you do next to seek treatment for your sick child? 40. Have you ever administered the chloroquine tablet to your sick child at 41. If yes, where did you get the chloroquine tablet? 42. Are you familiar with the correct dose o f chloroquine tablets for a child 43. If yes, what amount o f chloroquine tablets did you give to the sick child? Indicate the number o f tablets and the no of days administered? 1. Under 12 months: Day 1 I 1 Day2 I 1 Day 3 I 1 Day 4 I 1 home? 1. Yes I I 2. No I I with malaria? 1. Y es □ □ Day 5 Day 6 2. 1-4 years Day 1 | | Day2 | | Day 3 | [ Day 4 | | □ □ Day 5 Day 6 44. Do you ever try to treat the disease yourself at home? 1. Yes always I I 2. Sometimes I I 3. No I I 45. I f yes, why? □ d University of Ghana http://ugspace.ug.edu.gh 1. No money for hospital/clinic/health post 4. Health workers not friendly 2. Clinic or hospital too far □ 5. Have left over drugs from previous treatment 3. Long waiting time at hospital I I 6. Other (specify).......................................................... 46. If no to question 48, why? 47. What cause(s) Convulsion (local name)? 48. Has your child ever developed convulsion? l.Y e s I I 2. No 4 I If yes, what did you do? 1. treated child at home ^ ^ 4. did nothing 2. sent child to traditional healer I I 5. other (specify) | | 3. sent child to hospital/clinic I----1 SECTION F: CHOICE OF HEALTH CARE OL'TLKT 50. How far is the nearest clinic/health post? 1. less than lkm |----- 1 4. 6-10 km |----- 1 2. 1-2 km □ 5. 10-20km q 3. 2-5 km I I 6. more than 30km I I 51. Do you sometimes take your sick child to the hospital/clinic? 1. Yes CZH 2. No 52. I f yes, what consideration affects your decision to take your sick child to hospital? University of Ghana http://ugspace.ug.edu.gh 161 53. Do you sometimes take your sick child to a traditional healer? 1. Yes ^ No ------- 54. If yes, what factors affect your decision to take your sick child to a traditional healer? 55. Do you sometimes seek treatment for your sick child from a chemist/drug store? 1. Yes □ 2. No □ 56. If yes, what influence your decision to seek treatment for your sick child from a drug store/chemical? 57. Do you sometimes seek treatment for your sick child from a Faith □ □ Healer/spiritualist? 1. Yes 2. No 58. If yes, what consideration affects your decision to take your sick child to a Faith Healer/spiritualist? 59. Do you normally seek advice from somebody on what to do when your child is sick? l.Y es I---- 1 2. No I---- 1 60. If yes, who?......................................................................................................... University of Ghana http://ugspace.ug.edu.gh 162 SECTION G: SOURCES OF INFORMATION 61. How often do you listen to radio? 1. Very often I I 2. Often I I 3. Sometimes | | 4. Not at all |---- 1 62. Which station do you often listen to? 63. Which programmes do you often listen to? (List).......................................................... 64. How often do you watch television? 1. Daily I I 2. Week-ends I 1 3. Not at all I I 65. Which station do you often watch? 66. Which programme do you often watch? (list).............................................................. 67. From which sources o f information have you learned most about malaria and its prevention? 1. Radio 2. Television □ □ 3. Newspaper/magazines I 1 □ 4. Pamphlets/Posters □ 5. Schools/Teachers 6. Slogans/Music (specify)............... □ 7. Churches/Mosques 8. Community Meeting 9. Friends/Relatives 10. Work Place 11. Adult Literacy Class 12. □ □ □ □ □ Other University of Ghana http://ugspace.ug.edu.gh Any general comment on malaria? University of Ghana http://ugspace.ug.edu.gh 164 APPENDIX B FOCUS GROUP DISCUSSION GUIDE 1. What are the major childhood illnesses in this community? 2. Which one is the most common childhood illness? 3. What is the local name for malaria/fever? Any other local name? 4. What causes malaria/fever? 5. What are the signs and symptoms of malaria/fever in children? 6. What action do you normally take when your child has malaria/fever? What further action do you take to seek health care for your sick child? 7. What cause(s) convulsion (local name)? How do you manage convulsion? How can it be prevented? 8. From whom do you normally seek advice when your child is sick? Why? 9. How can malaria/fever be prevented? 10. What do you think should be done to reduce the incidence o f malaria in your community? 11. What medications are effective for the prevention o f malaria/fever? 12. What medications are effective for the treatment o f malaria/fever? THANK YOU University of Ghana http://ugspace.ug.edu.gh 165 APPENDIX C Sample Size Calculation (EPI) Formular n = z2pq d2 where: n = the desired sample size z = the standard normal deviate (95% o f 1.96) p = the proportion of target population estimated to seek scientific medical treatment (0.50) q = 1.0- p d = degree o f accuracy desired (0.05) =^> n (1.962 (0.501 (0.50) (0.05)2 384 University of Ghana http://ugspace.ug.edu.gh