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SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
 
PERFORMANCE  OF  COMMUNITY BASED AGENTS  IN HOME BASED 
CARE FOR MALARIA IN UNDER FIVES IN JIRAPA AND LAMBUSSIE  
DISTRICTS OF THE  UPPER WEST REGION,GHANA 
 
 
 
 
 
By 
 
 
PHOEBE BALAGUMYETIME 
(10361116) 
 
 
 
“THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, 
LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE 
AWARD OF MPHIL APPLIED EPIDEMIOLOGY AND DISEASE CONTROL 
DEGREE” 
 
 
 
 
 
JULY, 2014 
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DECLARATION 
I, Phoebe Balagumetime, do hereby declare that except for references to work done 
by other investigators which have been duly acknowledged, this thesis is the result of 
my own original research, and has not been presented, either in whole or in part, for 
another degree elsewhere. 
 
 
 
         
 
CANDIDATE:   ……………………………………… 
                                                      Phoebe Balagumyetime    
   
 
 
SUPERVISOR:  ……………………………………….. 
Dr. Frederick  Wurapa     
   
 
 
 
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ACKNOWLEDGEMENT 
 
Special thanks is due the Almighty God for his guidance and protection throughout the 
course. I am personally indebted to the Centers for Disease Control and Prevention and the 
President‟s Malaria Initiative  for providing financial support for my course. 
 
I am particularly grateful to my supervisors; Dr Frederick  Wurapa and Professor Edwin 
Afari for the  technical and moral support given to me.  
 
 I also acknowledge the  academic and administrative staff of the School of Public Health for 
for their immense support.  
 
I  thank the Upper West Regional Director of Health Services, Dr Alexis Nang-beifubah, and 
the Directors of Health Services of the sampled districts and their entire staff for their 
unrelenting support and cooperation. 
 
To the data collectors of both Jirapa and Lambussie districts, may God bless you  for the 
good work done inspite of the trying conditions under which you collected the data.Finally, 
the invaluable assistance of  Emmanual Bachan, Konlan Konbian and Douglas Aleungura in 
the data entry is very much appreciated. 
 
To many others, especially my collegues in cohort five and my family, I thank you  all for the 
support, love and encouragement. 
 
 
 
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TABLE OF CONTENTS 
DECLARATION....................................................................................................................... i 
ACKNOWLEDGEMENT ....................................................................................................... ii 
LIST OF TABLES .................................................................................................................. ix 
LIST OF ABBREVIATIONS ................................................................................................ xi 
ABSTRACT ............................................................................................................................ xii 
 
CHAPTER ONE ...................................................................................................................... 1 
1.0 INTRODUCTION.............................................................................................................. 1 
1.1 Background ...................................................................................................................... 1 
1.2 Problem Statement ........................................................................................................... 4 
1.2.1 Conceptual Frame work ................................................................................................ 6 
1.3 Justification ...................................................................................................................... 7 
1.4 Study objectives ............................................................................................................... 8 
1.4.1 General objective .......................................................................................................... 8 
1.4.2 Specific Objectives ....................................................................................................... 8 
 
CHAPTER TWO ..................................................................................................................... 9 
2.0 LITERATURE REVIEW ................................................................................................. 9 
2.1 Selection and characteristics of CHWs .......................................................................... 10 
2.2 Training of CHWs.......................................................................................................... 12 
2.3 Knowledge of CHWs ..................................................................................................... 12 
2.3.1 Case Management ....................................................................................................... 13 
2.3.2 Medicine supply .......................................................................................................... 14 
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2.3.3 Referrals ...................................................................................................................... 14 
2.3.4 Reporting system ........................................................................................................ 15 
2.4  Supervision ................................................................................................................... 15 
2.5 Opinions of Community Members about CHWs........................................................... 15 
2.6 Sustainaibility ................................................................................................................ 16 
 
CHAPTER THREE ............................................................................................................... 17 
3.0 METHODS ....................................................................................................................... 17 
3.1 Study Design .................................................................................................................. 17 
3.2 StudyArea ...................................................................................................................... 17 
3.2.1 Demographic Characteristics ...................................................................................... 17 
3.2.2 Climate ........................................................................................................................ 18 
3.2.3 Vegetation ................................................................................................................... 18 
3.2.4 Transport and Communication ................................................................................... 18 
3.2.5 Culture and Religion ................................................................................................... 19 
3.2.6 Family and Kinship ..................................................................................................... 19 
3.2.7 Health Services Organisation ...................................................................................... 19 
3.3 Study Population ............................................................................................................ 20 
3.4  Sampling ....................................................................................................................... 21 
3.4.1 Sample Size ................................................................................................................. 21 
3.4.2  Sampling Method ....................................................................................................... 22 
3.4.3 Variables ..................................................................................................................... 23 
3.44 Outcome Variable Definition ....................................................................................... 25 
3.5 Ethical Considerations ................................................................................................... 25 
3.5.1 Consenting Process ..................................................................................................... 26 
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3.6 Training of Research Assistants and Pretesting ............................................................. 27 
3.7 Data collection ............................................................................................................... 27 
3.8 Data Management and Analysis .................................................................................... 28 
3.8.1Field Editing................................................................................................................. 28 
3.8.2 Coding and Transcription ........................................................................................... 28 
3.8.3 Data Entry and Cleaning ............................................................................................. 29 
3.8.4 Statistical Analysis ...................................................................................................... 29 
3.8.5 Quality Assurance ....................................................................................................... 29 
 
CHAPTER FOUR .................................................................................................................. 30 
4.0 RESULTS ..................................................................................................................... 30 
4.1 Background Characteristics of Respondents ................................................................. 30 
4.1.1 Characteristics of Respondents ................................................................................... 30 
4.2 CBA Training................................................................................................................. 33 
4.3 Knowledge and Perceptions  of CBAs in HMM ........................................................... 34 
4.3.1 Causes and symptoms of malaria ................................................................................ 34 
4.3.2  Assessing the sick child ............................................................................................. 35 
4.3.3 Knowledge of dosage of ACTs ................................................................................... 36 
4.3.4 Ensuring Treatment Compliance ................................................................................ 37 
4.3.5 Knowledge on Danger Signs and Referrals ................................................................ 37 
4.3.6 Knowledge of ways to prevent Malaria ...................................................................... 38 
4.4  Practices of CBAs in HMM .......................................................................................... 39 
4.4.1 Drug Availability and Storage .................................................................................... 39 
4.4.2 Logistics Availability .................................................................................................. 39 
4.4.3 Management of Childhood Malaria ............................................................................ 40 
4.4.3.1 Giving age appropriate dose of ACTs ..................................................................... 41 
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4.4.3.2 Education on Malaria Prevention............................................................................. 42 
4.5 Records Review ............................................................................................................. 42 
4.5.1 Utilisation of CBA Services........................................................................................ 42 
4.5.2 Documentation and Reporting .................................................................................... 43 
4.5.3 IE&C Activities Carried Out ...................................................................................... 44 
4.6 Support Systems............................................................................................................. 44 
4.6.1 Monitoring and Supervision ....................................................................................... 44 
4.6.2 Motivation ................................................................................................................... 45 
4.7.3 Attrition of CBAs ........................................................................................................ 45 
4.8 Perception of Community Members on Performance of CBAs .................................... 45 
4.8.2 Perception of Health Workers on Performance of CBAs ........................................... 50 
4.9 Challenges of  CBAs ...................................................................................................... 51 
4.9.1 Strategies for Sustainability ........................................................................................ 52 
 
CHAPTER FIVE ................................................................................................................... 53 
5.0 DISCUSSION ................................................................................................................ 53 
5.1 Limitations of the Study................................................................................................. 63 
 
CHAPTER SIX ...................................................................................................................... 64 
6.0 CONCLUSIONS AND RECOMMENDATIONS ......................................................... 64 
6.1 Conclusion ..................................................................................................................... 64 
6.2 Recommendations .......................................................................................................... 64 
 
  
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REFERENCES ....................................................................................................................... 66 
APPENDIXES ........................................................................................................................ 77 
APPENDIX 1: INFORMATION SHEET/ CONSENT FOR PARTICIPANTS ................. 77 
APPENDIX 2: DATA COLLECTION TOOLS.................................................................. 80 
 
 
 
 
 
 
 
 
  
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LIST OF FIGURES AND MAPS 
Figure 1:Conceptual Framework ............................................................................................... 6 
Figure 2: Map of UWR  Showing Study Districts ................................................................... 20 
Figure 4: Knowledge of CBAs in Jirapa and Lambussie Districts on Signs and Symptoms of 
Malaria, 2013 ........................................................................................................................... 35 
Figure 5:  CBAs knowledge on Danger Signs in Jirapa and Lambussie Districts, 2013 ......... 38 
Figure 6: Availability and Completeness of   CBAs Reports in Jirapa and Lambussie  
Districts for 2012 ..................................................................................................................... 43 
Figure 7: Reporting Rates of CBAs in Jirapa And Lambussie Districts for  2012 .................. 44 
Figure 8: Proportion of CBAs Supervised in Jirapa and Lambussie Districts in 2012 ........... 45 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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LIST OF TABLES 
 
Table 1:Variable – Indicator – Data collection technique – Data source Matrix .................... 24 
Table 2: Profiles of Jirapa and Lambussie Districts where the study was conducted, 2013 ... 30 
Table 3: Discriptive characteristics  of CBAs  interviewed in Jirapa and Lambussie 
Districts,2013 ................................................................................................................... 31 
Table 4: Demographic and Socio-economic characteristics of mothers/care givers in Jirapa 
and Lambussie Districts, 2013 ......................................................................................... 32 
Table 5: Demographic and socio-economic characteristics of opinion leaders  in Jirapa and 
Lambussie Districts, 2013 ................................................................................................ 33 
Table 6:Training details of CBAs in Jirapa and Lambussie Districts, 2013 ............................ 34 
Table 7: Knowledge of CBAs in Jirapa and Lambussie Districts on the cause of malaria, 2013
.......................................................................................................................................... 34 
Table 8: Knowledge of CBAs on correct dosage of A/A for children 6- 11months in Jirapa 
and Lambussie Districts, 2013 ......................................................................................... 36 
Table 9: Association between formal education and knowledge of the correct dosage of A/A 
for children ....................................................................................................................... 36 
Table 10: Knowledge of CBAs on correct  dosage of A/A for children aged 12-59 months in 
Jirapa and Lambussie Districts, 2013 .............................................................................. 36 
Table 11: Association between formal education and knowledge of the correct dosage of A/A 
for children aged 12- 59 months ,2013 ............................................................................ 37 
Table 12: Association between CBA District of origin and knowledge of the right dosage  of 
A/A for children 6-11 months old in Jirapa and Lambussie Districts, 2013 ................... 37 
Table 13: Availability  and condition of  CBAs logistics in Jirapa and LambussieDistricts, 
2013.................................................................................................................................. 40 
Table 14: Assessment of sick children by CBAs in Jirapa district, 2013 ................................ 41 
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Table 15:Proportion of CBAs observed giving age appropriate dose of ACTs to children aged
.......................................................................................................................................... 41 
Table 16: Association between formal education and giving the correct dose of ACTs for 
children aged 6-59 months   in Jirapa District, 2013 ....................................................... 42 
Table 17: Children treated and referred by CBAs in Jirapa and LambussieDistricts in 2012 . 43 
Table 18: Responses from mothers/care givers in Jirapa  and Lambussie Districts, 2013 ...... 46 
Table 19: Responses of mothers/care givers on actions taken by CBAs for sick children in 
Jirapa and Lambussie Districts, 2013 .............................................................................. 47 
Table 20: Responses of Opinion leaders  in Jirapa  and Lambussie Districts,2013 ................ 47 
Table 21:Responses   of  mothers/care givers  on good and poor  performing areas of CBAs  
in Jirapa and Lambussie Districts, 2013 .......................................................................... 48 
Table 22:Responses of opinion leaders  on good and poor  performing areas of CBAs  in 
Jirapa and Lambussie Districts, 2013 .............................................................................. 48 
Table 23: Views of mothers/caregivers  on the performance of CBAs in Jirapa and Lambussie  
Districts, 2013 .................................................................................................................. 49 
Table 24: Views of opinion leaders  on the performance of CBAs in Jirapa and Lambussie 
Districts, 2013 .................................................................................................................. 49 
 
 
 
 
 
 
 
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LIST OF ABBREVIATIONS 
   AA ArtesunateAmodiaquine 
  ACT  Artemisinin based combination therapy 
 CBA Community-Based Agents  
  CCM Community Case Management  
 CHPS Community Based Health Planning and Services  
CBSV Community Based Surveillance Volunteers  
CDD Community Drug Distributors 
  CHN Community Health Nurse 
  CHW Community Health Worker 
  C-IMCI Community Intergrated Management of Childhood Illness 
CORPS  Community Resource Persons  
  CMD Community Medicine Distributors  
 DD Drug  Distributors  
   DDHS District Director of Health Services  
 DHIMS District Health Management Information Systems 
FGD Focus Group Discussion 
  FMOH Federal Ministry of Health 
  GDHS Ghana Demographic and Health Survey 
 GHS Ghana Health service 
  HBC Home Based Care 
   HBM Home Based Management 
  HBMF Home Based Management of Fever 
 HMM Home Based Management of Malaria 
 ICCM Intergrated Community Case Management 
IE&C Information, Education and Communication 
ITN Insecticide Treated Nets 
  KII Key Informant Interviews  
  KNUST Kwame Nkrumah University of Science and Technology 
MOH Ministry of Health 
   MDG Millennium Development Goals 
 NMCP National Malaria Control Programme 
 NMR Neonatal Mortality Rate 
  OPD Out Patient Department 
  ORS Oral Rehydration Salt 
  RBM Roll Back Malaria 
   RDHS Regional Director of Health Services  
 RHMT Regional Health Management Team 
 SDHT Subdistrict Health Team  
  TBA Traditional Birth Attendant 
  UNICEF United Nations Childrens Fund 
  UWR Upper West Region 
   WHO World Health Organisation  
  
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ABSTRACT 
 
Introduction:Home-based Management of Malaria (HMM) is a strategy to increase access to 
malaria treatment in Africa. In 2006, the strategy was launched in the Upper West Region 
(UWR) of Ghana. Community Based Agents (CBAs) were trained and equipped to provide 
home-based treatment  to children aged 6-59 months with malaria. HMM was expected to 
reduce the number of children seen in health facilities with malaria. However, there has been 
a consistent increase in the burden of malaria since 2009 despite the  role CBAs are  expected 
to play in reducing the burden of malaria. This study was conducted to assess the knowledge 
and performance of CBAs on HMM, eight years after it‟s implementation and to assess the 
perception of  community members  and health workers about the services provided by CBAs 
in the region. 
Methods: A cross-sectional study was conducted in two purposive selected districts in the 
UWR.We interviewed 384 CBAs and 154 mothers/caregivers using a structured 
questionnaire.We conducted  Key Informant Interviews (KII) with 13 community leaders and 
15 health workers and  held  2 Focus Group Discussions (FGDs) with mothers/caregivers. 
CBAs and health facility records were also reviewed and we observed the management  
practices  of 37 CBAs  offering services at the time of interviews. Variables obtained were 
age, sex, and indicators on knowledge and management practices. Data entry, cleaning and 
analysis was done using SPSS software version 18.0. Descriptive data analysis was done and 
categorical variables expressed as frequencies and relative frequencies. For bi-variate 
analysis, cross tabulation was undertaken to establish associations and  results  presented in 
tables. Significance level of 5% (0.05) was used. Qualitative data from KII and FGDs were 
translated and transcribed into English, coded and thereafter analysed and separated into the 
emerging themes. 
Results:The mean age of CBAs was 42.71(+/- 9.62) with 369(96%) being  females.  
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Majority of the  CBAs  352 (91.7%) knew the cause of  malaria and 318(82.8%) knew that , 
fever is the most common symptom of malaria. However, very few, 171(44.5%) knew the 
correct  dosage of Artemisinin-based Combination Therapy (ACTs) for children aged 6-11 
months. Out of the 37 CBAs observed, 86.5% (32/37), (95% CI: 74.2 –97.7) gave correct age 
appropriate dose, but only 10(27%) observed the children for danger signs. There was no 
significant association  between formal education and knowledge of the correct dosage  of 
ACTs for children aged 6-59 months. Residing in Jirapa was positively associated with 
knowledge on the correct dosage of ACTs  for children 6-11 months old (P-value 0.00). Of 
the 12,128 children who reported with malaria in 2012, only 5,343 (44%) were seen by 
CBAs. This was lower than the target of 60% in the guidelines. Monthly reporting rate of 
CBAs ranged from 53% to 79% in Jirapa and 43% to 88% in Lambussie. Only196(51%) of 
the CBAs had supervisory visits. Of the 154 mothers/caregivers  interviewed, 116(75.3%) 
had utilized the services of CBAs. Among the 116 who utilized the services of CBAs; 
95(81.9%) reported that CBAs took history, 86(74.1%) said their children were assessed 
before receiving treatment and 66(56.9%) were counseled on treatment compliance. Only 
9(7.7%) were educated on malaria prevention in their communities. In all, 104(67.5%) of  
mothers/caregivers and 12(92.3%) of opinion leaders  had good opinions about the role and 
performance of CBAs in the management of sick children. Mothers/caregivers at the FGDs 
were however of the view that CBAs are doing well in community education on malaria 
prevention. 
Conclusion: A high proportion  of  CBAs do not know the correct  dosage of ACTs  for 
children aged 6-11 months. Many CBAs were  not supervised. Although most CBAs took 
history and examined  children before giving treatment, observing for danger signs, client 
counseling and reporting on activities was not done regularly. We recommend  re-training 
and  regular supervision of all CBAs. 
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CHAPTER ONE 
1.0 INTRODUCTION 
1.1 Background 
Malaria is a global health emergency killing millions of people each year (Roll Back 
Malaria [RBM]/World Health Organisation [WHO],2012).The disease affects  people of all 
ages and economic groups,but the most affected are pregnant women and children under five 
years of age because of their lowered  immunity.Over 80% of malaria related illnesses and 
deaths occur in Africa (United Nations Children‟s Fund[UNICEF]/WHO,2006) with about 
75% of the deaths occurring  in children (WHO, 2012a). Malaria  kills a child every minute 
in Africa (UNICEF, 2013;WHO, 2014). 
Malaria is not only a cause of severe illness and death,  but also a major cause of 
school and work-absenteeism, low economic productivity and long-term disability from 
severe illness in endemic countries (National Malaria Control Programme, Federal Ministry 
of Health[FMOH], Nigeria, 2005). It is further reported that about 2% of children with 
recurrent episodes of complicated malaria particularly cerebral malaria results in brain 
damage (WHO/UNICEF, 2003). 
The economic toll  of malaria on healthcare systems is enormous, with the cost of 
treatment consuming as much as 40% of national healthcare budgets in developing 
countries.It is estimated that malaria-related illnesses and deaths  cost Africa's economy about  
US$12 billion per year (Management Strategies for Improving Health Services, 
2003;RBM/WHO,  2012) and the cost related to complicated malaria drives households into 
poverty  (The President‟s Malaria Initiative, 2007 as cited in Ghana Statistical Service & 
Ghana Health Service , 2009). 
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Like many other African countries, malaria is a leading cause of morbidity and 
mortality in Ghana,especially among pregnant women and children under the age of five 
(National Malaria Control Programme [NMCP], 2009). The disease is prevalent in all parts of 
the country with seasonal variations.  
It is approximated that 3 to 3.5 million suspected cases of malaria are reported yearly 
in public health facilities, constituting 30-40% of Out Patient Department  (OPD) attendance. 
Out of this figure, more than 900,000 are children less than five years of age (The President‟s 
Malaria Initiative, 2007 as cited in Ghana Statistical Service & Ghana Health Service,2009; 
UNICEF, 2012).Malaria is said to account for about 48.8% of total hospital admissions of 
children under five years ( NMCP, 2010) and  about 30% of under-five mortality in Ghana 
(UNICEF, 2012). According to Asante and Asenso-Okyere (2003), malaria accounts for an 
average of  9 work days lost per malaria episode by the patient and more than 5 work days by 
the caretaker in Ghana.School children also loose about four school days due to malaria 
illness.  
In the Upper West Region (UWR), malaria accounts for almost 50% of the total OPD 
attendance (Ghana Health Service (GHS), 2012) and the prevalence rate of malaria in 
children aged 6-59 months is 51% (Ghana Statistical Service,2012a). In a study conducted by 
Akazili, Aikins & Binka (2007) in Northern Ghana, direct or out of pocket expenditure on 
malaria constituted  29% of the total cost of malaria treatment and the  indirect cost, which 
involves  waiting and travel times  accounted  for 71% of the total cost of a malaria episode. 
The cost of malaria care was also estimated to be 1%  of the income of the rich and  34% of 
the poor household‟s income. 
The Millennium Development Goals (MDGs), which are the world's time-bound and 
quantified targets for addressing extreme poverty in its many dimensions enjoins all 
stakeholders to reduce by two- thirds under five mortality and to halt and reverse the 
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incidence of malaria by 2015 (United Nations Millennium Project, 2006;United Nations, 
2010 ). In Ghana, the under five mortality rate(U5MR) and neonatal mortality rate (NMR) are 
80/1000 and 30/1000 live births respectively.The rates are however higher in the UWR with 
U5MR and NMR being 142/1000 and 45/1000 live births respectively (Ghana Statistical 
Service & Ghana Health Service, 2009). Malaria is a major contributor to these mortality 
rates. 
Prompt access to effective anti-malarial treatment within 24 hours of onset of 
symptoms is one of the major strategies for reducing the malaria burden (WHO, 2005a).This 
can only be achieved if treatment is  close to communities or households .  In response to this 
challenge, African leaders committed themselves to actions targeted at ensuring  that 80% of 
malaria episodes are adequately treated within 24 hours of onset of symptoms by 2010 
(WHO/RBM, 2005c). However, initiatives to provide such access should take into 
consideration the poor, rural and vulnerable populations in malaria-endemic countries who 
are underserved by the formal health system (WHO 2000). 
In Ghana for instance, almost 50% of the total population live in rural areas (Ghana 
Statistical Service, 2012b), thus treatment of malaria is  challenged by geographic and socio-
economic barriers, inadequate and inequitable distribution of health-care infrastructure and 
the requisite man power..This means that patients with malaria, particularly children are 
likely to die before accessing health services. As a result, treatment of children with malaria 
at home , using shop bought drugs has become a common practice (Foster, 1991; Agyepong, 
1992; Mwenesi, Harpham, & Snow,1995;Buabeng, Duwiejua, Dodoo, Matowe,& Enlund, 
2007). The risk of taking incorrect doses and non compliance to treatment regimen in such 
home based treatments is very high. Additionally, self medication may not only result in the 
use of sub-standard and counterfeit medicines but also increase the risk of resistance to anti-
malarials. 
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In a bid to increase prompt access to early diagnosis and effective anti-malarial 
therapy,WHO is promoting Home-based Management of Malaria (HMM) in Africa.The 
strategy promotes access to pre-packed quality anti-malarial drugs within 24 hours of the 
onset of symptoms delivered through trained community resource persons. Several African 
countries have adopted the WHO home-based management of malaria in an effort to improve 
prompt access to treatment. HMM  is being implemented and scaled up in countries such as 
Ethiopia, Uganda, Burkina Faso and Nigeria (UNICEF, 2005)..  
The Ghana Health Service (GHS) in collaboration with UNICEF and the Department 
of Community Health of the Kwame Nkrumah University of Science and Technology 
(KNUST) have since the year 2003 made efforts to scale up and strengthen the 
implementation of HMM in the country.The strategy is aimed at increasing access to prompt 
and effective malaria treatment to children under five years delivered by trained Community 
Health Workers (CHWs). 
1.2 Problem Statement 
 
In 2006, the UWR launched HMM as an initial component of the Community 
Integrated Management of Childhood Illness (C-IMCI) in eight districts with support from 
UNICEF.The strategy was implemented through dialogue with opinion and political leaders 
and community entry and mobilization. A total of 2,583 CBAs were selected and trained on 
HMM and given pre-packed treatment of a combination of Artesunate and Amodiaquine 
(AA) to treat children  6-59 months old based on presumptive symptoms of malaria. 
Subsequent to the implementation, they were supported with logistics to facilitate their work. 
District and health facility  staffs were trained along side  the CBAs to enable them provide 
monthly monitoring and supervision to sustain the quality of case management and to avoid 
stock out of drugs and non-drug consumables.The implementation of HMM in the region is 
to ensure that about 60% of children  under five years especially in deprived areas which are 
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particularly under served by the formal health sector have access to prompt and appropriate 
anti-malarials to reduce the burden of malaria. 
A year after the  implementation of this strategy, results from the Ghana Demographic 
and Health Survey [GDHS], 2008, revealed that, only 20.2%  of the 41% of children under 
five years in the region who received anti-malarial drugs received the treatment the same day 
or the next day. Similarly, an assessment of routine data in 2010 by UNICEF on Integrated 
Community Case Management (ICCM) in Ghana  showed that the coverage of children seen 
by CBAs falls far short of the set target of 60% in the region. An indication that prompt 
access to anti-malarials is still a challenge despite the  role  CBAs are expected to play in 
improving access. 
Almost eight years after the introduction of  HMM  in the region, malaria has 
remained the top cause of OPD  attendance in all health facilities, with malaria in children 
under five years accounting for 25% of cases in 2009, 29% in 2010 and 31% in 2011 
respectively (Upper West Health Sector Annual Report, 2012), yet a decline has been 
anticipated.The regional routine data from 2010-2012 also indicate incomplete and low 
reporting rates (>50%) by CBAs and there are undocumented complaints of client 
dissatisfaction with the quality of care received from some CBAs. A variety of factors 
ranging from socio-cultural to health service related factors may be responsible for the 
problems enumerated, but the exact  factors are not known. 
Thus the apparent lack of and important need for  such information and it‟s related 
implications is of grave concern. It is for this reason that the study was conducted to assess 
the knowledge and performance of CBAs on malaria treatment and to assess the perception of  
community members and health workers about the services provided by CBAs in the region.  
 
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1.2.1 Conceptual Frame work 
 
The conceptual framework presented (Figure 1) describes the independent variables, and 
takes  into account contextual and key socio-cultural and health service related factors, which 
interact differently to impact on the performance of CBAs in the region. 
    Figure 1:Conceptual Framework 
Performance  
of  
CBA in HMM 
 
 
Service related factors  
 Training manuals and protocols  
Anti-malaria drug policy  
Pre-service training and updates  
Drug and logistic supply  
Reporting formats  
IE&C materials  
 Support systems  (motivation, 
quarterly meetings ) 
 Mo itoring an   sup rvision 
 
 
Knowledge and Perception   
•Knowledge on malaria , causes and prevention 
•Recognition of   signs & symptoms 
 of malaria  
•Identification of danger signs for referral   
•Value placed on HMM  
 
 
Socio cultural  factors: 
• Demographic factors (Age,  
gender, educational level) 
• Socio-economic (occupation) 
•Marital status  
•Religion  
•Cultural beliefs  
•No of years of service  
 
 
Practices   
• Administer standard malaria   
treatment  
•Counseling and follow up for  
treatment compliance  
•Referrals  
•IE&C and advocacy /health  
Promotion  activities  
Drugs and logistics supply and 
 management  
Documentation, reporting and  
record keeping 
 
Community Related  factors  
•Selection process of CBAs 
•Community awareness on HMM 
•Relationship with CBAs   
 
Community perception  on CBA performance  
 
 
 
 
 
 
 
 
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1.3 Justification 
Despite the widespread advocacy and strong evidence supporting HMM and the vital  
role of CHWs in  improving outcomes for childhood malaria in some countries (Lewin et al., 
2005), several concerns have been raised with respect to the performance of CBAs in the 
UWR. Many operational aspects such as selection and training of CBAs, drug supply 
systems, programme supervision, health information management  and motivational factors 
could affect  the performance of  CBAs. 
An earlier study conducted in the region by Bjerrum (2008) focused on incentives and 
motivational factors for CHWs participation in HMM.This study however incorporated a few 
of the operational details. At present, there is little good scientific evidence on the 
performance of  CBAs in the UWR, how well they can deliver safe and effective care to 
children with malaria in the community.  
 This study will therefore make specific recommendations which will be of immense 
benefits to policy makers and other development partners such as UNICEF. The NMCP and 
UNICEF will use the results of the study to assess the effectiveness and impact of HMM on 
malaria specific morbidity and mortality in children and evaluate the existing implementation 
guidelines to strengthen HMM in the region and the country at large.The Upper West 
Regional Health Administration will also use the results to identify the best strategy or mix of 
strategies to be used for the effective implementation of HMM  to reduce the malaria burden. 
 
 
 
 
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1.4 Study objectives 
1.4.1 General objective 
The overall objective of the study is to assess the performance of CBAs in HMM in children 
under five years of age in the UWR of Ghana. 
1.4.2 Specific Objectives 
1. To assess the knowledge and perceptions of CBAs in HMM  
2. To assess the practices of CBAs in HMM  
3. To assess the perceptions of community members and health workers on the 
performance of  CBAs  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER TWO 
2.0 LITERATURE REVIEW 
The recognition of home and community role in the management of malaria 
especially in children under five years has led to the development of many models for what is 
now called Community Case Management (CCM), although the terms HMM, Home-Based 
Care (HBC) and Home Based Management (HBM) are also used interchangeably. All these 
terms refer to the management of malaria and other childhood illnesses in the community 
(Sundararaman,1999). Likewise, community resource persons used in HMM have been given 
different names in different countries. In Ghana , they are called CBAs; CHWs in Burkina 
Faso, Medicine Distributors (MDs) in Nigeria and Drug Distributors (DDs) in Uganda 
(WHO/ Tropical Disease Research[TDR], 2007). 
In recent years,  HMM has gained wider acceptance and is endorsed by many (Were, 
2004;WHO, 2005a). The strategy has been  portrayed as a new paradigm for  ensuring early 
and effective treatment of malaria in children under five years at the community level. It‟s 
impact on reducing progression of simple malaria to severe malaria and overall childhood 
mortality has been well documented in some countries (Sirima et al., 2003;FMOH, 
2005).Uganda is currently leading the way, with a large-scale HBM programme, which is 
now the country's official national treatment policy. The Ugandan programme showed that 
over 52% of febrile children in implementing areas had access to treatment within 24 hours 
of onset of fever. Data from Community Drug Distributors (CDDs) also demonstrated a high 
recovery rate of between 79% – 99% ((Musoba, Lutwama, Kaitiritimba, & Jitta, 2007). 
Training of community resource persons and distribution of  pre-packed anti-malarial 
medicines reduced progression of simple malaria to complicated malaria by more than 50% 
in Burkina Faso and overall childhood deaths by 40% in Ethiopia (Kidane & Morrow, 2000; 
Baume,2002).  
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Root, Collins & Munguti (2003) reported that the most promising impact seen in 
HMM was the reduction in facility based mortality rate. In contrast, a systematic review in 
Kenya of the impact of HMM on health outcomes in Africa revealed that presumptive 
treatment of malaria by CHWs had no impact on malaria-specific or overall mortality inspite 
of the high utilization (Hopkins,Talisuna,Whitty, & Staedke, 2007). 
HMM goes beyond the mere distribution of anti-malarials to parents/caregivers of 
children with malaria. It involves all the actions and commodities needed such as; proper 
assessment and diagnosis of the sick child, provision of  appropriate medicines and support 
therapy in the form of counseling on the correct dose and follow ups in a timely manner for 
compliance to treatment regimen (Brieger, Osamor, Salami & Oladepo, 2004).The  
performance of CHWs can therefore be viewed as a chain of events (UNICEF/ WHO,2006), 
ranging from selection to management of sick children, documentation and reporting and the 
drug supply systems . 
2.1 Selection and characteristics of CHWs   
The overall  performance and acceptability of CHWs to the community can be 
influenced by who is chosen. First and foremost, the individual must come from and reside in 
the community, must be democratically selected by community members and be willing to 
work voluntarily (Brieger, 2004). However, cultural, political and social contexts of the 
programme  can sometimes  influence the selection and the criteria defining the most 
qualified CHWs acceptable to the community (UNICEF/ WHO, 2006). 
Batega,Greer & Plowman (2004), in an assessmentof  implementation and operation 
of Home Based Management of Fever (HBMF) in Uganda  noted  that 70% of DDs were 
democratically selected by community members. The  DDs  were also working as 
Community Resource Persons (CORPS), indicating a relatively high degree of integration of 
HBMF into other community-based health activities. 
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Similar findings were reported in Ghana from the  study conducted by WHO/TDR 
(2007) where some communities held meetings to select  distributors  while others selected 
the distributors through Focus Group Discussions (FGDs).On the other hand, findings from 
FGDs in a  rapid assessment of CCM in northern Uganda revealed that many participants 
were unhappy with the selection of their Community Medicine Distributors (CMDs).They 
felt that the selection was politicized and not fairly done, resulting in  the most qualified 
people  being left out.(Uganda Ministry of Health,2009).Besides where people associate such 
programmes with monetary gains, selection is usually not based on  competencies and 
commitment but for the monetary gains or as a “perk” rather than those who will perform  
(Personal Communication).  
The characteristics of selected CHWs  such as gender, marital status, age and 
education level can  also affect their performance. Meek, Kabwa & Kyomuhendo in 2005, 
reported that community members in Uganda preferred women as DDs to men. They 
indicated that mothers were reluctant to utilize the services of male DDs, especially at night, 
but were  more comfortable going to the houses of female DDs at night with sick children. 
Single female volunteers however had a higher turnover rate than their male counterparts  or 
married workers. Rahman et al., (1995) equally talks about the  important role of women 
volunteers  in the community, but added that their household commitments tend to discourage 
them from getting involved. 
Contrary to these findings, community members in Ghana were of the view that  male 
volunteers are  able to conduct more follow-ups  than women because they have to 
concerntrate  on their household chores (WHO/TDR (2007).).Notwithstanding these 
concerns, studies have shown that most programmes recommend the selection of women as 
CHWs to increase acceptability and accessibility to target populations (Bang, Bang, 
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Sontakke, & the SEARCH Team, 1994; Bang et al., 2005a;  Bang, Baitule, Reddy, 
Deshmukh & Bang, 2005b; Bang, Bang, Baitule, Reddy &Deshmukh, 2005c). 
 
Literacy  may also be an important criterion for the selection of  CHWs especially for 
programmes that use treatment guidelines or algorithms. Moreover activities such as training, 
documentation and record keeping is less complicated when the CHW has the ability to read 
and write. In Mali, literacy training was provided for  chosen CHWs  because of the low 
literacy rates (Winch et al., 2003). 
2.2 Training of CHWs 
Training is fundamental in the implementation of any activity (WHO,2005b). Studies 
have shown that, the  more exposure  CHWs have to „basic‟ training, the better the diagnosis 
and care given to children (Faiz,Abdullah,Kaosar & ShameemAra, 2001). Not only must 
CHWs be trained, but they must be trained with a formal training manual and for the  
recommended number of days. Meek et al., 2005 reported that most DDs were trained for two 
days as recommended, it was however detected in one out of the four districts studied in 
Uganda that the entire training lasted only three and half hours.The DDs also expressed the 
need for regular updates. On the other hand, CBAs in Ghana were trained for five days and 
both CBAs and their supervisors were given regular updates (WHO/TDR, 2007). 
2.3 Knowledge of CHWs  
In northern Uganda, the evaluation report on HBMF and HBC  revealed that almost 
all CMDs (99.2%) knew how malaria is transmitted and 88.3% could mention at least 3 ways 
of preventing malaria. When asked about the most common symptom of malaria, 82% knew 
that  it is fever (Uganda Ministry of Health, 2009). These results are similar to findings of the 
study conducted by Batega et al., 2004  where DD‟s knowledge on presumptive diagnosis 
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and treatment of malaria was high with  a majority (96%) knowing the correct dosage for 
children below two years of age and 100% for children 2-5 years of age. 
2.3.1 Case Management  
In a comparative analysis and documentation of processes that facilitated teams in Ghana, 
Nigeria, Burkina Faso and Uganda to implement HMM in various settings, it was reported 
that 59% of children treated with  anti-malarial in Burkina Faso, received drugs  for the 
recommended  3-day period. Among the children treated, 51.8% received the correct age-
specific dose, 31% were given under dose  and 17.2% were given over dose (WHO/TDR, 
2007). Hamel, Odhacha, & Roberts (2001) also reported that dosages of drugs given in 
Kenya  were often incorrect. 
According to Batega et al., (2004), DDs gave relatively good advice to caregivers 
about the management of their sick children and on treatment compliance. Majority of 
caregivers affirmed to this findings and said they  were satisfied with the way the DDs 
handled their sick children. Regardless of the good advice given to caregivers by DDs ,the 
findings further revealed that only about two-thirds of the DDs received Information, 
Education & Communication (IE&C) materials, which are important tools for relating to 
caregivers. Aside the indequate supply of IE&C materials to DDs, almost all aspects of the 
health system in the districts assessed required support for a successful HMM 
implementation. A good number of pre-packed drugs were found to be ruptured at all levels 
of the system, posing a serious threat to the program. 
Fapohunda et al., 2004  noted better counseling in districts with HBMF compared to 
the non-intervention districts; however counseling on danger signs, referral, feeding and 
giving fluids was rarely given. In the case of Ghana, CBAs counseled and gave the first dose 
of drugs as a demonstration to the mother/caregivers before giving the rest of the drugs to be 
taken at home. They also  made follow-ups  to ensure treatment compliance (WHO/TDR 
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(2007). Compliance is better and more effective with home visits and follow-ups (WHO, 
2005b). 
2.3.2 Medicine supply  
Stock out of medicines was found to be a major challenge and was the main reason 
for referral in northern Uganda, with 71.7%  of CMDs running out of Artemisinin-based 
Combination Therapy (ACTs).CMDs attributed non reporting of their activities to children 
being referred directly to hospitals because of the lack of medicines (Uganda Ministry of 
Health, 2009).With regards to storage, WHO/TDR (2007) reported that drugs were stored  in 
wooden cupboards and boxes. 
2.3.3 Referrals  
Of all the 240 CMDs interviewed in some districts in Uganda, 159 (66%) could 
mention at least four danger signs in children that needed referral. An additional 56 (23%) 
could mention three dangers signs (Uganda Ministry of Health,  2009). Despite the training 
given to DDs to understand the scope of their work and to make referrals in  complicated 
cases of fever, adherence to these  guidelines was a still a challenge (Meek et al., 2005). 
CHWs should know the circumstances that need referral and a reliable way of passing 
information about patients to a health facility and vice versa (Walley & Hubley,  2001). They 
should also communicate effectively to the mother/caregiver on the reasons and the  need for 
referral to alley fears and ensure compliance.  
Stock out of medicines, other than danger signs was the  main  reason for  referrals. 
Feedback was however good, as  71.3% of CMDs received regular feedback from the health 
facility staff about referred cases. The feedback was either obtained from the health staff 
during  meetings or by family members of the patient (Uganda Ministry of Health,2009). 
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2.3.4 Reporting system  
In the study conducted by Meek et al, 2005, less than 30% of  DDs were  reporting 
regularly, and  for those who report there is little or virtually no time for the health workers to 
have a meaningful interaction with them in the form of support supervision and meetings. 
Interviews with district and health facility staff  in Uganda revealed that information 
collected  by CMDs is rarely used for planning purposes or for the estimation of  medicines 
and other logistics (Uganda Ministry of Health,2009). 
2.4  Supervision 
Majority of CMDs (83.3%) admitted  having received  supervision in the last 6 
months. For those who got supervision, the median number of times they had been supervised 
was 4 times in 6 months. CMDs at the FGDs however indicated that supervision was too 
infrequent and irregular (Uganda Ministry of Health, 2009). Additional workload is said to be 
the main reason for irregular monitoring of CHWs activities in some places (WHO/TDR, 
2007). 
2.5 Opinions of Community Members about CHWs   
Analysis of caregivers FGDs indicated very positive perceptions and attitudes of  the 
CMDs and their work in all the districts. CMDs were described as understanding, hospitable, 
committed and kind people, always willing to provide  services to clients, even at odd hours. 
This good  attitude has build trust and confidence of  the community members in the CMDs, 
to the extend that caregivers in some areas admitted that they were performing better than the 
health staff (Uganda Ministry of Health, 2009). All the same, there were concerns regarding 
the limits of DDs‟ capacity to handle fevers of varying severity. Fears about the strategy and 
its appropriateness were also raised by some people and a gap between knowledge and 
practice was noted (Fapohunda et al, 2004). 
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2.6 Sustainaibility 
Community based health programmes dates as far back as 1970s, but most of these 
programmes came to a halt due to issues of sustainability. The MDGs have however created a 
renewed interest in strategies involving CHWs to increase coverage to basic health services 
especially in the rural and deprived areas (Bhattacharyya, Winch, LeBan, & Tien, 2001). 
Integrating HMM into other community-based health activities promotes sustainability 
(Batega et al., 2004). It has been noted that programmes that  are often not well integrated 
into the overall health care system are likely to suffer from supply and management 
problems, especially when development partners withdraw their support (Rohde et al., 2008). 
CHWs work on voluntary basis in most HMM programmes, an approach that has 
often resulted in  high attrition especially after the withdrawal of the funding agency 
(Pagnoni, 2009). In Nigeria for instance, attrition rate ranged from 10-49%  over a period of 
12 months (Salako,Afolabi,& Agomo, 2001;Ajayi,Kale, Oladepo, & Bamgboye, 2006;Ajayi, 
Kale, Oladepo, Bamgboye, 2006), whilst in Uganda, a dropout rate of about  16% was 
observed after 18 months of service. Majority of the respondents suggested that the CMDs 
should be given a token in order to encourage them to continue  the selfless work they are 
doing (Bategaet al.,2004). Bjerrum, (2008) recommended that some form of remuneration as 
well as a mechanism for providing transport and other resources is necessary to ensure 
continued motivation of CBAs and for sustainability of HMM.With regards to factors that 
helped to sustain  CHWs in their activities, the primary reasons cited for remaining with the 
programme were; seeing health improvements in their own families, the value placed on their 
activities by the community and the opportunities to learn (Snetro, 1999). The importance of 
seeing improvements in the community‟s health and CHWs having an influence in the 
community was  equally reported in Colombia (Robinson & Larsen, 2001). 
 
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CHAPTER THREE 
3.0 METHODS 
3.1 Study Design 
A cross-sectional study was conducted using quantitative and qualitative data 
collection techniques.Quantitative data was obtained by administering questionnaires to 
CBAs and  mothers/care givers of children  under five years of age. Questionaires were 
adapted from  a study conducted by the Ministry of Health in Uganda on HBMF and HBC in 
2009. Additional  data was obtained from the District Health Information Management 
System (DHIMS ), CBA records and by observing  the practices of CBAs  using a checklist 
developed from the CBA training manual.Qualitative data was obtained from Key Informant 
Interviews (KII) and FGDs . 
3.2 StudyArea 
The study was conducted in two districts in the UWR namely; Jirapa and 
Lambussie.The UWR is situated in the north-western part of Ghana. It is bordered to the 
south by the northern region, to the north and west by Burkina Faso and to the east by the 
upper east region. The three major ethnic groups are the Dagaaba, Sissala and the Waala. The 
Lobi and other minority tribes also live in the region. This  notwithstanding, these ethnic 
groups still maintain some salient and unique cultural features and practices. 
3.2.1 Demographic Characteristics 
The projected population of the region for 2013 using a growth rate of 1.9% is 
742,896  with 989 settlements. The population of Jirapa and Lambussie districts are  93,537 
and 54,655 respectively. With an area of 18,476 km, the region‟s population density stands at 
32 persons per square kilometer. The bad nature of roads and the poor road network in some 
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districts makes movement even more difficult. It is estimated that only about 15% of the adult 
population of the region are literate. 
3.2.2 Climate 
The climate is tropical with an average minimum temperature of 22.6oC and 
maximum of 40.0oC. There is one rainy season from May-October with an intensity of 100-
115 cm/annum and humidity ranging between 70-90% but falling to 20% in the dry season. 
The peak season for malaria transmission is from June –September. 
3.2.3 Vegetation 
The vegetation of the region is generally semi-savannah with light undergrowth and 
scattered shrubs.The major economic trees are Mango Dawadawa (Parkiafilicondia) and 
sheanut (Buterospermiumparkii). Food production is poor with resultant seasonal food 
insecurity. Crops grown are maize, yam, guinea corn, millet, rice, groundnuts and beans. 
Livestock rearing is buoyant with cattle, sheep, goats, pigs and poultry dominating. 
3.2.4 Transport and Communication 
The region has the smallest number of kilometres in terms of tarred road.  Only two of 
the district capitals are linked to each other and to the regional capitals by tarred road. The 
roads linking the region to other regions are untarred and during the rainy season traveling 
out of the region by road becomes a nightmare.The predominant means of transport is by 
road using lorries, motorcycles or bicycles. As far as communication within the health sector 
is concerned, the region is endowed with telephone facilities. These have proved useful in 
calling for ambulance services in time of need.  Staffs have also used the  telephone to 
consult each other on the clinical management of cases when the need arises. 
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3.2.5 Culture and Religion 
Christianity, islam and traditional beliefs are the predominant religions.  Traditional 
life and beliefs, like elsewhere in the country, are more prominent in the rural areas. The 
notable festivals are the “Dumba” festival in Wa, “ Jembenti” of  the Dagaaba as well as 
„Kobina  and “Kakube” in Lawra and Nandom traditional areas respectively. 
3.2.6 Family and Kinship 
With the exception of the Lobi, inheritance is patrilineal. Marriage is generally 
polygamous, with the extended family system making sharing of resources the order of the 
day and this could easily be tapped upon to strengthen community support systems for home 
based care.   
3.2.7 Health Services Organisation 
The Regional Health Management Team (RHMT) comprises of three main units: 
public health, clinical care and health support services. These units in conjunction with the 
office of the Regional Director of Health Services (RDHS)  are responsible for strategic 
planning, resource mobilization and distribution, training, technical support, monitoring and 
evaluation of service delivery in the districts. 
There are 9 district health directorates managed by District Health Management Teams 
(DHMTs); 2 additional districts have been created and are yet to be operationalised. The 9 
districts are further demarcated into 65 sub-districts and 108 Community based Health 
Planning and Services (CHPS) zones managed by Sub District Health Teams (SDHTs). A 
total of 89 health facilities including 6 government hospitals, 5 polyclinics,3 private hospitals 
and 5 private clinics provide various services in the region. Four out of the 9 districts in the 
region have no district or private hospitals.The regional hospital operates as a district hospital 
because of lack of requisite personnel and facilities. Apart from daily provision of services at 
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the health centres, outreach services are provided every month by staff from the health 
centres. 
With regards to CHWs, the region has 1,209 Traditional Birth Attendants (TBAs), 1,850 
Community based Surveillance Volunteers (CBSVs),184 guinea worm volunteers and 2,583 
CBAs who are providing services in 3,557 demarcated areas with supervision from sub 
district health staff. There are 861 outreach points for the provision of immunization and 
other services and this is done by Community Health Nurses (CHNs) and disease control 
officers. Community participation in health delivery is facilitated at all levels through 
community representation on various health committees at regional, district and sub district 
levels.  
Figure 2: Map of UWR showing study districts 
 
 
 
3.3 Study Population 
The quantitative study participants were CBAs and mothers/caregivers of children 
under five years. The qualitative study participants  also included mothers/care givers of 
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children under fives, district focal persons for HMM,  health facility in-charges and opinon 
leaders. 
3.4  Sampling 
3.4.1 Sample Size 
Estimating the sample size was based on the  assumption that all CBAs in the region were  
trained on HMM, a confidence level of  95% and an assumption that 50% of CBAs were 
performing well, with a  desired precision level of  5% .The calculation was therefore guided 
by the formular; 
  
        
  
 
n=required sample size 
z = confidence level at 95% (standard value of 1.96) 
p = Assuming 50% (0.5) of CBAs were  performing well (prevalence of main outcome of 
interest) 
d = desired precision level  of 5% (standard value of 0.05) 
Thus the sample size for CBAs was; 
  
                 
     
 
      
Sample size of mothers/care givers 
The sample size of mothers/caregivers was calculated based on the projected population of 
children under five years which is  20% of the total population. Data indicates that about 10% 
of mothers/caregivers of children under fives years  have visited a CBA with a sick child.  
  
        
  
 
 
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n= required sample size 
z = confidence level at 95% (standard value of 1.96) 
p = proportion of mothers/caregivers accessing CBA services  at  10% 
d = desired precision level  of 5% (standard value of 0.05) 
 
  
                 
     
 
 
      
Allowing for losses of 10%  
                  
      
3.4.2  Sampling Method 
Multi-stage sampling was used for the study. At the regional level, purposive 
sampling was  used to select two of the nine districts because of resource constraints and 
time. A sampling frame consisting of all the names of the CBAs and their respective 
communities was obtained from the two district offices and simple random sampling  used to 
select the CBAs to be interviewed. Names of the CBAs in each district were  written on 
pieces of paper. These papers were folded evenly and put in a container and shaken for some 
time. Each member of the study team was asked to pick one piece of paper at a time 
containing a name of a CBA until the number of CBAs to be interviewed was obtained. 
With regards to mothers/care givers, equal proportions  were assigned to each district 
and  randomly  selected from  the communities in which  the CBAs  were  randomly selected. 
For the selection of households, data collectors move to a central place in the community  and 
spin a pen. The direction to follow in the selection of households was determined by the 
direction of the tip of the pen. The first household with a mother/caregiver  with a child less 
than five years in the direction pre-determined through the spin of the pen  was selected and 
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the immediate next household with the target group was repetitively selected until the total 
number of 2 mothers/caregivers was selected per community.If a household has more than 
one mother/caregiver with a child under five years,only one was randomly selected and 
interviewed and if the data collector was unable to get the required number in the 
community,then the next nearest community was chosen.Purposive sampling  was also used 
in selecting opinion leaders and health facility in-charges in the communities in which the 
CBAs were  randomly selected based on their roles in the intervention and as supervisors to 
the selected CBAs.  
Variables which relate to health worker and community perceptions regarding the 
performance of CBAs was  qualitatively explored through KII with assembly members or 
chiefs, health facility  in-charges and district focal persons for HMM.In addition, one FGD 
was conducted in each district with 6-12 mothers/caregivers of children under five years 
moderated by an experienced  facilitator who was fluent in daagare and Sissali (the main 
local languages spoken in the two districts).The FGD and KII guides consisted open ended 
questions. Interviews with community leaders and mothers/caregivers who could not speak 
english were conducted in the local language and translated and transcribed into 
English.Convenience sampling was used for observing management practices of CBAs who 
were offering services at the time of interviews. 
Secondary routine data for the year 2012 from the CBAs, health facilities and district 
health directorates were reviewed.The records review supplemented the information gathered 
from the interviews and served as a basis for checking for consistencies in the data collected. 
3.4.3 Variables 
The scope of the study was guided by the training curriculum on HMM and  included; 
socio-demographics, knowledge and management practices, support systems and community 
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and health worker perception of  CBA performance. Table 1 shows the independent variables 
and data collection techniques and tools.  
 
Table 1:Variable – Indicator – Data collection technique – Data source Matrix 
     Variable Indicator Data 
collection 
technique 
Data 
collection  
Tools  
Data source 
Demographic 
characteristics 
Sex Interviews Questionnaire CBAs 
  Age     Mothers/care givers 
  Occupation     Opinion leaders 
  Religion     Health workers 
  Educational level       
  Marital status       
  No. of years in service       
Knowledge on 
causes, signs and 
symptoms and 
prevention of 
malaria  
Proportion with 
knowledge on causes, 
signs  and  symptoms and 
prevention of malaria  
Interviews Questionnaire CBAs 
        Mothers/care givers 
Perceptions  of  
CBAs on HMM  
Proportion of  CBAs with 
cultural beliefs affecting 
performance 
Interviews Questionnaire CBAs 
Assessment and 
management of 
fevers/malaria 
Proportion of  children 
assessed before given 
treatment 
Observation Checklist CBAs 
  Proportion of children 
given correct dose of  
ACTs  
      
Recognition of 
danger signs in 
children and 
referrals  
Proportion of CBAs  with 
knowledge on danger 
signs 
Interviews Questionnaire CBAs 
  No. of children referred Records 
review 
Checklist   
Availability of 
ACTs  and other  
logistics 
Proportion of CBAs with  
ACTs and other logistics 
Interviews Questionnaire CBAs 
  No. of CBAs storing 
ACTs appropriately  
Observation Checklist   
 
 
 
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     Variable Indicator 
Data 
collection 
technique 
Data 
collection 
Tools  
Data source 
Documentation and 
record keeping 
No. of  monthly 
reports submitted by 
CBAs  
Interviews Questionnaire  CBAs  
  
No.of copies of 
reports  available  
Records 
review   
Checklist   
Health education/ 
promotion activities 
No. of  CBAs with   
IE&C materials 
Interviews Questionnaire CBAs 
  
Proportion of CBAs 
carrying out  health 
promotion activities  
Records 
review  
Checklist CBAs 
Perceptions of  
community members 
and health staff  on CBA  
performance  
Proportion of 
community members 
with positive views 
about the 
performance of 
CBAs 
Interviews Questionnaire 
Mothers/ 
care givers 
        Health staff 
        
Opinion 
leaders 
Frequency of 
Supervisory visits 
Number of 
supervisory visits 
received 
Interviews Questionnaire CBAs 
    
Records 
review 
Checklist Health staff 
 
3.44 Outcome Variable Definition 
The main outcome measure  was CBAs performance; defined as the ability of CBAs to elicit 
signs and symptoms of malaria, assess and give age appropriate dose of ACTs to children, 
identify and respond to danger signs. Others include; health education activities carried out  
and documentation and  reporting. 
3.5 Ethical Considerations 
Ethical clearance to conduct the research was obtained from the Ethical Review 
Committee of the GHS, the Regional Health Directorate, District Health Directorates and the 
subdistricts involved in the study.  
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3.5.1 Consenting Process 
Permision to conduct the study in the region was sought from the RDHS through the 
School of Public Health (SPH). This was followed by a request to the  RDHS for a letter to 
the selected districts seeking for permission to enter their districts. At the district level,letters 
were circulated to the facility  in-charges through their respective District Directors of Health 
Services (DDHS) about the study and their participation. At the community level,permission 
to be admitted into the communities was sought from the chiefs and other relevant 
community leaders through the health facility in-charges.Verbal consent was obtained from 
the study participants and where the study subjects did not understand English it was 
interpreted in the local dilect for them. 
a) Possible Risks and Discomforts 
Participants were  assured that the research would  not pose any risks to them,but they 
could experience some minor discomfort when being observed or in answering certain 
questions and that they had the right to withdraw from the study at any time if they felt  
uncomfortable.Refusal to participate was not in any way going to affect them. 
b) Possible Benefits 
The study subjects were informed that participation is voluntary with no 
inducements,they may not benefit directly from the study but the findings would benefit the 
DHMT and the GHS in planning health service delivery. Their participation may also help in 
improving the care given to their  children  by CBAs  in the region. 
c) Confidentiality 
All  information obtained from this study has been  kept strictly confidential and is 
used only for the purpose indicated in the study. Numbers  linked to particular names are  
kept confidential and the results of the study will be disseminated in such a manner that no 
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27 
 
information will be linked to any person‟s identity. Reports containing findings and a set of 
recomemdations will be forwarded to the RDHS  and the DDHS of the study  districts. 
d) Conflict of Interest 
The investigator declare that there is  no conflict of interest 
3.6 Training of Research Assistants and Pretesting 
Research assistants who can speak and write english and the local dialects (dagaare 
and Sissali) commonly spoken in the study areas were carefully recruited and a two day 
training session organized for them on how to conduct interviews before embarking on the 
field work; the training content included an overview of the project and objectives of the 
study and interviewing skills. The data collection tools were also reviewed with research 
assistants to ensure standardization in the way the questions were to be asked. To improve 
validity, pre-testing of the data collection tools was carried out prior to the actual fieldwork in 
seven communities under Jirapa namely;Tizza Boi,Tampoe,Jeffiri,Sigri and Nangyiri.CBAs 
from these communities were not part of the study subjects .The process allowed for any 
ambiguous questions to be clarified and also gave the investigator an idea of the length of 
time it would take for the questionnaire to be administered.  
Participants in the pilot  also gave their opinion on whether or not the length of time 
was reasonable and also on the user friendliness and applicability of the questionnaire. The 
questionnaires from the pilot study were entered into the data entry screen and a frequency 
analysis obtained using SPSS version 18.0 .This assisted in uncovering  problems which were 
likely to arise during data entry and analysis. 
3.7 Data collection 
Data was collected from  22nd May  to 12th July  2013. Eight data collectors‟ and two  
supervisors were used for data collection. A structured questionnaire was used to interview 
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CBAs in their respective homes, the questionnaire included both closed and open ended 
questions.Questions included background data, training, knowledge and perceptions on 
malaria and HMM. Others include; drug and logistics availability , challenges and the support 
they get from the community and the formal health sector  in discharging their duties.A 
verification and observation component was included in the study because some areas such as 
assessment and management of the sick child and availability and storage of  drugs could 
only be objectively assessed by observing their practices. A checklist for observation was 
developed based on the training content and the expected practice after  training.  
Regarding mothers/caregivers and KII with opinion leaders, the data collection tool 
included the background data,knowledge on causes,symptoms, mode of transmission and 
prevention of malaria. The questions also explored the health seeking behavior of community 
members for sick children,the mode of selection of CBAs and their views about the 
performance of CBAs and the challenges faced by CBAs .Concerning the health workers, the 
questions elicited their involvement in the HMM implementation process,supervision and 
support for the CBAs,drug supply and  their perceptions of  CBA performance. 
3.8 Data Management and Analysis 
3.8.1Field Editing 
The investigator and supervisors personally undertook field visits and cross checked 
completed questionnaires in the field  for completeness,consistency and accuracy. During this 
process, missing data were identified and research assistants made to go back to collect the 
missing data. It also provided an opportunity for any other error in the data to be rectified. 
3.8.2 Coding and Transcription 
All the close-ended questions in the questionnaire were pre-coded whilst the open-
ended questions were coded after reviewing the responses and developing a coding manual. 
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The FGDs were tape-recorded and comprehensive notes taken during the discussions. The 
tapes were  transcribed and content analysis  conducted  manually. 
3.8.3 Data Entry and Cleaning 
Quantitative data  was entered by  two  data entry clerks using SPSS, version 18.0. 
Missing data was  carefully considered and accounted for and data cleaning conducted upon 
completion of data entry.Where there were discrepancies, these were resolved by cross 
checking with the hard copies of the data capture tools.  
3.8.4 Statistical Analysis 
Descriptive data analysis was undertaken using the same software,SPSS version 18.0 . 
Categorical variables were expressed as frequencies and relative frequencies and results  
presented in tables and graphs.For bi-variate analysis, cross tabulation was undertaken to 
ascertain  the relationship between formal education and knowledge and practices on the 
correct dose of ACTs for children  aged 6-59 months. Significance level of 5% (0.05) was 
used. 
3.8.5 Quality Assurance 
The following measures were adopted to ensure data quality: 
 The research assistants involved in the data collection had previous experience in data 
collection methods,they were fluent in english, dagaare and sissali and were  trained prior 
to the field work. 
 A field test was done and relevant amendments made to the questionnaire before data 
collection. 
 The investigator and other supervisors supervised the field work, undertook spot checks 
and also conducted field editing of the data. 
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CHAPTER FOUR 
4.0 RESULTS 
 
4.1 Background Characteristics of Respondents 
A total of 384 CBAs, 154 mothers/care givers,13 opinion leaders and 15 health 
workers were interviewed. The response rate for each category was 100%. Table 2 shows a 
summary of the sampling profiles of the two districts. 
Table 2: Profiles of Jirapa and Lambussie Districts where the study was conducted, 
2013 
Variable Jirapa Lambussie 
 
Sub districts 
 
7 
 
6 
 
Number of communities 
137 77 
 
CBAs interviewed 
209 175 
 
Mothers/care givers interviewed 
77 77 
 
Health Facility in-charges interviewed 
7 6 
 
District focal persons interviewed 
1 1 
 
Opinion leaders interviewed 
7 6 
 
Number of  monthly reports reviewed 
11 12 
4.1.1 Characteristics of Respondents 
Mean age of  CBAs was 42.71(+/- 9.62) years, with 369 (96%) being females. Of the 384 
CBAs interviewed , 371(97%) were married and almost 267(70%) were christians. More than 
200(50%) had no formal education. In terms of sources of livelihood, the most dominant 
occupation was subsistence farming.  
 
 
 
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Table 3: Discriptive characteristics  of CBAs  interviewed in Jirapa and Lambussie 
Districts,2013 
  Jirapa (%) Lambussie N(%) Overall  N(%) 
Sex 
Male 0 15(8.6) 4 
Female 209(100) 160(91.4) 369 (96) 
Age (Years) 
25-39 85(40.7) 71(40.6) 156(41) 
40-54 84(40.2) 88(50.3) 172(45) 
55-69 40(19.1) 16 (9.1) 56(14) 
Occupation  
Farming 158(75.6) 150(85.7) 308(80.2) 
Trading 36(17.2) 18(10.3) 54(14.1) 
Others 13(6.2) 2(1.1) 15(3.9) 
Formal sector 2(1) 5(2.9) 7(1.8) 
Marital Status  
Married 208(99.5) 163 (93) 371(96.6) 
Single 1(0.5) 8(4.6) 9(2.4) 
Divorced 0 2(1.2) 2(0.5) 
Separated 0 2 (1.2) 2(0.5) 
Religion  
Christian 168(80.4) 99(56.6) 267(69.5) 
Muslim 11(5.3) 36(20.6) 47(12.2) 
Traditionalist 28(13.4) 39(22.2) 67(17.5) 
Others 2(0.9) 1(.6) 3(0.8) 
Educational Level  
None 107(51) 93(53) 200(52) 
Primary 42(20) 50(28.6) 92(24) 
Middle School 31(14.8) 17 (9.7) 48(12.5) 
Junior High School 22(10.5) 9(5.2) 31(8.1) 
Senior High School 6(2.8) 5(2.9) 11(2.9) 
Other 1(0.5) 1(0.6) 2(0.5) 
 
Tables 4 and 5 presents the demographic and socio-economic characteristics of mothers/care 
givers and opinion leaders. 
 
 
 
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Table 4: Demographic and Socio-economic characteristics of mothers/care givers in 
Jirapa and Lambussie Districts, 2013 
  Jirapa N(%) Lambussie N(%) Overall N(%) 
Sex 
Male 1 4 5 (3.2) 
Female 76 73 149 (96.8) 
Age (Years)       
18-27 22 (29) 28(36) 50(33) 
28-37 45(58) 32(42) 77(50) 
38-47 10 (13) 15(19) 25(16) 
48-57 0 2(3) 2(1.3) 
58-67 0 0 0 
Occupation        
Farming 63 (82) 59 (76.6) 122 (79.2) 
Trading 11(14.2) 11(14.3) 22 (14.3) 
Others 2(2.6) 4 (5.2) 6(3.9) 
Formal sector 1(1.2) 3(3.9) 4 (2.6) 
Marital Status  
Married 76 (98.7) 71 (92.2) 147 (95.5) 
Single 1(1.3) 6 (7.8) 7 (4.5) 
Divorced 0 0 0 
Separated 0 0 0 
Religion  
Christian 65 (84.4) 51 (66.2) 116 (75.3) 
Muslim 5 (6.5) 19 (24.7) 24 (15.6) 
Traditionalist 5 (6.5) 7 (9.1) 12 (7.8) 
Others 2 (2.6) 0 2 (1.3) 
Educational Level        
None 37 (48) 37 (48) 74 (48) 
Primary 20 (26) 18 (23) 38(24.7) 
Middle School 2(3) 3(4) 5(3.2) 
Junior High School 16(21) 13(17) 29 (19) 
Senior High School 1(1) 2 (3) 3(1.9) 
Other 1(1) 4(5) 5(3.2) 
 
 
 
 
 
 
 
 
 
 
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Table 5: Demographic and socio-economic characteristics of opinion leaders  in Jirapa 
and Lambussie Districts, 2013 
  Jirapa (N%) Lambussie (%) Overall (%) 
Sex 
Male 7(100) 5 (83.3) 12 (92.3) 
Female 0 1(16.7) 1(7.7) 
Age (Years) 
20-30 1(14.2) 0 1(7.7) 
31-40 3 (42.9) 1(16.7) 4(30.8) 
51-60 0 2(33.3) 2(15.4) 
60+ 3(42.9) 3(50) 6(46.1) 
58-67       
Occupation  
Farming 4(57.1) 4(66.7) 8(61.5) 
Trading 0 0 0 
Others 2(28.6) 0 2(15.4) 
Formal sector 1(14.3) 2(33.3) 3(23.1) 
Marital Status  
Married 7(100) 6(100) 13(100) 
Single 0 0 0 
Divorced 0 0 0 
Separated 0 0 0 
Religion  
Christian 5 (71.4) 3(50) 8(61.5) 
Muslim 2(28.6) 3(50) 5(38.5) 
Traditionalist 0 0 0 
Others 0 0 0 
Educational Level  
None 0 2 2(15.4) 
Primary 2 0 2(15.4) 
Middle School 2 3 5(38.4) 
Junior High School 0 0 0 
Senior High School 2 0 2(15.4) 
Other 1 1 2(15.4) 
 
 
4.2 CBA Training 
In all, 382(99.5%) said they were trained prior to the implementation of HMM. All 
(100%) admitted that the training covered all the topics in the CBA training  content and 
more than half 220(57.3%) said the training was conducted for the recommended five days. 
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Table 6:Training details of CBAs in Jirapa and Lambussie Districts, 2013 
  Jirapa N(%) Lambussie N(%) Overall  N(%) 
Training before HMM  
Yes 207(99) 175(100) 382(99.5) 
No 2(1) 0 2(0.5) 
Duration of training  
Less than 2 days  4(1.9) 6(3.4) 10(2.6) 
3-4 days  41(19.6) 113(64.6) 154(40.1) 
5 days  164(78.5) 56(32) 220(57.3) 
Sufficiency of training    
Yes 206(98.6) 167(95.4) 373(97.1) 
No 3(1.4) 8(4.6) 11(2.9) 
Benefitted from  updates  
Yes 202(96.6) 172(98.3) 374(97.4) 
No 7(3.4) 3(1.7) 10(2.6) 
 
4.3 Knowledge and Perceptions  of CBAs in HMM 
4.3.1 Causes and symptoms of malaria  
Majority of CBAs, 352 (91.7%) knew that  mosquitoes transmit  malaria. 
Table 7: Knowledge of CBAs in Jirapa and Lambussie Districts on the cause of malaria, 
2013 
Cause of malaria Jirapa N(%) Lambussie N(%) Overall N(%) 
Mosquito bites 198 (94.7) 154(88) 352 (91.7) 
Living near stagnant water 6(3) 20 (11.4) 26(6.8) 
Drinking dirty water 2(0.9) 0 2(0.5) 
Don't know 1(0.5) 1(0.6) 2 (0.5) 
Others 2(0.9) 0 2 (0.5) 
 
 
Three hundred and eighteen (82.8%) knew that  fever is the most common symptom of 
malaria in children (Figure 3). 
 
 
 
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Figure 3: Knowledge of CBAs in Jirapa and Lambussie Districts on signs and symptoms 
of malaria, 2013 
 
 
 
Three hundred and eighty-three (99.7%) were of the view that the HMM strategy is highly 
beneficial. Some reasons cited for their satisfaction include; reduction in malaria related 
complications such as convulsions and a reduction in childhood deaths. The following 
statement describes the views of a CBA in Jirapa: “HMM is very good because I treat my 
own children with the ACTs when they have malaria”. 
4.3.2  Assessing the sick child    
Paramount among the responses given by CBAs as to what they will do, if a sick child 
is brought to them were; take verbal history from mothers/care givers, examine child for 
fever, sponge child with fever and observe for danger signs. To sum up, 42(11%) mentioned 
four key assessment areas and 153(40%) mentioned three which was good;127(33%) 
mentioned two and 58(15%) mentioned  one which was rated as poor knowledge.  
0
10
20
30
40
50
60
70
80
90
Fever Vomiting Poor
Feeding
Others Convulsion
P
ro
p
o
rt
io
n
 o
f 
re
sp
o
n
d
en
ts
 (
%
) 
 
Signs and Symptoms  
Jirapa
Lambussie
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Others, 4(1%) said they offer seats to care givers and examine the palms of the child for 
anemia. A higher proportion of CBAs, 108(62%) in Lambussie were able to mention four and 
three key assessment areas compared to 88 (42%) in Jirapa. 
4.3.3 Knowledge of dosage of ACTs  
Less than 50% of CBAs knew the correct dose of A/A for children 6-11months old. 
Table 8: Knowledge of CBAs on correct dosage of A/A for children 6- 11months in 
Jirapa and Lambussie Districts, 2013 
Dose Jirapa N(%) Lambussie N(%) Overall N (%) 
 
Correct dose  
 
126 (60.3) 
 
45 (25.7) 
 
171 (44.5) 
 
Wrong dose 
 
83(39.7) 
 
130 (74.3) 
 
213(55.5) 
 
 
Table 9: Association between formal education and knowledge of the correct dosage of 
A/A for children 6- 11months , 2013 
 
Knows correct 
dosage 
Does not know 
correct dosage 
POR(95%CI) P-value 
Formal Education   
 
Yes 
 
82 
 
119 
 
0.76 (0.50 - 1.14) 
 
0.18 
   
 
 
No 87 96 
 
 
The results in table 10 show that a higher proportion 269(70%) knew the correct dosage of 
A/A for children aged 12-59 months old. 
Table 10: Knowledge of CBAs on correct  dosage of A/A for children aged 12-59 months 
in Jirapa and Lambussie Districts, 2013 
Dose Jirapa N (%) Lambussie N (%) Overall N (%) 
Correct dose  168(80.4) 101(57.7) 269 (70.1) 
Wrong dose 41(19.6) 74(42.3) 115 (29.9) 
 
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Table 11: Association between formal education and knowledge of the correct dosage of 
A/A for children aged 12- 59 months ,2013 
Formal 
Education 
Knows 
correct 
dosage 
Does not 
know correct 
dosage 
POR(95%CI) P-value 
Yes 130 71 
0.67  
(0.43 - 1.04) 
0.07 
      
    
No 134 49 
 
From the bi-variate analysis, residing in Jirapa was positively associated with knowledge on 
the correct dose of A/A for children aged 6-11 months old as shown in Table 12. 
 
Table 12: Association between CBA District of origin and knowledge of the right dosage  
of A/A for children 6-11 months old in Jirapa and Lambussie Districts, 2013 
 
 Knows 
Correct 
dosage 
Does not 
know correct 
dosage 
POR (95%CI) P-Value 
District     
Jirapa 126 83 4.39(2.83-6.79) 0.00 
Lambussie 45 130   
 
4.3.4 Ensuring Treatment Compliance 
When asked what they do to ensure treatment compliance by mothers/care givers; 149 
(71%) of CBAs in Jirapa said they counsel caregivers, 131(63%) said they make follow ups 
and 115(55%) said they give first dose directly observed. In Lambussie 113(64%) reported 
that they counsel caregivers, 136(78%) said they make follow ups, whilst 91(52%) said they 
give first dose directly observed as a way of ensuring treatment compliance. 
4.3.5 Knowledge on Danger Signs and Referrals 
One hundred and seven (28%) and 113(29%) listed 3 and 4 dangers signs 
respectively, which is  measured as good knowledge and 71(18%) and 113 (29%)  listed one 
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and two respectively indicating poor knowledge.Three percent said they did not know any 
danger sign. Knowledge of danger signs however varied across districts, with a higher 
proportion 82 (47%) in Lambussie being able to mention 4  signs compared to 20 (9.5%) in 
Jirapa. 
Figure 4:  CBAsknowledge on danger signs in Jirapa and LambussieDistricts, 2013 
 
Overall, 353 (92%) said they refer children with danger signs to health facilities, but 
could not mention the number of children referred in the last six months. Thirty- Seven 
percent said they give pre-referral treatment to children above 6 months before referral, 
240(62.5%) said they refer straight  away and 0.5% said they keep the child and treat. A 
significant proportion 377(98.2%) admitted that care givers comply with referrals and 323 
(84.1%) said they receive feedback. 
4.3.6 Knowledge of ways to prevent Malaria  
Out of the 384 CBAs interviewed, 91% (190/209) in Jirapa said they educate 
caregivers on the use of  Insecticide Treated Nets (ITNs) for malaria prevention, 108(52%) 
said they educate them on environmental cleanliness and 91(43.5%) talked about wearing of 
0
10
20
30
40
50
60
70
80
90
100
Inability to
drink or
breastfeed
Vomits
every thing
he/she
drinks or
eats
Convulsion Sleeps and
difficult to
awaken
Dark
colour
urine
P
ro
p
o
rt
io
n
 o
f 
re
sp
o
n
d
en
ts
 (
%
) 
Danger signs  
Jirapa
Lambussie
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protective clothing. In the case of Lambussie, a higher proportion 164(94%)  said they 
educate caregivers on  the use of  ITNs, 139(79%) educate them on environmental cleanliness 
and 105(60%) educate them on wearing  protective clothing . 
4.4  Practices of CBAs in HMM 
For the purpose of this study, the areas observed were; drug availability and  storage  
and expiry dates. Others include logistics availability and treatment of children with malaria. 
4.4.1 Drug Availability and Storage  
In terms of drug availability, 153(73%) in Jirapa and 137 (78%) in Lambussie said 
they had stock out in the last three months. At the time of the interview only 66 (31.6%) of 
CBAs in Jirapa had ACTs  that were not expired, 2(0.9%) had  expired ACTs and the rest had 
complete stock outs. All the CBAs in Lambussie had run out of drugs at the time of the 
interview. Per the records at the district level, Lambussie got their last consignment of ACTs 
in July 2011 and Jirapa in August 2012. Some CBAs used  Amoxillin tablets to treat for 
malaria in place of ACTs. More than half the CBAs 259(67.4%) cited non availability of 
ACTs at the district and health facility stores as the main reason for stock outs, 8.1%  said 
they failed to make requisitions and 94(24.5%) said they were  not getting clients, therefore 
needless  making request for drugs. All the CBAs with drugs  stored them in kit boxes. 
4.4.2 Logistics Availability  
Most of the logistics supplied to CBAs were in a bad state. Table 13 presents the availability 
and the state of  some selected logistics. 
 
 
 
 
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Table 13: Availability  and condition of  CBAs logistics in Jirapa and 
LambussieDistricts, 2013 
Item  Jirapa N(%) Lambussie N(%) Overall N(%) 
Kit boxes 
Available in good condition 157(75.1) 144(82.3) 275(71.6) 
Available in poor condition 47(22.5) 22(12.6) 69 (18) 
Not available 5(2.4) 9(5.1) 40 (10.4) 
IE&C materials  
Available in good condition 110(52.6) 111(63.4) 221(57.5) 
Available in poor condition 98(46.9) 64(36.6) 162(42.2) 
Not available 1(0.5) 0 1(0.3) 
Raincoats 
Available in good condition 49(23.4) 17(9.7) 66 (17.2) 
Available in poor condition 105(50.3) 113(64.6) 218 (56.8) 
Not available 55(26.3) 45(25.7) 100 (26) 
Wellington boots   
Available in good condition 126(60.3) 52(29.7) 178 (46.4) 
Available in poor condition 62(29.7) 84(48) 146(38) 
Not available 21(10) 39(22.3) 60(15.6) 
Bicycles 
Available in good condition 29(13.9) 11(6.3) 40(10.4) 
Available in poor condition 174(83.2) 154(88) 328(85.4) 
Not available 6(2.9) 10(5.7) 16(4.2) 
4.4.3 Management of Childhood Malaria  
Only 37 CBAs in Jirapa were observed offering services at the time of the interviews. CBAs 
in Lambussie had all run out of  ACTs. Of the 37 CBAs observed, 31 (83.8%) asked if the 
child has fever and 33(89.2%) personally  touched the child for the presence of fever. Less 
than 50% asked for other symptoms of malaria. 
  
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Table 14: Assessment of sick children by CBAs in Jirapa district, 2013 
Indicator  (N=37) Yes  No 
Welcomed mothers  18 (48.6%) 19 (51.4%) 
 
Asked for child's name 4(10.8%) 33(89.2%) 
Asked for presence of fever  31(83.8%) 6 (16.2%) 
Touched child for fever  33 (89.2%) 4 (10.8%) 
Asked for other symptoms of malaria  17 (45.9%) 20 (54.1%) 
4.4.3.1 Giving age appropriate dose of ACTs 
The overall proportion of CBAs giving the correct age appropriate dosage  of ACTs 
was 32(86.5%),(95% CI: 74.2 –97.7). Eight (88.9%) gave the correct dosage to children aged 
6-11 months and 24(85.7%) gave correct dosage to children aged 12-59 months.  
Table 15:Proportion of CBAs observed giving age appropriate dose of ACTs to children 
aged  6-59 months in Jirapa District, 2013 
 Age and dose Frequency Percent  
6-11 months  
Correct dose  8 88.9 
Wrong dose  1 11.1 
12-59 months  
Correct dose  24 85.7 
Wrong dose  4 14.3 
Overall N(%) 
Correct dose  32 86.5 
Wrong dose  5 13.5 
 
 
There was virtually no relationship between formal education and giving the correct dosage  
of ACTs to children aged 6-59 months (Table 16). Seventy-three percent ( 27/37)  counselled 
mothers/care givers on the correct dosage and the need to complete the specified course of 
treatment.  
 
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Table 16: Association between formal education and giving the correct dose of ACTs for 
children aged 6-59 months   in Jirapa District, 2013 
  
Knows correct 
dose 
Doesnot know 
correct dose 
P-value 
Formal Education       
 
Yes 
 
15 
 
0 
 
0.057 
 
No 
 
17 
 
5 
4.4.3.2 Education on Malaria Prevention 
Only 6 (16.2 %) out of the 37 CBAs educated mothers/care givers  on prevention of 
malaria. Out of this  number, 5(83%) educated them on the use of Insecticide Treated Nets 
(ITNs) and 1(17%) talked about wearing of protective clothing. 
4.5 Records Review 
Monthly reports for the year 2012 were retrieved from CBAs, health facilities and 
DHIMS. Data collected were; number of reports submitted by CBAs, number of children 
treated and records of IE&C activities carried out. Others include; number of supervisory 
visits received and the number of children referred by CBAs to health facilities. 
4.5.1 Utilisation of CBA Services  
Of the 12,128 children who reported with malaria in the year 2012, only 5,343 (44%) 
were seen by CBAs. Number of children refered were higher in Lambussie than Jirapa.  
  
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Table 17: Children treated and referred by CBAs in Jirapa and LambussieDistricts in 
2012 
Jirapa District Lambussie District 
Month  
No. of 
children 6-
11 months 
receiving 
treatment  
No. of 
children 
12-59 
months  
receiving 
treatment  
No. of 
referrals  
No. of 
children 
6-11 
months 
receiving 
treatment  
No. of 
children 
12-
5months  
receiving 
treatment  
No. of 
referrals  
January 71 381 2 43 209 0 
February 75 362 7 25 202 0 
March 37 354 10 46 230 18 
April 28 257 4 15 201 0 
May 51 228 4 21 168 5 
June 39 457 6 16 199 5 
July 0 0 0 16 160 17 
August  17 376 0 15 82 17 
September 49 556 0 34 67 2 
October  20 125 0 6 11 85 
November  0 48 0 14 13 2 
December  0 4 0 5 10 5 
Total  387 3148 33 256 1552 156 
4.5.2 Documentation and Reporting 
Seventy-six (36%) CBAs in Jirapa and 77(44%) in Lambussie had copies of complete montly 
reports. 
Figure 5: Availability and completeness of   CBAs reports in Jirapa and Lambussie  
Districts for 2012 
 
 
0
10
20
30
40
50
Copies available
and complete
Copies available
but incomplete
Copies not
availableP
ro
p
o
rt
io
n
 o
f 
R
es
p
o
n
d
en
ts
 %
 
Monthly reports   
Jirapa
Lambussie
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Records from the facility and district offices indicated low reporting. Monthly 
reporting of CBAs ranged between 53% to 79% in Jirapa and 43% to 88% in Lambussie as 
shown in figure 6. In Jirapa, reports for the month of July could not be obtained  whereas in 
the case of Lambussie, reports for the months of May, July, September, October and 
November were incomplete. 
Figure 6: Reporting rates of CBAs in Jirapa and LambussieDistrictsfor  2012 
 
 
 
4.5.3 IE&C Activities Carried Out 
Twenty-five percent carried out IE&C  activities with records available, 245(63.8%) 
admitted verbally that they carried out the activities but had no records  and 42(10.9%) did 
not carry out any IE&C activities. 
4.6 Support Systems 
4.6.1 Monitoring and Supervision 
The frequency of  supervision varied across districts ranging from 0% to 36% in Jirapa and 
15.1%  to 49% in Lambussie. 
 
 
0
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Figure 7: Proportion of CBAs supervised in Jirapa and Lambussie Districts in 2012 
 
4.6.2 Motivation 
In total, 228 (59.4%) reported that  they were motivated; 119(68%) in Lambussie and 
109(52%) in Jirapa. Out of these numbers  54(49%) in Jirapa and 74(62%) in Lambussie said 
they were given transport money during meetings at the health facility. Others said they were 
motivated by the value placed on their activities, in kind and through awards . 
4.7.3 Attrition of CBAs 
On the whole, 54(14%) said they knew CBAs who had dropped out and the main 
reason for the attrition is the lack of motivation. Some responses as quoted were, “they left 
because there is no  volunteerisim anywhere in the world again” (CBA in Jirapa), “No pay, 
only  insults from community members”(CBA in Lambussie) and another CBA in Jirapa  
summed it by saying “No free government work so I  cannot be doing government work for 
free”. No district could provide updated information on the attrition of CBAs. 
4.8 Perception of Community Members on Performance of CBAs 
Seventy-one (46%) of mothers/caregivers did not know how the CBAs were selected. Table 
18 shows the responses provided by mothers/caregivers. 
  
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Table 18: Responses from mothers/care givers in Jirapa  and Lambussie Districts, 2013 
Indicator Jirapa N(%) Lambussie N(%) Overall N(%) 
How were CBAs selected  
Selected by chiefs/opinion 
leaders 
16(20.8) 27(35) 43(27.9) 
Selected by health workers 10(13) 1(1.3) 11(7.1) 
Selected democratically 9(11.7) 20(26) 29(19) 
Don't know 42(54.5) 29(37.7) 71(46) 
Who treats  sick children  
CBA 52(67.5) 68(88.3) 120 (77.9) 
Health worker 21(27.3) 9(11.7) 30(19.5) 
Don't Know 2(2.6) 0 2(1.3) 
Herbalist 1(1.3) 0 1(0.6) 
Traditional Birth Attendant 1(1.6) 0 1(0.6) 
Are CBAs services accessible    
Yes 72(93.5) 72(93.5) 144(94) 
No 0 5(6.5) 5(3) 
Don't Know 5(6.5) 0 5(3) 
Have you visited a CBA before 
Yes 57(74) 59(77) 116(75.3) 
No 20(26) 18(23) 38(24.7) 
 
Among the 116 (75.3%) mothers/caregivers who utilized the services of CBAs,   
15(12.9%) reported that they checked for danger signs and  only 9(7.7%) said they were 
educated on malaria prevention (Table 19). 
 
  
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Table 19: Responses of mothers/care givers on actions taken by CBAs for sick children 
in Jirapa and Lambussie Districts, 2013 
 Action Taken   Jirapa N(%) Lambussie N(%) Overall N(%) 
 
Took verbal history  50(87.7) 45(76.3) 95(81.8) 
 
Assessed child before giving treatment 42(73.7) 44(74.5) 86(74.1) 
 
Counselled on treatment compliance  34(59.6) 32(54.2) 66(56.9) 
 
Sponged child to reduce fever 24(42.1) 13(22) 37(31.8) 
 
Observed child for danger signs 5(8.7) 10(16.9) 15(12.9) 
 
Educated caregiver on malaria prevention  1(1.7) 8(13.5) 9(7.7) 
 
Examined child for pallor 4(7.0) 2(3.4) 6(5.2) 
 
 
Ten (76.9%) of  opinion leaders  indicated that the selection of CBAs was done by chiefs and 
opinion leaders (Table 22). 
Table 20: Responses of Opinion leaders  in Jirapa  and Lambussie Districts,2013 
Indicator Jirapa N(%) Lambussie N(%) Overall N(%) 
Selection of CBAs  
Selected by chiefs/opinion 
leaders 
4(57.1) 6(100) 10 (76.9) 
Selected by health workers 1(14.3) 0 1(7.7) 
Selected democratically 1(14.3) 0 1(7.7) 
Don't know 1(14.3) 0 1(7.7) 
Who treats  sick children    
CBA 5(71.4) 6 11(84.6) 
Health worker 2(28.6) 0 2(15.4) 
Don't Know 0 0 0 
Herbalist 0 0 0 
Traditional Birth Attendant 0 0 0 
Are CBAs services accessible    
Yes 6(85.7) 6(100) 12(92.3) 
No 1(14.3) 0 1(7.7) 
Don't Know 0 0 0 
Have you visited a CBA before 
Yes 6(85.7) 6 (100) 12(92.3) 
No 1(14.3) 0 1(7.7) 
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A sizeable number 126(81.8%) of mothers/caregivers said they did not know the poor 
performing areas of  CBAs.  
Table 21:Responses   of  mothers/care givers  on good and poor  performing areas of 
CBAs  in Jirapa and Lambussie Districts, 2013 
Activity   Jirapa N(%) Lambussie N(%) Overall N(%) 
Activities performed well 
Management of sick children 56(72.7) 8(62.0) 104(67.5) 
Health promotion activities 7(9.1) 20(26.0) 27(17.5) 
Home visits 9(11.7) 4(5.0) 13(8) 
Don't Know 5(6.5) 6(7.0) 11(7) 
 
Activities not performed well  
Don't Know 74(96.1) 52(67.5) 126(81.8) 
Disease Surveillance 0 5(6.5) 5(3.2) 
Home Visits 1(1.3) 13(16.9) 14(9.1) 
Health Promotion activities 0 1(1.3) 1(0.7) 
Management of sick children 2(2.6) 6(7.8) 8(5.2) 
 
 
Some opinon leaders were of the view that  CBAs are not performing well in home visits and 
management of sick children 
Table 22:Responses of opinion leaders  on good and poor  performing areas of CBAs  in 
Jirapa and Lambussie Districts, 2013 
Responses  Jirapa N(%) Lambussie N(%) Overall N(%) 
Activities performed well 
Management of sick children 6(85.7) 6 (100) 12(92.3) 
Health promotion activities 0 0 0 
Home visits 1(14.3) 0 1(7.7) 
Don't Know 0 0 0 
 
Activities not performed well  
Don't Know 0 0 0 
Disease Surveillance 0 0 0 
Home Visits 6(85.7) 4(66.7) 10(76.9) 
Health Promotion activities 0 0 0 
Management of sick children 1(14.3) 2(33.3) 3(23.1) 
 
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Based on the scale of “very good” and “good” as highly rated positive perceptions and “fair” 
and “poor” as highly negative perceptions about the performance of   CBAs; 31(20.1%)  of 
mothers/caregivers interviewed rated CBAs as “very good” and  109(70.8%)  rated them as 
“good”. 
Table 23: Views of mothers/caregivers  on the performance of CBAs in Jirapa and 
Lambussie  Districts, 2013  
Rating  Jirapa ( N%) Lambussie N (%) Overall N (%) 
 
Very good 
 
8 (10.4) 
 
23(29.9) 
 
31(20.1) 
 
Good 
 
63(81.8) 
 
46(59.7) 
 
109(70.8) 
 
Fair 
 
6(7.8) 
 
8(10.4) 
 
14(9.1) 
 
 
Only one opinion leader had negative perceptions about the performance of  CBAs 
 
Table 24: Views of Opinion Leaders  on the performance of CBAs in Jirapa and 
Lambussie Districts, 2013  
Ratings  Jirapa N(%) Lambussie N(%) Overall N(%) 
 
Very good 
3(42.9) 1(16.7) 4(30.8) 
 
Good 
3(42.9) 5(83.3) 8(61.5) 
 
Fair 
1(14.2) 0 1(7.7) 
 
On the contrary, responses from FGDs with mothers/caregivers indicate that CBAs 
were democratically selected. Comments from the participants affirmed that  CBAs treat 
most sick children in the community and their services are accessible. They added that the 
first point of call with a sick child is the CBA. However, they  are  sometimes compelled to 
go straight to a health facility because of proximity or also because of the perception that  
health workers  are  better trained. “The nurses check our childrens‟ temperature and they 
make them stand on a scale ” FGD women of Lambussie, “The nurses give our children 
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paracetamol syrup to mange the fever,but the CBAs do not have the syrup” FGD women in 
Jirapa.  
Whereas, mothers/caregivers and opinion leaders  reported that CBAs are performing 
well in the management of sick children, participants at the FGDs are of the view that they   
perform well in community education on malaria prevention. Analysis of the FGDs also 
demonstrated that CBA services are utilized by mothers/caregivers  and they were satisfied 
with the treatment received. It was however reported by a mother from Lambussie as quoted, 
“we are happy with their services but there are   instances when CBAs displace their 
frustrations on us because they do not get any thing from us or from the health workers”. 
Another  respondent in Jirapa said  “they are usually unhappy and will insult you when you  
delay in bringing your sick child or when you do not follow their treatment instructions. 
Mothers/caregivers  complained about the lack of ACTs. 
4.8.2 Perception of Health Workers on Performance of CBAs 
Very few 4(31%) facility in-charges interviewed were in their current positions at the 
inception of the HMM programme,  9(69%) have been in their current positions for about 1-2 
years. The two district focal persons interviewed have also been coordinating the programme 
for less than 5 years. 
Seventy-seven percent (10/13) of facility in-charges  said  most CBAs are doing 
extremely well and are very helpful because they reduce their work load. They  added that 
some CBAs support health staff  to mobilise mothers for child welfare services and others 
bring pregnant women for antenatal care. On the other hand, 2(15%) said their performance  
was satisfactory and 1(8%) said their performance was poor and they are not commited.  
The district focal persons indicated that majority of CBAs are doing  well and they are 
motivated  to work because of the improved  health status of children in their respective 
communities, but  with the  increasing number of CHPS compounds, there has been low  
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utilization of their  services. 
4.9 Challenges of  CBAs 
Majority of CBAs  322 (83.8%) and 346(90.1%) reported broken down bicycles and 
none replenishment of logistics as barriers to performance respectively. Others cited the lack 
of motivation and poor recognition by community members. Almost 90% (344/384)  
complained about the insults received from some community members and added that they  
are constantly accussed of receiving some form of renumeration from the formal health 
sector, which is untrue. As a result, they receive very little support from  community  
members. CBAs also lamented on their inability to work on their farms during the farming 
season thus contributing to the vicious cycle of poverty. Inaccessible roads and  adults 
demanding for treatment were not left out. A sizeable proportion  196(51%) complained of 
their inability to read and write resulting in low reporting, as one CBA in Jirapa lamented   “I 
can not afford to continue buying pito (local alcoholic beverage) for the person who helps me 
to write my reports because I can not read and write”.Other comments  were; “I have 
problems with my  family because i am not paid but i am committed” (CBA in Lambussie) 
and “ mothers prefer going to the hospital because they say we are not nurses”(CBA in 
Jirapa). Aside these challenges, the lack of supervisors support and conflicts with some health 
staff were also enumerated. Irregular supply of ACTs was also mentioned as a significant 
barrier to their performance. 
Responses from the FGDs and KII were not too different from what was reported by  
the CBAs. Shortage of drugs, lack of motivation and poor recognition and support for CBAs  
were enumerated as barriers to performance.In the same way, health workers complained 
about the lack of motivation for CBAs and funds for maintenance of their bicycles resulting 
in frequent breakdowns  thus affecting their performance. Health workers added that CBAs 
are unable to concerntrate on their farm work due to the nature of their job,yet they are not 
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given any motivation leading to low  commitment “ I pity the CBAs,because they are not 
given any motivation,but they have to work and also submit reports”,”any way they are 
doing well but some of the CBAs misuse their bicycles and we have seized some of them and 
packed them in the facility”(Health Facility in charges in Jirapa) 
4.9.1 Strategies for Sustainability 
Suggestions made by mothers/caregivers  for sustaining the programme were; 
provision of funds for maintainance of CBAs bicycles or the provision of monthly 
allowances. Other suggestions included; regular supply of ACTs and  paracetamol syrup or 
tablets for  CBAs to manage children with fever. Most health workers placed emphasis on 
regular updates  to sustain the competence of CBAs,institute annual awards for hard working 
CBAs and payment of their  health insurance premiums. The health workers also suggested 
that HMM should be implemented in areas without CHPS compounds to reduce the huge 
number of CBAs in the system which makes it extremely difficult for the formal health sector 
to institute any sustainable motivational package. 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER FIVE 
5.0 DISCUSSION 
 
In this study we assessed the knowledge and performance of CBAs on HMM  for children 
under five years and the perception of community members and health workers about the 
services provided by CBAs in Jirapa and Lambussie districts. One of the foremost concerns 
in the region is how to ensure a high level of performance by CBAs to attain the programme 
objectives. 
 Majority of the CBAs  being females is not unexpected as the criteria for selection 
gave prominence to women but preferably literate women. A similar observation was made in 
Uganda where the  bulk (62.0%) of the  distributors were women with most of them attaining 
primary-level education (WHO/TDR 2007). Again the occupational distribution of the 
respondents significantly reflects the generality of occupational distribution of the region at 
large where majority are engaged in subsistence agriculture. This phenomenon in itself 
creates seasonal barriers to accessing health care given the fact that households are virtually 
without any income during the lean season.  
The study explored concerns regarding CBA development with particular focus on  
knowledge on malaria and assessing sick children and treatment of   malaria. Our findings 
revealed that a high proportion of CBAs had access to pre -service trainings and updates, with 
most of them acknowledging that the training covered all the topics in the CBA training  
content. Most of the CBAs also admitted that the training was sufficient for them to gain 
adequate knowledge and skills. This is highly commendable. The contents of the training 
include; causes, symptoms  and prevention of malaria, assessing and classifying fevers, 
caring for the sick child and identifying danger signs and  referral. The others are; health 
education on malaria prevention, documentation and reporting  and drugs and supplies 
management. 
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Training is central to most approaches (WHO, 2005a) and selected CBAs must be 
given the requisite knowledge and skills to enable them deliver high-quality care. Trainings 
should also take the recommended number of days considering that more than 50% of the 
CBAs had no formal education and may require several days of training to make a significant 
difference. Moreover, it is believed that effective training facilitates learning and knowledge 
acquisition, which in tend leads to better practices. Pre-service training should not also be 
regarded as the end of training  but as the beginning, hence the  need for regular updates  to 
sustain the  competencies and quality of case management by CBAs. This notwithstanding, a 
few CBAs  admitted that, they were not trained and that  they  took over  from  relatives or 
friends who had either left  the job or died. This finding is quite disturbing and requires 
urgent action in the form of training, recognizing the fact that HMM involves the 
administration of drugs which can be harmful to human life, if not administered correctly. 
Key among the findings is the high knowledge of CBAs on the cause and the most 
common symptom of malaria in children which is fever; it ought to be borne in mind that 
fever is a potential indicator of malaria in children, it is therefore imperative for every CBA 
to recognize fever for prompt and appropriate action since majority of children who die from 
malaria, do so within 48 hours of onset of illness (WHO, 2005a). On the other hand, 
knowledge on other classical symptoms of uncomplicated malaria such as malaise, vomiting 
and loss of appetite varied considerably among CBAs. Knowledge on general symptoms of 
malaria is not only a prerequisite for quality of care but also crucial for the reduction of 
health cost, not only to the client but also to the health institution. This gap also featured in 
their knowledge of  danger signs of complicated malaria. Only 57%  CBAs could  mention 3-
4  danger signs and very few 15(12.9%) checked for danger signs in sick children. This is 
similar to the findings in a  study conducted by Fapohunda et al., 2004 where counseling on 
danger signs was rarely given. 
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CBAs are mandated to manage only uncomplicated malaria in children 6-59 months. 
It is therefore crucial for every practicing CBA to know the danger signs of complicated  
malaria for prompt referral. Delaying a few hours for treatment of children with complicated 
malaria could mean life or death. It is also reported that distributors are sometimes compelled 
to treat severely ill children because of the insistence of some mothers/caregivers. (Meek et 
al., 2005). This practice could be dangerous, because if a  child dies as a result of the 
mother‟s insistence on management at the community level when the child needed to be 
referred to a health facility, the  distributor‟s credibility could be seriously undermined 
(WHO/TDR, 2007). CBAs should therefore be given regular updates and made aware of the 
dangers  associated with delays or else there will be the tendency to keep children needing 
urgent referral which could result in needless deaths. Also, with the increasing emphasis on 
cost containment in health care provision it has become more important than ever for CHWs 
and health care providers to adhere to simple guidelines to minimize cost to individuals and 
their families.  
The study also found that majority of CBAs interviewed were more conversant with 
the dosage of A/A for children aged 12-59 months compared to children aged 6-11 
months.The inherent danger is that this age group could be under dosed thus promoting drug 
resistance or over dosed which could be life-threatening.The national policy (Ministry of 
Health[MOH],2009) recommends ACTs as the first line drug of choice for the treatment of 
uncomplicated malaria, but it was noted that a few CBAs gave amoxicillin tablets for 
treatment of malaria instead of ACTs, which has to be given  serious attention.  
An association was sought between formal education and knowledge on the age 
appropriate dose of ACTs.There was no significant difference in terms of formal education 
and knowledge on age appropriate dose. This could mean that formal education may not be a 
strong criterion for selection as a CBA; however, other sources such as non-formal education 
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and the effectiveness of the trainings might have contributed significantly to the improved 
knowledge. CBAs in Jirapa district were likely (p-value 0.00) to have more knowledge on the 
correct  dose of ACTs  for children aged 6-59 months from the bi-variate analysis. 
Follow up of clients by CBAs as part of measures to enhance  treatment compliance 
was quite satisfactory, although this could be improved with regular monthly or quarterly 
meetings to remind CBAs of the importance of follow ups. Such meetings could also serve as 
a platform for sharing ideas and experiences. With the rising trend of treatment failure and 
resistance to anti-malarial drugs, it is important to guarantee effective use and compliance to 
treatment regimes, thus counseling and follow ups for treatment compliance are both  
essential to prevent treatment failures and drug resistance. Experience from the CHPS 
concept shows that home visits and follow-ups leadsto treatment compliance for most home 
based care. It also provides an opportunity for the health care provider  to educate the family 
and  community members (personal communication).  
 
The abysmal performance of CBAs in terms of the proportion of children treated from 
the records reviewed is quite disturbing. This finding substantiates the results of the GDHS, 
2008 and the assessment by UNICEF in 2010 which indicated that less than 60%  of children 
had prompt access to anti-malarial drugs in the region. For some of the CBAs who performed 
poorly, family responsibilities, lack of motivation and low value placed on their activities by 
community members were some of the reasons cited. It was also observed that CBAs in the 
urban areas with improved access to health facilities and those in communities with CHPS 
were under-utilized. It has been demonstrated that community based health interventions are 
more successful in rural than in urban areas. A typical  example is the mass drug distribution 
for lymphatic filariasis in Ghana, where the programme in urban areas was  seriously  
affected (TDR, 2003) because of migration and the busy schedules of formal health workers. 
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CHPS is a strategy where CHNs are given additional training and deployed to 
communities especially the rural and deprived areas to provide “close to client” services. At 
the initial stages of the HMM implementation in 2006, the CHPS zones were few in the 
region, however with the increasing numbers, where most rural communities now have 
trained CHNs, mothers/care givers  prefer accessing  services from nurses because of the 
perception that they are better trained. It is therefore not surprising that CBAs operating in 
CHPS zones are under utilized in spite of the increased awareness of their services. It may be 
helpful to come out with innovative ways such a major decisive shift of CBA services from 
communities with CHPS to areas without CHPS. Demand for services could be also 
influenced by the perceived performance of the CBA or knowledge of mothers/caregivers on 
the symptoms of malaria.  
The erratic supply of ACTs as a major challenge raises concerns and the need to re-visit the 
controversy as to whether to charge a minimal fee for ACTs or allow mothers/caregivers to 
access CBA services using their National Health Insurance(NHIS) cards  to facilitate regular 
drug procurement and supply.This finding is similar to reports from other countries that 
adopted ACTs for HMM (Noor, Zurovac, Hay, Ochola&Snow, 2003; Nosten & White, 
2007). Lack of drugs was also identified as a threat to the sustainability of HMM in Nigeria 
(Ajayi ,Jegede , Falade , 2012).  
Shortage of drugs could be a result of poor logistics management at the region, district 
and health facility level. Moreover the bureaucracies and the cumbersome procurement 
processes at the national level could cause undue delays. Health commodity management 
requires that health providers establish consumption patterns and start the process of 
requisition when they reach the minimum stock levels to avoid complete stock out.  
Although majority of CBAs had IE&C materials, the proportion that carried out IE&C 
activities in their respective communities was low. Appropriate dissemination of information 
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to community members and patient education can improve health-seeking behaviours, 
treatment compliance and treatment outcomes (WHO, 2005). In the UWR, CBA‟s role relates 
to communication and awareness creation about prevention and treatment through 
community meetings, durbars and home visits using the IE&C materials provided. It is 
therefore surprising to note the ostensibly disconnect between the proportion of CBAs who 
knew the cause of malaria and the percentage who actually educated mothers/care givers on 
malaria prevention especially on the use of ITNs. 
Most CBAs refer cases to health facilities, which is a good practice; however stock 
out of drugs being a reason for referral is highly unacceptable. Shortage of drugs does not 
only result in interrupted treatment but also damages the reputation of the health sector, 
thereby undermining all the efforts associated with the programme. Caregivers could also 
lose confidence in the strategy and resort to alternate sources of care, which could be 
detrimental to the health of their children. Stock out of medicines was found to be the  main 
reason for referral in northern Uganda (Uganda Ministry of Health, 2009).  
The high rate of referrals in Lambussie is not surprising because all the CBAs had run 
out of drugs.The overall proportion of CBAs who received feedback on referred cases from 
health facilities was impressive, which is really an important and positive finding. However, 
the major sources of feedback, which is mainly from family members and during their routine 
home visits is not good enough. Feedback was mainly obtained from the health staff during  
meetings in Uganda (Uganda Ministry of Health, 2009). CBAs are partners in health care 
delivery and it is only fair that health workers give feedback on referred cases to boost their 
morale and encourage them to work better. Feedback also encourages them to become more 
efficient and committed to their roles. 
Strengthening HMM requires a strong health information system that begins at the 
front line which is the CBA level. In consequence, the low level of reporting by CBAs and 
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poor data quality observed in this study could have contributed to the  adverse outcomes such 
as the inadequate supply of drugs and other relevant logistics. Similar findings of poor 
monthly reporting by CMDs was revealed in some parts of Uganda (Uganda Ministry of 
Health, 2009).One basic question that needs to be considered is whether CBAs have adequate 
knowledge and skills to record and report appropriately considering the high levels of 
illiteracy and the detailed reporting format put in place. Some CBAs said they had to request 
for the services of literate folks in the community to record their activities and in return for 
the documentation, give them some motivation either in cash or kind which is quite 
expensive for them since they are not given any renumeration.  
In some countries, DDs who could read and write were chosen for the sake of proper 
documentation and record keeping (WHO/TDR,2007).This was however not possible 
because only 15% of the adult population in the region are literates, making it extremely 
difficult to get literate volunteers for each community. This high illiteracy rate also poses a 
serious challenge to the uptake of health promotion messages and other health programme 
implementation generally. One thing that could be done is to provide literacy training as 
documented in Mali (Winch et al., 2003). Recording and reporting also allows for systematic 
appraisal of CBA activities, patient progress and treatment outcome. It maintains a regular 
communication between the CBAs and the health staff and is  a requirement for the release of 
logistics and drugs.  
Also, paramount to this study is the use of data by health staff. Most health staff 
indicated that they send the reports to the higher level. It is prudent to forward data to the 
next level, but more importantly is the need for analysis  and use of  data at the lower level. A 
study by Unicef  identified a number of attitudinal and perceptual bottlenecks to CCM on the 
part of health officials (Haines et al., 2007). Data is vital for making appropriate and evidence 
based changes;without reliable data; policy makers and development partners  are unable to 
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plan effectively and allocate resources for the programme.The discordance between some of 
the responses from CBAs and the records reviewed is expected largely because of poor data 
management and recall bias.  
A number of health system deficiencies were identified. Although these factors are 
not direct appraisable items for the performance of CBAs; they are support systems needed to 
facilitate their work. Poor supervision of CBAs was identified in this study. This finding is 
not unique to this study alone, review of existing literature and national reports also noted 
low and irregular  supervision of DDs in most of the districts implementing the HBMF 
program (Meek et al., 2005). 
CBAs are lay people selected from the community and given basic training to care of 
sick children, they should therefore not be left on their own without support and supervision 
from the formal health sector. Regular and proper supervision does not only help to identify 
gaps and areas of poor performance, but also provides recognition and emotional support for 
the CBAs and strengthens the linkages between them  and the health sector. Communities 
with effective supervision of CHWs had better output with regards to appropriateness of 
treatment (WHO/TDR, 2007). 
The issue of motivation or incentives raised by many CBAs and community members 
in this study is not new and should be given the needed attention; moreover some CBAs had 
high expectations in terms of future engagement by the formal health system and other 
benefits for the services they render. They complain that a lot of  time is devoted to caring for 
sick children, and this prevents them from carrying out their farming or income generating 
activities which is their source of  livelihood. It is therefore not surprising that some 
respondents cited the lack of motivation as the main reason for attrition of some CBAs; the 
dilemma is the kind of motivation that should be given to ensure sustainability and not 
disrupt the existing social network. Individuals have varying degrees of motivation 
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(Katabarwa, Mutabazi, & Richards, 1999); some CBAs perceive volunteerism as a calling; 
however others stated that they cannot be volunteers for life. WHO recommends that 
incentives or remuneration for CHWs should be decided and agreed by the communities 
involved in the programme  implementation (WHO/TDR, 2007). 
From the mothers/caregivers point of view, a sizeable number reported that they did 
not know how the CBAs were selected. On the contrary a large proportion (77%) of the 
opinion leaders interviewd said they were selected by chiefs and opinion leaders. The FGDs 
also indicated that CBAs were selected democratically. This gives a confusing image on how 
the CBAs were selected. Community involvement in the selection of CHWs cannot be 
undermined because it has been identified as a key strategy for the success of many 
community based programmes. It was the most important means by which distributors were 
selected in the lessons learned in home management of malaria in four countries (WHO/TDR, 
2007). 
Results of a large-scale multi-country study, of similar projects also showed that, the 
more the target communities are involved, the better and more sustained the programme 
(Katabarwa & Mutabazi, 1998; Mutabazi & Duke, 1998). In the UWR, health workers were 
tasked to sensitize community leaders about the strategy, and they were made responsible for 
guiding the selection of suitable individuals based on the criteria given to them for approval 
at community meetings and durbars.  
The HMM strategy is a relatively new concept, the understanding of which is vital to 
its successful implementation among all stakeholders. Policy makers and health care 
providers are therefore expected to pass down information on the selection criteria to the 
lower levels especially to all community members for maximum support. In the selection of 
CBAs; first and foremost, the individual must come from, and reside in the community, must 
be committed, trustworthy and willing to work voluntarily. To also enable CBAs work 
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effectively, community members must be mobilized to recognize the significance of 
volunteer service and encourage them in their work 
 
Most sub district in-charges were not in their current positions at the inception of the 
programme, but assumed responsibilities by either learning on the job or by participating in 
refresher trainings. Thus majority had inadequate knowledge on HMM and the rationale 
behind the concept. Staff attrition was one of the main reasons cited; inasmuch as  staff 
movement is necessary for equitable distribution and for career progression,  management 
should put in measures to provide training for newly posted staff, because it is  extremely 
important and crucial for the immediate supervisors of CBAs and other staff  to be 
knowledgeable about  HMM; it is only when they understand the concept and the rationale 
behind HMM that they will attach seriousness to the activities of the  CBAs and provide the 
needed support  in terms of supervision and on the job training for quality care and  
sustainability of the programme.  
With regards to the views of community members and health workers about the 
performance of CBAs, there were diverse opinions. While some respondents said they were 
satisfied with their performance, others said some of them were not committed. Nevertheless, 
these few community concerns and negative perceptions could be reasons for clients‟ 
dissatisfaction and low utilization of the services provided by CBAs as indicated in the 
problem statement.  There is therefore the need to finds ways of addressing these concerns 
because “the global public health community recognizes that we can‟t reach key health goals 
without community health workers” (Ajayiet al, 2006). 
Most respondents were  of the view that in future the programme may not be 
sustainable unless efforts are made to improve the incentive scheme of CBAs. Therefore 
instituting performance related awards and payment of NHIS premiums for CBAs as 
suggested by some respondents is significant and could guard against volunteer fatigue and 
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attrition. One lesson learned from this study, is the use of sub district Internally Generated 
Funds (IGF) for quarterly CBA meetings where they are given a token for lunch or for 
transport. Periodic release of funds for maintenance of bicycles could also serve as a 
motivation and sustain their commitment and retention. 
5.1 Limitations of the Study 
Some limitations of the study that may have occurred are; 
 Recall biasespecially with  regards to mothers/caregivers  perceptions about CBAs  
performance.Mothers/caregivers  with a particular exposure or outcome may 
remember their experiences differently from those not similarly affected 
 Observer bias:  The observers of CBA practices may have pre-conceived expectations 
of what they should find in an assessment or management of a sick child  
 Hawthorne Effect: The presence of the study observers may have affected the 
performance of the CBAs,they may either perform better than they would have done  
because they are being observed or perform below standard because of nervousnessor 
fear. 
 Due to limited time and budget coupled with the lack of drugs at the time of the study, 
it was not possible to conduct many FGDs or observe many CBAs for case 
management. This may influence the results of some indicators.   
 
 
 
 
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CHAPTER SIX 
6.0 CONCLUSIONS AND RECOMMENDATIONS 
6.1 Conclusion 
The study was not only relevant but also timely as it provided useful information for 
addressing concerns on the performance of CBAs in relation to malaria case 
management.The study revealed that a high proportion of CBAs do not know the right dosage  
of ACTs  for children aged 6-11 months old. Although most CBAs take history and examine 
children before giving treatment, observing for danger signs, client counseling on treatment 
compliance and education on malaria prevention was not  done regularly. There is also poor 
documentation and record keeping  and low reporting of CBA activities.Most CBAs were  
not supervised regularly. Regardless of the fact that there were varied responses and 
application of knowledge and skills,majority of health workers and community members had 
an optimistic opinion about the HMM strategy and were  of the view that the CBAs are doing 
their work well.  
6.2 Recommendations 
The following recomendations are being made in the light of the findings from the study; 
 The Regional Health Directorate and the NMCP should re-train CBAs and institute 
regular updates  to sustain theircompetencies 
 The drug and logistics supply system must be re-examined and the following areas 
need to be considerd; 
a) NMCP,UNICEF, Regional and District Health Directorates should strengthen the 
utilisation of data to ensure that the drug distribution system is working efficiently to 
avoid stock outs and to increase public confidence  in HMM 
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b) Regional and district health leadership should train health staff on logistics 
management to enable them establish consumption patterns and maintain sufficient 
buffer stocks of drugs at the health facility and district stores  
c) NMCP in collaboration with the Regional Health Directorate should put in place  a 
sustainable means of repleninshing CBAs logistics  
 The District and SDHMT should strengthen facilitative supervision to CBAs. This 
could also serve as an opportunity to provide  on the job training and for addressing  
some concerns 
 Regional and District Health leadership should partner with community opinion 
leaders to identify a sustainable way of motivating CBAs  to improve   their 
commitment and retention. 
 In view of the unacceptable low utilization of CBA services in communities with 
CHPS, the regional and district leadership should establish a data base of all CBAs 
and come out with innovative ways such as a major decisive shift from communities 
with CHPS to areas without CHPS  
 Subdistrict staff should support  CBAs to improve documentation and record keeping 
considering the fact that majority are illiterate. They should visit the CBAs on a 
monthly basis to collect their reports.  
 Regional and District leadership should approve of the use of subdistrict IGF to 
organize quarterly  CBA meetings  
 
 
 
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REFERENCES 
Agyepong,I.A. (1992). Malaria: ethnomedical perceptions and practice in an Adangbe 
farming community and implications for control. Social Scienceand Medicine, 
35:131–137. 
 
Asante, F.A.& Asenso-Okyere,K.(2003).Economic Burden of Malaria in Ghana.(A Technical 
Report Submitted to the World Health Organization  African Regional Office)Accra, 
Ghana: University of Ghana, Institute of Statistical, Social and Economic Research. 
 
Ajayi, I.O., Kale, O.O., Oladepo, O., Bamgboye, E.A. (2006). Using “mother trainers” for 
malaria control: the Nigerian experience. International Quarterly of Community 
Health Education 27: 351-369 
 
Akazili, J.M.A., Aikins, M., Binka, F.N. (2007).Malaria treatment in Northern Ghana: What 
is the treatment cost per case to households? African Journal of Health Sciences, 
Volume 14, Numbers 1-2, January-June 2007 
 
Ajayi, I.O., Jegede, A.S, Falade, C.O. (2012).Sustainability of Intervention for Home 
Management of Malaria: The Nigerian Experience. J Community Medical Health 
Education 2:175. doi:10.4172/2161-0711.100017 
 
Bang, A.T., Bang, R.A., Sontakke, P.G. & the SEARCH Team (1994). „Management of 
Childhood Pneumonia by Traditional Birth Attendants‟, Bulletin of the World Health 
Organization, vol. 72, no. 6, 1994, pp. 890–905. 
 
University of Ghana          http://ugspace.ug.edu.gh
67 
 
Bhattacharyya, K., Winch, P., Le Ban, K.,Tien, M. (2001). Community Health Worker 
Incentives and Disincentives: How They Affect Motivation, Retention, and 
Sustainability. BASICS II. 2001, United States Agency for International 
Development, Arlington, VA 
 
Baume, C. (2002). Comparing care-seeking for childhood malaria: lessons from Zambia and 
Kenya. Arlington, Basic Support for Institutionalizing Child Survival (BASICS II) for 
the United States Agency for International Development. 
 
Brown,E.N.L. (2002). Early appropriate home management of fevers in children aged 6 
months to 6 years in Ghana.Reproduced from: Tropical disease research: results 
portfolio 3. Geneva, UNDP/World Bank/WHO Special Programme for Research and 
Training in Tropical Diseases(TDR Final Report Series 2001/02) 
 
Batega, D.W., Greer, G.J., Plowman, B.A. (2004). Home-based management of fever strategy 
in Uganda: Assessment of implementation and operation at district and community 
levels: Ministry of Health Uganda, the World Health Organization, and BASICS II for 
the United States Agency for International Development. Arlington, Va. 
 
Brieger, W.R., Osamor, P.E., Salami, K.S., Oladepo, O., Otusanya, S.A. (2004).Observations 
of patent medicine vendor and customer interactions in urban and rural areas of Oyo 
State, Nigeria.Health Policy and Planning,2004; 19: 177–82. 
 
Bang, A.T., Bang, R.A., Stoll, B.J., Baitule, S.B., Reddy, H.M., Deshmukh, M.D. (2005a).„Is 
Home-Based Diagnosis and Treatment of Neonatal Sepsis Feasible and Effective? 
University of Ghana          http://ugspace.ug.edu.gh
68 
 
Seven Years of Intervention in the Gadchiroli Field Trial(1996 to 2003)‟, Journal of 
Perinatology, vol. 25, suppl. 1, 2005, pp. S62–S71.53 
 
Bang,A.T., Baitule,S.B., Reddy,H.M.,Deshmukh, M.D, Bang,R.A.(2005b). „Low Birth Weight 
and Preterm Neonates: Can they be managed at home by mother and a trained village 
health worker?‟Journal of Perinatology, vol. 25, suppl. 1, 2005, pp. S72–S81. 
 
Bang,A.T.,Bang, R.A., Baitule,S.B., Reddy, H.M.,Deshmukh, M.D.  (2005c).„Management 
of Birth Asphyxia in Home Deliveries in Rural Gadchiroli: The effect of two types of 
birth attendants and of resuscitating with mouth-to-mouth, tube-mask or bag-
mask‟,Journal of Perinatology, vol. 25, suppl. 1, 2005, pp.S82–91 
 
Buabeng,  K.O., Duwiejua, M.,Dodoo,  Alex, N.O., Matowe, L.K., Enlund,H.(2007). Self –
Reported use of anti-malarial drugs and Health Facility management of malaria in 
Ghana. Malaria Journal 2007, 6:85 doi: 10.1186/1475-2875-6-85 
 
Bjerrum, S. (2008).Home- Based malaria management in rural Ghana. A study of Incentives 
and motivating factors for Community health workers participation (unpublished 
master‟s thesis),London School of Hygiene and Tropical Medicine 
 
Brieger, W.R. (2009). Home and community management of malaria: the sometimes 
forgotten component, Africa Health, November 2009, 14:43 
 
Foster, S. (1991).Pricing, distribution, and use of antimalarial drugs.Bulletin of the World 
HealthOrganization, 69:349–363 
University of Ghana          http://ugspace.ug.edu.gh
69 
 
 
Faiz, R.S., Abdullah, H., Kaosar, A., ShameemAra, B. (2001). „Acute Respiratory Infections 
in Rural Bangladesh: Cultural understandings, Practices and the role of mothers and 
community health volunteers‟, Tropical Medicine and International Health, vol. 6, no. 
4, 2001, pp. 249–255 
 
Fapohunda, Bolaji, M., Plowman, B.A., Azairwe, R., Bisoborwa, G., Langi, P.,  …Wang, X. 
(2004).Home based Management of fever Strategy in Uganda: Survey Report, 
GOU/WHO/Basics II 
 
Ghana Health Service (2006).In-service Training Policy and Guidelines for Implementation : 
Human Resource Development Directorate 
Ghana Statistical Service & Ghana Health Service (2009).2008 Ghana Demographic and 
Health Survey. Accra, Ghana: Ghana Statistical Service, Macro International 
 
Ghana Statistical Service.(2012b).Ghana Multiple Indicator Cluster Survey with an 
Enhanced Malaria Module and Biomarker, 2011, Final Report. Accra, Ghana 
 
Ghana Statistical Service (2012a).2010 Population and housing census.Accra, Ghana: 
Author. 
 
Ghana Health Service .(2012).Health Sector Annual Report, Upper West Region 
 
Hamel, M.J., Odhacha, A., Roberts, J.M., Deming, M.S. (2001).Malaria Control in Bungoma 
District, Kenya: A Survey of Home Treatment of Children with Fever, Bednet Use 
and Attendance at Ante-natal Clinics.Bull World Health Organisation. 2001; 79(11): 
1014-23. 
University of Ghana          http://ugspace.ug.edu.gh
70 
 
 
Haines A., Sanders D., Lehmann U., Rowe AK., Lawn JE., Jan S., Walker DG., Bhutta Z, 
(2007). Achieving child survival goals: potential contribution of community health 
workers. Lancet, 2007,369 (9579): 2121–31. 
 
Hopkins, H.,Talisuna, A.,Whitty,C.J.M., Staedke,S.G. (2007). Impact of Home based 
Management of Malaria on Health Outcome in Africa: a systematic review of 
evidence.Malaria Journal 2007, 6:134 doi: 10.1186/1475-2875-6-134 
 
Ikeoluwapo, O.A.,Catherine, O.F.,Bidemi, O.Y., Gbotosho,G.O  Happi.C.T., Franco 
Pagnoni,F.(2009).Feasibility, acceptability and use of artemisinin-based combination 
therapy for home management of malaria in south-west Nigeria.Bulletin of the World 
Health Organization; Type: ResearchArticle DOI: 10.2471/BLT.08.055038 
 
   Katabarwa, M.N, & Mutabazi, D. (1998).Communitydirected,ivermectin-treatment 
programmes foronchocerciasis control in Uganda: the selection and validation of 
indicators for monitoring sustainability atthe district level.Annals of Tropical 
Medicine and Parasitology, 93(6):653–658 
 
        Katabarwa, M,.Mutabazi., Richards, F.O.Jr.(1999). Monetary incentives and 
community-directed health programmes in some less-developed countries. Lancet 
1999, 354:1909 
 
Kidane, G,& Morrow, R.H. (2000).Teaching mothers to provide home treatment of malaria 
in Tigray, Ethiopia: a randomized trial. Lancet, 356:550–555. 
 
University of Ghana          http://ugspace.ug.edu.gh
71 
 
Lewin, S.A., Dick, J.,Pond, P.,Zwarenstein, M.,Aja, G., van Wyk, B., …Patrick M. 
(2005).Lay health workers in Primary  and community health care. Cochrane Data 
base Systemaic  Review 
 
Mwenesi, H., Harpham, T., Snow, R.W. (1995).Child malaria treatment practices among 
mothers inKenya. Social Science and Medicine, 401271–1277 
 
Mutabazi, D., &Duke, B.O.L. (1998).Onchocerciasis control in Uganda: how can self-
sustaining, community-based treatment with ivermectin be achieved? Annals of 
Tropical Medicine and Parasitology,92(2):195–203. 
 
Meek, S., BitarohoKabwa, P., Kyomuhendo, S. (2005).Review of Implementation of the 
Home-based Management of Fever Strategy in UPHOLD supported Districts  
 
Matsiko, C.W., Musoba, N.,Lutwama, J.,Kaitiritimba, R, &Jitta, J. (2007).An Assessment 
study on the Performance of Home Based Management of Fevers Strategy among the 
under 5 Children in Kabarole and Luwero Districts of Uganda 
 
Ministry of Health. (2009).A rapid assessment of community case management of childhood 
malaria, pneumonia and diarrhea in the context of home based management of 
fever(HBMF) and home based care (HBC) in northern Uganda.  Uganda:  Author. 
 
Ministry of Health. (2009).Anti-malaria Drug Policy for Ghana 
 
University of Ghana          http://ugspace.ug.edu.gh
72 
 
Noor, A.M, Zurovac, D., Hay, S.I., Ochola, S.A., Snow, R.W. (2003).Defining equity in 
physical access to clinical services using geographical information systems as part of 
malaria planning and monitoring in Kenya. Tropical Medicineand International  
Health 8:917-926.18. 
 
National Malaria Control Programme, Federal Ministry of Health, Nigeria. (2005).National 
strategies and guidelines for home and community management of malaria 
 
Nosten,F, &White, N.J. (2007).Artemisinin-based combination treatment of falciparum 
malaria.Am J Tropical Medicine Hygiene 77: 181-192 
 
Noor, A.M., Kirui, V.C., Brooker, S.J., Snow, R.W. (2009). The use of insecticide treated 
nets by age: implications for universal coverage in Africa. BMC Public Health. 2009 
Oct 1; 9:369. 
 
National Malaria Control Program.(2009). 2009 Annual Report . Accra, Ghana: 
Author. 
 
National Malaria Control Program.(2010). 2009 Annual Report . Accra, Ghana: 
Author. 
 
Pagnoni, F. (2009).Incentives for medicine distributors in home-based management of 
malaria programmes: An overview of TDR experiences “…and time is money” 
Bulletin of MedicusMundi Switzerland No. 112 
University of Ghana          http://ugspace.ug.edu.gh
73 
 
Rahman, S.H., Mohamedani, A.A., Mirgani, E.M., Ibrahim, A.M. (1995).Gender aspects & 
women participation in the control & management of malaria in central Sudan.Social 
Science and Medicine. Vol. 42, No.10, pp. 1433- 1446, 1995 
 
Robinson, S.A, & Larsen, D.E. (2001). „The Relative Influence of the Community and the 
Health System on Work Performance: A case study of community health workers in 
Colombia‟, Social Science and Medicine, vol. 30, no. 10, 2001, pp. 1041–1048 
 
Root, G., Collins, A., Munguti, K,. Sargent, K. (2003). Roll-Back Malaria Scoping Study; 
Final Draft, Malaria Consortium. 
 
Rohde, J.,  Cousens, S., Chopra., M, Tangcharoensathien.,V, Black, R., Bhutta, Z . A., Lawn, 
J.E. (2008).Alma-Ata: Rebirth and Revision 4: 30 years after Alma-Ata: has primary 
health care worked in countries?Lancet2008; 372: 950–61. 
 
RBM/WHO, Retrieved April 15,2012, from Roll Back Malaria Partnership web site: 
http:www.rbm.who.int/malariamessages.html  
 
Snetro, G. (1999).„Volunteer Community Health Promoter: Sustainability study report, Gaza 
and Nampula Provinces, Mozambique‟, Save the Children Mozambique, 1999, p. 10 
(internal document). 
 
Sundararaman, T. (1999).Community health-workers: scaling up programmes. Lancet, 
Retrieved from www.thelancet.com.Published online March 6, 2007 
University of Ghana          http://ugspace.ug.edu.gh
74 
 
Salako, L.A., Brieger, W.R., Afolabi, B.M., Umeh, R.E., Agomo, P.U., Asa, 
S.,…Akinlade,C.O. (2001). Treatment of childhood fevers and other illnesses in three 
rural Nigerian Communities. J Trop Paed 47: 230-238 
 
Sirima, S.B., Konate, A., Tiono, A.B., Convelbo, N., Cousens, S., Pagnoni, F. (2003).Early 
treatment of childhood fevers with pre-packaged antimalarial drugs in the home 
reduces severe malaria morbidity in Burkina Faso. Tropical Medicine and 
International Health.2003, 8:133-139. 
 
TDR: Tropical disease research: progress 2001-2002, New and improved policies and control 
strategies.(In 16th Programme Report). Special Programme for Research and 
Training in Tropical Diseases ; 2003:53-63.  
 
Management Strategies for Improving Health Services. (2003), Addressing Barriers in 
Malaria Control through Pharmaceutical and Commodity Management.The Manager  
2003.Vol. 12, No. 1  
 
The President‟s Malaria Initiative. (2007). Malaria Operational Plan FY-08, Ghana, .Accra, 
Ghana: The President‟s Malaria Initiative. 
 
UNICEF. (2005).Global partnership to Roll Back Malaria; World Malaria Report  WHO, 
Geneva  
 
United Nations Millennium Project.(2006).Retrieved 15th July 2013 from 
www.unmillenniumproject.org/goals/  
University of Ghana          http://ugspace.ug.edu.gh
75 
 
 
UNICEF/WHO. (2006). Management of sick children by community health workers, 
Intervention models and programme examples 
 
United Nations.(2010).Millennium Development Goals Report.New York 
 
UNICEF.(2012).Annual Report for Ghana, WCARO,retrieved 20/12/1013 from 
www.unicef.org/about/annualreport/files/Ghana_COAR_2012.pdf 
 
UNICEF.(2013).retrieved on 20/12/2013 from www.unicef.org/health/index_malaria.html  
 
WHO. (2000).The African Summit on Roll Back Malaria.Abuja, 25 April 2000. Geneva, 
World Health Organization  
 
Walley, J., & Hubley, J. (2001).Public Health: an action guide to improving health in 
development countries. Oxford University Press, New York, pp 154-164 
 
WHO/UNICEF.(2003).Africa Malaria Report. WHO/CDS/MAL/2003.1093. 2003.Geneva. 
 
Winch, P.J., Bagayoko, A., Diawara, A., Kané, M., Thiéro, F., Gilroy, K.,…  Swedberg, E. 
(2003). „Increases in correct administration of chloroquine in the home and referral 
of sick children to health facilities through a community-based intervention in 
BougouniDistrict, Mali‟.Transactions of the Royal Society of Tropical Medicine and 
Hygiene, vol. 97, no. 5, 2003, pp.481–490 
 
University of Ghana          http://ugspace.ug.edu.gh
76 
 
Were, W. (2004).Bringing malaria management closer to the home.MERA, RBM, WHO. 
Retrieved10/6/2013 from http://mosquito.who.int/homemanagement.html  
 
WHO. (2005a).Guidelines for Implementation of home management of malaria in the 
African Region, Regional Office for Africa 
 
WHO. (2005b).The Roll Back Malaria strategy for improving access to treatment of 
malaria.Geneva,World Health Organization (WHO/HTM/MAL/2005/1101). 
 
WHO/RBM.(2005c).InGlobal strategic plan 2005-2015. World Health Organization / Roll 
Back Malaria Partnership  
 
WHO/TDR. (2007).Lessons learned in home management of malaria: Implementation 
research in four African countries. World Health Organization / Special Programme 
for Research and Training in Tropical Diseases (TDR). 
 
WHO.(2012a).10 facts on malaria. Retrieved from http://www.who.int/features/fact 
files/malaria/en/index.html#  
 
WHO.(2012b).Malaria fact sheet. Retrieved 10/3/2013from 
http://www.who.int/mediacentre/factsheets/fs094/en/ 
 
WHO. (2014).Retrieved 10/3/2014 from www.who.int/mediacentre/factsheets/fs094/enKey 
facts 
 
 
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APPENDIXES 
 
APPENDIX 1: INFORMATION SHEET/ CONSENT FOR PARTICIPANTS 
 
PERFORMANCE  OF  COMMUNITY BASED AGENTS  IN HOME BASED CARE FOR 
MALARIA IN UNDER FIVES IN TWO DISTRICTS OF THE  UPPER WEST 
REGION,GHANA 
Principal Investigator: BalagumyetimePhoebe 
Address: School of Public Health, University of Ghana, Legon 
Tel: 0243516077      E-mail: phoebebala55@yahoo.com 
General Information: 
The purpose of this study is to assess the performance of community based agents in home 
based care for malaria in under fives in Jirapa and Lambussie districts of the Upper West 
Region.The study will involve  community based agents, mothers/care givers of children 
under five years ,opinion leaders and health workers in selected districts, communities and 
health facilities in the region. It is expected that findings from this study will provide 
information on the performance of community based agents  in the region  and also document 
worse and best practices to inform policy makers and other relevant stakeholders  to  
strengthen the  implementation of home based care. 
 As part of this study, you have been selected to help in obtaining information for this study. 
If you agree to be part of this research, it will involve either one or both of the following: 
 Answering some questions that will be posed to you by a member of the research team. 
 Allowing a member of the research team to observe your activities and/or review your 
data.  
The expected duration of each process will be between 30 to 45 minutes. 
 
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Possible Risks and Discomforts 
The research will not pose any risks to you. You may however experience some minor 
discomfort when being observed or in answering certain questions. You may refuse tobe 
observed or refuse to answer any question if you feel uncomfortable about it. 
Possible Benefits 
You may not benefit directly from this study but the findings would benefit the District 
Health Management Team and the Ghana Health Service in planning health delivery services. 
Your participation may therefore be helping in improving the care given to your children  by 
community based agents  in the region. 
Confidentiality 
All the information obtained from this study will be confidential and used for the purpose 
indicated for the study. The information will be securely stored without your name, in a file 
which will be only be accessible to the research team. A number linked to a particular name 
will be kept confidential. The results of this study will be disseminated in such a way that no 
information will be linked to your identity. 
Compensation 
 
Participation in this study is purely voluntary. There is no monetary compensation available 
to you for accepting to be part of this study. 
Choice of Participation 
You do not have to participate in this study if you do not wish to. Your refusal to participate 
will not attract any penalty. If you agree to participate, you can withdrawconsent and 
discontinue participation at any time. This will not affect you in any way. 
Contact Numbers 
If you have any questions, you may ask them now. You may also contact the following 
people if you have any challenges relating to your participation in the study: 
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Dr FrederickWurapa                                                        Balagumyetime Phoebe  
Tel: 0244221124                                                                Tel: 0243516077 
E-mail: wurapaf@gmail.com                                               E-mail: phoebebala55@yahoo.com 
Nana Abena 
GHS/ERC Administrator 
Tel: 0244712919 
E.mail: nanatuesdaykad@yahoo.com 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX 2: DATA COLLECTION TOOLS 
Form A. Questionnaire for interviewing Community Based Agents (CBAs) 
Greetings, my name is ……………………………I am a student of the University of Ghana, 
School of Public Health. As part of my MPhil dissertation, I am interested in finding out 
whether the training offered to CBAs has contributed to improving job performance, and you 
were randomly selected to participate. The survey is not meant to check on you as an 
individual but to help make recommendations to key stakeholders and policy makers on how 
to support you to strengthen home based management of malaria.  I will also like to find out 
any challenges that might have prevented you from applying your knowledge and skills in 
your job in the community.  I encourage you to be honest with your answers. This interview 
is strictly confidential and your responses will not be shared with anyone. Your name will not 
also appear in any of the reports. Participation in this survey is voluntary; you may refuse to 
answer any question or all the questions, I however hope that you participate because I 
appreciate your views.This interview would take no longer than 45 minutes.  Thank You  
Do you agree to participate in this survey? Yes  No  
 
Record time interview begins…………………………………………. 
Identification Codes (official use only) 
 
Questionnaire CODE----------------------------- 
 
 
 
District   ------------------------------------------ 
 
 
 
 
Sub district --------------------------------------- 
 
 
 
Community/village------------------------------ 
 
 
 
Name of CBA------------------------------------ 
 
 
 
Name of interviewer ----------------------------- 
 
 
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Interview  date:         
Day…………/Month………/Year……. 
 
 
 
NB: Circle appropriate options and fill in the space where indicated  
 
Section I: Background data 
No  Questions  Coding categories  Skips  
1. How old are you  
 
 
 
 
Age in completed years  
 
 
2. Sex Male……………………………………1 
Female…………………………………2 
 
 
3. Religious background   
 
Christian ………………………………1 
Muslim  ..………………………………2 
Traditionalist  …………………………3  
Others …………………………………96 
specify 
 
 
4. Marital status  
 
Single…………………………………..1    
Married ………………………………..2 
Divorced……………………………….3 
Seperated………………………………4 
 
5. What is your 
occupation?  
 
Farming ……………………………….1   
Trading  ……………………………….2 
Formal sector ………………………....3 
Others …………………………………96 
                            Specify 
 
6. What is your level of 
education? 
 
None ..…………………………………1 
Primary………………………………...2 
Middle school………………………….3 
Junior high school……………………..4 
Senior high school …………………….5 
Other…………………………………..96 
specify 
 
 
7. How long have you 
been working as a 
CBA?  
 
1-2yrs  ………………………………..1 
3-4yrs ………………………………..2 
5-6yrs  ………………………………..3 
Above 6yrs………………………….....4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Section II: CBA training  
No. Questions  Coding categories  Skips  
8. Were you given any training 
before you started this job?  
 
Yes ……………………………1 
No……………………………..2 
 
→13 
9. Which illnesses have you been 
trained to manage? (Multiple 
responses allowed)  
 
Malaria………………………..1 
ARI/Pneumonia………………2 
Diarrhea………………………3 
Disease surveillance …………4 
Others……………………….96  
specify 
 
 
10. How many days did the training 
you received take? 
 
Less than  2 days ……………1 
 3-4 days……………………..2 
 5 days………………………..3  
 
 
11. How long ago was the training?   
 
Less than 12 months…………1 
1-3years………………………2 
4-6 years …………………….3 
Don‟t know ………………….98 
 
 
12 Was the training long enough for 
you to gain sufficient skills? 
 
Yes…………………………...1 
No…………………………….2 
 
13 Have you benefitted from any 
training updates  
Yes……………………………1 
No…………………………….2 
 
→15 
14. In which areas were you given 
the updates  
 
Malaria………………..……...1 
Diarrhea………………………2 
ARI/Pneumonia ……………..3 
Disease surveillance ………...4 
Others ………………………96 
specify 
 
 
15 What are the three primary tasks 
that you perform in your 
community?  (Multiple responses 
allowed) 
 
Management of sick children  …1   
Disease surveillance …………..2 
Health promotion activities …..3  
Conducting deliveries …………4 
Referrals……………………….5 
Other 
………………………………96 
specify 
 
16 How many children have you 
treated for malaria in the past one 
year   
 
 
 
 
Don‟t Know ………………….98 
 
17. Are you the only CBA in this 
community  
 
 
Yes……………………………1 
No... ………………………….2 
→19 
18. How many are you? 
 
 
One…………………………….1 
Two …………………………...2 
Three…………………………..3 
 
 
19. Do you have any leadership 
position in the community? 
 
Yes ……………………………1 
No……………………………..2 
 
→21 
20. Which position? Chief………………………….1 
Assembly member…………...2 
Women‟s leader ……………..3 
Other(specify)……………….96 
 
 
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Section III: Knowledge and Perceptions 
No. Questions  Coding categories  Skips  
21. What causes malaria?  
 
Mosquito bites ………………………1 
Living near stagnant water…………..2 
When you offend the gods or 
ancestors……………………………... 3 
Drinking dirty water …………………4 
Other ………………………………..96 
                                 Specify 
Don‟t know…………………………..98  
 
 
 
 
22. What is the most common 
sign of malaria in children? 
 
 
Vomiting …………………………….1 
Convulsion ………………………….2 
Poor feeding …………………………3 
Fever 
………………………………………..4 
Others………………………………..96 
                           Specify  
Don‟t 
know………………………………...98 
 
 
 
23. Mention/describe 3 other 
signs of malaria in 
children? (Multiple 
responses allowed)  
 
Vomiting ……………………………1 
Fever  ……………………………….2 
Poor feeding…………………………3  
Convulsion  …………………………4 
Others ………………………………96 
specify 
Don‟t know …………………………98 
 
 
24. What do you do when a 
sick child is brought to 
you? (Multiple responses 
allowed)  
 
Take verbal history from caregiver ……1 
Ask and examine child for fever………..2 
Observe child for danger signs …………3 
Sponge child with fever ………………..4 
Give treatment ………………………….5 
Others ………………………………….96 
                                 Specify 
 
25. What drug do you use for 
treatment of malaria in 
your community?   
 
Artemisinin Based Combiniation 
(ACTs)………………………………..1 
 SP…………………………………….2 
Chloroquine…………………………..3 
Other ………………………………...96 
                          Specify  
 Don‟t know …………………………98 
 
 
26 What dosage of 
Atersuanate/Amodiaquine 
(AA) do you give to a 
child 6-11months old?  
 
 
½ tablet of AA…………………………1 
¼ tablet of AA ………………………...2 
1 tablet of AA………………………….3 
Other(specify)…………………………96 
 
 
27 What dosage of 
Atersuanate/Amodiaquine 
do you give to a child 12-
59 months  old? 
 
½ tablet of AA…………………………1 
¼ tablet of AA ………………………..2 
1 tablet of AA…………………………3 
Other ……….………………………..96 
                      Specify 
 
 
28. What do you do to ensure 
mothers/care givers 
comply with your 
treatment instructions? 
Counsel/educate care givers ……………1  
Make follow up ………………………..2 
Give first dose of medicines  directly 
observed ……………………………….3 
 
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(Multple responses 
allowed)  
Others ………………………………….96 
specify 
 
29 Mention  4 signs of a 
severely sick child 
(Multiple responses 
allowed)  
Child is not able to eat or breastfeed  …1 
Child vomits everything he/she takes …2 
Child has convulsions …………………3 
Child is lethargic and unconscious ……4  
Child has dark color urine …………….5 
Others………………………………….96  
specify 
Don‟t know …………………………98 
 
 
 
 
30 When do you refer a child? 
(Multiple responses 
allowed)  
 
Any sick child less than 6 months old …1 
No improvement after treating a child for 
24hours ……….……………………….2 
Child is severely sick or with the danger 
signs…………………………………….3   
Others ………………………………...96 
specify 
 
 
31 What do you do if you find 
a severely sick child?  
 
Give pre-referral treatment and refer 
promptly ……….………………………1 
Refer to  health facility…………………2 
Keep child and treat……………………3 
Use herbal preparations ………………4 
Consult the gods and ancestors ………5 
Others …………………………………96 
specify 
 
 
34. Do you usually refer 
patients to the  health 
facility? 
 
 
Yes ……………………………………1 
No……………………………………..2  
 
 
 
→39 
 
35. How many have you 
referred in the last 6 
months? (check records if 
available) 
 
 
 
 
 
Don,t 
know…………………………………98 
 
 
 
 
36. Do mothers/care givers 
comply with referrals? 
 
 
Yes …………………………………..1 
No …………………………………...2 
 
 
37. Do you usually get 
feedback from the health 
facility on children you 
have referred? 
 
Yes ……………………………………1 
No ……………………………………2 
 
 
→39 
 
 
38. How do you get the 
feedback? (Multiple 
responses allowed)  
 
Through family members………………1 
During meetings with health staff …….2 
Written notes ………………………….3 
During home visits…………………….4 
Others…………………………………96 
                       Specify 
 
39 What do you educate 
mother/care takers on to 
prevent malaria in children 
(Multiple responses 
Sleep under insecticide treated net………1 
Use insecticide sprays ………………….2 
Clean your surroundings……………….3 
Wear protective clothing……………….4 
 
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allowed) 
 
Drink or smear herbal preparations……5 
Use mosquito repellant………………....6 
Others ………………………………….96 
                            Specify 
 
40 Have you had any 
medicine stock out in the 
last 3 months?   
 
Yes ………………………………….1 
No……………………………………2 
 
→42 
 
 
41 What were the causes of 
the stock outs? 
 
 
Failed to make a request ………………1 
District/health facility did not have drugs 
…………………………………………2 
No money for transport to collect drugs 
…………………………………………3 
Others…………………………………96 
                                 Specify 
 
42. Do you have any 
medicines in stock today? 
Yes ………………………………….1 
No……………………………………2 
 
43. What materials were you 
supplied with following 
your training as a CBA? 
(Multiple responses 
allowed)  
 
Record books ……………………….1 
Kit box ……………………………...2 
Wellington boots…………………….3   
Job Aides ……………………………4 
Bicycles ……………………………...5 
IE&C materials (flip charts)………...6 
Rain coats…………………………....7 
Others………………………………96 
                                  Specify 
 
44. How many times have you 
received supervision in the 
the year 2012 
 
 
1-3…………………………………1 
4-6…………………………………2 
7-9…………………………………3 
10-12………………………………4 
None ………………………………6 
Don‟t, know………………………7 
 
 
45. Of these, how many took place 
in your home/community? 
  
46. Which type of supervision 
would you prefer? 
 
Supervisor visiting you at home ……1 
Supervisor meeting you at the health 
facility………………………………2 
Other ……………………………..96 
specify 
 
 
47 How many  reports have you 
submitted to your health center 
in the past year (2012)? 
 
 
1-3…………………………………1 
 4-6………………………………...2 
 7-9 ………………………………..3  
 10-12……………………………..4 
 
 
 
    
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No Questions  Coding categories  Skips 
48 If less than 6 reports, give 
reasons for low  reporting 
 
………………………………………
……................................................. 
 
 
49. What is your opinion about the 
workload? 
 
 
 O.K………………………………1 
 Too much………………………..2  
 Too little………………………...3 
 
 
 
 
 
50 Are you given any motivation 
for the work done?                                
 
Yes ………………………………..1 
No…………………………………2 
 
→52 
51 In what way are you 
motivated?  
 
Cash………………………………1 
In Kind……………………………2 
Awards…………………………...3  
T&T during meetings…………….4 
Other …………………………….96 
specify 
 
 
52 Do you know of any CBA who 
has dropped out? 
 
Yes ………………………………..1 
No…………………………………2 
 
→54 
53. If yes, do you know the reasons 
for the drop out? 
 
 
………………………………………
……………………………………… 
 
54. What is your general 
perception about the HMM 
strategy? 
 
………………………………………
……………………………………… 
 
55. What challenges do you face in 
the process of doing your 
work? 
 
………………………………………
……………………………………… 
 
 
Section IV: Practices   
I am also interested in knowing whether you use the knowledge and skills acquired from your 
training in your practice or not? This is not a test; it is to inform us how well the training has 
helped you to improve your job performance. Please think of any changes you made after the 
training, whether they are significant or not. If you have never used the knowledge or skills, I 
am also  interested in knowing the challenges that prevented you from using the skills.  
 
 
 
 
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Practices 
No. Check for the 
following;  
Coding categories  Comments  
56 ACTs Available and not expired ………1 
Available but expired …………...2 
Not available ………………….....3 
 
57 Storage of medicines    
 
Stored in dry cool place…………1 
Store in humid place…………….2 
Exposed to sunlight……………..3 
Other……………………………96 
                   Specify 
 
58 Monthly reports 
(2012)  
 
Copies available and complete ……1 
Available but incomplete …………2 
Not available ……………………...3 
 
59 Records of referred 
children  
Available…………………………1 
Not Available…………………….2 
 
60 IE&C/health 
promotion  materials 
 
Available…………………………1 
Not available……………………..2  
 
61 Health promotion 
activities carried out 
within the last six 
months 
Carried out and records available…1 
Carried out but no records ……….2 
Not carried out ……………………3 
 
 Check for the availability and condition of the following logistics  
62 Kit box with contents 
(use checklist) 
Available in good condition………1 
Available in poor condition……….2 
Not available……………………...3  
 
63 Raincoats  Available in good condition………1 
Available in poor condition………2 
Not available………………………3 
 
64 Welling boots  Available in good condition……...1 
Available in poor condition………2 
Not available……………………...3 
 
65 Bicycles  Available in good condition………1 
Available in poor condition……….2 
Not available……………………….3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Checklist for Observation of CBAs 
 
Observe any CBA treating a sick child using the checklist below 
 
A Assessing the sick child 
No Question  Coding categories  Comments  
1 Was child brought to CBA or CBA 
was called  
Child brought to CBA…1 
CBA called …………….2 
 
2 Did CBA greet and congratulate  
parent/care taker for seeking health 
care  
Yes ……………………1 
No……………………..2  
 
 
3 Did CBA ask for name of child 
 
Yes ……………………1 
No …………………….2 
 
4 Did CBA ask if child has fever  Yes ……………………1 
No……………………..2 
 
5 Did CBA touch the child to check 
for fever  
Yes…………………….1 
No……………………..2 
 
6 Did CBA ask for other signs and 
symptoms  of malaria 
Yes…………………….1  
No……………………..2 
 
7 If yes which ones   
(Multiple responses allowed) 
 
Vomiting………………1  
Diarrhea ………………2 
Loss of appetite……….3   
Other………………….96 
 
8 Did CBA ask or observe for danger 
signs  
Yes……………………1 
No…………………….2 
 
9 If  yes, which ones  Child unable to drink or 
breastfeed………………1 
Vomits everything she/he 
drinks or eats……………2 
Convulsions……………..3  
Difficult to awaken child or 
child is very sleepy ………4 
Others………………….96 
                   Specify 
 
B. Management of fevers and malaria 
10 Was 25mg/67.5mg (1/2 tablet) of 
AS/AQ given to child 6-11 months  
Yes …………………….1 
No………………………2 
Skip If child 
is above 
 6-11months  
11 Was 50mg/135mg (1tablet) of 
AS/AQ given to child 1-5yrs  
Yes ……………………1 
No……………………..2 
 
12 Did CBA counsel/educate 
parent/care giver on correct dosage 
and treatment compliance  
Yes ……………………1 
No……………………..2 
 
 
 Parent/caregiver education; 
 Did CBA educate parent/ care 
giver on prevention                                                                                                                                                                                                                                                                      
of malaria 
Yes………………………1  
No………………………2
 
 
 If yes,which ones Use of LLINs……………1 
Use of insecticide sprays…2 
Wear protective clothing…3 
Indoor residual spraying…4 
Others…………………96 
               Specify 
 
 
Record time interview ends………………………… 
 
Thank You for your time  
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Form B. Questionnaire for InterviewingMothers/care givers  
Greetings, my name is …………………………...I am a student of the University Of Ghana, 
School Of Public Health. As part of my MPhil dissertation, I am interested in finding out 
your views about the performance of the CBAs in your community  regarding home based 
care for malaria.  The purpose of this follow-up is to help make recommendations to key 
stakeholders and policy makers on how to strengthen Home based Management of Malaria 
(HMM).  I encourage you to be honest with your answers. This interview is strictly 
confidential and your responses will not be shared with anyone. Your name will not also 
appear in any of the reports. Participation in this survey is voluntary; you may refuse to 
answer any question or all the questions. This interview would take no longer than 35 
minutes.  Thank you for your time and agreeing to participate in this study, I appreciate your 
feedback  
Do you agree to participate in this survey? Yes No 
 
 Record time interview begins…………………………………………. 
 
Identification Codes (official use only) 
 
Questionnaire CODE---------------------------------- 
 
 
 
District   -------------------------------------------------- 
 
 
 
 
Sub district ----------------------------------------------- 
 
 
 
Community/village-------------------------------------- 
 
 
 
Name of Mother/care giver ----------------------------
------------------------------------------------------------ 
 
 
 
Name of interviewer ------------------------------------ 
 
 
 
Interview Date:  
Day -------/Month/…………Year……. 
 
 
 
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NB: Circle appropriate options and fill in the space where indicated 
 
Section I: Background data  
No  Questions  Coding categories  Skips  
1. How old are you  
 
 
 
 
 
Age in completed years  
 
 
 
2. Sex Male………………………………1 
Female…………………………….2 
 
 
3. Religious 
background   
 
Christian ………………………….1 
Muslim  …………………………...2 
Traditionalist  …………………….3  
Others …………………………….96 
specify 
 
 
4. Marital status  
 
Single……………………………...1    
Married ……………………….......2 
Divorced…………………………..3 
Seperated …………………….......4 
 
5. What is your 
occupation?  
 
Farming …………………………..1   
Trading  …………………….........2 
Formal sector …………………….3 
Others  ………………………......96 
                            Specify 
 
6. What is your level 
of education? 
 
None ………………………………1 
Primary…………………………….2 
Middle school……………………...3 
Junior High School………………..4 
Senior High School ……………….5 
Other………………………………96 
specify 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Section II: Knowledge and Perceptions 
No. Questions  Coding categories  Skips  
7. What causes 
malaria?  
 
Mosquito bites …………………………1 
Living near stagnant water……………..2 
When you offend the gods or ancestors 
…………………………………………..3 
Drinking dirty water …………………...4 
Other …………………………………..96 
                                 Specify 
Don‟t know……………………………98  
 
 
 
 
8 How is malaria 
transmitted from 
person to person 
 
When a mosquito bites an infected person 
and bites another person ………………1 
When you cough on another person ……2 
Eating from the same bowl …………….3 
Other  ………………………………….96  
                       Specify 
Don‟t know ……………………………98 
 
 
9. What is the most 
common sign of 
malaria in children? 
 
 
Vomiting ……………………………..1 
Convulsion …………………………...2 
Poor feeding ………………………….3 
Fever ………………………………….4 
Others…………………………………96 
                           Specify  
Don‟t know…………………………..98 
 
 
 
10. Mention 3 other 
signs of malaria in 
children? 
(Circle 
allmentioned) 
 
Vomiting ………………………….....1 
Diarrhea …………………………......2 
Poor feeding ………………………....3  
Convulsion  ………………………….4 
Others ……………………………….96 
specify 
Don‟t know …………………………98 
 
 
11. What do you do 
when your child has 
any of the  signs and 
symptoms of 
malaria? 
 
Visit the  CBA…………………………1 
Use herbal treatment…………………..2 
Buy drugs from chemist/drug peddlers...3 
Consult the gods/ancestors ……………6 
Other ………………………………….96 
                         Specify  
 
12. Who manages sick 
children  in this 
community? 
 
CBA……………………………………1 
Herbalist……………………………….2 
Health worker …………………….......3  
Chemical seller/drug peddlers ……......4 
Don‟t know……………………………98 
 
 
13 How many CBAs 
are in this 
community?  
 
 
 
 
Don‟t know……………………………98 
 
 
14. How were the CBAs  
selected 
 
Selected democratically…………………1 
Selected by health workers……………..2 
Selected by the chief/opinion leaders…..3 
Other ……………………………….96 
specify 
Don‟t know ………………………..98 
 
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 Are the services of 
the CBAs accessible 
to all ? 
 
Yes……………………………………1 
No…………………………………….2 
 
16. Have you or any 
family member 
visited the CBA 
before with  a sick 
child 
 
Yes……………………………………..1 
No………………………………………2 
 
→19 
 
 
17 What did the CBA 
do when you sent 
your sick child? 
(Multiple responses 
allowed) 
 
Took history  …………………………..1 
Assessed child before  treatment……….2     
Observed child for danger signs ……….3 
Examined child‟s palmer for pallor ……4 
Counselled on treatment compliance 
…………………………………………..5  
Educated on malaria prevention………..6 
Sponged child to reduce fever …………7 
Others ………………………………….96 
specify 
 
 
18 What did the CBA  
do after giving your 
child treatment?  
 
Counseled/educated  on treatment 
compliance…………………………….1 
Made follow up to ensure treatment 
compliance……………………………..2 
Educatedparent/caregivers on malaria 
prevention……………………………..3 
Others…………………………………96 
specify 
 
 
19 What other activities 
does the CBA  carry 
out in the 
community on 
health? (Multiple 
responses allowed)  
Organizes health promotion activities 
…………………………………………2 
Keeps surveillance on diseases ………..3 
Conducts deliveries …………………...4 
Other………………………………….96 
                               Specify 
 
20 What is your view 
about the 
performance of the 
CBAs ? 
 
Very good…………………………….1 
Good………………………………….2 
Fair……………………………………3 
Poor…………………………………...4 
 
21 Are you satisfied 
with  the CBAs 
performance  
Yes……………………………………..1 
No………………………………………2 
 
22 How does the CBA 
contribute to the 
health of your 
children? 
(Multiple responses 
allowed)  
Takes care of our sick children…………1 
Organizes health promotion activities …2 
Keeps surveillance on diseases …………3 
Conducts deliveries …………………….4 
Other…………………………………..96 
                               Specify 
 
 
23. What is the  CBA  
doing well in this  
community? 
Management of sick children……………1 
Health promotion activities…………….2 
Home visits……………………………...3  
Disease surveillance ……………………4  
Other…………………………………...96 
 
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                                 Specify 
Don‟t know ……………………………98 
 
 
    
24 What is the CBA not 
doing well in this  
community 
Management of sick children………..1 
Health promotion activities………….2 
Home visits…………………………...3  
Disease surveillance ………………….4  
Other…………………………………96 
                                 Specify 
Don‟t know …………………………98 
 
 
25 What factors affect 
the performance of 
the CBA in 
providing services to 
your community?  
Lack of medicines……………………1 
Lack of logistics ……………………..2 
Lack/inadequate motivation…………3 
Poor recognition of CBA activity……4 
Lack of confidence in CBA ………….5 
Other…………………………………96 
                               Specify  
 
 
26 What do you do to 
support the CBA,s 
work?  
 
Provide Food stuff……………………..1 
Farm for CBA ………………………....2 
Cash incentive…………………………..3  
Others………………………………….96 
                                     Specify 
 
 
27 What is your 
general perception 
about the HMM 
strategy? 
Probe: Any thing 
else 
 
Highly beneficial………………………1 
Beneficial  ……………………………..2  
Not beneficial …………………………3 
Don‟t know ………………………….98 
 
 
 
28. What can be done to 
improve the 
performance of the 
CBAs 
 
Provide incentives………………………1 
Supply  
medicines………………………………..2 
Supply logistics ………………………..3 
Provide refresher training……………...4 
Increase awareness……………………..5 
Others………………………………….96 
                                  Specify 
 
 
 
 
Record time interview ends………………………… 
 
Thank You for your time  
 
 
 
 
 
 
 
 
 
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Form C. Questionnaire for interviewing District Focal Person    
Greetings, my name is …………..I am a student of the University Of Ghana, School Of 
Public Health. As part of my MPhil dissertation, I am interested in finding out your views 
about the performance of the CBAs in your community district regarding home based care for 
malaria.  The purpose of this follow-up is to help make recommendations to key stakeholders 
and policy makers on how to strengthen Home based Management of Malaria (HMM).  I 
encourage you to be honest with your answers. This interview is strictly confidential and your 
responses will not be shared with anyone. Your name will not also appear in any of the 
reports. Participation in this survey is voluntary; you may refuse to answer any question or all 
the questions. As part of the survey I will also be reviewing some of your records. This 
interview would take no longer than 30 minutes. 
 
Do you agree to participate in this survey? Yes                                 No 
 
 Record time interview begins…………………………………………. 
Identification Codes (official use only) 
 
Questionnaire CODE---------------------------------- 
 
 
 
District-------------------------------------------------- 
 
 
 
 
Name and position of district focal person  
 
----------------------------------------------------------- 
 
 
Name of interviewer ………………… 
 
--------------------------------------------------- 
 
 
 
 
Interview Date 
Day -------/Month/…………Year……. 
 
 
 
IIEY 
 
 
 
 INFORMANT GUIDE FORSTRICT HEALTH TEAM STAFF 
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1. How long have you been coordinating the HMM programme 
 
 1-2yrs     
 3-4yrs   
 5-6yrs   
 Above 6yrs  
2. What do you know about HMM…………………………………….. 
 
3. In which year was HMM implemented in your district? ……………… 
 
4. How many sub districts are currently implementing HMM 
…………………………………………………………………………. 
 
5. What was the implementation process……………………………………… 
 
6. Were CBAs trained prior to implementation?  
 
 
1. Yes                 2. No 
 
a) If yes, for how long? ……………………………………………………. 
 
 
b) What topics were they trained on? 
………………………………………………………………………… 
 
7. What are their primary tasks in the community? 
…………………………………………………………………. 
 
8. Have CBAs been given any kind of updates in the past three years  
(2010-2012?) 
 
1.   Yes                                                           2. No 
 
a) If yes what topics were they trained on?................................... 
 
c) If No why? …………………………………………………… 
 
9. How many CBAs are in each community? 
 
 1     
 2   
 3   
 
10. Who determines the medicine requirements for the CBAs? 
…………………………………………………………………………………. 
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11.  What is the procedure for requesting for medicines by the CBA? 
…………………………………………………………………………… 
 
12. How long does it take for the CBA to get supplies of medicines? 
……………………………………………………………………………. 
 
13. When was the last time the CBA received medicines? 
 
 1-2months      
 2-3months    
 4+ months 
 
14. How does the medicines get to the CBA in the community?..................... 
 
15. How are the medicines stored by the CBAs at the community level ? 
………………………………………………………………………….. 
 
16. What quantity of medicines was supplied to the CBAs in the last supply? (Check with 
bin cards and ledger)…………………………………………. 
17. Do CBAs submit reports to the district? 
 
1. Yes                           2.  No    
 
18. How often do they submit reports to you? 
 Monthly       
 Quarterly     
 Bi-annually  
 Annually  
 
19. How many reports have you received from the CBAs in the last year (2012)? 
(Crosscheck with copies of reports submitted)………………….. 
Reports Observed 
 
20.  If reports observed are less than 6, any reasons for CBA not reporting 
regularly………………………………………………………………… 
 
21. How is the data collected from the CBAs utilized?……………………… 
 
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22. What support and supervision has the sub district received on HMM from the district 
in the last 12 months? ………………………………………….. 
23. What support and supervision has the CBA received on HMM from the district in the 
last 12 months?  (Verify from reports)………………………. 
24. How many meetings have you held with CBAs in the last year? 
(2012)? (Verify from minutes)……………………………………………… 
25. What are your views about the performance of the CBAs?.......................... 
 
 
26.What monitoring processes are in place for the programme?........................... 
 
 
27. What plans does the district have for sustainability of the program? 
…………………………………………………………………………… 
 
Record time interview ends………………………… 
 
Thank You for your time  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
University of Ghana          http://ugspace.ug.edu.gh
98 
 
Form D. Questionnaire for interviewing Health Facility In-charge  
Greetings, my name is …………..I am a student of the University Of Ghana, School Of 
Public Health. As part of my MPhil dissertation, I am interested in finding out your views 
about the performance of the CBAs in your district regarding Home based Management of 
Malaria (HMM).  The purpose of this follow-up is to help make recommendations to key 
stakeholders and policy makers on how to strengthen home based management of malaria.  I 
encourage you to be honest with your answers. This interview is strictly confidential and your 
responses will not be shared with anyone. Your name will not also appear in any of the 
reports. Participation in this survey is voluntary; you may refuse to answer any question or all 
the questions.As part of the survey I will also be reviewing some of your records. This 
interview would take no longer than 30 minutes.   
 
Do you agree to participate in this survey? Yes  No  
 
 Record time interview begins…………………………………………. 
 
Identification Codes (official use only) 
 
Questionnaire CODE---------------------------------- 
 
 
 
District   ---------------------------------------------------     
 
 
 
Sub district 
 
 --------------------------------------------- 
 
 
Name and rank of health facility In-charge  
--------------------------------------------------------- 
 
 
Name of interviewer ………………… 
 
--------------------------------------------------- 
 
 
 
 
Interview Date:Day/ -------/Month/…………Year……. 
 
 
 
F THE HEALTHILITIES 
 
 
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1. How long have you been the facility In-charge?  
 
 1-2yrs     
 3-4yrs   
 5-6yrs   
 Above 6yrs  
 
2. What do you know about HMM…………………………………………… 
 
3. How long have CBAs implemented HMM in this sub district under your support? 
 
_____Months ______Years 
 
4.  Have you been or were you involved in any of the following activities for the 
implementation of the HMM program? Circle all that apply 
1. Selection of CBAs  
2. Training of CBAs 
3. Supervision of CBAs  
Other(specify) ……………………………………………………….. 
 
5. How many CBAs are you responsible for supervision and supply of medicines? 
............................................................................................... 
 
6.  Describe the type of support or supervision that you give to the 
CBA?....…………………………………………………………………… 
 
7. How many supervisory visits have you carried out per CBA in the last 12 
months?..................................................................................................... 
 
8. What were some of the observations made during your supervisory visits? 
….………..………………………………………………………………… 
 
9. Do you give any feedback on supervision on HMM activities to your CBAs? 
          1.         Yes                               2.         No  
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     a) If yes how do you give feedback and how often?  ………………………… 
 
b) If no, any reasons? 
 
10. Have CBAs been making referrals to your health facility? 
 
1. Yes            2.No (skip to Q12) 
 
a) If yes, approximately how many referrals do they make in a month?........... 
 
11. Do you usually give feed back to the CBA on the referred cases? 
 
1. Yes               2.  No 
 
a) If No, any reasons?........................................................................................ 
 
b) If yes, how do you give the feedback?........................................................ 
 
Logistics   management 
12. Who quantifies the medicines for the CBAs? 
 Sub district In-charge  
 District focal person  
Others (specify)……………………………………………………………… 
13. What is the time lag between placing an order by a CBA and receipt of supplies of 
medicines  at the community? 
 0-1 month 
 2-3 months  
 4 months and above  
14. How do the medicines and other supplies get to the CBA? 
 
 Sub district sends medicines and supplies to CBA  
 CBA collect medicines from health facility 
Others (Specify)………………………………………………………. 
15.  Have you had drug stock-out in the last 3 months? 
 
1. Yes                         2. No  
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a) If yes what were the reasons ………………………………………… 
 
Please check if in store 
Balance of drugs and consumption 
16. How do CBAs store their drugs in the community?................................ 
Reporting 
17.Do the CBAs report to you on their activities? 
 
   1.             Yes                   2 .      No 
 
18. How often do they report to you? 
 Monthly       
 Quarterly     
 Bi-annually  
 Annually  
19. How many CBAs reports have you received in the last year (2012)? 
…………………………………………………………………………. 
 
Reports Observed 
 
a) If reports observed are less than 6, any reasons for CBA not reporting 
regularly…………………………………………………………………… 
Give reasons for any mis-match between stated and observed number ofreports 
……………………………………………………………………… 
20. How is the data collected from the CBA utilized by the health facility? 
……………...……………………………………………………………………… 
 
21. Do you give feedback to CBAs on their reports? …………………………….. 
 
22. How many meetings have you held with CBAs in the last year? 
(2012)? (Verify from minutes) 
23. What is your impression about the performance of your CBAs?.......................... 
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24.  In your opinion what are the major challenges encountered by the CBA in the 
implementation of the HMM strategy?.............................……………………… 
25. What plans does the subdistrict have for sustainability of the program? 
…………………………………………………………………………………… 
Record time interview ends………………………… 
 
Thank You for your time  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Form E. Key Informant Interview for Opinion Leaders    
Greetings, my name is …………………………...I am a student of the University Of Ghana, 
School Of Public Health. As part of my MPhil dissertation, I am interested in finding out 
your views about the performance of the CBAs in your community regarding Home Based 
Care for Malaria (HMM).  The purpose of this follow-up is to help make recommendations to 
key stakeholders and policy makers on how to strengthen HMM.  I encourage you to be 
honest with your answers. This interview is strictly confidential and your responses will not 
be shared with anyone. Your name will not also appear in any of the reports. Participation in 
this survey is voluntary; you may refuse to answer any question or all the questions. This 
interview would take no longer than 30 minutes.  
Do you agree to participate in this survey? Yes                                 No 
 
 Record time interview begins…………………………………………. 
 
Identification Codes (official use only) 
 
Questionnaire CODE---------------------------------- 
 
 
 
District   ------------------------------------------------- 
 
 
 
 
Sub district………………………………………. 
 
 
 
 
Community ---------------------------------------- 
 
 
 
 
Name of opinion leader   
----------------------- ------------------------------------ 
 
 
 
Name of interviewer …………………………… 
 
 
 
 
Interview Date: Day/ -------
/Month/…………Year……. 
 
 
 
 
 
  
  
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Section I: Background Data  
 
1. Sex     
1. Male      
 
 2. Female       
 
2. Religious background   
 
 Christian  
 Muslim  
 Traditionalist   
     Others (specify)……………………………………………………… 
3. How old are you  
 
Age in completed years      
 
4. Marital status  
 
 Single        
 Married     
  Divorced  
      Seperated 
5. What is your occupation?  
 Farming        
 Trading      
  Formal sector  
 Others (specify) …………………………………………….. 
6. Educational level? 
 
 None  
 Middle school  
  Primary    
  
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  Junior High School   
 Senior High School     
Section II: Perceptions about CBA Performance  
 
7. What do you do when a child is sick in this community? 
 Send child to CBA 
            Visit the traditional birth attendant  
 Use herbal treatment 
 Buy drugs from chemist /drug peddlers 
 Consult the gods/ancestors   
8. Who manages sick children with malaria in this community 
 CBA 
 Herbalist 
 Health worker  
 Chemical seller/drug peddlers  
 Traditional birth attendants  
9. How many CBAs are in this community?  
  1 
  2 
  3 
10.How were the CBAs  selected 
 Selected democratically 
 Selected by health workers 
 Selected by the chief/opinion leaders  
Other (specify)……………………………………………………… 
11.Are the CBAs services accessible to all in the community? 
 
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1.   Yes                       2.  No 
 
12.Have you or any family member or friend visited a CBA with  a sick child 
 
1.   Yes 2.  No (If no skip to Q 15)           
 
13.What did the CBA do when you sent the sick child? ((Circle all mentioned)  
 Took history and gave treatment 
 Assessed and examined child before giving treatment  
 Observed child for danger signs  
 Examined child‟s palmer for pallor  
 Counselled on treatment compliance 
 Educated on malaria prevention  
 Sponged child to reduce  fever 
Others (specify)…………………………………… 
14. What did the CBA do after giving the child treatment?  
 Counseled parents/caregivers on treatment compliance 
 Made follow up to ensure treatment compliance 
 Gave child treatment and sent them away 
Others (specify)…………………………………………………. 
15. What other activities does the CBA carry out in the community on health?  
……………………………………………………………………………. 
 
16. What  are your views about the performance of the CBAs?  
Very good                Good   Fair           Poor  
17. How does the CBA contribute to the health of your children?...................... 
18. What is the  CBA  doing well and what is he/she not doing well in this  community 
………………………………………………………………… 
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19. What factors affect the performance of the CBA in providing services to your 
community? (Good and bad factors, including drugs, management of sick children, 
referrals).………………………………………………… 
20. What do you do to support the CBA in his/her work? …………………. 
21. What are your experiences with regards to CBA practices in management of malaria 
(probe for assessing children, interpretation of the symptoms, providing treatment, 
issues of trust, confidence, and competence)? 
…………………………………………………………………………… 
22. What is your general perception about the performance of the CBA and the HMM 
strategy?………………………………………………………….. 
23. What can be done to improve the performance of the CBA?................... 
       Record time interview ends………………………… 
 
      Thank You for your time  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Form F.Focus Group Discussion Guide for Mothers/care givers 
Greetings, my name is …………..I am a student of the University Of Ghana, School Of 
Public Health. As part of my MPhil dissertation, I am interested in finding out from your 
point of view, the performance of the CBAs in your community regarding Home based 
Management of Malaria (HMM).  The purpose of this follow-up is to help make 
recommendations to key stakeholders and policy makers on how to strengthen home based 
management of malaria.  I encourage you to be honest with your answers. This interview is 
strictly confidential and your responses will not be shared with anyone. Your names will not 
also appear in any of the reports. This Participation in this survey is voluntary; you may 
refuse to answer any question or all the questions. This interview would take no longer than 
45 minutes.  I will however  ask for your permission to record the  proceedings Thank you for 
your time and agreeing to participate in this discussion .I appreciate your feedback  
1. What  do you know about the HMM strategy  
 
2. Who manages children sick children  in this community 
 
3. How was your CBA  selected 
 
4. How accessible are the services of the  CBAs in this community   
 
5. What does he/she do when you send a sick child?  
 
6. What does he/she do after giving your child treatment?  
 
7.  What are your views about the performance of your CBAs?  
 
8. What is the  CBA  doing well and what is he/she not doing well in this  
community? 
 
9. What factors affect his/her performance in providing services to your 
village?(Good and bad factors) 
10. What do you do to support the CBAs  in their work?  
11. What can be done to improve the performance of the CBA? 
            
Record time interview ends………………………… 
 
Thank You for your time 
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