PATTERNS, PERCEPTIONS AND MANAGEMENT OF CEREBRO- SPINAL MENINGITIS IN THE KASSENA-NANKANA EAST AND WEST DISTRICTS BY APWAH FREDERICK 10164117 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL GEOGRAPHY AND RESOURCE DEVELOPMENT DEGREE JUNE, 2013 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION Candidate’s Declaration I hereby declare that this thesis is my own work produced from research undertaken under supervision and that no part of it has been submitted for another degree or qualification in this institution or elsewhere. Candidate’s Name: APWAH FREDERICK Signature: ....................................................... Date................................. Supervisors’ Declaration We hereby declare that the preparation and presentation of the thesis was supervised in accordance with the guidelines on supervision of thesis laid down by the University of Ghana, Legon. Principal Supervisor’s Name: NAA PROF. JOHN S. NABILA Signature:…………………................................ Date................................. Co-Supervisor’s Name: DR. JOSEPH K. TEYE Signature:………………….................................. Date............................... University of Ghana http://ugspace.ug.edu.gh iii ABSTRACT Cerebrospinal Meningitis (CSM) has been a long-standing health concern especially in tropical West Africa. CSM has been studied extensively especially in its immunological and clinical aspects in the study area in particular and the northern part of Ghana in general. However, begging questions and gaps remain in its comprehensive assessment in local-specific contexts. Consequently, the objective of the study was to gain better insight into its patterns, perceptions and management in the Kassena-Nankana East and West Districts within the broader context of the Meningitis Belt of Africa. Guided by Meade’s human ecological triangle, a Geographical Information System’s Approach was used to generate a rate map to show magnitude and spatial patterns. Charts were also used to show seasonality and demographic patterns. A comprehensive approach was also adopted in assessing views on the issues of perceptions and management. A sample size of 250 respondents was drawn from the general public and 100 respondents comprising people who have experienced the disease before in the last two years was also considered. The study revealed that, meningitis is still an issue to reckon with in the study area, as it portrays rates higher than the national average and falling within the hyper endemic zone of the Meningitis Belt of Africa. Besides, marked spatial variations have also been observed in relation to sub zones, as well as with demographic categorisations (age and sex) and seasonality. The study showed that, majority of the people have knowledge about the disease, however, both naturalistic and supernatural attributions are made for causes of meningitis. With the variations observed in relation to the spatial, seasonal as well as demographic patterns, it was concluded that a holistic and strategic approach is required in dealing with the specifics, while recommending further research into the causes and extent of these observations. University of Ghana http://ugspace.ug.edu.gh iv DEDICATION To my dear mother, Madam Ann Doris Balunu Apwah. University of Ghana http://ugspace.ug.edu.gh v ACKNOWLEDGEMENTS This work would not have come to fruition without the invaluable contributions by a number of personalities. Especially, the work benefited greatly from the intellectual advice and guidance of Naa Prof. John S. Nabila and Dr. Joseph K. Teye (my supervisors). I express my sincere and special appreciation to them for their immense contribution. I am also grateful to Messrs Asia Ambrose, Head of the Meteorological Station at Navrongo, James K. Addo, Data Manager at Ghana Health Service―Disease Surveillance Unit at Korle-Bu―Accra, Alatinga Louis, and Allan Frank (GHS, Paga) for assisting me with relevant data. I am also thankful to all who have contributed in one way or the other towards the success of this work. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS Contents Page DECLARATION...............................................................................................ii ABSTRACT.....................................................................................................iii DEDICATION..................................................................................................iv ACKNOWLEDGEMENTS...............................................................................v TABLE OF CONTENTS..................................................................................vi LIST OF TABLES.............................................................................................x LIST OF FIGURES..........................................................................................xi LIST OF ACRONYMS..................................................................................xiii CHAPTER ONE INTRODUCTION...........................................................................................1 1.1 Introduction to the study........................................................................1 1.2 Problem statement……………………………………………..............4 1.3 Research objectives................................................................................6 1.4 Research questions.................................................................................6 1.5 Rational for the study.............................................................................7 1.6 Scope of the study..................................................................................7 1.7 Organization of the study.......................................................................8 CHAPTER TWO REVIEW OF RELATED LITERATURE....................................................9 2.1 Introduction............................................................................................9 2.2 The nature and epidemiology of meningitis..........................................9 University of Ghana http://ugspace.ug.edu.gh vii 2.2.1 A brief history of meningitis......................................................9 2.2.2 Types and causes of meningitis...............................................10 2.2.3 Symptoms and complications of meningitis............................13 2.2.4 Health determinants and risks of meningitis............................13 2.2.5 The Meningitis Belt of Africa..................................................14 2.3 The concept of health and disease: Attributions, beliefs, practices and management.........................................................................................15 2.4 Disease patterns and trends: The spatial, seasonal and demographic dimensions...........................................................................................18 2.5 Theoretical Perspectives and Epidemiological Approaches to Medical Geography............................................................................................20 2.5.1 Medical Geography..................................................................20 2.5.2 The supernatural theory of disease causation...........................20 2.5.3 The germ theory of disease causation......................................22 2.5.4 The disease ecology approach..................................................25 2.5.5 The triangle of human ecology.................................................26 2.5.6 Empirical studies on previous meningitis concerns.................30 2.5.7 Conceptual framework.............................................................36 CHAPTER THREE THE STUDY AREA AND RESEARCH METHODOLOGY...................39 3.1 Introduction..........................................................................................39 3.2 The study area......................................................................................39 3.2.1 Location and physical characteristics.......................................39 3.2.2 Socio-demographic structure....................................................41 University of Ghana http://ugspace.ug.edu.gh viii 3.2.3 Economic features....................................................................42 3.3 Research methodology.........................................................................44 3.3.1 Study design.............................................................................44 3.3.2 Sources of data.........................................................................45 3.3.3 Data collection..........................................................................46 3.3.4 Sampling procedure for questionnaire.....................................47 3.3.5 Ethical considerations and clearance........................................50 3.3.6 Data limitations........................................................................50 3.3.7 Data analysis and presentation.................................................51 CHAPTER FOUR THE MAGNITUDE, SPATIAL PATTERNS AND SEASONAL TRENDS OF MENINGITIS..........................................................................................53 4.1 Introduction..........................................................................................53 4.2 The Context of the Meningitis Belt of Africa......................................53 4.3 The Context of Ghana..........................................................................56 4.4 Magnitude and patterns of meningitis in the study area.......................61 4.4.1 The magnitude and spatial patterns of meningitis....................61 4.4.2 Seasonal distributions and trends in meningitis cases..............68 4.4.3 Meningitis and observed demographic patterns.......................74 4.5 Conclusion...........................................................................................76 CHAPTER FIVE KNOWLEDGE, PERCEPTIONS AND MANAGEMENT OF MENINGITIS.................................................................................................78 University of Ghana http://ugspace.ug.edu.gh ix 5.1 Introduction..........................................................................................78 5.2 Socio-demographic characteristics of respondents..............................78 5.3 Awareness of meningitis......................................................................82 5.4 Perceived causes or drivers of meningitis............................................84 5.5 Knowledge of symptoms of meningitis...............................................88 5.6 Management of meningitis..................................................................89 5.7 Socioeconomic implications of meningitis..........................................93 5.8 Conclusion...........................................................................................95 CHAPTER SIX SUMMARY, CONCLUSIONS AND RECOMMENDATIONS...............97 6.1 Introduction..........................................................................................97 6.2 Summary..............................................................................................97 6.3 Conclusion...........................................................................................99 6.4 Recommendations..............................................................................100 6.4.1 Understanding and managing meningitis...............................100 6.4.2 Issues for further research......................................................101 REFERENCES.............................................................................................102 APPENDICES..............................................................................................114 Appendix A: Questionnaire for the general public......................................114 Appendix B: Questionnaire for survived meningitis cases.........................117 Appendix C: In-depth interview schedule for key informant (health personnel)...............................................................................120 Appendix D: Navrongo demographic surveillance systems’ clusters and their localities (zones)............................................................121 University of Ghana http://ugspace.ug.edu.gh x LIST OF TABLES Table 3.1: Categories of zone, selection procedure and sample size........49 Table 4.1: Annual meningitis reported cases, rates of attack, reported deaths and (CFR %) in Ghana from (2008-2012)....................57 Table 4.2: Regional and national averages of attack rates and case fatality rates for the year 2012..............................................................58 Table 4.3: Vital reported CSM statistics from the study districts (2008- 2012)........................................................................................62 Table 4.4: The magnitude of meningitis in the study districts in relation to the regional and annual figures for 2012.................................63 Table 5.1: Background characteristics of respondents..............................79 Table 5.2: Source of information on meningitis.......................................83 Table 5.3: Perceived causes/drivers of meningitis....................................84 Table 5.4: Symptoms on meningitis.........................................................89 Table 5.5: Measures to control meningitis................................................90 Table 5.6: Vaccination, time of vaccination and reason for not vaccinating...............................................................................92 Table 5.7: Socioeconomic effects of meningitis.......................................93 University of Ghana http://ugspace.ug.edu.gh xi LIST OF FIGURES Figure 2.1: The triangle of human ecology................................................27 Figure 2.2: Meningitis patterns framework................................................38 Figure 3.1 A map of Ghana showing the location of the study districts (Kassena-Nankana East and West Districts)............................43 Figure 3.2: Epidemiological study designs................................................45 Figure 4.1: The Meningitis Belt of Africa showing average annual rates per 100,000..............................................................................54 Figure 4.2: Number of reported meningitis cases in Ghana (2008-2012)..56 Figure 4.3: A map of Ghana showing the national and regional averages or reported meningitis cases for the year 2012............................60 Figure 4.4: The study districts, the host region (Upper East Region) and national attack and case fatality rates for 2012........................64 Figure 4.5: A map of the study area illustrating zones and spatial distribution of reported Meningitis cases (2008-2012)............66 Figure 4.6: Annual spatial (zonal) distribution of reported meningitis cases in the study area (2008-2012)................................................67 Figure 4.7: Seasonal (monthly distribution) of reported meningitis cases in the study area (2008-2012)......................................................68 Figure 4.8: Distribution of number of reported meningitis cases (monthly averages for 2008-2012 and monthly mean rainfall amounts..70 Figure 4.9: Distribution of number of reported meningitis cases (monthly averages) for 2008-2012 and monthly mean air temperature..72 University of Ghana http://ugspace.ug.edu.gh xii Figure 4.10: Distribution of number of reported meningitis cases (monthly averages) for 2008-2012 and monthly mean relative humidity...................................................................................73 Figure 4.11: Annual distribution of reported meningitis cases by age.........74 Figure 4.12: Annual distribution of reported meningitis cases by sex.........75 University of Ghana http://ugspace.ug.edu.gh xiii LIST OF ACRONYMS CDC Centre for Disease Control CSM Cerebrospinal Meningitis DHD District Health Directorate DHMT District Health Management Team GIS Geographic Information System HIV/AIDS Human Immuno Virus/Acquired Immuned Deficiency Syndrome KNED Kassena-Nankana East District KNWD Kassena-Nankana West District MCM Meningococcal meningitis MOH Ministry of Health NDSS Navrongo Demographic Surveillance System NHRC Navrongo Health Research Centre PCM Pneumococcal meningitis UNEP United Nations Environmental Programme WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Introduction to the study Cerebro-spinal Meningitis (CSM) is a dangerous epidemic and endemic disease. CSM is characterised by inflammation of the protective membranes covering the brain and spinal cord known as the meninges, giving rise to complex forms of symptoms including severe headache, sudden onset of fever, stiff neck, tenderness of the back, permanent damage to the brain and ultimately death (Welch, & Nadel, 2003; Ministry of Health [MOH], 2010). There are four main types of meningitis; bacterial, viral, fungal and parasitic or amoebic and a fifth type which is non infectious. Bacterial meningitis is the main cause of major epidemic outbreaks in Africa and will be the focus of this paper. Bacterial meningitis is now among the top 10 infectious causes of death worldwide (Grimwood et al., 2000). Having been described as far back as 1805, Meningitis has come to stay as a global health concern, with different regions experiencing different incidence rates at various seasons. The incidence of CSM, as it manifests itself in spatial and temporal patterns can be attributed to a constellation of factors. Among these factors are the characteristics of the infecting organism, the resistance of the host, and, the environment (physical and social) (Sultan et al., 2005). It is further noted that CSM is one disease that is closely linked to climate as, evidenced by its spatial and temporal patterns throughout the world University of Ghana http://ugspace.ug.edu.gh 2 (McMichael, 2004; McMichael, et al., 2006; Sultan et al., 2005; Harrison et al., 2009). Given compelling evidence of global climate change with climatologist estimating upwards trends in global temperatures to up to 2 o C by the year 2100, regional and local patterns of CSM must be closely monitored (Patz et al., 1996). Equally important to the study are considerations pertaining to critical socio- cultural conditions, dynamics and outlooks, such as attitudes and perceptions. Various studies have shown that the socio-cultural orientation of a people could also inform their overall perception on the incidence of diseases and management efforts (Furnham et al., 1999; Green, 1999; Madge, 1998). These constitute a critical component in the overall effort to appreciate the existence, patterns as well as trends of health related issues in a given population. Thus, people perceive the incidences of health phenomena variously depending to a significant extent on their socio-cultural context and orientation. An observation of the global and regional distribution and patterns of meningitis indicate that CSM is very much a function of space and time. Thus, CSM like many other diseases does not occur at the same time, with uniform patterns globally, but with marked intraregional and regional variations (Manchanda et al., 2006). According to Grimwood et al. (2000), there have been some major outbreaks in Asia (China 1979, and 1980, Vietnam, 1977, Mongolia 1973-1974 and 1994-1995, Saudi Arabia 1987, Yemen 1988). Five common types (serogroups)―(A, B, C, Y and W135) are responsible for over 90% of global infections, with serogroup Y and w135 on the rise mostly associated with Hajj pilgrims and also common in Burkina Faso (Manchanda, University of Ghana http://ugspace.ug.edu.gh 3 et al., 2006). In temperate regions the number of cases increases in winter and spring. Serogroups B and C together account for a large majority of cases in Europe and the Americas e.g. (Spain 1995-97 and Canada and US 1992-93). The African continent has been experiencing epidemic meningitis for over a decade. In the geographical region known as the “Meningitis Belt” incidence occurs in irregular cycles (5-12 years) and affects millions of people, with a case fatality rate of between 10-50%. Epidemics in Africa are associated with bacterial N. Meningitides and mostly occur in the dry season (Integrated Disease Surveillance and Response [IDSR], 2003; WHO, 2012). Meningitis represents a main health challenge in the meningitis belt which stretches from Senegal in the West to Ethiopia in the East and covers most parts of northern Ghana (GHS, 2011). It ranks 51st amongst the 60 diseases reported by the Ghana Health Services (GHS, 2004). Meningitis was among the top ten causes of deaths of all ages― national for 2009― ranking 9 th (a mortality rate of 2.3 percent), the first eight being; malaria (13.4%), HIV/AIDS related conditions (7.4%), Anaemia (7.3%), Cerebro-vascular accidents (6.4%), Pneumonia (6.2%), Septicaemia (5.1%), Hypertension (4.1%) and Cardiac diseases (4.0%). Diarrhoeal diseases occupied the tenth spot with a mortality rate of 2.3%, with all other causes being 41.5% (GHS, 2009). Periodic outbreaks of cerebrospinal meningitis occur, particularly in the northern regions of the country and widespread epidemics remain a public health threat (WHO Country Cooperation Strategy, 2008-2011, for Ghana). In 2012, the Upper East and Northern regions of Ghana recorded over 230 total University of Ghana http://ugspace.ug.edu.gh 4 reported cases of cerebro-spinal meningitis (CSM) in just two months−January and February (Africa Report Posted on Thursday, 23 February 2012 13:33). Recent developments indicate that the rest of the country lies effectively within the risks zone of the disease aside the three regions of the north, as evidence point to the fact that the Meningitis Belt is pushing towards the south of the country―all regions of the country have reported of meningitis at least in the last five years (GHS, 2013). 1.2 Problem statement CSM continues to occupy its place as one of the major threats to human health and socio-economic structures of communities in especially most parts of tropical Africa (Heymann, 2003; Frasch, 2005; & Roberts, 2008). Evidence of change in mean climatic (dry-hot) conditions accompanied by agent mutation and resistance together with diverse human risks behaviour and deposition have combined effectively to ensure that CSM remains a major public health issue especially in the Meningitis Belt of Africa and adjoining regions (Sultan et al., 2005). It is therefore increasingly clear that this phenomenon represents a worrying source of concern, for communities, health practitioners and policy makers since everybody is at risk in these endemic areas, with high poverty levels and already overburdened health care systems. In the Kassena-Nankana East and West Districts which lie in the northern part of the country and within the Meningitis Belt of Africa, CSM continues to be a public health burden. During the 1996/97 major outbreak, the War Memorial Hospital in Navrongo was overwhelmed by meningitis cases. The Kassena- University of Ghana http://ugspace.ug.edu.gh 5 Nankana District recorded 1,396 cases with 69 deaths (Enos, 1997). CSM has since continued to hit the area in its endemic and sporadic forms. Recent evidence indicates that the study area is leading in the whole of the Upper East region and represents one of the highest rates nationally (DHMT-KNWD, 2012; DHMT-KNED, 2012; GHS, 2013). The worrying phenomenon of meningitis has prompted expansive studies on especially the study area and the northern parts of the Ghana. While most of these studies have basically explained the clinical, immunological and some other aspects of its epidemiology, (Gagneux et al., 2000; 2002; Hodgson et al., 2002; Forgor et al., 2005), there is scant and incomprehensive literature on the spatial distribution and patterns as well as the seasonal trends of meningitis in the study area. Further, local perceptions on the phenomenon have not also been adequately dealt with. Hence, there is little geographical and social means of analysing and appreciating the distribution patterns for policy formulation and implementation to help manage and control meningitis in the study area. Mead and Emch (2010) assert that for the comprehensive and holistic analysis and appreciation of a health related concern on a population in a given area, there is the imperative need to pay attention to the local contexts pertaining to the critical interactive issues of population, habitat and behaviour. It is against this background that the study seeks to examine the spatial patterns, seasonality and to as well assess the knowledge and perceptions on CSM. Further, the study seeks to assess the management dimensions and socioeconomic implications of meningitis as a health concern in the area, in University of Ghana http://ugspace.ug.edu.gh 6 the hope that this perspective would add to literature that would help in the better appreciation and management of the disease in the area. 1.3 Research objectives The general objective of the study is to evaluate and assess the patterns, perceptions and management of meningitis in the Kassena-Nankana East and West Districts. The specific objectives of the study are to:  describe the magnitude, spatial patterns and seasonality of meningitis in the study area,  assess the level of knowledge and perceptions of the people about meningitis in the area,  assess the management and socioeconomic implications of meningitis in the study area,  make recommendations for the management of meningitis in the study area. 1.4 Research questions  What are the patterns of Cerebrospinal meningitis in the study area?  How is meningitis perceived in the study area?  How is meningitis being managed?  What are some of the socioeconomic implications associated with the meningitis scourge? University of Ghana http://ugspace.ug.edu.gh 7 1.5 Rationale for the study Considering the fact that, habitat, behavioural and other socio-demographic characteristics as well as agent type and mutation drive meningitis, it is only instructive that a study be made to assess the patterns and associations between the various critical factors noted above. The significance of the study further ties in well with local, national and international efforts aimed at understanding all aspects of the disease, and to garner efforts to halt and reverse its infections. 1.6 Scope of the study The study pays attention to three dimensions of scope―Geographical, content and time. Geographically, the study focuses on the Kassena-Nankana East and West Districts of the Upper East Region of Ghana. The study further narrows down to five zones covering both districts that the Navrongo Health Research Centre (NHRC) uses for surveillance and monitoring health programmes−East, West, Central, North and South zones. Content wise, the study covered magnitude, patterns, attitudes, perceptions management and socio-economic implications of meningitis. Focus was on responses from people who have survived the meningitis scourge, the general public and health personal in charge of meningitis programmes in the study area. Regarding the scope of time, the study covered a five year period−assessing data from 2008-2012 for the study area. All these have been considered in relation to the national situation within the broader context of the Meningitis Belt of West Africa. University of Ghana http://ugspace.ug.edu.gh 8 1.7 Organisation of the study The study is made up of six chapters. Chapter one looks at the introduction to the study, problem statement, research objectives, research questions, rational for the study, the scope of the study and the organisation of the thesis. Chapter two focuses on the review of related literature. Chapter three covers the study area and research methodology. Chapter four describes the magnitude and patterns of meningitis in the study area. Chapter five discusses the knowledge, perception and management of meningitis. Finally, presented in Chapter six are the summary of findings, conclusion and recommendations of the study. University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO REVIEW OF RELATED LITERATURE 2.1 Introduction This chapter starts with a discussion on issues pertaining to the nature and epidemiology of meningitis. The chapter proceeds with a brief definition of medical geography as a discipline, and the review of relevant medical geographical perspectives and approaches (supernatural theory of disease causation, the germ theory and the disease ecology approach). The chapter then looks at the patterns and trends of diseases in medical geography and the multidimensional perspectives of the concept of health. Valuable empirical studies germane to the study have also been reviewed. A conceptual framework for the study concludes the chapter. 2.2 The nature and epidemiology of meningitis 2.2.1 A brief history of meningitis Hippocrates (c.460 BC-370 BC) described conditions central to meningitis as far back as ancient Greece. In the 16 th Century A.D., Robert Whytt (1714 to1766) described in a posthumous report a ‘‘dropsy of the brain’’ (now known as tuberculosis meningitis), however, no link was established between that condition and any agent that causes it (Hippocrates, 1988). In the same vein, Anton Weichselbaum (1845-1920) an Australian bacteriologist is purported to have found the agent of meningitis; bacteria which he termed University of Ghana http://ugspace.ug.edu.gh 10 meningococcus in 1887. It appears the first recorded major outbreak occurred in Geneva, Switzerland in 1805, given by Vieusseux (as cited in Leimkugel et al., 2009). A year later, meningitis is said to have occurred in New England. And throughout the 19 th century across Europe and North America epidemics occurred and also in Africa (Greenwood, 1999). According to Waddy (1957), Ghana (then Gold Coast) recorded its first outbreak of meningitis in Cape Coast in 1900. This incidence was reported to have occurred among labour from East Africa brought in by the British to assist in their campaign against the Ashanti. Subsequently, there have been major outbreaks of epidemics notably in 1906, 1919/21, 1944/45, and 1948/50. Major outbreaks were also reported to have occurred in 1960/61 and 1972/73. The 1996/97 outbreak is considered the biggest in the history of the country (Woods et al., 2000). In recent times, meningitis in Ghana is more prevalent in the northern parts of the country, even though the southern parts especially the forest belt have been recording sporadic incidences. 2.2.2 Types and causes of meningitis Meningitis may develop in response to a number of causes. Bacteria, virus, protozoa and fungi are the main causal microorganisms. Meningitis may also be caused by non infectious factors such as physical injury, cancer or certain drugs (Ryan et al., 2004; MOH, 2010). Mention can also be made of Different types of bacteria cause bacterial meningitis. Three types commonly identified are: Neisseria meningitides, Haemophilus influenzae, and Streptococcus pneumonia). Neisseria meningitides: are bacteria that can cause University of Ghana http://ugspace.ug.edu.gh 11 illness in people of any age. At any time, about 5-15% of people have these bacteria in their throats or noses without getting sick. The bacteria are spread through saliva (spit) during kissing, sharing of food, drinks or cigarettes, and by close contact with infected people who are sneezing or coughing. People who have come in close contact with the saliva of a person with meningitis from this type of bacteria may have to get antibiotics (medicine) for protection. Meningitis caused by these bacteria is called “meningococcal.” There are vaccines, which can be used to help prevent this kind of meningitis (Ryan et al., 2004; Trotter et al., 2005; MOH, 2010). Different common serogroups have also been identified. These are: A, B, C, Y and W135 (Manchanda, et al., 2006). Haemophilus influenza: type b bacteria, also called Hib, can also cause meningitis. There is a vaccine called “Hib vaccine” that could prevent infants and young children from getting Hib disease. Most adults are resistant to this type of meningitis, and thanks to the vaccine, most children under 5 years of age are protected. Certain people who have come in close contact with the saliva of a person with meningitis from this type of bacteria may have to get an antibiotic for protection. Streptococcus pneumonia: are bacteria that cause lung and ear infections but can also cause “pneumococcal” meningitis. These bacteria are usually found in the throat. Usually, most people who have these bacteria in their throats stay healthy. However, people having chronic medical problems or with weakened immune systems, and those who are very young or very old, are at higher risk for getting pneumococcal meningitis. Meningitis caused by Streptococcus University of Ghana http://ugspace.ug.edu.gh 12 pneumoniae is not spread from person-to-person. People in close contact with someone who has pneumococcal meningitis do not need to get antibiotics. Other bacteria can also cause meningitis, but meningitis from these other bacteria is much less common and usually not contagious (Massachusetts Department of Public Health, 2011). Bacterial meningitis is the main cause of meningitis outbreak in the Meningitis Belt of Sub Saharan Africa. A second type of meningitis is viral meningitis, also known as aseptic or nonpurulent meningitis. Different viruses can cause meningitis. Viral meningitis is less severe than bacterial meningitis. Examples of viruses that can lead to meningitis include mumps and viruses that spread through mosquitoes and other insects (arboviruses). Rare but more deadly is the third type; - fungal meningitis. High risk people include those with HIV/AIDS, leukaemia, or other forms of immunodeficiency and immunosuppression. Examples of fungal causing meningitis are Cryptococcus and Candida. Protozoa is another cause of meningitis, even though very rare as compared to the other main causes. One main example is toxoplasma in HIV/AIDS (MOH, 2010). Aside the traditional infectious causes of meningitis discussed above, there are also other non-infectious causes that may cause inflammation of the meningis of the brain and cause meningitis. Examples of these non infectious causes are; cancers, certain drugs that weaken the body immune system, head and brain injury and diabetes. These non infectious causes are also very rare. University of Ghana http://ugspace.ug.edu.gh 13 2.2.3 Symptoms and complications of meningitis Complex forms of symptoms are associated with meningitis. With children of less than one year old, symptoms include; fever, irritability, refusal to eat, poor suckling, vomiting, drowsiness and weak cry, bulging fontanel etc. With adults and older children, symptoms include; fever, neck pains severe headaches, photophobia, coma, convulsion, vomiting and so forth (Welch, & Nadel, 2003; MOH, 2010). 2.2.4 Health determinants and risk factors of meningitis With respect to CSM, just like many other health concerns, certain conditions may predispose one to its contraction. These are the determinants and risks factors. Health determinants are generally defined as the underlying social, economic, cultural and environmental factors that are responsible for health and disease, most of which are outside the health sector (Last, 2001; Lee, 2005; Marmot, 2005; Irwin et al., 2006). A risk factor refers to an aspect of personal habits or an environmental exposure that is associated with an increased probability of occurrence of a disease. Since risk factors can usually be modified, intervening to alter them in a favourable direction can reduce the probability of occurrence of disease (Bonita et al., 2006). While all the risk factors for meningococcal outbreaks in Africa are not understood, several conditions have been identified as having some association with the development of epidemics in the meningitis belt. They include: Medical conditions (immunological susceptibility of the population), demographic conditions (travel and large population University of Ghana http://ugspace.ug.edu.gh 14 displacements), socioeconomic conditions (poor living conditions and overcrowded housing), and climatic conditions (temperature, drought and dust storms) (CDC. website www.cdc.gov). 2.2.5 The Meningitis Belt of Africa The Meningitis Belt throws more light on another concept in geography―patterns. The basic premise or general assumption would always be that all things being equal health effects should show a uniform pattern among a population in a given locality. However, certain complex, overlapping and ever-changing constellatory factors always ensure that patterns of health concerns would vary given the conditions in a given location or area (Sultan et al., 2005). Surely, other health concerns like malaria, onchocerciasis, and tuberculosis in Africa may show different patterns. Meningitis is not distributed evenly but occurs in clusters throughout the world. The African continent has been reporting epidemics since 1909 (WHO, 2011), and has become the major host to this disease. But of critical concern is an area in Sub-Saharan Africa known as the “Meningitis Belt”, which accounts for a hugely disproportionate percentage of meningitis occurrences throughout the world. The “Meningitis Belt” is an area roughly circumscribed to the bio geophysical Sahelo-Sudanian band, which stretches from Senegal in the West to Ethiopia in the East. Outbreaks of meningitis occur yearly in 25 countries in this region. Africa has 80% of the disease burden, with epidemics usually occurring in irregular cycles of every 5-12 years, especially in the dry season (December-June) and dying out in the intervening rainy season (Sultan et al., 2005). University of Ghana http://ugspace.ug.edu.gh http://www.cdc.gov/ 15 Further, 25 countries and over 300 million people are at risk, 700,000 cases were recorded, with a case fatality rate of 10-50% in the 2009 (WHO, 2010). The typical coincidence with periods of low humidity, high temperatures and dusty conditions subsidence and disappearance of it give the indication that, environmentally these are critical factors that may play an important role in the occurrence of meningitis incidence. The definable frontier being the junction of the savannah belt and the forest zone- where there are sever alterations between humid and dry season conditions, with epidemics really being reported in the forest and coastal zones (Waddy, 1958; Moore, 1992; Cheesbrough et al., 1995; Greenwood, 1999; Molesworth, 2002). 2.3 The Concept of health and disease: Attributions, beliefs, practices and management According to the WHO (1948), as a concept, “Health is the state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity”. In relation to this, the concept “wellness” has been defined as: “an approach to personal life that emphasizes individual responsibility for well-being through the health-promoting life behaviours” Hurley & Schlaadt, 1992 (as cited in Edlin et al., 2000). Drawing on this, six dimensions of health and wellness have been identified to the inclusion of: emotional, intellectual, spiritual, occupational, social and physical. The underlying assumption in this context is holism since these dimensions are interrelated and interlinked in defining one’s health and wellbeing. (Edlin et al., 2000) University of Ghana http://ugspace.ug.edu.gh 16 Central to health and health behaviour like any other behaviour is attribution. Thus, the causal and explanatory line of thought employed to aid in the understanding of happenings in the world. The concept of attribution has long been recognised as playing a critical role in decision making among alternative courses of actions (Kelley, 1973; Anderson, 1983). In the same vein, it is also stated that people with culturally diverse background most often make varied attributions to illness, health, disease, symptoms and treatment. It is further, noted that these cultural differences in health attributions have critical implications for the understanding and management of health concerns, since over time attributions would play an important role in the formation of beliefs concerning health and illness. An element of reciprocity is introduced, as health beliefs constitute a cognitive and psychomotor schema that shape the way people make attributions (Furnham et al., 1999; Murguía et al., 2003). In their study on cultural health attributions, Murguía et al. (2000) note that, even though Latino populations are diverse, collectively and as a whole they are much likely to believe in attributional equity as a primary cause of illness (e.g. a just retribution from God for ones behaviour). They are therefore predisposed to the utilisation of ethnomedical approaches to healthcare such as Santeros (practitioners/priests of Santeria who combine indigenous rituals with the saints of the Catholic Church), herbalista (herbalists) and folk remedies. In a similar study, Madge (1998) pointed out much earlier on that African patients may be more likely to attribute illness to a spiritual or social cause University of Ghana http://ugspace.ug.edu.gh 17 rather than a physiological or scientific cause. Thus, depending on the particular condition, remedies or management could include both material (e.g. herbal remedy), and spiritual (e.g. amulets) explanations and techniques (Chipfakacha, 1994; Madge, 1998). For instance in Ethiopia, Mulatu (1999) found that most Ethiopians were more likely to attribute mental illness to cosmic or supernatural causes, including curses or possessions. It has further been noted that not all diseases have mutually exclusive causes. Thus, circumstances may allow for a naturalistic interpretation in a given episode and personalistic (witchcraft) explanation at another time or with a different patient. Yet, at both, interpretation may hold relevance and apply at a given situation (Green, 1999). A very illustrative example is given that, in most of Africa today most people are in the known that STDs and HIV spread primarily through sex contact. “However, human agency ― manifested as a desire to send a harmful “message” to someone― may be the ultimate explanation of why the virus victimised a particular person” (Green, 1999, p. 468). These bases definitely influence people’s perceptions, choices of seeking healthcare and disease management in different ways given their socio- cultural context and orientation. This underscores the fact that local perceptions are a critical component in the broader efforts to appreciate the nature of a particular health related concern in given locality. University of Ghana http://ugspace.ug.edu.gh 18 2.4 Disease Patterns and trends: The spatial, seasonal and demographic dimensions Essentially, the study of geographic patterns of disease is seen as falling within the ambit of the classic triad in descriptive epidemiology of “time, person, and place”. Following this, place represents a platform for the mix of behavioural, environmental, and possibly genetic factors that may underlie variations in rates of disease across populations. Here, the primary focus is both to describe such variations and to identify possible causes that could explain them. Thus the exploration of regional or local variations for patterns could be done by either one or a combination of the following approaches: Qualitative description, mapping, and graphical and tabular presentation of variables of interest (Rothman et al., 2008). In relation to seasonality and patterns of infectious diseases, Rothman, et al. (2008, p. 607) further identified cyclical patterns as a major type under a broader time patterns category. They stated that; “cyclical patterns are not surprising, given the known cycles in the size and activity of vector populations, the change in physical environment that influences exposure, and in many human setting, the physiological functions and behaviours”. By this assertion, Rothman et al. (2008) argue for a closer examination of the complex interplay of underlying factors such as vector, the physical environment and the socio-cultural context within which cyclical patterns of health concerns are manifested. From the view point of variation and seasonal trends in diseases, descriptive observations could be made at both international and local levels. Thus, University of Ghana http://ugspace.ug.edu.gh 19 international patterns could give clues to local patterns, while local patterns could show further variations. Drawing on the assertion above, the difficulty that arises is the identification of the appropriate scale of analysis on the interaction between levels of susceptibility and variations of underlying environmental factors. Thus, while certain patterns may be visible at a wider scale or at the international level same may not be through at the local (small-area) level. Besides, apparent geographic variations in disease rates and patterns may be less real due to problems associated with the enumeration of cases (numerator) or the population (denominator) at risk or both. Given this assertion on the possible limitations to the otherwise obvious variations, great care is required in any interpretation. Critically required in these instances would be the clear and unambiguous definition of one’s scope (study area). Besides, such a study should also strive for accurate or good data from the appropriate sources. According to Pascual and Dobson (2005, p. 18); “meningitis in western Africa shows recurrent seasonal patterns every year. Epidemics typically start at the beginning of February and last until May”. Pascual and Dobson (2005) further noted that explanations of observed infectious disease patterns on the basis of some seasonally varying environmental factors such as temperature, humidity, and rainfall come together as a critical pathway for appreciating the effect of climate change on disease dynamics. There may however be marked local variations in “uniform” patterns within larger scales. University of Ghana http://ugspace.ug.edu.gh 20 2.5 Theoretical Perspectives and Epidemiological Approaches to Medical Geography 2.5.1 Medical Geography Much earlier on, Hippocrates (c.460-377 B.C.) demonstrated familiarity with the importance of cultural-environmental interactions for disease observation― more than 2,000 years ago. The study of these interactions, which are important to disease etiology, health promotion, and health service promotion alike, continues to this day as medical geography. Following Brown, McLafferty and Moon (2010, pp. 327-328) “Geography has been able to make an important contribution to understanding how the spatial and temporal proximity of human populations to infectious agents in the physical environment contribute to risk of infectious diseases”. According to Meade and Emch (2010), medical geography employs concepts and methodologies from the disciplines of geography to investigate health related concerns. Health/medical geography is an integrative, multi stranded sub discipline that has room within its broad scope for a wide range of specialist contributions. Medical geography is seen as both an ancient perspective and a new specialization. 2.5.2 The supernatural theory of disease causation Proponents of the theory make attributions of diseases and illness to supernatural and unseen forces. The notion that disease is supernatural in origin has a very long history. However, its origins cannot be attributed to the intellectual credit of any one or group of scholars as its dimensions and forms University of Ghana http://ugspace.ug.edu.gh 21 vary markedly across cultures and time. It gained its distinction from the observations of common causal dispositions of diseases among and across cultures. At the heart of this theory is superstition, which can be defined as the irrational belief in the existence of unseen forces (frequently thought of as evil spirits) controlling peoples fate or the outcomes of events, usually with negative effects, unless particular actions are taken to prevent the ill effects or to produce the desired good effects; this may involve a person's behaviours and actions, avoidance of actions, places, etc., or the use of amulets amongst other things. Superstition according to Dawkins (as cited in Beck & Fortsmeier, 2007) is defined as a wrong idea about external reality. Murdock (1980, p.17) further puts the supernatural theory into categorizations: Mystical causation―which accounts for the impairment of health as the automatic consequence of some act or experience of the victim mediated by some putative impersonal causal relationship rather than by the invention of a human or supernatural being; animistic causation― ascribes the impairment of health to the behaviour of some personalized supernatural entity-a soul, ghost, spirit or god; and magical causation―simply produced by magic. Even though, it is as old as humanity, this theory seems not to have lost its relevance in contemporary times even in the face of qualitative refinements of alternative theories of disease causation such as the germ theory and the ecological theory. It may be erroneous for the assumption to be made that this theory finds inordinate followers only in remote rural settings and among illiterate folks (simple societies). It is a truism that, even many well educated University of Ghana http://ugspace.ug.edu.gh 22 and intelligent people hold on to various superstitions under the euphemistic banner of cherished traditions of some sort. The supernatural theory of disease causation does not show empirically the grounds on which cause and effect meet and unite. One other criticism is that, some people find in the supernatural theory of disease causality a handy way to castigate their enemies. Yet, because health concerns like epidemics took a greater toll on the poor than the rich in most societies, the rich could employ the supernatural theory as a justification for scolding the poor for their sinful behaviour (Tesh, 1988). The relevance of this theoretical review would help place into perspective people’s perceptions about meningitis in the study area. As noted, perceptions about diseases are varied and culture specific. 2.5.3 The germ theory of disease causation The origins of the germ theory of diseases causation (also known as the Pathogenic theory of medicine) could trace back into ancient times, but its modern incipient forms dates to 1862 in the publications of the Viennese physician Dr. M. A. Plenciz. The emergence of the Germ theory in its even more crystallized forms is widely attributed to the works of the French Chemist―Louis Pasteur (1822-1895) ―a century later in 1864. Other key proponents of the germ theory include two German Physicians namely; Robert Koch (1843-1910) and Friedrich Gustav Jakob Henle (1809-1885). A main assumption of the Germ theory is that a diseased condition arises as a result of the main invasion by specific micro-organisms. Thus, illness is University of Ghana http://ugspace.ug.edu.gh 23 caused by bacteria, virus and other micro-organisms. The theory further posits that a specific germ is responsible for each disease. Also, these micro- organisms are capable of reproduction and transportation outside of the body. One of the strengths of the theory lies in the fact that, it introduces another dimension to the understanding of disease causation. Up to the time that the theory was propounded, causation of illness and disease had rested on ancient Shamanism, superstition and religion, of invading entities and spirits (Baker, 2005). Also, the emergence of the germ theory initiated a forward drive in medicine that resulted in massive advancements and developments in antiseptics, antibiotics, and the better understanding and appreciation of microbiology and pathology―laying the foundation of modern science. However, the germ theory at the earlier stages of its evolution and even in contemporary times runs into criticisms. The assertion is that it shifts personal responsibility for health and well-being onto the sole sphere of the medical profession who possessed the knowledge to get rid of those germs (Baker, 2005). Thus, given this line of thought, the “germ era” contributed in no small measure to the decline of public hygienic health in the 19 th century in especially the west, were it started and had multitudes of ardent and inordinate disciples. It is also argued that, the Germ theory failed to answer some few important observations: For instance, why is it that not everyone who is exposed to a bacteria or virus falls ill? For example, medical doctors in general practice University of Ghana http://ugspace.ug.edu.gh 24 typically come into close contact with scores of flu sufferers every day. Yet, they do not generally get the flu. Also, how is it possible to avoid illness without avoiding contact with bacteria and viruses? Unless we live in isolation in a sterile environment, it is impossible to avoid contact with bacteria and viruses. Yet again, by changing our diet, getting enough physical activity and rest, taking nutritional or herbal supplements, etc, we can avoid falling ill so often (Seah, 2013). Finally, why is it that certain treatments, like Homeopathy, and Traditional Chinese medicine, prove effective against infectious diseases when they do not directly target the bacteria and virus? Besides, why is it that other therapies like osteopathy and chiropractic which involves manipulation of the body’s skeletal structure have high success rates, for instance in helping sufferers recover from flu (Seah, 2013). It is found that the germ theory of disease, while it seems to make sense and has a lot to offer, does not totally prove that germs "cause" diseases. Could it well be the other way around? - That once a person is sick (due to whatever other reasons), that person's body allows germs to thrive? Furthermore, evidence is mounting that the fight of disease with antibiotics, vaccinations and pasteurization on the basis of the germ theory comes serious side effects. The review of the germ theory in this context it was hoped would help broaden the scope of the study to cover various attributions made to the causation of the prevalence of disease in a given locality. This apparently helped put people’s knowledge, perceptions, beliefs, practices and even management University of Ghana http://ugspace.ug.edu.gh 25 choices in context, assisting in the explanations of such outlooks in given circumstances. 2.5.4 The disease ecology approach The ecological theory, as first proposed by early epidemiologists such as Hippocrates, forms the basis for this study. Ecology is a branch of biology concerned with complex relationships between organisms and their environment (Hawley, 1950). Disease ecology examines the relationship between population and the changing environment, it further shows how processes of population interactions support or discourage disease. As noted earlier, Hippocrates is the first epidemiologist who advised to search the environment for the causes of diseases. Hippocrates was born on the Greek island of Cos around 460 B.C. A body of medical writing was produced by him and his disciples. The Hippocratic approach to medicine, as interpreted by Galen and others, dominated European medical thought well into the nineteenth century (Thagard, 1997). Hippocrates argued that, whoever wishes to investigate a health related phenomenon properly should proceed in the first place to give due consideration to the seasons of the year and what effects each produces (Meade & Erickson, 2000). The concept of ecology changed within biology as it matured from an emphasis on organism to an emphasis on relations and functions of the system. The foundational biological concepts and processes, however entered in the 1960s into cultural ecology into both anthropology and geography and thus into the sub disciplines of medical anthropology and medical geography University of Ghana http://ugspace.ug.edu.gh 26 (Meade & Emch, 2010). The concepts of cultural-environmental interactions in systems became more useful for understanding the basis of infections and parasitic diseases. Brown et al. (2010, p. 37) noted that; “disease ecology has been commonly understood to include features of the environment, population and culture in the explanation of patterns of diseases”. Brown et al. (2010) further stated that the core questions it seeks to address are: “why is this disease here”, or why is this disease in places like this?” ―where places are set of locations with common attributes. 2.5.5 The triangle of human ecology (the disease ecologic approach/model) The disease ecology comes in as one of the tremendously powerful and useful approaches in the study and analysis of health concerns (diseases) in the context of human―environment interaction. Meade et al. (2000; 2010) and others have built on the disease ecology model as originally articulated by May (as cited in Mayer, 1996). Essentially, the disease ecologic approach seeks the understanding of the interactive and evolving processes of humanity (including, culture, society, and behaviour); the physical (e.g. topography, vegetation and climate); and biology (including, vector and pathogen ecology) in producing a disease foci. This approach represents an attempt at portraying the critical concept of holism which is central in geographical studies. Further, it comes in strongly as a potent means of explaining the distribution of disease foci among a population. The approach further places the sport light on the material aspects of culture in the complexities of health concerns. University of Ghana http://ugspace.ug.edu.gh 27 The disease ecology approach has a lot to offer, however it has been mainly criticised as being overly ambitious-attempting to capture everything under the sun, as it seeks explanations to concerned phenomena. Thus, in such an over elaborate endeavour, detail may be sacrificed for superficial and general patterns and trends. The geographical study of health and disease in general and meningitis in particular, could best be conducted by adopting the ecological approach as presented by the diagram below. The diagram focuses on three main categories of factors that affect the state of human health: population, behaviour, and habitat. Figure 2.1: The triangle of human ecology Source: Mead and Emch, (2010). State of health Population Habitat Behaviour genetic s age gender natural belief s social built social organisation Organisation technology University of Ghana http://ugspace.ug.edu.gh 28 Population: - This makes reference to biological organisms (in this instance humankind) that may carry and host disease. For instance, Population characteristics such as genetic susceptibility, age, and gender could determine whether or not a host can physically and emotionally cope with infection. It is further presumed that, this host−disease interaction could partly determine the sort of health outcome and pattern that would be generated in a specific locality at a given period. Habitat: - It constitutes part of the environment or context within which people live, that which may directly or indirectly affect them as they engage in their daily routine. The habitat is usually put into three categories or types: - Natural habitat; which includes, topography, land cover, land use, climate and weather patterns. The social habitat constitutes the second category; this includes family, friends, culture and spiritual influence (the social environment consists of the groups, relations, and societies within which people live). The third as shown by the diagram is the built habitat or environment, which includes, the building or settlement types we live in, work at, and travel within during our daily routines (construction materials, sanitation and waste disposal, water sources, building designs, air flows and lighting, health care facilities and transportation). Behaviour: - This refers to the observable aspects of culture. It emanates from cultural precepts, economic constraints, social norms and individual orientation, outlook and psychology. Mobility, roles cultural practices and technological interventions are covered here. According to Glanz et al. (2002), health behaviour is influenced and determined to a significant extent by University of Ghana http://ugspace.ug.edu.gh 29 individual or personal believe or perceptions. Thus, a wide range of intrapersonal factors such as age, sex, ethnicity, personality socioeconomic knowledge and self-efficacy could affect health behaviour. This characterization of the distribution of health-related states or events is one broad aspect of epidemiology called descriptive epidemiology. Descriptive epidemiology provides the “What, Who, When, and Where” of health-related events. In the same vein, several ecological processes have been noted to have the potential of resulting in strong spatial patterns of risks or incidence (Ostfeld, et al., 2005). According to Pavlovsky (as cited in Ostfeld et al., 2005), the concept of landscape epidemiology consists of three observations/assumptions. First, diseases and health concerns tend to be limited geographically. Secondly, this spatial variation arises from underlying variation in the physical and/or biological conditions that support the pathogen and its vectors and reservoirs. Thirdly, if those abiotic and biotic conditions can be delimited on maps, then both contemporaneous risks and future changes in risk patterns and trends should be predictable. The relevance of the human ecological theory lies in the fact that, the agent, host and habit components and interconnectedness have been adapted and used in the conceptual framework. It is considered that, the where, when, who, and how much questions which are central to Geography, would also prove useful for the contextual examination of meningitis in the study area. Thus, the approach is very critical for targeting disease in space and time and epidemiological maps can be generated (Ostfeld et al., 2005). This would help explain the patterns and perception of meningitis in the study area. This model University of Ghana http://ugspace.ug.edu.gh 30 also meets the demands of the multifactorial causation theory and the general systems theory as they propose a multi-perspective analysis of geographic phenomena. 2.5.6 Empirical studies on meningitis concerns The incidence of meningitis has been studied from many different perspectives as part of the efforts to contribute to its understanding and management at various localities at different times. Whereas some scholars focused their investigation on its clinical and immunological dimensions, others studied some aspects of its epidemiology. Thus, the various approaches and methodologies adopted were apparently to address specific research needs in given contexts. For the purpose of this study, a number of related empirical studies have been reviewed to help draw on some of the applied conceptual and methodological insights that hold relevance to and provide valuable grounds for the study. Hodgson et al. (2001) investigated the survival and sequelae of meningococcal meningitis in the Kassena-Nankana District of the Upper East Region of Ghana. A background information to the study noted that bacterial meningitis, remains an important cause of mortality and morbidity in the area. For the survival and disability studies, a list of all clinically or laboratory diagnosed meningitis cases at the district during the 1997 epidemic was compiled from the hospital records. A Geographical Information System (GIS) was used to locate the nearest eligible controls to the home of the case. The Navrongo Demographic Health System (NDSS) was used to determine dates University of Ghana http://ugspace.ug.edu.gh 31 of deaths or migration of patients and controls. The sampling procedure for the disability study involved a simple random sample of survivors of the epidemic who could be traced. Conclusions were that, excess deaths occurred during the first thirty (30) days after the onset of meningitis. Hearing impairments was also noted as the major sequel. Similar studies (Heymann, 2003; Frasch, 2005; & Roberts, 2008) also hint on the devastating implications of meningitis in the meningitis belt of Africa. Greene et al. (2005) studied Michigan’s high viral meningitis incidence rates from 1993-2001. Cases were analysed for standard epidemiological indices, geographical distribution and spatio-temporal clusters. Surveillance data was collected on all diagnoses of reportable disease or conditions, as defined by the Michigan Public Health Code. For the statistical analyses, cumulative indices and relative risks were calculated using SAS for windows v8. The disease incidence mapping was done using Arc View GIS v3. Time series analysis techniques were also applied to the data using R v1. Results were thematised as; demographics of cases (cases ranged in age categories), temporal trends (seasonal distribution), and spatial trends. Generally, the results confirm the existence of certain high-risk groups and disease clustering in both space and time within the study area. The study also supported several findings from previous studies of viral meningitis including risk factors related to seasonality, age, race, and crowding. Thus, the age specific analysis indicated that youth is considered a predisposing factor for meningitis University of Ghana http://ugspace.ug.edu.gh 32 The study recommended that, the identification of spatial and temporal clusters in the investigation should encourage further research aimed at identifying local and socio-demographic influences on infectious disease agent transmission. Forgor et al. (2005) investigated the influence of climatic factors on the incidence of Meningococcal meningitis (MCM) and Pneumococcal meningitis (PCM) in the Kassena-Nankana District of northern Ghana. Epidemiological data (meningitis cases) was gathered from health facilities in the district between January 1998 and December 2004. Meteorological data (humidity, temperature, sunshine, dusty hazy days, and wind speed) was gathered from the Navrongo meteorological station. Statistical analysis were run for weekly and monthly aggregates of meningitis cases and corresponding meteorological data, which were double entered using visual FoxPro. Negative binomial regression in Stata software version 9.0 was used to determine the lag period in the environmental variable that best predicted the incidence of meningitis. Results of the study showed that, concurrent weekly increase in temperature and concurrent weakly decrease in total rainfall significantly influenced the risk of MCM and a concurrent weekly decrease in rainfall significantly influenced the risk of PCM. Conclusions were that, climatic factors that trigger MCM and PCM are similar, not always the same and often result in different timing of outbreaks University of Ghana http://ugspace.ug.edu.gh 33 of the two diseases. The duration of preceding absence of rainfall appears to be the best predictor of both MCM and PCM. Baffoe-Bonnie et al. (2006) assessed human health vulnerability and public health adaptation to climate change: risks and responses in Ghana. The main purpose of the study was to strengthen the knowledge base at national level, on vulnerability and adaptation to climate change in areas such as human health and agriculture. A background to the assessment revealed that, climate change is projected to increase threats to human health, either directly or indirectly, particularly in lower income populations within tropical and subtropical countries. Meningococcal meningitis was cited as one of the air-borne diseases driven by climate change. The assessments were done in the Ashanti and Upper West Regions of Ghana. The methodology of the study involved time series projections based on the following: health variables (monthly outpatient morbidity data was broken down by age and sex and year for incidences of selected diseases), climate variables (rainfall, mean air temperature, mean relative humidity and rainfall amount), analysis of the health data against their seasonal changes, disease incidence by different age groups and the estimation of the socio-economic burden of diseases. Findings indicate that, climate change and variability would adversely affect vulnerable groups with diseases such as meningitis and diarrhea likely to rise. While health systems and their responsiveness to changing climate are to be University of Ghana http://ugspace.ug.edu.gh 34 monitored, recommendations included education, adaptation and resource mobilization for a concerted attack against especially air-borne and other diseases. Colombini et al. (2009), in a study in Burkina Faso looked at costs for households and community perceptions of meningitis epidemics. Districts for the study were selected on the bases of experiencing an on-going epidemic. Meningitis cases were selected using lists of patience recorded in medical registers at health centres. Community members were also selected to give a representative sample of social characteristics such as: age, sex, socioeconomic status, occupation and village of residence. The study revealed that, environmental (including sun, wind and the Harmattan season) and supernatural causes (activities of sorcerers or soul eaters) were noted as the main causes of meningitis. Respondents reported that, people who have contracted meningitis due to environmental causes could respond to modern medical care and survive. However, those afflicted by a sorcerer would not. These imputed causes according to the study, affected preventive as well as therapeutic approaches individuals and groups adopt, which included a mix or a combination of interventions offered by soothsayers, traditional healers and modern health workers. The study concluded that, even though, modern concepts of disease and health seeking have made significant penetration, beliefs and care seeking behaviour with regard to meningitis in Burkina Faso remain influenced by traditional thinking. The study also concluded that, meningitis epidemics have a very high economic cost for families and societies. University of Ghana http://ugspace.ug.edu.gh 35 Vaughn et al. (2009) set out to look at the general issue of health management in differentiated communities. The primary aim was to assess the role of cultural differences and how those differences affect treatment decisions and the need for medical educators, health practitioners and other stake holders to appreciate this for effective health management. Specifically, the study touched on the following thematised areas: 1) health attributions and the effects of different cultures on those health attributions; 2) models of common cultural beliefs; 3) cultural practices of health and healing; 4) cultural-bound syndromes; 5) effects of immigration and other socio- cultural factors on health; 6) assessment of cultural background through treatment and therapy approaches; and 7) cultural considerations in medical education. The findings and conclusions were that, considering the increasing diversity, complexity and pervasiveness of cultural health attributions, beliefs and practices, it is pertinent that due attention is given to such factors in the overall appreciation and management of specific health concerns in given localities. The review of the above empirical studies is of enduring relevance to the study in that, critical contextual, methodological and conceptual issues have been gleaned out that helped guide the study. First, meningitis has been noted as important cause of mortality and morbidity especially in northern Ghana. Secondly, there are strong indications of some association between climate and meningitis. It has been noted that, there are wide variations in terms of spatial, seasonal, and socio-demographic dimensions of meningitis. Besides, beliefs and perceptions about health concerns have all been shown. Finally, it University of Ghana http://ugspace.ug.edu.gh 36 has also been deduced that, meningitis incidence mapping could prove critical to the comprehensive study of the disease. 2.5.7 Conceptual framework A number of conceptual frameworks have been developed to explain the incidence of certain diseases―deriving from many theoretical perspectives. The Meningitis patterns framework has been developed drawing on relevant concepts, principles and linkages from the conceptual approaches reviewed− the ecological theory, the human ecological triangle and the empirical studies. The frame ultimately considers population/host, habitat and behaviour, as the vertices of the triangulate system. The multivariate nature of CSM as a geographically related health concern should be considered by paying attention to the significance of the various individual influencing factors (population/host, habitat and behaviour) in their unique perspectives and in relation to each other as a system. This would help address the core issues of the study. The population or host, in the conceptual framework covers the nature of the population and its composition and considers variables such as age and sex distribution and patterns as they relate to the incidence of meningitis. These are variables that would help to explain the patterns of meningitis in the study area. Next to be considered on the conceptual framework is the habitat as a critical component and one of the vertices of the triangle. Here, it is considered that, physical or environmental conditions and human organisational context have University of Ghana http://ugspace.ug.edu.gh 37 some association with the patterns of CSM. Environmental or physical conditions such as seasonal variations in especially temperature and rainfall have been shown to have some influences on disease patterns in peculiar localities with varying outcomes. The third and last vertex on the triangular framework represents behaviour. Thus, the concept of behaviour in specific terms of attitude and perceptions that a people hold towards a disease could have an effect on patterns of that health condition in that particular locality. For instance, the perceptions a people or a section of a population hold about the causes and treatment of disease could help explain the state of that disease in that particular society. The combinations of these factors- population, habitat and behaviour, in the conceptual framework offered good conceptual grounds to situate the research in the study area. Particularly, it pays attention to the need for the consideration of the geographical concepts of space, time, patterns and holism―as a system, bearing enduring relevance to the study of spatial and temporal phenomenon (Bertalanffy, 1950; 1968). University of Ghana http://ugspace.ug.edu.gh 38 Figure 2.2: Meningitis patterns framework Source: Adaptation of the triangle of human ecology (Meade & Emch, 2010). HABITAT  Human (Residential type)  Physical (Surroundings) POPULATION /HOST  Gender,  Age etc. BEHAVIOUR  Attitudes  Behaviour  Culture etc CSM Magnitude, Patterns, Perceptions, Management. University of Ghana http://ugspace.ug.edu.gh 39 CHAPTER THREE THE STUDY AREA AND RESEARCH METHODOLOGY 3.1 Introduction This chapter focuses on the study area and the methodology. The location and physical characteristic, socio-demographic characteristics and economic features of the study area have been looked at. The methodology coverers issues such as, study design, sources of data, research instruments and target population, sampling procedure and sample size, data analysis and presentation, ethical clearance and data limitation concerns. 3.2 The study area 3.2.1 Location and physical characteristics The Kassena-Nankana East and West Districts lie within the Guinea Savannah woodlands. The districts fall approximately between latitude 11°10’ and 10°3’ North and longitude 10°1’ West. The Districts have a total land area of about 1,674 sq.km and stretch about 55km North-South and 53km East-West. The Districts share boundaries to the North with Burkina Faso, to the East with Bongo and Bolgatanga Districts, West with the Builsa District and Sissala District (in the Upper West Region) and South with West Mamprusi District (in the Northern Region). The districts were hitherto one entity known as the Kassena-Nankana District but separated only in 2008 into the Kassena- University of Ghana http://ugspace.ug.edu.gh 40 Nankana East and Kassena-Nankana West Districts, with the district capitals being Navrongo and Paga respectively (KNEDA, 2012). The vegetation of the district is of the Sudan and savannah type with grassland separating deciduous trees. The District is covered mainly by the Sahel and Sudan-Savannah types of vegetations; comprising open savannah with fire- swept grassland and deciduous trees. Some of the most densely vegetated parts of the District can be found along river basins and forest reserves. Examples are the Sissili and Asibelika basins, Kologo and Naaga forest reserves. However, the activities of man over the years have affected the original (virgin) vegetation cover. Common trees found are dawadawa, baobab, sheanut and mangos. The climate conditions of the district are characterized by the dry and wet seasons, which are influenced mainly by two (2) air masses – the North-East Trade winds and the South-Westerlies (Tropical Maritime). The area falls within the Tropical Continental climatic zone as classified by Dickson and Benneh (cited in Yaro, 2004). The Harmattan air mass (North-East Trade Winds) is usually dry and dusty as it originates from the Sahara Desert. During such periods, rainfall is virtually absent due to low relative humidity, which rarely exceeds 20 per cent and low vapour pressure less than 10mb. Day temperatures are high recording 42° Celsius (especially February and March) and night temperatures are as low as 18° Celsius. The District experiences the tropical maritime air mass between May and October. This brings rainfall averaging 950mm per annum. There is a Meteorological Services Department at Navrongo, which records the weather situation in the area. University of Ghana http://ugspace.ug.edu.gh 41 3.2.2 Socio-demographic structure According to the 2010 Population and Housing Census, the Kassena-Nankana East has a total population of 109,944, with a male proportion of 53,676 and a female proportion of 56,268. The Kassena-Nankana West District has a total population of 70,667 with a male proportion being 34,747 and a female proportion of 35, 920 (GSS, 2012). Thus the total population for the study area stands at 180611. The sex composition favours female. Together, the two districts would give a total population of 180,611, with a combine male proportion of 88,423 (49%) and that of the female being 92,188 (51%). The District recorded a population density of 91 persons per sq.km. This is higher than the national density of 7.97 persons per sq. Km but below the regional density of 104.1 persons per sq. Km. On settlement structure, aside Navrongo and Paga―the two District capitals, and a few other settlements that records population of over 5,000 residents, most areas of the District live in rural settlements. Type of dwelling:- households in the Districts are mainly compound houses, followed by separate and semi-detached houses. Modern flats and apartments constitute a very small percent of dwelling type (0.8%). The health system in the KND is modelled along the district health care concept. The Navrongo War Memorial Hospital serves as the main referral centre to all health centres and clinics in the two districts. The Navrongo Health Research Centre (NHRC) also conducts high quality demographic and health research in the area to inform policy. The District health Management University of Ghana http://ugspace.ug.edu.gh 42 Directorate also ensures that, health education activities ranging from public address systems to talks with individuals are organised. This is paramount in ensuring the course of work performance of health institutions through durbars, community meetings and promotional health talks at service points. Communities are sensitised to report early for treatment. School health activities are also carried out in the districts. 3.2.3 Economic features The major occupations in the Districts are Agriculture, employing about (68%) of the total labour force; production/transport and labourers constitute (10.4%); Sales workers (9.2%); Service workers (5.6%); Administration/Managerial workers (0.1%); Professional technical workers (3.5%); and others (0.1%). In terms of its contribution towards the Gross Domestic Product and labour employment, the primary sector activities which are dominated by agricultural practices contribute about 68.6 percent. The secondary sector’s performance, dominated by small-scale enterprise activities contribute about 3 percent to the Gross Domestic Product and about 2 percent exclusively to labour employment, thus excluding those who are engaged in direct primary agricultural activities. The tertiary sector whose contribution comes mainly from informal private individual economic activities, records about 11 percent to the district’s local economy in terms of her Gross Domestic Product (GDP) and also accounts for about 30 percent to the labour employment figure. For further information on the profile of the study area and study sites (See Ghana Districts.com; UNDP, 2010 and Figure 4.5). University of Ghana http://ugspace.ug.edu.gh 43 Figure 3.1: A map of Ghana showing the location of the study districts (Kassena-Nankana East and West Districts) Source: Field work, (2013). GIS generated. University of Ghana http://ugspace.ug.edu.gh 44 3.3 Research methodology 3.3.1 Study design A study design serves critical research needs. It among other things provides a guide that offers order and clarity in the process of study (Sarantakos, 2005; Kumekpor, 2006; Panneersevam, 2010). For this study, the approach is the mixed method. Thus, the mixed method deals with the collection and analysis of both quantitative and qualitative data (Creswell, 2009). The mixed method approach was used because the study relied on both quantitative and qualitative information to adequately address the research questions and objectives. This way, the figures would help establish the patterns while the voices of people would help give meaning to the figures behind the patterns. This, it was hoped would aid in the comprehensive understanding of the issues of concern. Specifically, the cross sectional epidemiological study design was used. The cross sectional study is analytical, and comes under observational study under the broader epidemiological study design (Figure 3.2). A cross sectional study takes place at a single point in time and provides room for the researcher to look at numerous things at once (age, occupation, gender etc). It is often used to look at the prevalence of something in a given population (Bonita et al., 2006). Data from cross sectional studies provide useful indications of trends, due to its inherent descriptive and analytical qualities (Bonita et al., 2003; Tolonen et al., 2006). The cross sectional design was preferred because the study sought to assess the University of Ghana http://ugspace.ug.edu.gh 45 patterns, seasonality, perception management, and socioeconomic implications of CSM in the study area. Figure 3.2: Epidemiological study designs. Note: *Cross- sectional/prevalence design used. Source: Bonita et al., (2006). 3.3.2. Sources of data Data for the study were obtained from two main sources―primary and secondary. The primary data was drawn from the general public, people who have experienced meningitis before in the last two or three years, and health personnel. The secondary data were obtained from records of health institutions in the area EPIDEMIOLOGICAL STUDY DESIGNS Observational Studies Experimental Studies Descriptive Studies Analytical Studies •Ecological/Correlational *Cross-sectional/prevalence •Case Control/Case-reference •Cohort •Randomised controlled trials/ Clinical trials •Cluster randomised control trials •Field trials •Community trials/ Community intervention studies. University of Ghana http://ugspace.ug.edu.gh 46 such as the Navrongo War Memorial Hospital, the Navrongo Health Research Centre (NHRC), the District Health Directorates (DHDs) from the two districts, the Ghana Health Service Disease Surveillance Unit, Korle-Bu―Accra, as well as other published books and articles from internet search and other relevant sources. Meteorological data was also obtained from the synoptic weather station in Navrongo. 3.3.3 Data collection For the collection of data, both quantitative and qualitative methods were used. As indicated in the sources of data section, meningitis statistics were obtained from both the districts and national health records. Also, the main research instrument for gathering the primary data from the survey respondents (the general public and those with immediate past experience of the disease) was the semi-structured questionnaire. People who have experienced the meningitis scourge were targeted because they are the ones who have experienced the disease and could offer practical information for the study. The general public was also of interest because they are the potential victims of the disease. Qualitative information was also gathered from Health personnel working with meningitis units and programmes in the district using in-depth interviews schedules. This was because they possess relevant information about the disease. This was to give more meaning to give more meaning to the figures. University of Ghana http://ugspace.ug.edu.gh 47 To ensure that issues of validity and reliability were adequately catered for, a number of measures were employed. Three trained field assistants were employed and instruments pre-tested. The instruments were also developed drawing from similar works by early researches. For the questionnaire and interview schedule administration, the same set and order of questions were employed. Also, to cater for threats such as history, maturation and mortality, the survived meningitis case frame (people who experienced meningitis before) was limited to two years. This served the purpose of enabling respondents to have a vivid remembrance of experiences with the disease and to give relevant information. 3.3.4 Sampling procedure for questionnaire For the study, as noted above, the target population was made up of three categories of respondents. These are the “general public”, people who have experienced meningitis before in the last two years and health personnel with a meningitis programmes in the study area. Selection of the general public was based on the communities. This was done using the quota sampling technique because quotas were taken from each of the five zones within the district. The district has been demarcated into five zones based on the geographical position of the district. They are the North, South, East, West and Central zones. The South zone has 74 communities, East 52 communities, West 49 communities, North 49 communities and Central 21 communities, giving a total of 245 communities. Within the five zones, 20% of the communities were selected for the study because the communities within each University of Ghana http://ugspace.ug.edu.gh 48 zone have similar characteristics and it is hoped that this percentage ensured a fair and proportional representation of the communities within each zone. This gave a total of 49 communities comprising 15 communities for the South zone, 10 for West, 10 for North, 10 for East and 4 Central zones. According to Sarandakos (2005), one of the cardinal principles of sample size determination is the homogeneity of the target population. The more homogenous the target population the smaller the sample size can be and vice versa. The lottery method was employed to select the communities within the zones. Here, the names of the communities within each zone were written out and picked randomly till they required number of communities per zone was obtained. This technique ensured equal chances of each community being selected and also eliminated any biases in the selection process. The study units were then selected from households from the selected communities. Because of time and budgetary constraints, 250 respondents were selected in all from the sampled communities. Proportionately, 77 from the south zone, 51 each from the north, west and zones, and 20 from the central zone. This method ensured an even selection of respondents from the communities as well as reduced biases (Table 3. 1). University of Ghana http://ugspace.ug.edu.gh 49 Table 3.1: Categories of zone, selection procedure and sample size. Zone Name of zone Number of communities in zone Number of communities sampled Number of respondents per each zone 1 South 74 15 77 2 North 49 10 51 3 West 49 10 51 4 East 52 10 51 5 Central 21 4 20 Total 5 245 49 250 Source: Field work, (2013). For those who have experienced meningitis before, a sampling frame of survived meningitis cases was created based on the records from the health institutions. To get a fair representation of cases for the interview, the simple random sampling method was employed to generate the sample. With the simple random sampling, each unit of all the population has an equal chance of being selected. It is both the easiest random sample to understand, and the one on which other types are modelled (Neuman, 2003; Nadar, 2005; Pannerselvam, 2010). Because it is a cross sectional study and in order that threats to validity is minimised, sampling was limited to two years of recorded meningitis cases as noted early on. Based on the two year period data availability, a sample size of 100 was randomly generated. The survived meningitis cases constituted a suitable target unit because, as victims they had better information to offer about their experience with meningitis. University of Ghana http://ugspace.ug.edu.gh 50 Health personnel working with meningitis programme in the study area was purposively selected. The health personnel were seen as suitable target units because of their direct involvement in the treatment and management of the disease. 3.3.5 Ethical considerations and clearance The purpose of the research was made very clear to the major actors in the research process and their consents and views taken on board. These included the outfits from which meningitis data was acquired and the respondents .This was deemed necessarily due to the fact that the study is health related and respondents needed to be fully aware of its purpose, in order that doubts were not invoked in their minds that could affect the outcome of the research. It is believed this greatly enhanced the execution of the whole exercise even though several limitations were encountered. 3.3.6 Data limitations A number of issue emerged at various stages of the research that proved daunting and threatened to limit a comprehensive and more efficient execution of the study. First and foremost were financial constraints which limited the researcher in trying to cover more grounds in terms of selecting a higher sample that would have been more representative. However, with a thorough sampling procedure, it was hoped that the issue of representativeness was addressed. University of Ghana http://ugspace.ug.edu.gh 51 Additionally, health personnel were a little bit hesitant in giving in-depth information about the disease. The purpose of the research, as being purely an academic exercise and the assurance of confidentiality had to be consistently appealed to in order to attain the needed information despite prior notification during pre-study visitations. It was also very hectic to trace and locate especially people who have experienced meningitis before. Those sampled from the health records were scattered all over the two districts and on a number of times, visits of more than once had to be embarked upon before target respondents could be reached. It was also the desire of the researcher to have covered a much longer period, for the study area in order to show trends, but had to finally settle for a five year (2008-2012) period due to fragmented records on meningitis cases. In addition, in trying to generate the rate map of meningitis for the study area, a number of difficulties were encountered. For instance, the zones into which the study area has been put by the NHRC were too arbitrary and running into each other. It was with the assistance of an expert that more geographically meaningful demarcations were made. 3.3.7 Data analysis and presentation Data was analysed, using both qualitative and quantitative methods. For the quantitative analysis, SPSS version 16.0 was employed. Specifically, simple descriptive statistics such as frequency tables, bar charts, and line graphs were used to show patterns and trends pertaining to the questionnaire and interview University of Ghana http://ugspace.ug.edu.gh 52 schedules. Maps were also used to show patterns for continental (meningitis belt) and national rates. A rate map was also generated using Geographical Information Systems (GIS) ―for the study area. Specifically, ArcGIS version 9 was used to generate the rate map. Regarding the rate map, different geographical areas or zones were shaded in different colours according to the differences of case values― employing pattern matching. For the qualitative data content analysis and simple descriptive narrative were used for the analyses and presentation of the key findings. University of Ghana http://ugspace.ug.edu.gh 53 CHAPTER FOUR THE MAGNITUDE, PATTERNS AND SEASONALITY OF MENINGITIS 4.1 Introduction This chapter presents information on the dimensions of meningitis in the context of the Meningitis Belt of Africa. It then proceeds to analyse data sought on the magnitude, spatial patterns and seasonality of meningitis. Information on the demographic distribution of meningitis in the study area is also presented. 4.2 The Context of the Meningitis Belt of Africa Discussion and analysis of the Meningitis Belt of Africa are presented in this section. This comes in critically as a background context for the analysis of meningitis in Ghana and ultimately the study area. As noted earlier, meningitis magnitudes are strikingly high in this “belt”. Thus, meningitis remains a major public health challenge in the "meningitis belt" which stretche