Malaria‐related beliefs and behaviour in southern Ghana: implications for treatment, prevention...

Tropical Medicine and International Health

V O L U M E 2 N O . 5 PI’ 488-499 M A Y 1997

Malaria-related beliefs and behaviour in southern Ghana: implications for treatment, prevention and control

Collins K. Ahorlu, Samuel K. Dunyo, Edwin A. Afari, Kwadwo A. Koram and Francis K. Nkrumah

Noguchi Memorial lnstitnte fo r Medical Research, University of Ghana, I.egon, Ghana

Summary A research infrastructure was established in two ecological zones in southern Ghana to study the variables of malaria transmission and provide information to support the country’s Malaria Action Plan (MAP) launched in 1992. Residents’ beliefs and practices about causes, recognition, treatment and prevention of malaria were explored in two ecological zones in southern Ghana using epidemiological and social research methods. In both communities females constituted more than 80% of caretakers of children 1-9 years and the illiteracy rate was high. Fever and malaria, which are locally called Asra or Atridi, were found to represent the same thing and are used interchangeably. Caretakers were well informed about the major symptoms of malaria, which correspond to the current clinical case definition of malaria. Knowledge about malaria transmission is, however, shrouded in many misconceptions. Though the human dwellings in the study communities conferred no real protection against mosquitoes, bednet usage was low while residents combatted the nuisance of mosquitoes with insecticide sprays, burning of coils and herbs, which they largely considered as temporary measures. Home treatment of malaria combining herbs and over-the-counter drugs and inadequate doses of chloroquine was widespread. There i s a need for a strong educational component to be incorporated into the MAP to correct misconceptions about malaria transmission, appropriate treatment and protection of households. Malaria control policies should recognize the role of home treatment and drug shops in the management of malaria and incorporate them into existing control strategies.

keywords malaria, perceptions, treatment seeking, prevention, Ghana

correspondence Dr Samuel K. Dunyo, Noguchi Memorial Institute for Medical Research, University of Ghana, PO Box 25, Legon, Ghana. Fax: +z33 21 502182

Introduction

Malaria i s a major health problem in tropical Africa accounting for more than 80% of the global estimated 120 million clinical cases each year (WHO ry92). In Ghana, malaria is estimated to cause 8 % of all certified deaths and ranks as the commonest cause of death in children under 5 years of age (Ahmed 1989). Available data suggest that malaria, which was the major cause of healthy days lost by the labour force a decade ago (Morrow 1984), still

accounts for the majority of out-patient attendances throughout the country. The role of mosquitoes as vectors of transmission was demonstrated by Ross at the turn of the century. Since then, the behaviour of the malaria parasite and the mosquito vectors have been studied extensively and the knowledge gained has contributed immensely to various strategies for malaria control. These control programmes have often overlooked the role that communities’ beliefs, attitudes and behaviour can play in the transmission, treatment and control of the disease ( W H O 1969).

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Illness ideas and behaviour collectively termed 'explanatory models' may enhance or interfere with the effectiveness of control measures (Klein et al. 1995) . Interference with the local ecology may create new problems such as man-made mosquito breeding sites through dams, mining and clearing of rain forest for farming. In addition, participation in control efforts may not be active if communities perceive malaria as a less important health problem (Ruebush et al. 1995). An understanding of communities' beliefs and behaviour i s therefore crucial to the success of a specific control measure, or may make the application of that control measure much easier and more effective than it otherwise would be.

Ghana launched its yyear Malaria Control Action Plan (MAP) (1993-1997) in November 1992 with the objective, as recommended by WHO, to reduce malaria-related morbidity and mortality to such low levels that it will cease to be a public health problem. The focus of attention in the strategy of the MAP is o n prompt diagnosis and adequate treatment in the context of Primary Health Care (PHC) (Ministry of Health 1992). The Noguchi Institute established an infrastructure in two ecological zones in southern Ghana to study the variables of malaria transmission and provide the necessary information to support the malaria control measures. These included demographic, parasitological, entomological and immunological parameters and knowledge, attitudes and perception of residents about malaria. This paper reports residents' knowledge and beliefs about the causes, symptomdrecognition, treatment, prevention and control of malaria and how these might influence transmission and the success of control programmes.

The Ministry of Health ( M O H ) of the Republic of

Background

Dodowa and Prampram, both in the Dangme West District of the Greater Accra Region of Ghana, have been the sites for the study of the epidemiology of malaria with special emphasis on transmission, morbidity and mortality in southern Ghana since

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1971. This rural district lies between latitudes 5'40' and 6"19' north of the equator and longitude ooze' and o"o5' east and west (respectively) of the Greenwich meridian. Its boundaries are shown in Figure I. Most of the district i s coastal savannah with the Gulf of Guinea as its southern boundary. The north-western part (where Dodowa is located) has forest vegetation partially reduced to shrub through farming with only scattered large tropical trees to bear witness to a former more luxuriant vegetation. Demographic and malariometric surveys were conducted in the two communities in the dry and wet seasons of T ~ Y Z and 1993. The populations of Dodowa and Prampram were 6558 and 6682 respectively ( r g g z census), with the age and sex distribution of the two populations conforming to a broad-based pyramidal pattern typical of communities in developing countries (Bogue 1969) .

In the forest zone prevalence of malaria infection (parasite rate) ranged from 42.2% in the dry season to 51.3% during the rains, while in the coastal savannah zone the rates were 20 and 36.6% in the dry and rainy seasons respectively. Malaria was responsible for considerable morbidity with annual incidences of 10&6/rooo population and 68.5/1000 population at Dodowa and Prampram respectively. More than 50% of the cases were children 0-9 years (Afari et al. 1995) . Malaria mortality was, however, low in the study area. Plasmodium falciparum was responsible for 9 8 % of infections in the rainy season. During the dry season, however, P. malariae contributed 5 and 8% of infections at Prampram and Dodowa respectively. The main vectors were Anopheles gamhiae s.1 and A. funestus. In uiuo sensitivity of P. falciparum to chloroquine ranged from 83.8 to 99.3% in the forest and coastal savannah zones respectively (Afari et al. 1994).

Methods

The study combined epidemiological and social research methods to determine the human factors influencing the transmission of malaria a t Dodowa and Prampram in the coastal forest and savannah

Figure I Map of Dangme West District (DWD) showing -1, study communities. Insert: map of Ghana showing location of DWD and the country's ecological zones.

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https://www.researchgate.net/publication/21679529_Fever_episodes_in_a_holoendemic_malaria_area_of_Tanzania_parasitological_and_clinical_findings_and_diagnostic_aspects_related_to_malaria?el=1_x_8&enrichId=rgreq-ffa68924825f50b887e4b569f043c666-XXX&enrichSource=Y292ZXJQYWdlOzE0MDAxMjY3O0FTOjE4MjU5Nzg0MTg1ODU2MUAxNDIwNTQ2MTI2NjM4

Tropical Medicine and International Health VOLUME 2 NO. 5 P P 488-499 MAY 1997

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\ ' SAVANNA ZONE

FOREST ZONE 5'30'

0 15 MIS

0 5 10 15 20 2 5 K m E

U W R .

. . . . . .

Dangme West District I 0-00' 0"l 1 - TRUNK ROAD SECONDARY / FEEDER ROAD

-II-H- RAILWAY L I N E + + REGIONAL BOUNDARY - - DISTRICT BOUNDARY - RIVERS/STREAMS

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zones respectively. The research was conducted between January and September 1995. Six focus group discussions (FGDs) were held in each community with 8-10 participants in each group to explore the knowledge, beliefs, attitudes and practices of the community about malaria using an FGD guide. Participants in 4 of the FGDs were parentskaretakers of children under 10 years of age selected by age, sex and educational background; these are variables that influence free discussions in the communities (unpublished observation). Two additional discussions were held with the political and opinion leaders selected by gender. The FGD guide was translated into the local (Dangme) language and pre-tested for feasibility and clarity and the results used to update the guide and survey questionnaire before the main study. Proceedings were recorded with the aid of tape recorders and note takers.

A household survey was then conducted using a pre-tested, semi-structured personal interview questionnaire administered to caretakers of children 1-9 years of age in a random sample of 50% of houses selected from a regularly updated housing list maintained for the two communities since the start of the malaria research programme in 1992. A caretaker was defined as the paredguardian who provides the daily essential needs of the child such as bathing, feeding, clothing, sending to school or to hospital when sick. Information was collected on types and condition of houses which are pertinent to malaria transmission, educational level, employment and income of respondents, knowledge about malaria transmission, manifestations, management practices a t home and outside and malaria preventionkontrol practices.

A total of 125 children aged 1-9 years in each community were randomly selected from the houses used for the household survey and followed up for a period of 3 months (June-August 1995) for the occurrence of fevedmalaria. During the follow-up period every study child was visited once a week to record any history of fever/symptoms of malaria and to record axillary temperature using an electronic thermometer (Hartmann digital). Thick and thin blood films were made for all children with a history/clinical findings suggestive of malaria. Slides were stained with Giemsa for microscopy. In-depth

interviews were conducted with the caretakers of children identified with a history of fevedmalaria to collect information on causes, recognition, treatment and prevention of malaria in the homes, mother’s recognition and treatment of complications (anaemia, convulsion), choice of treatment and reason(s) and cost of such treatment. All FGDs and in-depth interviews were conducted by the first author (CKA), a social scientist and z research assistants from the Sociology Department (University of Ghana) who could speak the local (Dangme) language and were trained in FGDs, while the cross-sectional survey and malaria follow-up data were collected by field assistants recruited from the communities and trained in the interview process and supervised by the authors. The recorded proceedings were transcribed and analysed manually by content analysis. The survey data were entered and analysed using DBase4 and SPSS computer software packages respectively. The research objectives and methods were explained to residents and oral informed consent was obtained from participants before the research instruments were administered. Parasitological aspects of the home diagnosis of malaria will be published elsewhere.

Results

Demographic characteristics of respondents (caretakers of children) and conditions of their houseshedrooms are presented in Table I. More than 80% of caretakers were female. Prampram is predominantly a fishing community with most respondents engaged in fish mongering and petty trading. At Dodowa petty trading was recorded as the commonest occupation even though the community is noted for its farming activities. This may be because the majority of respondents were females engaged in selling the farm produce and other items.

Local perceptions of causes and recognition of malaria

Because of the high level of consensus in ethnomedical concepts about malaria among the groups interviewed and between the coastal savannah and forest communities, results were grouped together.

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Table I Demographic characteristics of respondents and conditions of their houseslbedrooms

Study community

Demographic housing characteristic Prampram Dodowa

Demographic Number of caretakers Fema1e:male ratio Single parent [ %) Teenage parent [ %) Illiteracy rate [%) Mean household size

Complete wall status Provision of ceiling Eaves closed Screened doorways Screened windows Respondents with bednets

Housing (%)

48 3 8:1

24.0

70.0 5.5

8.9

82.7 33.3 26.7 28.6 3 1 . 2

17.8

574 7:T 22.0

4 .o 40. r 4.6

82.9 35.7 38.0 22.3

27.2 16.6

Fever and malaria, which are locally called Asru or Atridi, represent the same thing and are used very much interchangeably. The belief is that there are two kinds of fever, the common fever and the ‘male’ or ‘high’ fever known locally as Asraku or Asratsutsu. Asraku is described as more dramatic with those affected behaving wildly as ‘mad’. Various signs and symptoms are used by community members to recognize Asra. Among these are headache, yellowish urine, ‘hot body’ (locally called bedorla), vomiting, loss of appetite, yellow eyes, paleness, weakness, chills and rigors, yellowish stool, diarrhoea, excessive drinking of water, bitterness in the mouth, dullness, sleeplessness or sleepiness, convulsions and frequent yawning. Even though not all the signskymptoms need be present in a given episode of Asra or Atridi, conditions such as headache, ‘hot body’ and yellowish eyes and urine are among the most important signs suggestive of malaria.

Caretakers, therefore, seem generally well informed about the major symptoms of malaria; knowledge that corresponds to the clinical case definition of malaria. Most respondents are aware that mosquitoes transmit malaria and the presence of mosquitoes in the community is a source of worry. Mosquitoes are present throughout the year and increase during the rainy season and their biting is

said usually to commence around 1700 h till the early hours of the following morning. The presence of mosquitoes in the community was attributed to the stagnant waters around houses and bush as well as empty cans and broken bottles which collect water whenever it rains. The problem of mosquitoes is summed up in the following response from a respondent:

Mosquitoes worry us a lot especially during the rainy seasons. They bite us and give us disease and also disturb our sleep with their noises.

Those who do not share the mosquito concept as well as many of those who believe that malaria is transmitted by mosquitoes believe that malaria can be acquired in other ways such as the heat from the scorching sun and any other heat-related work, eating oilylfatty food, unripe and over-ripe fruits like mangoes and pawpaw, ‘poor eating habits’, constipation and drinking too much alcohol. It is also believed that eating food on which house-flies have settled can cause malaria because house-flies contaminate the food. Another belief is that a lactating mother who spends too much time in the hot sun can give malaria to the child through breast-feeding. Some responses on beliefs about mechanisms of malaria acquisition are noted below:

I think malaria is caused by mosquito bite and when the child walks or spends too much time in the hot sun, his blood becomes hot and this causes malaria.

We don’t know exactly what causes malaria, but I think playing or working in the sun and eating unripe mangoes can cause malaria. When you work, walk or play in the hot sun or near fire, it melts your blood and this leads to Asru.

Convulsions known in Dangme as biorwe (literally meaning sky illness) were recognized as a major childhood health problem. Respondents gave a very elaborate description of convulsions and all had seen at least a child with an attack. However, conflicting views were given on the relationship between malaria and convulsions. Most respondents are of the view that it is not the malaria itself which causes convulsions but the high body temperature


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due to malaria. Those who did not relate malaria to convulsions attributed it to evil spirits such as witchcraft flying in the sky (but not seen with naked eyes), intestinal worm infestation or a sore in the stomach. The first line of action in treating convulsions is sponging with cold water left overnight in a cooking pot to reduce the high temperature. The child may be sent to the clinic after sponging but in many cases home treatment, usually provided by elderly people, is preferred. There are also specialist herbalists and spiritualists whose services are readily available to the community for a token fee. Perception on causes, treatment and prevention of convulsions is summed up to a large extent by the following statements:

I think Asrn can cause convulsion because of the high temperature but worms can cause it too. When a child has convulsion, it shakes with fits and rolls the eye balls up. When this happens you have to sponge the child with water which has been left overnight in a bnnku pot (i.e. maize meal cooking utensil). After that you grind garlic and smear the child’s body with it. If you don’t want the child to get convulsion then, when you see that the temperature is going up, you have to smear the child’s body with garlic mixed with shea butter.

You see, some of these convulsions are due to evil forces, so they have to be given some concoctions

drug stores and foods believed to ‘give blood’ such as kontomere (leaves of cocoyam used as vegetable), a lot of fish, egg and milk. Mosquitoes are believed to suck blood, which can lead to anaemia.

Knowledge, beliefs and practices of malaria treatment and prevention

Three main sources of malaria treatment in the community were identified, namely the clinic or hospital, drugs purchased from the drug stores and peddlers and herbal treatments both self-prepared at home and by herbalists. Asra is mostly treated at home with drugs like paracetamol, aspirin, cotrimoxazole and all forms of herbal preparations for bathing, drinking, inhaling and enema. Chloroquine is usually self-administered, especially a t Dodowa, where it is sold to the mothers by the community health nurses during child welfare clinics (CWCs). In many cases Asrn is treated with a combination of herbal and biomedicine. Taking malaria (Asra) cases to the health centre was the last thing to do in the community after the sickness has failed to respond to home treatment. The purchase of drugs outside the clinic was confirmed in the following response:

Whenever my children are not well, I give them chloroquine and paracetamol once a week but when they get more sick I give the paracetamol 3 times a day and the chloroquine one tablespoon a day until they feel fine or recover.

which brings the person back to life and in some cases too, the hospital is enough for recovery. To prevent the child from having convulsions, there is a stone called mawu gbie literally meaning God’s stone and believed to be dropped when thunder strikes, which is put in water for the child to bath frequently. At times, the patient will be cut with a knife or razor blade and a black powder prepared from fowl’s blood and feathers is put into the cuts. With these marks, the person will never be attacked again.

Notable among the herbs used for treating malaria are pineapple peels, the bark of the Nynmedua, mango, and pear trees, the leaves of the guava, nim, bamboo and pawpaw trees and wild bush tea. The roots of the mango tree are also used. These plant products are usually boiled together with some other ingredients such as lemon, lime, ginger and camphor into concoctions and used for drinking, bathing, inhaling and enema. They are usually self-prepared a t home except in severe cases, when herbalists are consulted. Though the clinic is the last resort, many respondents testified that a t times the malaria can be completely cured only there and the statements below underscored this position:

Anaemia, known locally as ebe muor, is recognized as lack of blood and this is reflected in the local term for it. It is believed that malaria can cause it because it makes the child eat poorly and look pale just as in malaria. The general treatment is to replace the lost blood through blood tonics from

I feel the treatment a t the clinic is better. Though the herbal treatment is also very good, it takes a

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longer period for the condition to improve, while at the clinic after one injection the condition improves. When the child is sick and I don’t have money to send him to the clinic, I go to the drug store to buy drugs, and give them to the child together with the herbal preparations.

Comparatively, the cost of treatment from the clinic is considered very high as it ranges between 1900 and 3000 cedis (US$1.3-2.0 a t the current rate), while treatment a t home by the use of drugs bought from the drug stores or community nurses ranges between zoo and 1000 cedis (US$o.r-o.7). Drugs bought from the nurses are also considered more expensive than those bought from the drug stores. Herbal treatment is virtually free. Whoever paid for the cost of treatment decided where to go and in most cases it was the husband. In a few cases it was the mother-in-law who decided. This is summed up in the following response:

At the clinic it cost me about 1900 cedis to treat malaria but a t the drug store it cost me only 5 0 0 cedis and the herbs are free. However, because the drug store treatment is on ‘try-and-error’ basis and the herbs have to be taken for a long time, when you see that your child’s case is becoming worse, you have to go to the clinic if you have the money because at the clinic you will be examined before drugs are given to you.

It is believed that malaria caused by mosquitoes can be prevented to some extent by avoiding mosquito bite through the use of a bednet, spraying the room with insecticide, burning of coils and cassava chips such as gari and konkonte, and certain herbs in the rooms. Other measures include fanning with a cloth or electric fan. However, respondents admitted that these methods are not totally effective because mosquitoes continue to bite them and they continue to suffer from malaria. The coil, apart from its ineffec- tiveness, is believed to cause catarrh in those who use it frequently. Asra caused by food can be prevented by eating ‘good’ food while Asru caused by heat cannot be prevented, even though it can be reduced by not playing, walking and working in the sun too much and also by not working near fire or any other source of heat for a long time. Heat- related Asra, according to the people, will remain

with them as long as the sun continues to shine and they continue to work, play and walk in the sun. Here are some of the responses in relation to malaria prevention:

It depends on how we prevent mosquito from biting us and also when we avoid working in the hot sun, then we can control malaria but this is highly improbable.

Malaria cannot be prevented because we were all born with it and it grows in us and once a while, it manifests itself by giving us fever. When we treat it, we get better but the malaria is still there and will come again but to prevent it from coming you have to take an enema every day.

Bednet usage was found to be rather low in both communities (Table 1). The general view, however, is that it can help to prevent mosquito bites to some extent. Some respondents said they used to use bednets in times past but cannot afford to replace the old and torn ones and hence stopped using them. Some are of the view that sleeping under a bednet makes them feel uncomfortable because they sweat a lot and that when mosquitoes enter the net the nuisance is rather worse. Bednets are said to cost between 8000 and T O ooo cedis (US$5.3-6.7) each, a price considered too expensive. The response helow highlights some reasons for their low utilization:

We don’t use bednets, but people sleep under bednets to prevent mosquitoes from biting them. The problem associated with a bednet is that you sweat a lot when sleeping under it. 1 don’t know the price now but I think only few people can afford it.

From the above statements, one is tempted to say that money may be one of the limiting factors on bednet usage in the community, hence the low level of usage. All things being equal, many of the community members may want to use a bednet especially during the rainy seasons.

Discussion

Reduction of malaria transmission in endemic regions of the world is desired by all. The earliest

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and most sustained attempts a t malaria eradication carried out in West Africa decreased the amount of malaria to such low levels that interruption of transmission appeared to be likely (Bruce-Chwatt & Archibald 1958). The expected goal of cessation of transmission was, however, not achieved because even the very low density of Anopheles gambiae was sufficient to maintain a degree of transmission. Major obstacles for success were technical problems of lack of an ideal drug against all tissue forms of the parasite, resistance of the mosquito vectors to commonly used insecticides, a financial slump and lack of political commitment on the part of govern- ments of the endemic regions. Apart from these the behaviour of residents was not adequately studied and incorporated into the design and implementation of those programmes (Bruce-Chwatt 1954, 1979; Gillett 1985). This study documents the behaviour of residents about malaria with regard to recognition, treatment, prevention and health seeking.

Even though the majority of houses were built of concrete or mud with complete wall and roof status (Table I ) , most have unscreened windows or doorways and open eaves. It is said, concerning human dwellings (Gillett 1 9 8 5 ) ~ that any opening ~ 1 . 4 mm across will aliow mosquitoes to ‘break in’ to bite and in so doing (for those infected) deposit sporo- zoites. Considering this fact, it is obvious that the houses/bedrooms in the study communities provide no protection for the inhabitants a t night-the peak biting period for the Anopheles mosquito vectors. Residents, therefore, by inadequate screening of houses, invite them to feed. The role of mosquitoes constitutes a minor component in caretakers’ knowledge about transmission of malaria. Even though residents are familiar with the breeding and biting habits of the mosquitoes, few houses are pro- tected against them and the use of bednets, which may reduce the number of bites from infected mosquitoes, i s rather low in the area. The main reason for the low bednet usage is cost, as most residents cannot afford between US$s and US$7 for a net. In response to the nuisance problem of mosquitoes the community practises other, though ineffective, measures to reduce mosquito bites, such as burning of herbs, coils and fanning with cloth or other material. All indications are that they desire to use bednets, especially during the rainy season.

Studies have demonstrated (Bradley et al. 1986) that bednets provide a barrier to nuisance mosquitoes and insecticide-treated ones have been shown (Choi et af . 1995) to be effective in preventing malaria and have the added advantage (Lindsay et al. 1989) of reducing the numbers of mosquitoes and other insect pests, such as head lice and bed bugs, which have been identified as important nuisance insects in our study communities (unpublished observation).

The known phenomenon that child rearing is mostly the task of mothers/female caretakers in Ghanaian society is highlighted. These caretakers are well informed about the major symptoms of malaria but poorly informed about its transmission and management. Similar findings have been reported from northern Ghana (Hudelson & Adongo 1995). The ability of mothers to identify clinical malaria has been studied in some detail in Africa. Reports from Nigeria and Tanzania indicate low recognition (Molineaux & Gramiccia 1 9 8 ~ ; Rooth & Bjiirkman 199z), while a high recognition rate of malaria symptoms has been reported from Kenya (Spencer et al. 1987; Ruebush et al. 199s). Caretakers recognize the link between malaria and convulsions and to a lesser extent anaemia, both of which are common causes of malaria-related mortality. A common belief is that convulsions are spiritual in origin and they are therefore treated from that point of view, as in northern Ghana (Hudelson & Adongo 1995) and elsewhere in Africa (Mwenesi et al. 199s; Winch et al. 1996) . Malaria awareness of the caretakers of those who bear the brunt of malarial disease (i.e. children 1-9 years of age) (Afari et al. 1995) i s shrouded in many misconceptions which are likely to adversely affect control measures (Ruebush et al. 1992). Residents in both communities have been exposed to malaria research activities since 1992, including indoor and outdoor mosquito collection, but still share folk understandings of malaria similar to those published in a study conducted in a more rural community in the Dangme-West District (Agyepong 1992). Knowledge of the mosquito-malaria link in some of the residents may be the result of the research exposure.

suspected to be malaria begins in the home where treatment i s also initiated using home-prepared herbs

The earliest recognition of a febrile illness



C. K. Ahorlu et 01. Malaria-related beliefs in Ghana

and/or analgesics and usually inadequate doses of chloroquine purchased at local drug shops without prescription. The final recourse, after the sickness has failed to respond to home treatment, is the formal health sector. The practice of home treatment of malaria using mainly herbs, analgesics and inadequate doses of chloroquine purchased over the counter appears to be widespread in the three ecological zones of Ghana; coastal, forest and northern savannah and several other communities in Africa (Deming et al. 1989; Rooth & Bjorkman 1992; Snow et al. 1992; Ruebush et al. 1995; Mnyika et al. 1995). The use of inadequate doses of antimalarial drugs may be particularly relevant in Ghana considering the alarming spread of chloroquine resistance in Africa. Cost of treatment from the formal health sector (health centre) is higher than drugs purchased over the counter while herbal treatment is virtually free. While this may be a major reason for the widespread practice of home treatment, communities are probably also maintain- ing what used to be the practice before the evolution of the formal health sector. Other reported reasons for the high utilization of shops include lack of access to health centres and hospitals in most rural communities because of distance, cost and/or lack of transportation, and long waiting times (Hassouna 1983; Igun 1987).

The primary goal of Ghana’s MAP is to reduce morbidity and mortality through prompt diagnosis and adequate treatment. The focus of delivery of such services has been through the hospitals, health centres, clinics and primary health care infrastructure. However, such settings where treatment is provided by trained personnel, represent only part of the providers of care for malaria patients. It has been estimated that only 20% of Africa’s rural population have access to medical facilities (MacCormack 1984). For example, the formal health sector in each of the study communities and their surrounding villages, representing at least 10 ooo people, has only one health centre staffed with a few nurses and a medical assistant (an experienced nurse with one year additional training in clinical diagnosis and therapeutics). In addition, most health centres in Ghana, especially those in rural communities, have no laboratory facilities and diagnoses are made on clinical observations

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similar to what is being done at home. The formal health sector facilities are therefore inadequate to meet the health needs of the people, including malaria treatment. There are, however, 4 drug shops strategically located and well stocked with chloroquine and other antimalarial drugs in each of the study communities which are highly patronized.

malaria control in Ghana. In view of the associated high mortality, febrile illnesses suspected to be malaria require prompt recognition and appropriate treatment, regardless of whether patients treat them- selves or seek attention from a health facility. Since the diagnosis and treatment of malaria is occurring in the home, efforts should be directed at improving its quality. This means educating residents to remove misconceptions likely to adversely affect control efforts and to recognize and give credence to those cultural beliefs and practices that may contribute positively to recognized control strategies. In particular, there is the need for an educational campaign to correct misconceptions about malaria transmission and to address the problem of inadequate and inappropriate treatment and protection of households, especially children 1-9 years of age, against mosquitoes. While the findings show that dwellings in the region afford inadequate protection from mosquitoes, this problem may be very difficult to solve because of the substantial amount of money involved in providing screened windows, doorways and ceilings. The use of bednets, which is already recognized, should be promoted through emphasis on their protective effect. The added advantage of treating bednets with residual insecticides should be made known to the communities and, since cost is considered a major reason for its low utilization, policy-makers under the MAP and for that matter the government and other related public spirited organizations, especially non-governmental organizations, should consider subsidizing part of the cost of nets to enable all families to invest in them. If malaria-related mortality is to be reduced, then control efforts should build on the current perception and treatment of severe malaria by residents by increasing their awareness of the symptoms and signs of potentially life-threatening malaria and its appropriate treatment. Such a campaign should be

The findings have practical policy implications for


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targeted at caretakers of children under 10 years in particular and the public in general and designed to meet the needs of a target group many of whom are illiterate. Even though attempts to change traditional beliefs and behaviour may not initially be easy, indications of likely success are that knowledge about the link between mosquitoes and malaria has already begun to filter through and must be actively sustained. It is likely that residents will continue to use over-the-counter drugs in combination with herbal medication despite the associated dis- advantages such as misuse of antimalarial drugs, particularly inappropriate doses. It must, therefore, be accepted that this constitutes part of the natural process of fever treatment in the communities. Policy-makers should therefore realize that drug shop operators, currently ignored in the MAP, are likely to continue as a major source of antimalarial drugs in the communities and must be made partners in the malaria control programme and efforts made to improve the services they can offer. In this regard, shop operatorskales agents should be provided with information about the dosages and appropriate use of antimalarial drugs and encouraged to pass it on to their customers. Such education on prompt recognition and appropriate use of antimalarial drugs and their easier access, e.g. through community providers/distributors, may contribute to a reduction in malaria morbidity, especially in the child population.

Acknowledgements

We are grateful to the staff of the Epidemiology Unit of the Noguchi Institute and the two Research Assistants from the Sociology Department of the University of Ghana (Ms Mabel Numao-fio and Maxwell Abotsi) and field assistants for the data collection and microscopy of blood films. We also thank the chiefs, elders and residents a t Dodowa and Prampram, especially our respondents for participating in the study. We sincerely thank Professor Marcel Tanner and his team for their invaluable comments and suggestions for the preparation of this manuscript. This investigation received financial support from the UNDPNorld Bankhpecial Programme for Research and Training in Tropical Diseases (WHO/TDR).

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