Malaria in Ghana: Gaining Insight on Knowledge, Attitudes, and Beliefs Toward Malaria Vector Control

Chytanya Kompala, Bonnie MacLeod | NYU Steinhardt 2014                                      Accra, Ghana May 2012

Chytanya Kompala and Bonnie MacLeod are undergraduate students of Public Health at New York University. They both recently spent a semester abroad in Accra, Ghana where they worked at Child and Associates, a local pediatric clinic. During their time there, Chytanya Kompala and Bonnie MacLeod conducted research on malaria prevention through individual vector control.

Introduction

Malaria presents itself as a major public health concern due to the high rates of morbidity and mortality caused by the disease, especially in sub-Saharan Africa. Sub Saharan Africa accounts for 80% of the estimated 2 million deaths per year caused by malaria worldwide.1 Currently, malaria is the leading cause of morbidity and mortality for pregnant women and children under five. These demographics are a major concern and add a heightened level of urgency to the situation. Not only is malaria negatively affecting the health of individuals, but it also puts a major strain on the heath system and creates an economic burden on the nation. In Ghana, 30%-40% of outpatient cases are due to malaria and 61% of hospital admissions of children below age five are due to malaria.2 The high rates of malaria put a major strain on Ghana economically. Increased rates of malaria are linked with poverty. Furthermore, when an individual is infected with malaria, the economic burden for the country is heightened due work and school absenteeism. Because of these alarmingly high rates, recently there has been a large push from the global health community to reduce the prevalence of the disease. Due to the global spotlight on reducing the prevalence of malaria in sub Saharan Africa, especially from the Millennium Development Goal 6, some progress has been made to reduce malaria related morbidity and mortality. More than one-third of the 108 malaria endemic countries (9 countries within Africa and 29 outside of Africa) documented reductions in malaria cases of greater than 50% in 2008 compared to 2000.3 Specifically in Ghana, there have been attempts to strengthen health care services and make prevention strategies more available. The Ghanaian Roll Back Malaria campaign has partnered with several organizations including WHO, UNICEF, NetMark, and bilateral agencies to promote insecticide treated nets (ITNs) campaigns.4 In spite of this progress, there are still endemic rates in many African countries including Ghana and further interventions need to be implemented.

In order to combat this epidemic, efforts need to be made on the government, community, and individual levels. In West Africa, and specifically Ghana, individuals do not necessarily perceive malaria to be a major burden on their lives. This is a contributing factor to the lack of prevention among individuals. Given the nature of malaria transmission, and the difficulties eliminating mosquitoes on a large scale, it is the responsibility of the individual to protect themselves against the disease.
In an effort to control the burden of malaria, several preventive methods have been developed and proven effective. Malaria vector control is used to protect individuals against becoming infected by mosquito bites. This has been shown on a community level to reduce the incidence of malaria transmission.5 Malaria vector control is most often achieved through prevention methods including insecticide treated nets (ITN), residual spraying, personal repellents, and maintaining a clean environment. All of these means of control can be employed at the individual level, thus placing the responsibility of preventing transmission in the hands of individuals. The ability to effectively use individual methods of prevention lies heavily on the knowledge, attitudes and beliefs one holds on malaria within the community.

Background
We conducted a study consisting of individual surveys taken by patients in a private family practice clinic in the Greater Accra region. This survey questioned patients about perceptions of malaria and knowledge about personal methods of protection and treatment. During this study, we were able to observe local attitudes towards the disease and individuals’ perceived risk of infection. In this study, we analyze the usage and believed effectiveness of several means of personal prevention against malaria.

Methods

Site Description
This study was conducted in the main lobby of Child and Associates. Child and Associates is a private pediatric clinic that also treats adults located in North Dzorowulu of the Greater Accra Region. The general Greater Accra Region is malaria endemic and malaria is a common reason for patients to come in to the clinic. On average, about twelve patients were received a day. Child and Associates is a part of Omni Clinic, which includes a laboratory and dental services.
Methodology
This study used social research methods to determine individuals’ perceived risk of becoming infected with malaria and their knowledge, attitudes and beliefs towards the disease. The research was conducted between January and March 2012. Participants were selected based on the criteria of being patients of Child and Associates, living in the Greater Accra Region, and being parents. Surveys were individually verbally conducted by trained interns. Patients were approached in a professional way. This survey was completely voluntary and some patients chose not to participate in the study for personal reasons.
Instrument
The survey was designed to grasp a concept of the knowledge, attitudes, and beliefs surrounding malaria within this specific community. The categories of the survey include demographics (age, sex, education level, neighborhood of residence, and occupation), perceived risked, prevention methods and treatment. A total of 53 parents were selected from the waiting room of the clinic. When asked what the participant’s perceived risk was, we then followed by asking why this was the case. To understand what the participant’s basic knowledge about malaria was, we asked them where malaria comes from and what are the risk factors that can increase one’s chance of becoming infected with malaria. Next, we asked them what specific methods of personal prevention they used to understand what are the most popular methods of prevention. Then, the participants were asked to rate the effectiveness of using nets, repellents, having clean surroundings, wearing protective clothing and staying indoors as methods of protection from malaria. This demonstrated local beliefs about the effectiveness of specific means of protection. Then, to understand their knowledge about the pathology of the disease, we asked them what they believed to be safe hours of the day, and the signs and symptoms of malaria. We also asked whether parents would treat themselves the same way they would treat their children if infected with malaria to gage if their would be any discrepancies. Finally, we asked what they believed was the most effective treatment.

Results and Analysis
From our raw data, we coded the responses depending on the question to better quantify the results. We began by comparing demographic variables by looking for correlations between different sets of data.

Demographics
The majority of our participants are female and hold a graduate degree. Out of 53 participants, on a scale from one to ten, one being the least and ten being the highest, the average perceived risk is 3.8. Males perceive their risk to be slightly higher by 0.5 compared to females as demonstrated in Figure 1. Older age groups have slightly higher perceived risks, with an increase of 0.2 for every seven years of age as demonstrated in Figure 2. Participants with higher levels of education perceive their risks to be lower by 0.3 per every degree earned as demonstrated in Figure 3. As age increases, the number of modes of protection used decreases. As the level of education increases, the number of modes of protection increases. In addition, as the perceived risk increases, the number of modes of protection increases as demonstrated in Figure 4.
Prevention Methods Used
We asked participants if they use clean surroundings, bed nets, repellents, sprays, clothing, drugs, or staying indoors to prevent malaria. 41.5% of participants use clean surroundings. 56.6% of participants use nets. 71.7% of participants use repellents. 20.8% of participants use spray. 17.0% of participants use protective clothing. 5.7% of participants use drugs. 9.4% of participants stay indoors to avoid mosquitoes as demonstrated in Figure 5. We asked participants to rate nets, repellents, clean surroundings, clothing and staying indoors on a scale from one to five, five being the most effective. Participants on average believe that clean surroundings are the most effective with a score of 4.3, followed by nets with a score of 4.2, repellents at 3.5, staying indoors at 2.9, and protective clothing at 2.9 as demonstrated by Figure 6.
Knowledge and Understanding
In order to quantify participant’s general knowledge and understanding of malaria, we created a ranking system from 1-3. Participants received three points if they knew the “safe hours” of the day (early morning to afternoon), and identified both fever and headache as symptoms of malaria. Participants received two points for identifying the “safe hours” or identifying both fever and headache as symptoms. Participants received one point if they were unable to correctly identify either of these. 31 out of 53 participants received 2 points, 14 received three points, and 8 received one point as demonstrated in Figure 7. In addition, 23 participants listed body aches and pains as a symptom. 14 participants included nausea/stomach problems, and 14 participants included  fatigue/weakness.
Treatment
When asked what participants would do if they or their child showed signs of malaria, the most common response was to see the doctor. 15 participants said they would respond differently if their child showed symptoms compared to if they showed symptoms. When asked what was the most effective treatment, the most common response was medication.

Figure 1: Gender vs. Perceived Risk 

Figure 2: Age vs. Perceived Risk

Figure 3: Education vs. Perceived Risk

Figure 4: Perceived Risk vs. Number of Modes of Protection Used

Figure 5: Frequency of Use of Different Modes of Protection

Figure 6: Average Ranking of Different Modes of Protection on a Scale of 1-5

Figure 7: Frequency of Knowledge Ratings

Discussion and Conclusion
Our findings show that malaria control is an ever pressing burden on this community. With an average perceived risk of 3.8, it can be said that malaria is an everyday mild concern. When examining the personal malaria vector control, education and understanding of effective modes of prevention is essential. The majority of the population of our study is highly educated; most of our participants hold college and/or graduate degrees. Such levels of education may be a contributing factor to the overall low average perceived risk of 3.8. These high levels of education may have contributed to the high levels of personal vector control, and should be encouraged to be used even further. Additionally, it is interesting to note that 12 out of 53 participants say they would self medicate if they believed they had malaria. This may potentially be concerning due to the high and spreading levels of drug resistance.

Future Steps
On an individual level, the most effective way to prevent becoming infected wtih malaria is to continually take anti-malarial drugs. However, these drugs are extremely expensive and are not advised to be taken for multiple years at a time. A more realistic option for locals in a malaria endemic community such as Accra is the use of multiple, daily modes of protection. Rather than simply relying on one means of protection to prevent malaria, the use of different and concurrent methods of protection should be used. For example, individuals should strive to always wear repellent, especially in the evening and early morning as well as spray their homes and sleep with insecticide-treated bed nets. In order for this behavior change to take place, individuals require adequate knowledge and understanding about malaria and how one is infected. Specifically, it is important for individuals to understand the safe hours of the day as well as risk factors that can increase their chances of infection.
In order for this change to be possible within a community, local governments and agencies should support educating individuals and the use of individual vector control. In addition, governments should promote increasing the accessibility of bed nets, sprays, and repellents by ensuring their affordabilty and availability. This could be done by subsidizing the cost or increasing the production of these products so that they are more readily available. Specifically, pregnant women and children under five are more vulnerable to malaria related morbidity and mortality and therefore the government should push to target these groups further.
To further our study, it would be interesting to conduct this survey within a rural population and compare the findings. It would be meaningful to compare the knowledge rankings about malaria in terms of rural and urban communities to see if education campaigns are comparable.

_____________________                                                                                            1 Okech Kenya                                                                                                                       2 MDG Ghana                                                                                                                        3 Full Malaria Report                                                                                                             4 Roll Back Malaria Monitoring and Evaluation                                                            5 Full malaria Report

References

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