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«Cultural Epidemiology For Malaria Control In Ghana INAUGURAL DISSERTATION Zur Erlangung der Würde eines Doktors der Philosophie vorgelegt der ...»

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Cultural Epidemiology For Malaria Control In Ghana



Erlangung der Würde eines Doktors der Philosophie

vorgelegt der

Philosophisch-Naturwissenschaftlichen Fakultät der

Universität Basel


Collins Stephen Ahorlu


Accra, Ghana

Basel, Juni 2005

Genehmigt von der Philosophisch-Naturwissenschaftlichen Fakultät der Universität Basel auf

Antrag von Prof. Dr. M. Tanner, Prof. Dr. M. G. Weiss, und Prof. Dr. F. Binka.

Basel, den 18 Juni, 2005 Prof. Dr. Hans-Jacob Wirz Dekan der Philosophisch-Naturwissenschaftlichen Fakultät To God be the glory for the great things he has done!

Dedicated to my family:

Cynthia, Stephanie, Reginald.

Also to Mabel and My mother (Agnes Ami Dzowoedzi Anappy), For your love, devotion and prayers.

Table Of Contents Table Of Contents Table Of Contents

List of Figures

List of Tables

List Of Abbreviations


Financial Support

Ethical Review



Chapter 1: Introduction

1.1 Current Global Malaria Situation

1.2 Control Strategies

1.3 Social And Behavioural Research In Malaria

1.4 General Overview Of Cultural Epidemiology Framework

Chapter 2: Study Aims And Objectives, And Methods

2.2 Specific Objectives

2.3 Study Area

2.4 General Methods Used For Data Collection

2.4.1 Free Listing And Rating

2.4.2 Participatory Mapping

2.4.3 Focus Group Discussions

iTable Of Contents

2.4.4 In-Depth Interviews

2.4.5 Insiders’ Perspective (EMIC) Interviews

2.5 Data Analysis

Chapter 3: Culture And Malaria Affecting Children And Pregnant Women In Two Rural Ghanaian Communities



3.2 Introduction and Background

3.3 Methods

3.3.1 Study Area

3.3.2 Study Methods

3.4 Results

3.4.1 Common Illnesses

3.4.2 Causes Of Malaria-Related Illness

3.4.2 Home-Based Management Of MRI

3.4.3 Social Support

3.4.4 Treatment Of MRI Outside The Home

3.4.5 Treatment Failure

3.4.6 MRI Effect On The Blood Of Patients

3.4.7 Prevention And Control

3.4.8 Comparing MRI In Children And Pregnant Women

3.4.9 Presence Of Mosquitoes

3.4.10 Bednet Use

3.5 Discussion

Chapter 4: Sociocultural Determinants Of Treatment Delay For Childhood Malaria......37

4.1 Abstract

4.2 Introduction

4.3 Study Area And Methods

4.3.1 Study Area

4.3.2 Methods

4.3.3 Data Analysis

–  –  –

4.4 Results

4.5 Discussion

Chapter 5: Saying And Doing: Comparing Vignette-Based Accounts With Case-Based Experience Of Childhood Malaria-Related Illness In Southern Ghana

5.1 Abstract

5.2 Introduction

5.3 Study Area And Methods

5.3.1 Study Area

5.3.2 Study Methods

5.3.3 Data Analysis

5.4 Results

5.5 Discussion

Chapter 6: Community Concepts Of Malaria-Related Illness With And Without Convulsions In Southern Ghana

6.1 Abstract

6.2 Background

6.3 Study Area And Methods

6.3.1 Study Area

6.3.2 Study Methods

6.4 Results

6.4.1 Patterns Of Distress For Childhood MRI With And Without Convulsions...............85 6.4.2 Perceived Causes

6.4.3 Self-Help At Home

6.4.4 Outside Help-Seeking

6.4.5 Prevention

6.5 Discussion

6.6 References

6.7 Appendix 1a. Vignette Depicting MRI With Convulsion Positive (MRI-CP).................100

–  –  –

6.8 Appendix 1b. Vignette Depicting MRI With Convulsion Negative (MRI-CN)...............101 Chapter 7: Malaria-Related Illness In Pregnancy: Experience, Meaning, And HelpSeeking

7.1 Abstract

7.2 Introduction

7.3 Study Area

7.4 Study Methods

7.4.1 Data analysis

7.5 Results

7.5.1 Demographic Characteristics Of Respondents

7.5.2 Recognition

7.5.3 Seriousness of MRI

7.5.4 Absence From Work Or School

7.5.5 Self Help At Home

7.5.6 Outside Help-Seeking

7.5.7 Timely, Appropriate Treatment

7.5.8 Symptoms

7.5.9 Perceived Causes

7.5.10 Prevention

7.6 Discussion

Chapter 8: General Discussions And Conclusions

8.1 Methodological Issues

8.2 Specific Issues Discussed For Each Paper In The Thesis

8.2.1 Ethnographic Study

8.2.2 Sociocultural Determinants Of Treatment Delay For Childhood Malaria-Related Illness

8.2.3 Saying And Doing: Comparing Vignette-Based Accounts With Case-Based Experience Of Childhood Malaria-Related Illness In Southern Ghana

8.2.4 Community Concepts Of Malaria-Related Illness With And Without Convulsions In Southern Ghana

–  –  –

8.2.5 Malaria-Related Illness In Pregnancy: Comparing Vignette-Based Accounts Of Pregnant Women And The General Population

8.3 General Comments And Recommendations

8.4 Recommendations

8.5 Further Research Questions



Curriculum Vitae

–  –  –

Acknowledgements This study was a collaborative effort with several people at the Noguchi Memorial Institute for Medical Research (NMIMR), Legon (home institution); the Swiss Tropical Institute (STI), Basel, (Training Institution); and the District Health Management Teams (DHMT) of Akuapim North and Keta Districts (study sites in Ghana).

I wish to thank the chiefs, elders, assemblyman/woman and members of the two study communities for allowing the study to be conducted in their communities, and graciously taking valuable time to participate in the data collection, without which the study would not have been possible. Meda moase pii, Akpenami kakaaka.

I am particularly indebted to Professor Francis Nkrumah for his personal interest in my career development and training. Thank you, Prof. I also wish to thank Dr. Koram, Professor David Ofori-Adjei, Professor Wilson and Dr. Boakye for their encouragements, and creating congenial environment at NMIMR for this study to take place. Many thanks go to the staff of Epidemiology Department of NMIMR, especially David Mensah, Ben Abuaku and Grace Anyadi for their various contributions to get this work done. I would like to thank Yaw and Robert for their ‘combat readiness’ to make several field trips with me.

My sincere thanks go to Fred Ayifli for your role as my research assistant on the field, I am very grateful for all the moments we share together. May God richly bless you. To my four dedicated field assistants: Saviour, Koanya, Amankwa and Aryee Oloso. Thank you very much for making data collection possible. Thanks to the administrative staff of the WHO Office in Ghana for facilitating my travels.

I am particularly grateful to my supervisor Professor Mitchell Weiss for his useful guidance and assistance, without which this thesis would not have been written. Thank you very much for the numerous reviews, comments, suggestions and all the support you gave to see this work through. Professor Marcel Tanner, thank you so much for your personal interest in my work and welfare, thanks so much for all the support you gave me when my father passed away in the course of this study. Thank to Don de Savigny for your useful comments and suggestions, and Brigit, Penelope, Jacob, Tom, Christian and Esther for your interest and

–  –  –

encouragement. Many thanks to Eliane and Christine for being there for me at all times, and ready to meet all my requests, and Abdallah, thank you for your friendship and statistical support.

Daryl, thank you for your friendship, and useful comments on the papers presented in the thesis. Daniel thanks so much for your friendship, reading the papers and helping to format this thesis into its current form. Claudia thank for your friendship and timely intervention to translate the summary into German. Many thanks go to Heidi, Simon and Martin for library and computer assistance. To Laura, Sama, and Sharlenna, Dorothy, Stephanie, Abudulai, Sohini, and all the students, I say thank you all for your encouragements and the moments we have shared together at STI.

I will like to thank Jennifer and Paul Jenkins for encouragement and opening your doors to receive me and my family when we needed a bigger place to stay; may God continue to sustain you in every area of your life. To Anita and Jim Cooper, ‘my parents in Basel’, all I can say is that may God richly bless you, and keep you from falling, and may your dreams come true. I will like to thank all the members of the Basel Christian Fellowship for your brotherly love and fellowship. Special thanks to Pastor David Maduka, John Scheuring, Otto Blaser, Mark Hill, Taiwoo Fashola and Paul for your prayers and encouragement. Thanks to Ursula and Knut Offen of FGBMFI, Lorrach Chapter in Germany for your spiritual support.

My final thanks go to Anti, Yaa, Adwoa, Mr. & Mrs. Alomatu, Maxwell, Gideon, Eric, Ken Anappey, Sam, Abaeku, Rev.& Mrs. Avevor, Mr & Mrs. Sedofiah, and FBMFI Gateway Chapter members for your encouragement and support, especially to my family when I was away putting this work together. May God richly bless you all. To all those who are inadvertently missing from this list, I say thank you all for being there for me.

xivFinancial Support/Ethical Review

Financial Support I am very grateful to WHO/TDR for awarding me a Research Training Grant to cover the cost of my studies at the Swiss Tropical Institute, Basel, and fieldwork for the entire work reported in this thesis. Special thanks go to Steve Wayling and Paula Bevin for their support and quick responses to my requests during the course of this study.

Ethical Review This study was approved by the institutional review boards of Noguchi Memorial Institute for Medical Research and the Swiss Tropical Institute. It was also reviewed by the WHO/TDR ethical review committee.

–  –  –

Zusammenfassung Malaria ist eine Bedrohung für mehr als 40% der Weltbevölkerung und ist verantwortlich für mehr als 300 Millionen Akutfälle jedes Jahr, was zu 1.2. Millionen Todesfälle im Jahr 2002 geführt hat. Über 80% der Morbidität und Mortalität in Bezug auf Malaria ist in subsaharischen Länder Afrikas anzufinden, wobei Kinder unter 5 Jahren und schwangere Frauen dem grössten Risiko ausgesetzt sind.

Die Situation in Ghana in Bezug auf Malaria ist typisch für das subsaharische Afrika, wo Malaria die Hauptkrankheit unter den zehn häufigsten gesehenen Krankheiten in Kliniken ist.

Wegen der grossen Armut in diesem Gebiet besteht die Behandlung in den meisten Haushalten zuerst aus einer Kombination aus Kräutern und rezeptfreien Medikamenten.

Solche rezeptfreien Antimalaria Medikamente, hauptsächlich Chloroquine und Analgetika, werden meistens in unzulänglichen Dosierungen verkauft. Gerade in Ghana, sowie in anderen afrikanischen Gebieten südlich der Sahara, wo hauptsächlich das potentiell tödliche Malaria Plasmodium falciparum auftritt, kann eine frühzeitige und effektive Behandlung Leben retten, in dem der Verlauf der Krankheit zu schwerwiegender Malaria verhindert wird.

Deshalb ist die frühzeitige Erkennung und die effektive und rechtzeitige Behandlung von Malaria ein wichtiges Element von globalen Kontrollstrategien.

Das Hauptziel der Studie war es das Auftreten, die Verteilung und die bestimmenden Faktoren der MRI Erfahrungen, deren Bedeutungen und das darauf basierende Verhalten festzustellen, besonders da diese das Risiko und das schützende Gesundheitsverhalten beeinflussen, welche relevant sind für Malariainterventionen. Die Studie wurde in zwei ländlichen Gebieten in Ghana durchgeführt (Obosomasi, das sich in der Waldvegetationzone befindet, und Galo-Sota in der Küstensavannezone) über einen Zeitraum von Oktober 2002 bis April 2004.

Zwei zu unterscheidende, jedoch miteinander zusammengehörende Datensammlungsphasen wurden in dieser kulturell epidemiologischen Studie eingesetzt. Die erste ethnographische Phase brachte lokal relevante Kategorien in Bezug auf die Krankheitserfahrungen, deren Bedeutungen und das darauf basierende Verhalten durch verschiedenste teilnehmende Methoden hervor (Freies auflisten und Einstufung, teilnehmendes Kartieren,


Fokusgruppendiskussionen und Tiefeninterviews). Auf diese Phase aufbauend, benutzte die zweite Phase die dadurch erzeugten Kategorien und Repräsentationen um ein EMIC Interview, das sich auf die Perspektive der Betroffenen zentriert, zu erstellen. Dieses Interview ist ein Instrument, womit die Häufigkeit, die Determinanten und die Distributionen dieser lokal relevanten Kategorien gemessen werden kann. Das daraus gewonnene Wissen ist notwendig um adäquate Interventionsstrategien für alle Gruppen innerhalb einer Bevölkerung erstellen zu können.

Die wichtigsten Resultate sind:

Malaria wird als Hauptgesundheitsproblem in diesen Gemeinden anerkannt, dass Kinder und schwangere Frauen mehr als andere Segmente der Bevölkerung nachteilig betrifft.

Moskitos werden als die Hauptursache der in Verbindung mit Malaria stehenden Krankheiten ohne Fieberkrämpfe angesehen. Dieses Ergebnis steht konträr zu früherer Studien im südlichen Ghana, was auf sich verändernde lokale Vorstellungen zeigt.

Menschen in den Gemeinden berichteten, dass Hitze erzeugt durch die Sonne eine Hauptursache der in Verbindung mit Malaria stehenden Krankheiten ohne Fieberkrämpfe ist.

Dieses Resultat weißt auf die Notwendigkeit weitere Studien hin, welche die Verbindung zwischen Hitze erzeugt durch die Sonne und Auslösern der klinischen Malariaepisoden untersuchen.

Die Eigenbehandlung der in Verbindung mit Malaria stehenden Krankheiten Zuhause ist sehr verbreitet und besteht aus einer Mischung von Kräuter- und biomedizinischen Medikationen.

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