Cultural epidemiology for malaria control in Ghana

Malaria is a threat to more than 40% of the world’s population and responsible for more than
300 million acute cases each year, which resulted in 1.2 million deaths in 2002. Over 80% of
the malaria-related morbidity and mortality occur in sub-Saharan Africa with children under
five and pregnant women at highest risk.
The malaria situation in Ghana is typical of sub-Saharan Africa, where malaria is ranked first
among the ten diseases most frequently seen in most health facilities in the country. Due to
widespread poverty, however, many households depend on a combination of herbs and overthe-
counter drugs, usually consisting of inadequate doses of antimalarials, chiefly chloroquine
and analgesics. In Ghana, as in other parts of sub-Saharan Africa, where malaria is due
mainly to Plasmodium falciparum and potentially fatal, early and effective treatment saves
lives by preventing disease progression to severe malaria. In view of this, prompt recognition
and effective timely treatment of malaria is a critical element of global malaria control
strategies.
The overall goal of this study was to determine the occurrence, distribution, and determinants
of MRI experiences, meanings and behaviours, inasmuch as these affect risk, and protective
behaviours relevant for intervention to reduce malaria-related morbidity and mortality in
children and pregnant women. The study was carried out in two rural communities
(Obosomasi, located in the forest vegetation zone, and Galo-Sota, in the coastal savannah
zone) in Ghana, over the period from October 2002 to April 2004.
This was a cultural epidemiological study employing two-stage data collection strategies. The
first stage was ethnographic study, which made use of free listing and rating, participatory
mapping, focus group discussions and in-depth interviews to generate relevant local malariarelated
illness experiences, meanings and behaviours. The second stage made use of these
relevant categories and representations to design EMIC (insiders’ perspective) interviews,
which are tools to assess the occurrence, determinants and distributions of these categories
to guide appropriate interventions for all segments of the population studied.
Results indicate that:
Malaria is recognised as a leading health problem in these communities, affecting children
and pregnant women more than other segments of the population.
Mosquitoes were identifies as the leading causes of malaria-related illness without
convulsions, a finding at odds with earlier studies in southern Ghana, indicating changing
local perceptions.
Local people reported that heat from the sun is a major cause of malaria-related illness
without convulsions, and this finding suggests a need for further study to determine the link
between heat from the sun and triggers of clinical malaria episodes.
Home treatment for malaria-related illness is very common and entails the use of herbal and
biomedical medications.
The clinic and hospital were preferred sites for treatment of MRI, including convulsions,
outside the home, but most patients get there rather late.
Convulsions were identified as a component of the malaria-related illness complex, and
mosquito bites and febrile malaria episodes were identified as two important causes of MRI
with convulsions. This finding was also a departure from most previous reports from sub-
Saharan Africa.
Despite relating mosquito, malaria and convulsions to one another, local people continue to
implicate supernatural forces among causes of convulsions, but explaining that spirits take
advantage of malaria attacks to make their mischief.
Local healers continue to play an important role in the management of convulsions, but
mainly as one aspect of the holistic healing process, involving both rituals to drive away
mischievous spirits and biomedical treatments. That is, local healers perform rituals to drive
away the spirit causing the convulsions, which paves the way for biomedical treatment and a
complete cure. Local healers are also reputed to have ‘medicine’ to protect children from
convulsive attacks.
Despite the general agreement between the accounts of pregnant women and the general
population, there were some significant differences suggesting the need for gender-specific
interventions to control malaria-related illness in pregnancy. The recent introduction of
intermittent preventive treatment appears responsive to this need, but it may need to be
extended as a community programme to achieve the goal of reducing the malaria-related
disease burden in pregnancy.
Vignette-based interviews evoke responses specifying categories of malaria-related illness
experiences, meanings, and behaviours similar to case-based interviews, but with differences
in frequencies of reporting these categories.
This is the first time that the cultural epidemiology framework has been applied to study the
sociocultural aspects of malaria covered in this thesis, and it substantially adds to the growing
body of knowledge of the importance of sociocultural factors in malaria control. The
implications of the findings for interventions are discussed in individual papers presented in
the thesis, and in consisting of a discussion of the overall study and conclusions.