Seeking treatment for uncomplicated malaria: experiences from the Kintampo districts of Ghana

Knowledge, attitude and practices of malaria preventive measures among mothers with children under five years in a rural setting of Ghana

BACKGROUND

Malaria remains a major public health concern around the world, particularly in resource-constrained countries. Malaria still accounts for 40% of all Out-Patient Department (OPD) cases in Ghana, with children under the age of five being the most vulnerable group. The study assessed the knowledge, attitudes, and practices of malaria preventive measures among mothers with children under 5 years old in a rural setting in Ghana.

METHODS

A cross-sectional study design with a quantitative approach was used in this study. The study was facility based and involved the use of interviewer administered questionnaires to collect data from 281 mothers with children under the age of five. Simple random sampling method was used to select the respondents. The data collected was analysed using the statistical package for the social sciences (SPSS) version 22 and results presented in tables.

RESULTS

There were 281 mothers, with 59.4% having children at the age of a year. The findings revealed that the majority of participants have a high level of knowledge about malaria's causes, signs, and symptoms. Again, the majority of participants demonstrated a positive attitude toward malaria prevention, such as seeking treatment at a hospital within 24 h of suspecting their children had malaria and demonstrating good knowledge of malaria prevention practices. Despite this, 35.5% of respondents were not actively engaged in malaria prevention practices in a day prior to the interview. Respondents' occupation, level of education, and religion had a statistically significant association with mothers' attitude towards prevention (p-values < 0.05 and 0.01).

CONCLUSION

The study's findings clearly demonstrate that the majority of mothers were knowledgeable about the causes, signs and symptoms, and preventive measures of malaria in children under the age of five. There was also statistically significant association between mothers' demographic information, including level of education, occupation, religion, and their attitude towards malaria prevention. A keen interest should be directed toward the consistent application of low-cost preventive measures.

Are Malaria Risk Factors Based on Gender? A Mixed-Methods Survey in an Urban Setting in Ghana

Malaria still represents one of the most debilitating and deadly diseases in the world. It has been suggested that malaria has different impacts on women and men due to both social and biological factors. A gender perspective is therefore important to understand how to eliminate malaria. This study aimed to investigate malaria from a gender perspective in a non-for-profit private health facility, HopeXchange Medical Centre, based in Kumasi (Ghana). A sequential mixed-methods design, comprising quantitative and qualitative methods, was used. This study found low ownership (40%) and use (19%) of insecticide-treated nets (ITNs). Most malaria cases were women (62%), who were less educated and had more external risk factors associated with infection. Our study reported a trend of preferring malaria self-medication at home, which was practiced mostly by men (43%). Our data suggest that women are more likely to be exposed to malaria infections than men, especially due to their prolonged exposure to mosquito bites during the most dangerous hours. Our study highlighted the need for future malaria control policies to be more focused on social and behavioral aspects and from a gender perspective.

Stakeholders' perspectives on training over the counter medicine sellers and Community-based Health Planning and Services facilities to dispense antibiotics in Ghana

Background

Dispensing of antibiotics by over the counter medicine sellers (OTCMS) is a major driver of inappropriate use and resistance in low and middle income countries. Recent studies in Ghana revealed the need to consider training OTCMS and Community-based Health Planning and Services (CHPS)/health posts to dispense some antibiotics. Feasibility of training OTCMS and CHPS to dispense some antibiotics was explored in this study.

Methods

This was an explorative study involving 10 in-depth interviews (IDIs) among staff of Ghana health services (GHS), pharmacy council and the association of OTCMS at the district and regional levels. Next, findings were presented to the Ghana Antimicrobial Resistance (AMR) platform for further discussions at the national level. Five IDIs were also performed among selected members of the AMR platform as a follow-up on emerging issues. Data were thematically analysed and presented as narratives with quotes to support the findings.

Results

Two opposing views were found in our study. Leadership of OTCMS and GHS staff at the district health directorate supported the suggestion that OTCMS and CHPS should be trained to dispense specific antibiotics because they are already dispensing them. The leadership of OTCMS explained that some of their members are experienced and could be trained to improve their practices. In contrast, participants from pharmacy council, GHS in the region and national AMR platform generally alluded that OTCMS and CHPS should not be trained to dispense antibiotics because their level of education is inadequate. GHS personnel from the region further explained that training OTCMS could further compromise inappropriate antibiotic use in the context of already weak regulation enforcement. GHS and pharmacy council in the region rather suggested that OTCMS and CHPS should focus on public health education on disease prevention and appropriate antibiotic use.

Conclusions

There is general lack of consensus among stakeholders on whether OTCMS and CHPS should be trained to dispense specific antibiotics. Further stakeholder engagement is required to carefully consider this suggestion as views on feasibility differ. Ministries of health and healthcare agencies in Ghana and LMIC should improve access to approved health services to improve antibiotic use in rural settings.

Sub-chronic toxicity evaluation of top three commercial herbal antimalarial preparations in the Kumasi metropolis, Ghana

PURPOSE

Safety data on commonly used herbal medicinal (HM) products (HMPs) and marketed in Ghana are scarce. We assessed the sub-chronic toxicity of three most-patronised commercial antimalarial HMPs in Kumasi, Ghana.

METHOD

Top three HMPs (designated as herbal products 'A' (HPA), 'B' (HPB) and 'C' (HPC)) were selected after a mini-survey and sub-chronic toxicity evaluation conducted in accordance with Organisation for Economic Co-operation and Development (OECD) 407 guidelines. Control rats received clean water while test groups received daily adult human dose (DAHD), 5× DAHD or 10× DAHD of either HPA, HPB or HPC for 30 days. Rats were killed on day 31 to obtain biochemical, haematology and histology samples for analysis. Data were analysed by one-way analysis of variance (ANOVA) and post hoc Tukey's test.

RESULTS

The three HMPs produced alterations in liver morphology predominantly characterised by prominent foci of fatty change with scattered hepatocytes containing intracytoplasmic fat globules and congested central veins and sinusoids. The lungs showed alveolar with evidence of inflammation and foci of epithelial sloughing. Alveolar spaces were also obscured by debris and inflammatory cells. HPA and HPC produced scattered intensely congested heart vessels while HPB(10) produced haemorrhage and amorphous exudates within the heart. All HMPs produced neither treatment-related deaths nor significant change in haematological and biochemical parameters, except for HPA and HPB which decreased (P<0.05) aspartate aminotransferase (AST) and HPB, which elevated (P<0.05) fasting blood glucose (FBG).

CONCLUSION

Data from the present study suggest the potential of the herbal products (HPs), HPA, HPB and HPC, to cause major organ-system dysfunction or damage. We advise cautious use of these products and recommend further safety evaluation in chronic toxicity models.

Self-medication practice with antimalarials & the determinants of malaria treatment-seeking behavior among postpartum mothers in a rural community in Nigeria

BACKGROUND

The majority of the population has inappropriate malaria treatment-seeking behavior and little is known about self-medication practice with antimalarials among postpartum mothers.

AIM & OBJECTIVES OF STUDY

The study, therefore, aims to determine the prevalence of self-treatment practice with antimalarials and identify factors that determine inappropriate treatment-seeking practice in this susceptible group.

RESEARCH METHODS

The study is a cross-sectional study that was conducted using a purposive sampling technique. In the study, 150 respondents were administered questionnaires by one-on-one interviews, and results were presented as frequencies and proportions. A chi-square test was done to determine the association between independent categorical variables and the dependent variable.

RESULTS

In the study, 91 (60.7%) of the women claimed they did malaria screening tests in the laboratory/clinic before treatment, while only half of them sought professional care for treatment after the screening test. Additionally, most of the participants claimed they practice self-medication with antimalarials for themselves (64, 42.7%), and their newborn children (34, 22.7%). The experience of adverse effects (χ² = 4.790, df = 1, p = .029) drug prescription by doctors (χ² = 10.26, df = 1, p = .001) and the experience of malaria in the rainy season (χ² = 4.86, df = 2, p = .027) was significantly related to receiving malaria treatment in the clinic/hospital.

CONCLUSION

The study has shown that the practice of self-medication and inappropriate malaria treatment behavior is common in postpartum women in rural settings hence public health intervention that will develop standardized self-treatment guidelines for uncomplicated malaria will be useful in promoting appropriate self-treatment practice in this population. Highlights Self-medication practice with antimalarials among postpartum mothers both for themselves and their newborn child was 42.7% and 22.7% respectively One of the reasons adduced for such practice is that malaria is expensive to treat (37, 24.7%) Artemether/lumefantrine combination was the most commonly used drug for treatment (75.3%), and most of the participants preferred parenteral medication (68%) to oral drugs The experience of adverse effects was significantly related to receiving treatment in the clinic/hospital Of the 60.7% of women who claimed they did malaria screening test, only half of them sought professional care after the test.

Every medicine is medicine; exploring inappropriate antibiotic use at the community level in rural Ghana

Background

Inappropriate antibiotic use is an important driver of antibiotic resistance. This study sought to explore inappropriate antibiotic use and confusing antibiotics with other medicines in Ghana using ethnomethodology research approach.

Methods

This was an explorative study involving 15 in-depth interviews among health professionals and private dispensers and eight focus group discussions among 55 community members. Qualitative data were coded using Nvivo 12, thematically analysed and presented as narratives with quotes to support the findings.

Results

Self-medication was common and antibiotics were used to treat specific diseases but respondents were not aware these were ‘antibiotics’. Various antibiotics were used for indications that in principle do not require systemic antibiotics, like stomach ache and sores on the body. Antibiotics, in particular tetracycline and metronidazole, were poured into “akpeteshie” (local gin) to treat hernia and perceived stomach sores (stomach ulcer). These practices were copied/learnt from various sources like over-the-counter medicine sellers, family, friends, radio/television, drug peddlers, pharmacies and doctors. Medicines in capsules were referred to as ‘topaye’ or ‘abombelt’ in Twi (local dialect) and perceived to treat pain associated with diseases. Antibiotics in capsules were described with colours which appeared confusing as some capsules with different drugs in them have similar colours.

Conclusion

Inappropriate antibiotic use were influenced by general lack of knowledge on antibiotics and identification of antibiotics by colours of capsules which leads to confusion and could lead to inappropriate antibiotic use. There is the need for public health education on appropriate antibiotic use and standardization of appearance of antibiotics and other drugs to optimize use.

Routine data for malaria morbidity estimation in Africa: challenges and prospects

BACKGROUND

The burden of malaria in sub-Saharan Africa remains challenging to measure relying on epidemiological modelling to evaluate the impact of investments and providing an in-depth analysis of progress and trends in malaria response globally. In malaria-endemic countries of Africa, there is increasing use of routine surveillance data to define national strategic targets, estimate malaria case burdens and measure control progress to identify financing priorities. Existing research focuses mainly on the strengths of these data with less emphasis on existing challenges and opportunities presented.

CONCLUSION

Here we define the current imperfections common to routine malaria morbidity data at national levels and offer prospects into their future use to reflect changing disease burdens.

Determinants of Inappropriate Antibiotics Use in Rural Central Ghana Using a Mixed Methods Approach

Background: The consequences of antibiotic resistance are projected to be most severe in low and middle income countries with high infectious disease burden. This study examined determinants of inappropriate antibiotic use at the community level in rural Ghana.

Methods: An observational study involving qualitative and quantitative methods was conducted between July, 2016 and September, 2018 in Ghana. Two household surveys were conducted at two time points (2017 and 2018) among 1,100 randomly selected households over 1 year. The surveys focused on antibiotic use episodes in the past month. Four in-depth interviews and two focus group discussions were performed to further explain the survey results. Determinants of inappropriate antibiotic use were assessed using a mixed effect logistic regression analysis (multilevel analysis) to account for the clustered nature of data. We defined inappropriate antibiotic use as either use without prescription, not completing treatment course or non-adherence to instruction for use. Qualitative data were thematically analyzed.

Results: A total of 1,100 households was enrolled in which antibiotics were used in 585 (53.2%) households in the month prior to the surveys. A total of 676 (21.2%) participants out of 3,193 members from the 585 reportedly used antibiotics for 761 episodes of illness. Out of the 761 antibiotic use episodes, 659 (86.6%) were used inappropriately. Paying for healthcare without health insurance (Odds Ratio (OR): 2.10, 95% CI: 1.1–7.4, p-value: 0.026), not seeking healthcare from health centers (OR: 2.4, 95% CI: 1.2–5.0, p-value: 0.018), or pharmacies (OR: 4.6, 95% CI: 1.7–13.0, p-value: 0.003) were significantly associated with inappropriate antibiotic use. Socio-demographic characteristics were not significantly associated with inappropriate antibiotic use. However, the qualitative study described the influence of cost of medicines on inappropriate antibiotic use. It also revealed that antibiotic users with low socioeconomic status purchased antibiotics in installments which, could facilitate inappropriate use.

Conclusion: Inappropriate antibiotic use was high and influenced by out-of-pocket payment for healthcare, seeking healthcare outside health centers, pharmacies, and buying antibiotics in installments due to cost. To improve appropriate antibiotic use, there is the need for ministry of health and healthcare agencies in Ghana to enhance healthcare access and healthcare insurance, and to provide affordable antibiotics.

To sell or not to sell; the differences between regulatory and community demands regarding access to antibiotics in rural Ghana

Background

In Ghana, there is extensive over-the-counter dispensing of antibiotics, resulting in high levels of inappropriate use, and an increase in antibiotic resistance. Regulations prevent Licenced Chemical Sellers (LCS, Over-the-Counter Medicine Sellers) from selling antibiotics other than Cotrimoxazole. In practice, however, these sellers sell a variety of antibiotics. This paper aims to provide insight into the differences between regulatory and community demands on the sale of antibiotics, and to explore how these differences in demand could be resolved to facilitate safe and appropriate use of antibiotics in rural Ghana.

Methods

A total of 32 in-depth interviews were conducted in the Kintampo North and South Districts in Ghana; 16 among antibiotic suppliers, predominantly LCS, and 16 among community members. Six focus group discussions were also conducted among 40 community members. Data were coded using Nvivo 10 and thematically analyzed in line with study objectives. The results are presented as narratives with quotes to illustrate the findings.

Results

Generally, antibiotic suppliers were aware that regulations prevent LCS from selling antibiotics except Cotrimoxazole. However, LCS sell all types of antibiotics because of community demand, economic motivations of LCS, and the poor implementation of regulations that are intended to prevent them from selling these medications. Factors that influence community demand for antibiotics include previous knowledge of effectiveness of some antibiotics, delays in seeking care at health facilities, financial constraints, and distance to health facilities. LCS suggested that they should be trained and allowed to sell some types of antibiotics instead of being prevented completely from selling. Community members also suggested that Community-based Health Planning and Services (CHPS) compounds should be equipped to dispense antibiotics.

Conclusion

The sale of antibiotics by LCS at the community level is influenced by both structural and individual contextual factors. There is a need to educate community members on the appropriate access and use of antibiotics in rural Ghana. In addition, rather than enforcing rules that go against practice, it may be more effective to regulate the sale of antibiotics by LCS and train them to make their dispensing more appropriate. CHPS compound could also be equipped to dispense some antibiotics to improve appropriate antibiotic access at the community level.

Strengthening the Referral System through Social Capital: A Qualitative Inquiry in Ghana

The referral system in health care has been noted as very influential in determining which services are accessed and when. Nonetheless, existing studies have relied on specific measurable factors relating to health personnel, transportation and communication infrastructure, and finance to explain the challenges facing the referral policy in developing countries. While this is understandable, the role of social capital remains mostly uncharted even though it is implicit in the well-known lay referral system. Using various facets of the social capital concept, this paper empirically examines how the resources embedded in both structural and cognitive aspects of social relationships influence knowledge of, and adherence to, referral policy. This study is based on semi-structured in-depth interviews conducted with 79 adults in the Ashanti Region of Ghana in 2015. Of the 79 participants, 28 lived in urban areas and 51 in rural localities. Eight health personnel and eight community leaders also contributed to the study. Additionally, six focus group discussions were held. The findings indicated that both cognitive and structural forms of social capital considerably underpinned the ability and willingness of people to adhere to the referral process. Moreover, the role of social capital was double-barrelled. It contributed in a significant way to encouraging or dissuading potential patients from rightly embracing the policy. In addition, precepts of social capital reinforced both positive and adverse effects of the other determinants of the policy such as finance and transportation. However, the magnitude of such impact was linked to how ‘resourceful’ and ‘trustworthy’ one’s available social acquaintances were. The paper suggests that a cautious engagement with social capital will make it a potentially powerful tool for understanding the gaps in and improving the effectiveness of referral policy.

Treatment-seeking behaviour in low- and middle-income countries estimated using a Bayesian model

BACKGROUND

Seeking treatment in formal healthcare for uncomplicated infections is vital to combating disease in low- and middle-income countries (LMICs). Healthcare treatment-seeking behaviour varies within and between communities and is modified by socio-economic, demographic, and physical factors. As a result, it remains a challenge to quantify healthcare treatment-seeking behaviour using a metric that is comparable across communities. Here, we present an application for transforming individual categorical responses (actions related to fever) to a continuous probabilistic estimate of fever treatment for one country in Sub-Saharan Africa (SSA).

METHODS

Using nationally representative household survey data from the 2013 Demographic and Health Survey (DHS) in Namibia, individual-level responses (n = 1138) were linked to theoretical estimates of travel time to the nearest public or private health facility. Bayesian Item Response Theory (IRT) models were fitted via Markov Chain Monte Carlo (MCMC) simulation to estimate parameters related to fever treatment and estimate probability of treatment for children under five years. Different models were implemented to evaluate computational needs and the effect of including predictor variables such as rurality. The mean treatment rates were then estimated at regional level.

RESULTS

Modelling results suggested probability of fever treatment was highest in regions with relatively high incidence of malaria historically. The minimum predicted threshold probability of seeking treatment was 0.3 (model 1: 0.340; 95% CI 0.155-0.597), suggesting that even in populations at large distances from facilities, there was still a 30% chance of an individual seeking treatment for fever. The agreement between correctly predicted probability of treatment at individual level based on a subset of data (n = 247) was high (AUC = 0.978), with a sensitivity of 96.7% and a specificity of 75.3%.

CONCLUSION

We have shown how individual responses in national surveys can be transformed to probabilistic measures comparable at population level. Our analysis of household survey data on fever suggested a 30% baseline threshold for fever treatment in Namibia. However, this threshold level is likely to vary by country or endemicity. Although our focus was on fever treatment, the methodology outlined can be extended to multiple health seeking behaviours captured in routine national survey data and to other infectious diseases.

Factors influencing choice of care-seeking for acute fever comparing private chemical shops with health centres and hospitals in Ghana: a study using case-control methodology

Background

Several public health interventions to improve management of patients with fever are largely focused on the public sector yet a high proportion of patients seek care outside the formal healthcare sector. Few studies have provided information on the determinants of utilization of the private sector as against formal public sector. Understanding the differences between those who attend public and private health institutions, and their pathway to care, has significant practical implications. The chemical shop is an important source of care for acute fever in Ghana.

Methods

Case–control methodology was used to identify factors associated with seeking care for fever in the Dangme West District, Ghana. People presenting to health centres, or hospital outpatients, with a history or current fever were compared to counterparts from the same community with fever visiting a chemical shop.

Results

Of 600 patients, 150 each, were recruited from the district hospital and two health centres, respectively, and 300 controls from 51 chemical shops. Overall, 103 (17.2 %) patients tested slide positive for malaria. Specifically, 13.7 % (41/300) of chemical shop patients, 30.7 % (46/150) health centre and 10.7 % (16/150) hospital patients were slide positive. While it was the first option for care for 92.7 % (278/300) chemical shop patients, 42.7 % (64/150) of health centre patients first sought care from a chemical shop. More health centre patients (61.3 %; 92/150) presented with fever after more than 3 days than chemical shop patients (27.7 %; 83/300) [AOR = 0.19; p < 0.001 CI 0.11–0.30]. Although the hospital was the first option for 83.3 % (125/150) of hospital patients, most (63.3 %; 95/150) patients arrived there over 3 days after their symptoms begun. Proximity was significantly associated with utilization of each source of care. Education, but not other socioeconomic or demographic factors were significantly associated with chemical shop use.

Conclusions

The private drug retail sector is the first option for the majority of patients, including poorer patients, with fever in this setting. Most patients with fever arrive at chemical shops with less delay and fewer signs of severity than at public health facilities. Improving chemical shop skills is a good opportunity to diagnose, treat or refer people with fever early.