Inequality in Household Decision-Making for Early Treatment of
Malaria in Young Children: A Case Study in Northern Ghana

Sophie Cowan, ‘06

Department of International Health
Georgetown University

Abstract

Objective: To explore how Ghanaian socio-cultural beliefs, household power structures and decision making, and economic status are barriers to prompt and appropriate malaria treatment in children under five years of age.
Methods: A random sample size of 100 young mothers who brought their children under five years of age to the pediatric ward at the Navrongo War Memorial Hospital in northern Ghana for treatment of malaria participated in a quantitative study to provide data with regard to child health care decision making in the household, power structures within the household, knowledge of symptoms of moderate and severe malaria, knowledge about treatment of malaria, sources of health care utilized, education level, and economic status.
Results: Respondents were well informed about the major symptoms of malaria, but very few were able to make a distinction between moderate and severe malaria which has significant implications for effective malaria management. The majority of respondents attempted to give drugs at home before seeking care at the hospital, but doses of antimalarials were not given properly or were ineffective due to drug resistance. The vast majority of respondents consulted an older woman in the household before administering treatment to their child which often led to a delay in effective treatment. In addition, the child’s father was readily informed of his child’s illness by the mother and in the majority of cases made the final decision for the child to go to the hospital.
Conclusion: All of the findings in this study indicate a need for a broad educational campaign and empowerment of young mothers to enhance their ability to differentiate between moderate and severe malaria, ensure prompt and correct management of malaria cases within the home, and reduce inequalities in household decision-making.

keywords malaria, treatment-seeking behavior, inequality in household decision-making, Ghana, child mortality, chloroquine, home treatment, pre-packaged antimalarial drugs, prevention

Background

Malaria, a mosquito-borne disease, kills more than one million people annually with 90% of these deaths occurring in sub-Saharan Africa. In addition, it is responsible for 300-500 million fever episodes per year globally and imposes $12 billion a year in economic costs in sub-Saharan Africa alone (Bawah and Binka 2005). Despite decades of national and international malaria control programs, progress to eradicate the disease in developing countries has been unsuccessful. Most of the blame is directed at governments’ mismanagement of funds or their inadequate health care infrastructure, but social and cultural barriers that prevent the success of control programs have largely been ignored (Ahorlu et al 1997).  Resources can be utilized to control malaria much more efficiently if local socio-cultural norms and inequalities are taken into consideration before national policy is determined and programs launched.

In Ghana, a prime example of a sub-Saharan African country that has been unable to control malaria despite numerous expensive undertakings, malaria continues to be the most important cause of morbidity (40% of out patient attendance) and mortality and ranks as the most common cause of death in children under five years of age (25%) (Bawah and Binka 2005). In addition, drug resistance to chloroquine, one of the most inexpensive and widely available anti-malarials in Ghana, is rapidly increasing because inadequate doses are administered in the home as a result of the lack of health education and a clear malaria control program (Ahorlu et al. 1997; Mockenhaupt et al. 2004; Müller et al. 2003). In a recent trial, clinical treatment failure of chloroquine in uncomplicated malaria was observed in 29% of cases and resistant P. falciparum genotypes were detected in 84% (Mockenhaupt et al. 2004).

One major focus of the World Health Organization’s (WHO) Roll Back Malaria program in Ghana is the promotion of insecticide treated bednets (ITNs) to prevent malaria. According to a Malaria Baseline Survey conducted by the Ministry of Health (MoH) in 2001, however, only 9.1% of children under age five use ITNs (WHO 2002).  Another main focus in malaria control is increasing access to prompt and appropriate treatment within twenty-four hours of illness by promoting the management of malaria within the home. Lastly, replacing chloroquine as the first line of treatment with amodiaquine combination therapy and other new antimalarials has the potential to reduce morbidity and mortality. These are all valid areas for controlling malaria, but social inequalities and cultural practices are entirely neglected in the countrywide control efforts (Ahorlu et al 1997). In order for control efforts to produce successful results in Ghana and worldwide, research into local beliefs, behavior and inequalities need to be prioritized and incorporated into policy decisions (Uzochukwu and Onwujekwe 2004).

Several recent studies in Ghana have focused on malaria-related cultural beliefs and behavior towards causes, prevention and treatment that shed light on areas that have largely been neglected in the policy realm. A study exploring the cultural barriers in Ghana to timely and appropriate treatment of malaria found that although caretakers seem generally well informed about the major symptoms of malaria, knowledge about the cause varied considerably among respondents, and caretakers are poorly informed about proper management (Ahorlu et a.l 1997; Hill et al. 2003).  Home treatment included inadequate doses of analgesics, herbal preparations and chloroquine (Müller et al. 2003). Taking malaria cases to the health centre was usually the last resort after the illness failed to respond to home treatment. In addition, the cost of treatment at the clinic was considered very high and it was also reported that whoever paid for the treatment, in most cases the husband, decided where to go; in some cases it was the mother-in-law who also decided (Ahorlu et al. 1997).

Another study in southern Ghana reported that the common belief persists that malaria convulsions are spiritual in origin, but biomedical treatment for convulsions is now being utilized more than traditional healers. However, only 28% of respondents recommended appropriate treatment of convulsions within twenty four hours indicating that widespread education on the importance of timely treatment needs to be prioritized (Ahorlu et al. 2005). 

Another malaria treatment-seeking behavioral study conducted in neighboring Burkina Faso found that self-diagnosis and self-treatment at the household/village level were very common (Müller et al. 2003). Caretakers treated malaria cases with left-over drugs from former disease episodes, drugs bought from local shops or through treatment by traditional healers. Sixty-nine percent of treatments took place in households, 16% in local health centres, 13% in villages and 1% in hospitals. Treatment-seeking at a hospital or health centre was associated with accessibility and disease severity (Müller et al. 2003). Similarly, a study conducted in Nigeria found that the poorest households are more likely to use traditional healers, medicine dealers and community health workers. It was emphasized that “these health care providers are likely to offer very low quality treatment and it is inequitable because they are the most important source of treatment of malaria for the poorest quartiles”(Uzochukwu and Onwujekwe 2004).

Building upon the past studies, this paper presents data from a health care decision-making and treatment utilization study in rural Ghana that explores which factors including socio-cultural beliefs, household decision making, and economic status influence the treatment sources people seek when malaria symptoms occur in under fives.

The study was undertaken because young Ghanaian women of childbearing age are typically the target of health information dissemination in the countrywide effort to control and successfully treat malaria in children under age five, however, household decisions regarding malaria treatment in young children depend upon the power relations within the household and thus the young women are often unable to implement the health knowledge that they have received. Very little data and evidence exist with regard to the inequality of power structures within the household and is an area that this study aims to explore. The final outcome of the study sheds light on various social and cultural factors relating to the distribution of power and resources within the household that create inequalities in access to timely management of malaria in young children.

Methods

Study area and population

The study was conducted in the pediatric ward of the War Memorial Hospital in the Kassena-Nankana District in the Upper East Region of northern Ghana. Approximately 143,000 people reside in the 1,674 square kilometers of rural Sahelian savannah that has an average annual rainfall of 850-950 mm during the rainy season in May-September followed by a dry and hot season. Most residents practice subsistence farming of millet and livestock and limited irrigation farming is facilitated by the Tono Irrigation Project. The majority of people reside in multi-family compounds and an on-going census conducted by the Navrongo Demographic Surveillance System (NDSS) tracks births, deaths, migration, mortality rates and other demographic features. Although fertility and mortality rates have declined recently in the district, levels remain high. Malaria is holoendemic resulting in elevated levels of childhood mortality. The mortality rate for children under the age five years remains above 150/1,000 which is much higher than the national average of 110/1,000 (NDSS 1999).  The district has only one hospital located in the town of Navrongo where only 10% of the population resides. In addition, four health centres and 3 clinics located in various parts of the district provide basic primary care and are often inadequately staffed.

Data collection and analysis

A random sample size of 100 young mothers who brought their child under the age of five years to the pediatric ward at the Navrongo War Memorial Hospital for treatment of malaria were selected after their child was diagnosed with severe malaria by the doctor. All interviews were conducted by a trained field worker in the local languages between September and October 2005. The fieldworker was highly trained in the importance of obtaining informed consent before beginning the interview process to prevent violation of privacy and human rights. The interviewees were readily informed of the purpose of the study, confidentiality agreements, the risk and benefits of the study and the voluntary nature of participation.  The study was reviewed and approved by the Institutional Review Board of the Navrongo Health Research Centre.

The quantitative study provides data with regard to child health care decision making in the household, power structures within the household, knowledge of symptoms of moderate and severe malaria, knowledge about treatment of malaria, sources of health care utilized, education level, and economic status. All data was entered into Epi-Info 3.3 and analyzed using the Epi-Info computer software as well.

Results

Socio-demographic characteristics

Ninety-seven percent of the women interviewed were the biological mother of the under-five being treated for malaria and the mean age of the mother was twent-eight years. In addition, ninety-five percent of the women were married and the ethnic origin of the women was closely divided between the Kassena (50%) and the Nankani (44%). The low level of education among the respondents is highly evident with forty-nine percent having never attended school; only twenty-nine percent of respondents completed their primary education. Low levels of education is clearly a tremendous barrier to successful malaria management. Respondents were mostly Christian (79%) and of the sixty-three percent of women who have an occupation, twenty-eight percent are farmers and thirty-five percent are traders/artisans. Many respondents had difficulty specifying their monthly income because it is inconsistent or they do not receive a set salary, but the overall mean monthly income for the thirty-six percent of respondents who reported an income is 92,150.00 cedis (about $10 US); sixty-four percent of respondents indicated no monthly income.

Knowledge of cause, prevention, and symptom recognition of malaria

Cause and Prevention
Seventy-six percent of respondents demonstrated their knowledge that the mosquito transmits malaria, but many of these women also indicated other main causes of malaria such as eating sweet food (34%), eating bad food (34%), cold weather (16%), inheritance (7%) and growing teeth (4%). Additionally, seventy-nine percent of the mothers attempt to prevent malaria within their household, usually with insecticide treated bednets (70%) followed by use of coils (7%), cleaning around the house (5%), eating good food (4%), other (3%) and indoor insecticide spraying (1%). Of the twenty-one respondents who do not prevent malaria within their household, seventeen responded that they don’t know how and four responded that prevention measures are too costly.

Symptom recognition
Respondents were very knowledgeable about the symptoms of malaria and readily responded that vomiting, hot body, very hot body, diarrhea, urine changes to yellow, loss of appetite, body itching, and chills are common indicators that a child under five has malaria.  However, ninety-four percent of respondents are not able to differentiate between moderate and severe malaria. This has important implications because a caretaker who can not identify severe malaria cases may not seek prompt and appropriate care for their child. Of the few women who can differentiate between moderate and severe malaria, the two most important signs of moderate malaria are hot body and vomiting whereas severe malaria is characterized by vomiting, very hot body and convulsion. The women who are able to differentiate between moderate and severe malaria received the health information mainly through a community health worker, but also responded that information was received from a health centre, hospital, traditional birth attendant, relative or radio.

Sources of health information
A major source of health information and basic health services is the child welfare clinic within the district. Ninety-seven percent of respondents have attended child welfare clinics in the past and currently sixty-nine percent of the mothers attend the clinic. The majority of mothers have attended the clinic within the last three months for immunizations, health information or other basic health services. The most common information received from the health provider during the mother’s last visit to the clinic was about nutrition and hygiene. About one third of the mothers also learned about malaria signs and symptoms and one fifth received information on child immunizations. However, twenty percent of the child welfare clinic’s participants responded that no information was provided during their last visit. The majority of mothers (77%) have used the information from the child welfare clinic without asking any other relative’s permission indicating some level of autonomy in implementing health information, but twenty-three percent of the mothers responded that they have never used the information without a relative’s approval.

Knowledge of appropriate treatment for moderate and severe malaria

Sources of health care
The four main sources of health care available to the respondents in the study are the hospital, community health officers (CHO), traditional healers and a health center. Forty- three percent of respondents patronize the hospital the most whereas twenty-eight and twenty-two percent patronize a CHO or a health center respectively. Even though traditional healers were recognized as a very available source of health care in the community, only five percent of respondents indicated that they patronize a traditional healer for their health care needs. Since this study was conducted at the hospital, it is not surprising that this group of mothers patronized the hospital the most. These findings do not necessarily represent the general population’s most common source of health care because they may not be as likely to attend the hospital due to geographical or economic constraints.

Respondents not able to differentiate between moderate and severe malaria
Of the ninety-four respondents who can not differentiate between moderate and severe malaria, forty indicated the first appropriate action to take when a child under five has malaria is to use herbs followed by using drugs at home and visiting the hospital as a last resort. Only three respondents indicated that consulting a traditional healer was appropriate action in response to malaria. Fifty-nine respondents give drugs at home with chloroquine being the most widely used even though current drug policy in Ghana emphasizes newer amodiaquine combination therapy whereas thirty-five respondents use herbs and six sponged the child.

Respondents able to differentiate between moderate and severe malaria
Giving drugs at home was the most common form of treatment for a child who has moderate malaria. Chloroquine and paracetamol were used most often because a doctor or chemist had prescribed them before and because they are widely available. For respondents who recognize severe malaria symptoms, the most common treatment plan is to visit a hospital followed by self-treatment with drugs at home if a visit to the hospital is not possible.

Treatment administered at home
Medicine was administered at home in eighty-one percent of the illnesses before the child was brought to the hospital. Sixty-five children were given paracetamol, forty-two were given chloroquine, and nine received herbal medicine.

The mean number of days that malaria symptoms were present in the child before coming to the hospital was three days. Forty-three percent of respondents delayed their visit to the hospital due to a lack of money for transportation or drugs, thirty-two percent did not think the sickness was serious enough to visit the hospital and fourteen percent of the respondents attempted to treat malaria themselves. 

Transportation and cost of hospital visit

The majority of respondents either walked (38%) or rode a bicycle (36%) to the medical facility and the mean cost of transportation for the fifteen percent of respondents who hired a taxi or a truck was 7,350 cedis. When interviewed, respondents expected to stay at the hospital for their child’s treatment for an average of five days. Seventy-two percent of the mothers were aware that the government provides free medical care to children under five and learned of this service during a previous visit to the hospital or health centre, through relatives, or on the radio. The cost of drugs and laboratory fees are paid out of pocket, however, and the respondents who incurred these fees for their child’s treatment spent an average of  46,000 cedis ($5) and 26,000 cedis ($3) respectively.

Autonomy in the household on health care decision-making

Consultation with older women before implementing treatment
Older women are respected by all generations, especially the younger, for their wisdom and experience in life including how to make decisions regarding the treatment of illness. Sixty-three percent of respondents received advice from an older woman who in the majority of cases lived in the same compound. The older women prioritized using herbs as the first line of treatment in the home (58.7%) followed by giving drugs (30.2%) and visiting the hospital (9.5%). The vast majority of young mothers (90.5%) strictly follow the advice given and thus the older women clearly play an integral role in the decision making process with regard to the treatment of the child. 

In general the respondents did not gain a significant amount of useful information with regard to their child’s illness or the level of severity from their consultations. More than forty percent of the illnesses were incorrectly diagnosed. Over fourteen percent of illnesses were diagnosed as respiratory related and illnesses diagnosed as convulsions were not associated with malaria. Less then fifteen percent of the respondents who were given a malaria diagnosis by the person they consulted were told whether it was a moderate or severe form of malaria.

Final health care decision-making: husband vs. mother- in-law
When a child is ill, the mothers responded that the child’s father and mother-in-law are the two members of the household who are informed most often because the husband provides money for health care and the mother-in-law has experience in the diagnosis. The husband was the first person informed in sixty-six percent of the cases whereas the mother-in-law was the first person informed in thirteen percent of the cases.

In over half of the cases, the child’s father made the decision that the child should be seen by a doctor whereas the mother decided in only twenty-eight percent of the cases. Additionally, the mother-in-law decided the child should be seen by a doctor ten percent of the time and family members were always in agreement when the final decision was made to bring the child to the hospital.

Although sixty-eight percent of the mothers responded that they would be able to give treatment to their child without consulting any member of the compound, this independent decision-making is rarely the course of action taken. Mothers responded that they have more autonomy in deciding how to treat their under five child if the illness is moderate or if the mother has prior experience with handling the illness in children. Of the thirty-two percent of mothers that are unable to treat their ill child without consulting a member of the household, severe illness, never having experienced the illness before and no formal education were the main reasons why the mother was not allowed to make her own decisions.

Household assets and correlation to autonomous decision-making

The majority of respondents do not live in a household with a modern design and seventy-six percent live in a household where mud is the main material for the walls. Additionally, seventy-one percent of respondents use a borehole as their main source of drinking water and eighty-seven percent responded that free range is the toilet facility available. Education level and income level were not significantly correlated to autonomous decision-making, source of health care patronized the most or the amount of time spent at home with the sick child before visiting the hospital because the sample size of the study was too small to make any definitive conclusions. Further studies need to be conducted in order to research any possible correlations.

Discussion

This study explored the respondents’ knowledge of malaria signs and symptoms as well as the barriers that prevent respondents from implementing their knowledge to seek treatment for their child. Although the respondents have easy access to health information at child welfare clinics and antenatal clinics and have demonstrated their ability to recognize malaria in the early stages, it is evident that there are power structures within the household that prevent the young mothers from accessing prompt appropriate treatment for their under fives with malaria.

In Ghana, the current national policy dictates that resources for health education campaigns be channeled to women of childbearing age at antenatal and child welfare clinics because it is believed that educated women will seek prompt appropriate treatment for themselves and their children. The result is that this young population is well educated with regard to recognizing illness and how to seek prompt treatment, but they lack the autonomy to make decisions regarding treatment within the household. This national policy initiative neglects the reality that the pervasive inequality within the household is a barrier to successful malaria campaigns and many resources are wasted as a result.

From this study and another recently conducted, it is evident in the Kassena-Nankana District that within the household the husband dominates the decision making process in areas including economic wellbeing, education of the children, and access to health care (Ngom et al. 2003). It is not the husband, however, who has the appropriate health information or experience to be the main decision maker with regard to whether a child under  five years of age needs medicine or a visit to a clinic. Empowering women to become the main health care decision makers for themselves and their children is essential for the well being of all, but it is not a process that will occur overnight. Cultural norms may evolve slightly over time, but significant change often takes generations. In the interim, national policy needs to allocate funding for educational campaigns to target husbands so that the main decision-maker in the household will implement prompt appropriate action in the event a child becomes ill instead of waiting until the symptoms become severe.

Another barrier within the household that prevents an ill child from receiving prompt appropriate treatment are the decisions made by the mother-in-law or older woman living in the same compound. Although the older woman is respected for her wisdom and experience with previous familial illnesses, this study found that in many cases the illness is misdiagnosed and the treatment suggested is inadequate. Regardless of whether the young mother agrees or disagrees with the older woman’s treatment advice for the ill child, the vast majority of young mothers strictly follow the advice given out of custom and respect. Of the older women who can appropriately diagnose a child with malaria, very few are able to aide the mother in differentiating between moderate and severe cases. This inability to determine which cases are severe leads to a very dangerous situation in which the illness may progress to a point beyond treatment capacity. The role of the older woman in health care decision making is a culturally ingrained norm and must be taken into consideration when malaria control programs are designed (Sirima et al. 2003). The nationally directed health education campaign needs to prioritize targeting older women as well as husbands because they are both gate-keepers to prompt appropriate treatment of malaria in children.

This study also demonstrates that both the mothers who exhibit autonomy in treatment decisions and the mothers who do not almost always attempt to treat their child at home with either drugs or herbs before attending a medical facility, but the dosage of medicine is often inadequate. Not only does the use of inadequate doses of antimalarials contribute to the alarming spread of drug resistance, but the child’s illness often progresses to a very severe stage (Ahorlu et al. 1997).  By the time a husband or older woman grants permission and money for the mother and child to visit a clinic very little can be done to save the child. Educational campaigns to ensure that the mothers give adequate doses of antimalarials within the home would prevent myriad cases of moderate malaria from progressing to severe malaria (Nsungwa-Sabiiti et al. 2004). In addition, less finances and time would be lost if women did not have to bring their sick child to a clinic for another round of antimalarials after attempted treatment in the home.

Home based management of malaria with pre-packaged antimalarial drugs has become an international focus to malaria control efforts. This method of control should be strengthened in Ghana because mothers are more likely to be granted autonomy in treating their child’s illness in the home than at an outside medical facility. The husbands benefit from the home based management plan because they will provide less money for treating the illness and won’t be left to manage the household alone when the wife brings an ill child to the clinic. Older women can still retain their decision-making status in the household as long as they are trained in the proper diagnosis and management of malaria in the home at the same time that the young mothers are trained.

Another important consideration in the home based management of malaria is that the drug shop operators must be adequately trained and the drugs must be packaged correctly and available locally (Ahorlu et al. 1997; Sirima et al. 2003). In addition, the government needs to ensure that its new policy of promoting amodiaquine combination therapy instead of chloroquine is reinforced by subsidized pricing and increased availability at the local drug shops. Shop keepers need to be trained to sell correct doses and pass on information about the appropriate use of antimalarials to their customers (Ahorlu et al. 1997; Sirima et al. 2003).  To ensure that the drug stores initiate the selling process with a complete stock of drugs, they need to be front loaded by a small government stipend. Once the first stock of drugs is sold, the store will be able to replenish the stocks in the future with the small profit earned. Drugs should be appropriately priced so that drug stores make enough profit to replenish their stock, but above all the drugs must be affordable to ensure that access is available to everyone. Finally, the drugs should contain a label as well as pictorial instructions on how to administer the drugs appropriately (Sirima et al. 2003).

Conclusion

This study shows that in order for malaria control programs to become more effective and sustainable in reducing morbidity and mortality in Ghana, cultural norms and inequalities need to be incorporated into policy decisions. One way to ensure this occurs is to establish a sustainable network of social scientists who contribute to the core malaria control efforts. Collaboration between social and biomedical scientists provides a multidisciplinary and integrated approach to controlling malaria (Ngalame et al. 2004; Soloman 2005).  In addition, all of the findings in this study indicate a need for a broad educational campaign and empowerment of young mothers to correct the misconceptions about the cause of malaria, ensure prompt and correct management of malaria cases within the home, and reduce inequalities in household decision-making.

Note: This investigation as conducted as part of the author’s Fall 2005 research/internship abroad as an International Health major at Georgetown University.

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