Prevention Of Malaria
Malaria continues to be a greater cause of morbidity and mortality in Ghana. The government of Ghana and other donor agencies are making tremendous efforts to prevent and control the disease. In spite of these efforts by the government, malaria has not yet been defeated in its bastion.
The aim of the study was to find out the experiences community nurses have about the existing methods of preventing malaria and the challenges facing them in their effort to prevent the disease in Dormaa municipality.
Qualitative research was used to find out the preferred methods in the community. Also the study investigated the various misconceptions the people have about the preventive methods and the challenges nurses encounter. 18 community nurses from all the health posts in the municipality were interviewed through semi-structured questionnaires.
The study revealed that repellants and ITNs were the most preferred methods used to prevent malaria in Dormaa. Residents have various misconceptions about these preventive methods. It also came out that lack of funds and inadequate personal restrain the activities of nurses in their efforts to promote health in the area.
1.1 Background of Study
Malaria is a major cause of morbidity and mortality in the world. Malaria poses a greater threat to about 40% the population of the world, particularly pregnant women and children under the age of five. In year 2010, there was an estimation of almost 220 million cases of malaria and 660,000 deaths respectively. Sub-Saharan Africa is the region mainly affected with about 85% of these cases occurring in that region (Abora, et. al. 2013.) According to WHO (2013), malaria kills 1300 children in a day and one child every minute globally. Malaria is pandemic throughout the tropical regions in the world. It is considered to be one of the killer diseases in sub-Sahara Africa. It was estimated that 300 million cases of malaria was recorded on the globe annually (Dugbartey & Apedo, 1998.) The world needs 3 billion dollars to combat malaria every year (UNICEF, 2012).
The 2010 report from 106 malaria endemic countries indicates that the cost of funding for the control of this disease was 1.5 billion dollars in only 2009. This seriously threatens the 2015 global target, since the report further indicates that fund inflow remained at 1.8 billion dollars as against over 6 billion dollars required within the period mentioned (WHO, 2010). Malaria kills over a million people every year globally with 90 percent of the deaths coming from Africa. Children under five years also constitute 70 percent of this number. In sub-Saharan Africa, one in five children death is the result of malaria (Molavi, 2003.)
In Ghana, malaria has rendered many people mentally handicap and psychiatric morbidity (Dugbartey & Apedo, 1998). Malaria has caused a section of the population into poverty and this situation has reduced national output, hence slowing down national development. Despite the fact that several attempts have been made over the years to combat the disease in Ghana, statistics for 2010 indicated that an average of 8200 cases were reported daily, and a total of 3 million cases for a whole year. Out of this figure, over 3000 deaths were recorded. The most vulnerable population was children and pregnant women (Tettey, 2011).
Malaria is the leading killer disease in Ghana. In 2008 Ministry of Health (MOH) budgeted 846,142,000 dollars for malaria. It is estimated that malaria accounts for 33% of death in children under five year old and 36% of all hospital admission sickness in the country (Ghanaweb, 2012.) Every year 3.5 million people are infected with malaria and approximately 20,000 people also die from malaria of which most of them are children under five years of age. Most of the children who are able to survive from malaria suffer from convulsion and brain disorders, which affect their growth and development. In 2008 the cost of malaria was 760 million dollars and that was 10% of the country’s gross domestic product. Upon this entire devastating situation little attention has been given to research in this area of study (Tweneboa-Kodua, Otuo & Mahama 2012.)
The incidence rate of Malaria in Dormaa Municipality of Ghana continues to increase. Available records at the Minisry of Health for Dormaa Municipality shows annual malaria incidence increasing from year 2005 to 2007. In year 2005, Out Patient Department (OPD) cases diagnosed, as malaria was 51,163. This figure rose to 66,833 and 93,216 in year 2006 and 2007 respectively. In year 2008 however, the figure dropped from 93,216 recorded the previous year to 88,381 (Majoros, 2011.) These figures show that malaria is still a major threat to the population of Dormaa and Ghana in general. The aim of the study is to find out the experiences community nurses have about the existing methods of preventing malaria.
1.2 Statement of Problem
The Ministry of Health has been at the forefront in the fight against malaria in Ghana. The goal of the Malaria Control Programme in the country is to reduce malaria morbidity and mortality, as well as reduce social and economic effects brought about by the disease (MOH, 2010). The principal strategies being used for malaria control are LLINs, IRS, prevention of malaria in pregnancy, and effective diagnosis and treatment (UBOS, 2010). However, malaria remains the leading cause of morbidity and mortality as well as responsible for a large burden on the country’s health system (MOH, 2010; UBOS, 2015).
The use of appropriate combinations of non-chemical and chemical methods of malaria vector control in the context of integrated vector management has been recommended by the World Health Organization (WHO, 2004). Indeed, a combination of malaria prevention strategies has been shown to have greater impact than single methods in several studies (Fullmanet al., 2013; Hamel et al., 2011; Kleinschmidt et al., 2009). However, most of these studies have focused on the use of ITNs and IRS. The integrated approach, which advocates for use of several malaria prevention methods beyond ITNs and IRS in a holistic manner, is therefore being explored as a complementary strategy to existing malaria control efforts.
Information on the use of an integrated approach to malaria prevention is scarce as integrated malaria vector management has not been as yet, adequately explored in Ghana (Muteroet al., 2012). Although it would be likely that the use of multiple preventive measures would have a greater impact on a disease than the application of single method, it remains necessary to investigate community experiences, perceptions and practices on the use of this more complex preventive strategy. This research was necessary to generate new knowledge and increase the understanding of this innovative approach for malaria prevention among rural communities in Ghana. The findings from this research will inform malaria control practice and policy in Ghana and furthermore, the knowledge obtained will be transferable to other communities throughout the world, where malaria is endemic and a major public health concern.
1.3 Study Objectives
- To determine knowledge and practices on malaria prevention at households
- To implement an intervention on the integrated approach to malaria prevention in the community
- To evaluate the impact and experiences of using integrated malaria prevention in the community
- To assess community perceptions, utilisation and barriers to integrated malaria prevention in the community.
1.4 Research Questions
- What is the knowledge and practices on malaria prevention at households?
- What intervention measures are made on malaria prevention in the community?
- What is the impact and experiences of using integrated malaria prevention in the community?
- What are the community perceptions, utilisation and barriers to integrated malaria prevention in the community?
1.5 Significance of Study
The research provides information on community knowledge, experiences, perceptions and practices on using the integrated approach to malaria prevention. The findings of this research are expected to be used in developing future studies on the use of integrated malaria prevention in rural communities in Ghana and beyond.
The findings from the research have been disseminated to the communities where the studies were conducted. Therefore, in addition to contributing to knowledge for the scientific community through publications and conference presentations, the local population has also benefitted from learning about the various available malaria prevention measures beyond ITNs and IRS which have largely been promoted in Ghana. In addition, the local leaders and community health workers were appreciative of the research efforts to contribute to malaria prevention, and continued to promote the various methods in the integrated approach in their respective villages.
The research has therefore contributed to knowledge at both scientific and community levels.
The research further demonstrates the concept that a pilot project targeting a disease of public health importance can lead to improvement in knowledge and practices. Indeed, the evaluation of the project (study I, phase 3) showed increase in knowledge on malaria prevention methods as well as improvement in non-conventional practices in the integrated approach such as early closing of windows and doors to prevent mosquito entry into houses. Whereas early closing of windows and doors is not done in many areas, this research provides evidence that once communities are trained in such malaria prevention methods, it is likely to lead to improved practices. This information is expected to be vital in potential scaling up of the integrated approach to malaria prevention in other parts of Ghana as well as in other malaria endemic countries.
1.6 Scope of Study
In order to understand the preventive measures used in preventing malaria spread in Ghana, this study is taken in Dormaa, Ghana to observe and analyse the challenges and prospects of malaria prevention in Dormaa.
1.7 Organization of Research
This research will comprise five chapters.
- Chapter one introduces the integrated approach to malaria prevention, provides context, rationale, aim and objectives of the study.
- Chapter two reviews existing literature on malaria parasites and vectors, malaria burden, malaria prevention globally and in Ghana, the various malaria prevention methods, integrated vector management, the integrated approach to malaria prevention, and health service delivery in Ghana in relation to malaria control.
- Chapter three describes the methods used in the research including study design, sample size, data collection, data analysis and ethical issues.
- Chapter four presents the results and discussion for study.
- Chapter five, which is the final chapter of the research, provides conclusions and recommendations.
Conclusions and Recommendations
Besides mosquito nets, knowledge and practices on other malaria prevention methods was low in study. Use of IRS, another core malaria prevention strategy, was also low in the baseline. Therefore, there is still need to increase coverage and utilisation of IRS and ITNs as the current major malaria prevention methods in Ghana. Popularity of mosquito nets was due to their being the most promoted malaria prevention method in Ghana, with less emphasis on other practices in the integrated approach. There is potential to improve practices on malaria prevention in endemic communities by targeting other methods beyond ITNs, such as installing screening in windows and ventilators. Therefore, the integrated approach to malaria prevention, which advocates the use of several methods in a holistic manner, should be further explored to improve practices on malaria prevention in Ghana.
The intervention (study I phase 2) that promoted the integrated approach to malaria prevention by training community volunteers, community sensitisation, and establishing demonstration households was well perceived by the study community. The general population in the community benefitted from the sensitisation carried out during the intervention phase, health education carried out by the trained volunteers, as well as learning from the practices of the demonstration households that were using the integrated approach. With the success of the pilot project intervention, a wider population could benefit from similar interventions promoting use of multiple malaria prevention methods at households in Ghana and beyond.
Following the interventions implemented in study I phase 2, there was increase in knowledge and improved practices on malaria prevention in the community. This included knowledge and practices on methods such as screening of houses, and early closing of doors and windows which are not core malaria prevention strategies in Ghana and globally. However, knowledge of multiple malaria prevention methods in the evaluation in comparison to the baseline was not statistically significant. It is therefore important that future programmes aimed at promoting integrated malaria prevention have a strong behaviour change strategy including community sensitisation so as to increase knowledge and practices on use of multiple malaria prevention methods.
Community volunteers trained on the integrated approach to malaria prevention played a key role in promoting the strategy in the community. It is therefore evident from study I phase 3 (evaluation) that such volunteers are instrumental in promoting use of multiple malaria prevention methods in Ghana which could be utilised in other endemic countries. However, due to the finding from the evaluation that laziness and complacency were limiting use of some of the malaria prevention methods, more effort is still needed to change these negative attitudes among communities. Improvement in attitudes towards malaria prevention is likely to lead to improved practices hence reduce morbidity and mortality caused by the disease in Ghana and other endemic countries.
The use of the integrated approach to malaria prevention benefitted the demonstration households mainly through observed reduction in mosquito population indoors and occurrence of malaria as established in the evaluation. These changes among the demonstration households are attributed to the interventions implemented during the intervention including screening in windows and ventilators, and provision of LLINs. In addition, the other practices in the integrated approach implemented by the households such as early closing of doors, and removal of stagnant water contributed to the positive outcomes observed. However, further studies to quantify the protective effect of the integrated approach among households particularly regarding malaria prevalence, and contribution of each of the methods are required.
Awareness on various malaria prevention methods in the integrated approach was high, and perceptions on use of integrated malaria prevention were promising in study II. However, there were concerns about the many methods in this approach, cost implication and potential health effects of the insecticide based measures such as IRS and space spraying. Practices on integrated malaria prevention were low in study II as mosquito nets were predominantly used as a single method. The use of the integrated approach can be improved by promoting use of multiple malaria prevention methods in communities through various communication channels such as mass media including newspapers and radio.
It was established in study II that environmental risk factors associated with malaria such as presence of stagnant water in compounds were present in the community. In addition, several structural deficiencies on houses were observed that promote entry of mosquitoes. These housing deficiencies included lack of screening in ventilators and open eaves, and external doors not fitting perfectly hence space for possible mosquito entry. Environmental conditions that favour mosquito breeding, and poor housing structure increase the risk of malaria transmission in communities. It is therefore important that malaria prevention strategies including environmental management, and improving structural conditions of houses are strengthened to complement existing malaria prevention approaches in Ghana.
- Stakeholders involved in malaria control especially the Ministry of Health should intensify efforts of promoting other prevention methods in addition of ITNs and IRS. Behaviour change communication campaigns targeting multiple methods are recommended to improve knowledge and practices on malaria prevention.
- Projects to promote the use of integrated malaria prevention should be scaled up by researchers and other partners such as non-governmental organisations so as to benefit other areas since the intervention implemented in this research had positive outcomes to households and the community.
- Community volunteers particularly those that exist in rural communities such as community health workers should be empowered by health practitioners to promote use of multiple methods in the prevention of malaria.
- The use of the integrated approach can be improved by stakeholders involved in malaria control such as Ministry of Health and non-governmental organisations through promoting use of multiple malaria prevention methods in communities through various communication channels such as mass media including newspapers and radio.
- Health practitioners and other stakeholders involved in malaria control should increase community sensitisation so as to reduce complacency on malaria prevention, and minimise the negative perceptions about malaria prevention methods that use insecticides as well as increase their use.
- There is need for the Ministry of Health to particularly promote environmental management including removing mosquito breeding sites as a key strategy in the prevention of malaria in rural communities in Ghana.
- Environmental health practitioners and other professionals concerned with health need to encourage improvement in structural conditions of houses in rural communities to limit mosquito entry into houses as a complementary strategy in the prevention of malaria in endemic areas.
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