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\ud 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

Community concepts of malaria-related illness with and without convulsions in southern Ghana

BACKGROUND: Malaria, both with or without convulsions, is a serious hardship for people living in endemic areas, especially in sub-Saharan Africa. Community references to malaria, however, may encompass other conditions, which was collectively designated malaria-related illness (MRI). Inasmuch as the presence or absence of convulsions reportedly affects timely help-seeking for malaria, a local comparison of these conditions is needed to inform malaria control. METHODS: Vignette-based EMIC interviews (insider-perspective interviews) for MRI with convulsions (convulsion positive, MRI-CP) and without convulsions (convulsion negative, MRI-CN) were developed to study relevant features of MRI-related experience, meaning and behaviour in two rural communities in Ghana. These semi-structured interviews elicited both qualitative narrative and categorical codes for quantitative analysis. Interviews with 201 respondents were conducted. RESULTS: The conditions depicted in the vignettes were well recognized by respondents and named with various local terms. Both presentations were considered serious, but MRI-CP was more frequently regarded potentially fatal than MRI-CN. More than 90.0% of respondents in both groups acknowledged the need to seek outside help. However, significantly more respondents advised appropriate help-seeking within 24 (p = 0.01) and 48 (p = 0.01) hours for MRI-CP. Over 50.0% of respondents responding to questions about MRI-CP identified MRI-CN as a cause of convulsions. CONCLUSION: Local comparison of MRI-CP and MRI-CN based on vignettes found a similar profile of reported categories of perceived causes, patterns of distress, help-seeking and preventive measures for both presentations. This differs from previous findings in sub-Saharan Africa, which assert communities regard the two conditions to be unrelated. The perceived relationships should be acknowledged in formulating strategies to control malaria through timely help-seeking and treatment to reduce childhood mortality

Socio-cultural determinants of treatment delay for childhood malaria in southern Ghana

We studied socio-cultural determinants of timely appropriate treatment seeking for children under 5 years suspected of having a perceived malaria-related illness. Caretakers of children with suspected malaria were interviewed about illness-related experiences, meanings and behaviour in two endemic villages in southern Ghana. Only 11% of children suspected of having a perceived malaria-related illness received timely appropriate treatment consistent with the Abuja target of treating malaria within 24 h of illness onset; 33% of children received appropriate treatment within 48 h. Reported perceived causes of phlegm predicted timely, appropriate treatment within 24 h of illness onset (P = 0.04) in a multivariate logistic regression model; playing on the ground (P < 0.01) predicted such treatment within 48 h. Two categories of distress, paleness or shortage of blood (P = 0.05) and sweating profusely (P = 0.03), also predicted timely, appropriate treatment within 24 h in a multivariate logistic regression model. Knowing that mosquitoes transmit malaria was not associated with timely, appropriate help seeking for the children, even though such knowledge may promote personal protective measures, especially use of bednets. Patterns of distress and PC were related to timely, appropriate help seeking, but not as expected. Effects on health seeking of illness-related experience and meaning are complex, and explaining their role may strengthen interventions for childhood malaria

Willingness to pay for small solar powered bed net fans: results of a Becker-DeGroot-Marschak auction in Ghana

Long-lasting insecticidal nets (LLINs) are one of the main interventions recommended by the World Health Organization for malaria vector control. LLINs are ineffective if they are not being used. Subsequent to the completion of a cluster randomized cross over trial conducted in rural Greater Accra where participants were provided with the 'Bɔkɔɔ System'-a set of solar powered net fan and light consoles with a solar panel and battery-or alternative household water filters, all trial participants were invited to participate in a Becker-DeGroot-Marschak auction to determine the mean willingness to pay (WTP) for the fan and light consoles and to estimate the demand curve for the units.; Results demonstraed a mean WTP of approximately 55 Cedis (~13 USD). Demand results suggested that at a price which would support full manufacturing cost recovery, a majority of households in the area would be willing to purchase at least one such unit

Molecular epidemiology of Mycobacterium africanum in Ghana

BACKGROUND: Mycobacterium africanum comprises two phylogenetic lineages within the M. tuberculosis complex (MTBC) and is an important cause of human tuberculosis (TB) in West Africa. The reasons for this geographic restriction of M. africanum remain unclear. Here, we performed a prospective study to explore associations between the characteristics of TB patients and the MTBC lineages circulating in Ghana. METHOD: We genotyped 1,211 MTBC isolates recovered from pulmonary TB patients recruited between 2012 and 2014 using single nucleotide polymorphism typing and spoligotyping. Associations between patient and pathogen variables were assessed using univariate and multivariate logistic regression. RESULTS: Of the 1,211 MTBC isolates analysed, 71.9 % (871) belonged to Lineage 4; 12.6 % (152) to Lineage 5 (also known as M. africanum West-Africa 1), 9.2 % (112) to Lineage 6 (also known as M. africanum West-Africa 2) and 0.6 % (7) to Mycobacterium bovis. Univariate analysis revealed that Lineage 6 strains were less likely to be isoniazid resistant compared to other strains (odds ratio = 0.25, 95 % confidence interval (CI): 0.05-0.77, P < 0.01). Multivariate analysis showed that Lineage 5 was significantly more common in patients from the Ewe ethnic group (adjusted odds ratio (adjOR): 2.79; 95 % CI: 1.47-5.29, P < 0.001) and Lineage 6 more likely to be found among HIV-co-infected TB patients (adjOR = 2.2; 95 % confidence interval (CI: 1.32-3.7, P < 0.001). CONCLUSION: Our findings confirm the importance of M. africanum in Ghana and highlight the need to differentiate between Lineage 5 and Lineage 6, as these lineages differ in associated patient variables

Perceptions on the effect of small electric fans on comfort inside bed nets in southern Ghana : a qualitative study

Long-lasting insecticidal nets (LLINs) are known to be highly effective in reducing malaria transmission, morbidity and mortality. However, among those owning an LLIN, use rates are often suboptimal. A reported barrier to bed net use is discomfort due to heat. This qualitative study was part of a larger evaluation conducted in communities without electricity in rural Ghana to assess whether 0.8 W solar powered net fans can increase net use.; Twenty-three key informant interviews with household heads in the study communities in Shai-Osudoku District, southern Ghana, were conducted from July to August 2015. The purpose of the interviews was to obtain insight into perceptions of participants about the net fan system in relation to LLIN use.; While all study participants reported using LLINs, with mosquito nuisance prevention as the prime motivation, heat was also mentioned as a key barrier to net use. Respondents appreciated the net fans because they improved comfort inside bed nets. The LED light on the fan stand became the main source of light at night and positively influenced the perception of the intervention as a whole.; The general acceptance of the net fan system by the study participants highlights the potential of the intervention to improve comfort inside mosquito nets. This, therefore, has a potential to increase bed net use in areas with low access to electricity

‘Making the dust fly’: (A case study of) design research promoting health and sustainability in addressing household infections

Global health crisis, such as antimicrobial resistance, threaten planetary health, as they have a direct impact on the environment, as well as to humans and animals. Personal and environmental hygiene form the best and most natural ways of reducing home infections and hence the need to take antibiotics. Despite this our understanding of cleaning in the home and interventions on home cleaning are limited. In this paper we present a project, which combined design research with environmental microbiology, to address this issue and to co-design sustainable cleaning interventions for human and planetary health. We focus on the design of a co-design workshop which led to the development of cleaning interventions tested for a month by several households. We share the challenges faced and the lessons learnt, which we envisage will help guide design researchers moving into this exciting research field of planetary and human health

An evaluation of Wb123 antibody elisa in individuals treated with ivermectin and albendazole, and implementation challenges in Africa

The development of antibody testing for the diagnosis of lymphatic filariasis (LF) is intended to enhance the monitoring and evaluation activities of the Global Program for the Elimination of LF. This is due to the fact that antibody tests are expected to be the most sensitive at detecting exposure to LF compared to antigen that takes longer to develop. To this end a new antibody-based enzyme linked immunosorbent assay (ELISA) to Wuchereria bancrofti antigen Wb123 has been developed and further designed into a point of care rapid diagnostic test, under evaluation. In pretreatment surveys, individuals were tested for antigen using the immuno-chromatographic test (ICT) card, and night blood microfilariae, after which all positives were treated using Ivermectin and Albendazole. The Wb123 ELISA was tested in antigen positive individuals, three months after they were treated. Samples were also tested for ICT and night blood microfilariae. The results revealed a reduction in microfilariae and ICT prevalence after treatment. Antigen and antibody prevalence increased with age. However, there was no correlation with the antibody responses observed. The mean WB123 antibody titers were higher among ICT positives, but not significantly different from ICT negative persons. While the Wb123 is targeted for use in untreated populations, further evaluations and guidelines will be required to define its use in populations that have undergone treatment for the control of LF.Keywords: Lymphatic filariasis, elephantiasis, antigen, antibody, Wb123, Ghan

Challenges and Opportunities in Conducting and Applying Design Research beyond Global North to the Global South

With an increase in international projects, comes increased opportunities for design researchers to contribute to research that tackles Sustainable Development Goals in the Global South. Nevertheless, the role of design within this context is disparate and detached, with very limited design literature on the subject. As such, this paper has identified the key challenges and barriers that design researchers face in conducting and applying design research in a Global South Context. Based on a workshop with design research experts doing research in Global South, the literature and lessons learnt from running a design-led project in Ghana, we are presenting and discussing 45 challenges grouped under 13 themes. We envisage that these will form the first step towards developing strategies for mitigating these challenges and help current and future design researchers to engage further in international research in the Global South