KWAME NKRUMAH UNIVERSITY OF SCIENCE AND

TECHNOLOGY

PREVALENCE OF MALARIA IN GHANA: A CASE STUDY OF

THE BOSOMTWE-ATWIMA KWAWOMA DISTRICT IN THE

ASHANTI REGION.

A SUMMARY OF THESIS SUBMITTED TO THE DEPARTMENT

OF SOCIAL SCIENCES

IN PARTIAL FULFILMENT OF

BACHELOR OF ARTS (GEOGRAPHY AND RURAL

DEVELOPMENT)

COLLEGE OF ARTS AND SOCIAL KUMASI, GHANA

SUBMITTED BY

BENEDICTA OFOSUHEMAA ASANTE

2007

DECLARATION

I declare that I have personally undertaken this research under the supervision of Dr.

Mrs. Charlotte Mensah herein submitted.

I take full responsibility for errors, misinterpretation, misrepresentation and other

shortcomings.

…………………………………

BENEDICTA O. ASANTE

(Student)

May, 2007.

APPROVAL

I certify that I have supervised the student in undertaking the study herein and I confirm

that the student has my permission to present it for assessment.

…………………………….

Dr. Mrs. CHARLOTTE MENSAH

(Supervisor)

May, 2007.

DEDICATION

This dissertation is dedicated to my siblings Asante Sasu Sylvester, Asante Aboagyewaa

Grace and Asante Kwame Andrew, and the inhabitants of Bosomtwe-Atwima-Kwawoma

District most especially the people of Obo, Abono and Kuntanse.

ACKNOWLEDGEMENTS

Several people have helped me in the writing of this dissertation. First and foremost, I owe

a debt of gratitude to the Almighty God for giving me the strength and knowledge.

I am particularly grateful to Dr .Mrs. Charlotte Mensah, my supervisor, for the healthy

criticism, advice, instructions and useful suggestions I received from her.

I wish to register my deep appreciation to authors of the books, articles and journal I used

freely as references, especially Pro.Dr. Dr. .Bour’s Journal of the University of Science

and Technology Volume 13, WHO and GHS technical reports.

I also wish to record my acknowledgement to the contribution of various research studies

I conducted with Agyemang –Offei Robert, Asiamah Emmanuel and Wiafe Micheal.

My thanks also go to my parents Mr. and Mrs. Asante, my Grandmother, my Aunties, Mrs.

Mary Nkrumah Asante, Mrs.Christiana Asante and to my uncle Nana Adjei Francis for

their prayers and support and inspiration for my education.

Lastly, I wish to express my profound gratitude to Mr. David Assibi, the Medical Assistant

of Kuntanase General Hospital for his contribution to my research. To all my lecturers

especially Mr. J. Koomson, my friends and my classmates, I say thank you!

As for any errors, substantial or marginal which may be found in the dissertation, I am

entirely responsible for them.

ABSTRACT

Malaria ranks among the foremost health issues facing the world, especially tropical

countries. This endemicity of malaria has threatened health delivery services of the

country. Ashanti region records one of the highest malaria cases in the country. This

research studies the prevalence of malaria worldwide. The research further talks about the

incidence of malaria in the Lake Bosomtwe Area, and the history of the Bosomtwe-Atwima

Kwawoma district. In this paper, I explored the causes, effects, preventions and treatment

of malaria. Questionnaires were used in collecting data from selected respondents at a

random sampling. Specific attention was given to causes of malaria in the lake Bosomtwe

area as unsanitary practices, ignorance and lack of protective devices. Poverty and death

were explored in this research as the major effects of malaria on the inhabitants.

This study was concluded that, the causes of malaria can be prevented by taking necessary

precautions such as the use of treated mosquito nets, repellants and taking malaria vaccines.

In addition, it was discussed in the text that, malaria can be treated with the use of orthodox

and herbal medicine. Finally, this study recommends that, government and other agencies

should make it their ultimate aim to publicize the awareness of malaria in the Lake

Bosomtwe Area.

Key Words: District, fever, health, malaria, Ghana, Ashanti Region.

TABLE OF CONTENTS

Page

Declaration……..…………………………………………………………………………..ii

Dedication…..………………………………………………………………………….…..iii

Acknowledgement……………………………………………………………………….....iv

Abstract….……………………………………………………………………………….....v

Table of Contents……..………………………………………………………………....…vi

List of Tables….…………………………………………………………………………...viii

List of Abbreviations…….………………………………………………………….....…...ix

CHAPTER 1 Introduction……….…….………………………………………..…....1

1.1 Background………………………………………………………………......................1

1.2 Problem Statement………………………………………………………………….......2

1.3 Relevance of the study………………………………………………………………….3

1.4 Research Objectives…………………………………………………………………….4

1.5 Research Questions…………………………………………………………………......4

1.6 Conceptual Framework……………………………………………….…………….......4

1.7 Assumptions……………………………………………………..……………….……..6

1.8 Scope of study …………………………………………….…………………………....6

1.9 Organization of report ……………………………………………………………….…6

CHAPTER 2 Literature Review…………….……………………………………….7 2.1 Introduction…………………………………………………………………….……..…7

2.2 Global Burden of Disease………………………………………………………………..8

2.3 Human Related Factors…………………………………………………………………..9

2.4 Knowledge on Malaria……………………………………………………………….…10

2.5 Socio-Economic Factors……………………………………………………………...…11

2.6 Environmental Factors/Climate…………………………………………………………15

2.7 Causes of Malaria…………..…………………………………………………...………16

2.8 Life cycle of Plasmodium……………………………………………………..………...17

2.9 Pathogenesis of Malaria…………………………………………………………………17

2.10 Genetic Resistance……………………………………………………………..……....20

2.11 Clinic Features………………………………………………………………..………20

2.12 Diagnosis of Malaria……………………………………………………...……….…..22

2.13 Prevalence, Incidence & Determinants of Malaria………………………….…………23

2.14 Management of Malaria………………………………………………………………..24

CHAPTER 3 Methodology……………………………..…………..………………....26

3.0 Introduction…………………………………………………………………..............26

3.1 Political Background………………………………………………………..………..26

3.2 Geography………………………………………………………………….…...........26

3.3 History of Study Area………………………………………………….…………….27

3.4 Population Size…………….. ……………………………………….………………31

3.5 Study Design and Sample Size………………….…………………………………....31

3.6 Data Collection and Tools……………………………………………………..….….31

3.7 Pre-testing………………………………………………………………….…….…..31

3.8 Data Handling and Storage……………………………………………………….….32

3.9 Ethical Consideration…………………………………………………………….…..32

3.10Limitations………………………………………………………………………..…33

CHAPTER 4 Research Findings…………………………..…………..…………..…34

4.0 Introduction………………………………………………………………………...34

4.1 Demographic Characteristics of Respondents……………………………….…..…34

4.2 Malaria Prevalence……………………………………………………………...…..38

4.3 Causes of Malaria Prevalence………………………………………….………..….39

4.4 Effects on Malaria Prevalence……………………………………….………..……40

4.5 Treatment and Prevention of Malaria Prevalence……………………………..…....41

4.6 Health Official Response…………………………………………………….….….42

CHAPTER 5 Summary, Conclusions and Recommendations………………......43

5.1Summary of Major Findings…………………………………………….………….43

5.2Conclusions……………………………………………………………..…………..43

5. 3Recommendations……………………………………………………………….…44

5.4 Limitations of the Study……………………………………………………..…….45

5.5 Suggestion for Future Research……………………………….…………………...45

LIST OF BIBLOGRAPHY………………………………………………….…….…46

LIST OF TABLES, FIGURES AND PLATES

TABLE PAGE

4.1 Educational Background of Respondents …………….……………………….....35

4.2 Age of Respondents..……………………………….……………………………36

4.3 Occupations of the Respondents…………………...………………………….…37

4.4 Sex of Respondents…………………………………………………………....….38

4.5 Prevalence of Malaria………………………………………………………..……38

4.6 Response of Causes of Malaria……………………………...……………….…...39

4.7 Response of Effect of Malaria……………………………………...……….……40

4.8 Response of Treatment and Prevention of Malaria………………………….……41

FIGURE

1.1 Conceptual Framework……………………………………………………..…...5

3.1 Map of Bosomtwe-Atwima Kwanwoma District………………..………….....30

PLATES

1 An overview of Lake Bosomtwe………………………………………...34

2 An Anopheles Mosquito……………………………...………………….40

LIST OF ABBREVIATIONS

ACTs Artemisinin Based Combination Therapy

DALYs Disability Adjusted Life Years

GHS Ghana Health Service

IPTp Intermittent preventive therapy in pregnancy

ITNs Insecticide-treated mosquito nets

LLITNs Long Lasting Insecticide Treated Nets

MOHsw Ministry of Health and Social Welfare

MOP Malaria Operational Plan

NIMR National Institute of Medical Research

NMCP National Malaria Control Programme

NMTSP Natinal Malaria Medium Term Strategic Plan

RBM Roll Back Malaria

RDTs Rapid Diagnostic Tests

UNDP United Nations Development Programme

UNICEF United Nations Children Education Fund

WHO World Health Organization

CHAPTER ONE

1.1 INTRODUCTION

Malaria ranks among the major health and development challenges facing some of the

poorest economies. Endemic in ninety-one countries, accounting for forty percent of the

world’s population, malaria affects an estimated three hundred million people. Though in

most cases treatable, malaria is responsible for more than a million deaths per year. In Sub-

Saharan Africa, the most affected region, malaria related illnesses claim the life of one out

of every twenty children below age five. For adults, mortality rates are lower but frequent

debilitating attacks reduce the quality of life for chronic sufferers

(www.who/malaria.html).

In the last decade, the prevalence of malaria has been escalating at an alarming rate,

especially in Africa. An estimated 300-500 million cases each year cause 1.5 to 2.7 million

deaths; more than 90% of the deaths are in children under 5 years of age in Africa. Malaria

(9% of global disease burden) ranks third among major infectious disease threats in Africa

after pneumococcal acute respiratory infections (3.5%) and tuberculosis (TB)

(2.8%). Malaria cases in Africa account for approximately 90% of malaria cases in the

world. Between 1994 and 1996, malaria epidemics in 14 countries of Sub-Saharan Africa

caused an unacceptably high number of deaths, many in areas previously free of the

disease. Adolescents and young adults are now dying of severe forms of the disease

(www.malaria.org).

The partial success of the eradication programs resulted in a sharp spatial concentration of

malaria in tropical areas. The same areas also suffer most from a set other illnesses related

to the economic development stage [Sachs (1997, 1999), Gallup and Sachs (1998a, b)],

including intestinal diseases causes by contaminated water and communicable diseases

such as tuberculosis.

As a primarily rural parasitic disease transmitted by mosquito bites, malaria is less

immediately affected by improved urban sanitation and housing in the course of economic

development; indeed, after the failure of the eradication efforts, malaria has at times been

portrayed as a largely unavoidable side effect of tropical location.

Malaria, debilitating infectious disease characterized by chills, shaking, and periodic bouts

of intense fever. Caused by single-celled parasites of the genus Plasmodium, malaria is

transmitted from person to person by the bite of female mosquitoes (www.malaria.org).

Although malaria was once widespread in North America and other temperate regions, the

last major outbreak of malaria in North America occurred in the 1880s. The disease today

occurs mostly in tropical and subtropical countries, particularly sub-Saharan Africa and

Southeast Asia. According to the World Health Organization, malaria is prevalent in over

100 countries. Each year more than 300 million cases of malaria are diagnosed, and more

than 1.5 million die of the disease.

1.2 PROBLEM STATEMENT

The Bosomtwe district in the Ashanti Region of Ghana is a peri-urban district which is

located south of the Kumasi metropolis. The tribe is largely of the Asantes. The population

that is unemployed is high. Malaria poses a serious health problem in Ghana; it is

hyperendemic with a crude parasite rate ranging from 10 – 70% and plasmodium

falciparum the major malaria parasite, dominating. Although numerous efforts have been

made to fight malaria in the country and the district at large, as in many endemic countries,

achievements have been minimal. It is the number one cause of morbidity accounting for

40% of outpatient attendance with annual reported cases of 2.2 million between 1995 -

2001, and over 10% ending up on admission (Kusi 2003). From the UN classification of

childhood diseases it ranks third in Africa (Ministry of Health 2002). Lake Bosmtwe, the

only Crater Lake is situated in the Amakom sub – district. The district has a stretch of

weeds long river body, this and many activities of the inhabitants assist in the bleeding of

the female mosquitoes, hence increase in the prevalence of malaria in the district. The

perception is that prevalence of malaria in the Lake Bosomtwe district is as a result of the

daily activities of inhabitants, hence the research work.

1.3 RELEVANCE OF THE STUDY

Lake Bosomtwe is one of the biggest natural lakes in Africa. Lake Bosomtwe is one of the

most important tourist attraction centers in Ashanti region and Ghana as a whole serving

as a foreign exchange earner to the economy of Ghana. It is about 30 minutes’ drive that is

31km away from Kumasi. Tourists love the lake because a range of mountains surrounds

it. It makes great fun for tourist to stand along the crater and watch the fishing folks

paddling the carved boats or canoes.

Tourists are giving the chance to ride on the Lake for 45-50 minutes. The revenue generated

from this is use for the development of the area, making this study very important. The

study will also benefit the residents living in this area since it seeks to address the causes

and preventions of malaria .The study will also add to existing literature on malaria in

Ashanti region and Ghana as a whole.

1.4 RESEARCH OBJECTIVES

The main objective is to determine the prevalence of malaria in Lake Bosomtwe

The specific objectives include:

1. To determine the causes of malaria in lake Bosomtwe

2. To ascertain the effect of malaria on the people living in this area

3. To identify the possible prevention methods of malaria in lake Bosomtwe

1.5 RESEARCH QUESTIONS

1. What are the causes of malaria in Lake Bosomtwe?

2. How are the people affected by the incidence of malaria in the district?

3. What are the possible prevention methods of malaria?

1.6 CONCEPTUAL FRAMEWORK

Malaria is endemic and a clinical disease in the Lake Bosomtwe Area. Malaria is usually a

human cause disease. The conceptual framework in figure 1.1 helps in understanding how

malaria is cause and its effects on the people of the study area. This conceptual framework

reveals that, malaria is cause by poor sanitation. Figure 1.1 illustrates poor sanitation such

as stagnant water in cans, gutters and disposed ties. The throwing of faces around our

surroundings and bushy surroundings. These areas serve as breeding places for the

Anopheles mosquitoes. The inhabitants when biting by these mosquitoes exhibits

symptoms such as fever, chills, high temperature and headache, hence malaria infections.

Figure 1.1: Conceptual Framework

(Construct of Author, 2007)

MALARIA

Stagnant water in cans

Gutters and disposed ties

Throwing of sewage and faeces around surroundings

Breeding of the female Anopheles Mosquitoes

Anopheles mosquitoes bites inhabitants

The inhabitants get fever, chills, high temperature,

and headache

Bushy surroundings

1.7 ASSUMPTIONS

1. Malaria is a disease that is both preventable and curable.

2. The prevalence of malaria has caused poverty.

1.8 SCOPE OF STUDY

The study covered the whole of the district. It involved all the 21 villages; inhabitants,

opinion leaders, and healthcare officers in the district.

1.9 ORGANIZATION OF REPORT

Chapter one has presented the background information to the study, the problem statement

and the justification for the study the objectives. Chapter two presents a review of related

literature on the level of knowledge about the malaria, life cycle of plasmodium and

pathogenesis, causes of malaria, scientific classification of mosquitoes, management of

malaria, prevalence, incidence and determinants of malaria, diagnosis of malaria, clinical

features and genetic resistance. Chapter three describes the profile of the study area, the

study type and population chosen and the general procedure that the study followed.

Chapter four presents the results and discussions and chapter five, the conclusions and

recommendations of the study.

CHAPTER TWO

2.0 LITERATURE REVIEW

This chapter deals with the review of relevant literature to the study.

2.1 INTRODUCTION

From the study of Nayyar, et al (2006), Malaria is a mosquito-borne infectious disease of

humans and other animals caused by arasitic protozoans (a type of unicellular

microorganism) of the genus Plasmodium. Commonly, the disease is transmitted via a bite

from an infected female Anopheles mosquito, which introduces the organisms from its

saliva into a person's circulatory system. In the blood, the protists travel to the liver to

mature and reproduce. Malaria causes symptoms that typically include fever and headache,

which in severe cases can progress to coma or death. The disease is widespread in tropical

and subtropical regions in a broad band around the equator, including much of Sub-Saharan

Africa, Asia, and the Americas. Five species of Plasmodium can infect and be transmitted

by humans. The vast majority of deaths are caused by P. falciparum and P. vivax, while

P. ovale, and P. malariae cause a generally milder form of malaria that is rarely fatal. The

zoonotic species P. knowlesi, prevalent in Southeast Asia, causes malaria in macaques but

can also cause severe infections in humans. Malaria is prevalent in tropical and subtropical

regions because rainfall, warm temperatures, and stagnant waters provide habitats ideal for

mosquito larvae. Disease transmission can be reduced by preventing mosquito bites by

using mosquito nets and insect repellents, or with mosquito-control measures such as

spraying insecticides and draining standing water.

Malaria is typically diagnosed by the microscopic examination of blood using blood films,

or with antigen-based rapid diagnostic tests. Modern techniques that use the polymerase

chain reaction to detect the parasite's DNA have also been developed, but these are not

widely used in malaria-endemic areas due to their cost and complexity. The World Health

Organization has estimated that in 2010, there were 219 million documented cases of

malaria. That year, the disease killed between 660,000 and 1.2 million people, many of

whom were children in Africa. The actual number of deaths is not known with certainty,

as accurate data is unavailable in many rural areas, and many cases are undocumented.

Malaria is commonly associated with poverty and may also be a major hindrance to

economic development. Despite a need, no effective vaccine exists, although efforts to

develop one are ongoing. Several medications are available to prevent malaria in travellers

to malaria-endemic countries (prophylaxis). A variety of antimalarial medications are

available. Severe malaria is treated with intravenous or intramuscular quinine or, since the

mid-2000s, the artemisinin derivative artesunate, which is superior to quinine in both

children and adults and is given in combination with a second anti-malarial such as

mefloquine. Resistance has developed to several antimalarial drugs; for example,

chloroquine-resistant P. falciparum has spread to most malarial areas, and emerging

resistance to artemisinin has become a problem in some parts of Southeast Asia (Nayyar,

et al, 2006).

2.2. GLOBAL BURDEN OF DISEASE

Malaria is considered the most consequential parasitic infection in humans. There are as

many as 350-500 million clinical episodes per year worldwide (UNICEF, 2003) and while

most estimates of mortality caused by malaria lie at around 1 million deaths per year (Snow

et al. 2005), some calculations go as high as 3 million (Breman et al, 2004). Almost all of

these deaths occur in children (Phillips, 2001), living in malarious countries in sub-Saharan

Africa (SSA) (Ukoli, 1990) where 25% of all childhood mortality below the age of five

(about 800,000 young children (Shepard et al., 1991) is attributable to malaria. Of those

children who survive cerebral malaria, more than 15% suffer neurological deficits (NIMR

2006, & Schönfeld et al, 2007) which include weakness, spasticity, blindness, speech

problems and epilepsy. Where such children are poorly managed and do not have access

to specialized educational facilities, these deficits may interfere with future learning and

development Children under the age of five years are at highest risk for malaria because

they have not yet acquired protective immunity. People with semi-immunity are infected,

but do not get a severe disease as a rule. In stable transmission areas newborns are protected

by the IgM antibodies of their mother and through breastfeeding. After three months

children have a higher susceptibility for an infection with the parasite. In high transmission

areas this time period lasts until the age of 3-5 years. In areas with a seasonal transmission

the period can last 10 years. Without re-infection the acquired immunity can dissapear in a

matter of years (Eddleston et al. 2008).Furthermore children under five years of age

experience the biggest malaria burden because they are often super-infected with other

parasites and/or that they often suffer from nutritional deficiencies. These lead to a weaker

immune system, which leads to a higher susceptibility for malaria. Moreover, a malaria

infection and malnutrition are reasons for an increasing anaemia burden in children

(Greenwood et al.1991).

2.3 HUMAN RELATED FACTORS

There is a large amount of data on malaria related morbidity and mortality in children under

five. (Menard et al, 2010) suggested that, the risk of infection and its severity is lower in

the first few months of life. Reasons for this are complex but probably include transmission

of protective antibodies across the placenta, the presence of red cells containing Hbf –

which are relatively resistant to malaria infection, breast feeding and lack of exposure

(Hviid, & Staalsoe T.2004).The protective effect of maternal antibody is likely to be less

when effective malaria control is achieved and the overall level of malaria infection

declines. In lower transmission settings clinical malaria is spread more widely across the

age groups. In such settings, occupational issues may become more important than age;

this is especially true where mosquitoes which transmit malaria bite outdoors away from

dwellings. Forest workers in south-east Asia are one example of this phenomenon (Erhartet

al, 2004). In these settings young adults, especially males, may be more at risk than

children; because they are the group at most risk from being bitten by forest dwelling

vectors (Dysoley et al, 2008). Furthermore this information was supported by a study that

was done in Kenya that explored factors affecting use of permethrin-treated bed nets during

a randomized controlled trial found that children less than five years of age were less likely

to use nets compared to the individual adults (Alaii et al, 2003).

2.4 KNOWLEDGE ON MALARIA

A number of studies have investigated differences in knowledge and reported health

seeking behavior between men and women. Most found either no difference or those

women had more limited decision-making and financial power to act. This was associated

with failures and delays in seeking treatment, with differential understanding of malaria

between men and women, and differential health-seeking behaviour. Women delayed

seeking care until men were available, while men were less willing to spend on child health.

(Al-Taiar et al 2007 & Oberlander and Elverdan 2000).These differences are critical when

considering the main child-caring role of women and children‘s increased vulnerability to

malaria. Furthermore according to (Minja et al., 2001), it was stated that knowledge,

attitude and behavior practices regarding malaria were shown to influence the ITN

ownership. Some other studies that were done by

(Victora, 2003, Nganda 2004&Magesa et al., 2005) reported that knowledge of the

problem; affordability and accessibility are among major obstacles for the ITN ownership

and use. Net ownership has also been related to the educational levels of household

members. This is a complicated relationship since educational attainment can have the

impact on an individual‘s ability to understand and access information regarding malaria

prevention methods. In Malawi it was found that net ownership was less common in

households where the head/caretaker had not completed primary school and in homes

where the house had mud walls or a grass roof (Holtz et al., 2002). This is being supported

by (Nuwaha, 2001) with evidence that educational attainment is associated with malaria-

specific knowledge and uptake of preventive measures. Rhoida Y et al 2004concluded that

the success in implementing preventive interventions amongst pregnant women in

Tanzania is thus likely to be determined in part by awareness of malaria and the strategies

available to prevent it. In order for the ITN distribution programme to succeed, the

knowledge gaps, practices and attitudes that may negatively influence the intervention

uptake.

2.5 SOCIO-ECONOMIC FACTORS

Socioeconomic conditions of the community have direct bearing on the problem of malaria.

Ignorance and impoverished conditions of people contribute in creating source and spread

of malaria and hinder disease control strategy (Collins et al, 1997&Yadav et al., 1999).

This was also evidenced by Filmer 2002, that high costs of malaria treatment may lead to

delays in treatment seeking behavior, whereby he found that the poorest groups in a society

did not seek care as much as the non-poor, and did so at lower level public facilities.

Economic inequities in areas such as the control of household resources also affect access

to ITNs. In one study in Benin, many women explained that since they were financially

dependent on their husbands, they were unable to purchase an ITN for themselves and their

children unless their husbands prioritized the use of bednets (Krause G, et al 2000)).The

study also revealed that when women did earn an income and had control over this income,

they were much more likely than men to purchase an ITN for their household.(Krause G,

et al 2000) Alnwick 2000,also observes that malaria afflicts primarily the poor, who tend

to live in dwellings that offer little or no protection against mosquitoes. Furthermore,

(Brown, 1997) notes that ―the continuation of brutal poverty and hunger in much of the

world is undoutbtedly linked to large numbers of unnecessary deaths from malaria. A

survey in Zambia also found a substantially higher prevalence of malaria infection among

the poorest population groups (Roll Back Malaria, 2001). According to (Makundi et

al,2007) it was reported that the burden of malaria is greatest among poor people, imposing

significant direct and indirect costs on individuals and households and pushing households

into in a vicious circle of disease and poverty. Furthermore, vulnerable households with

little coping and adaptive capacities are particularly affected by malaria. Households can

be forced to sell their food crops in order to cover the cost of treatment (Wandiga et al,

2006.) Depleting household resources and leading to increased food shortages, debts, and

poverty for the poorest households. The costs of malaria are highly regressive, with the

poorer households spending a significantly higher proportion of their income on the on the

treatment of malaria than their least poor counterparts.

In Ghana, both direct and indirect costs associated with a malaria episode represent a

substantial burden on poorer households. A study found that while the cost of malaria care

was just 1 per cent of the income of the rich, it was 34 percent of the income of poor

households (Akazili, 2002). Similarly, (Kuate,1997) found that the burden of illness rests

disproportionately on the economically disadvantaged women who were not employed,

women living in poor neighbourhoods, and those living in households without modern

facilities. This is being supported by a study that was done on the use of ITNs whereby it

was only recently appreciated that a net treated with insecticide offers much greater

protection against malaria. Unfortunately, the commercial price of nets and insecticide is

beyond the poorest income groups of the population (World Health Organization, 2003).

Ziba et al 1994: found that in Malawi, use of malaria prevention measures (bednets,

insecticides, mosquito coils, other insect repellents, burning leaves, etc) was income-

dependent. In households where the head earned a larger than average income, use of

commercial methods (mosquito coils, insecticide spray, bednets) was more common. Use

of inexpensive and less effective, natural methods (burning leaves, dung, or wood) was

associated with lower income. Occupational and cultural differences related to undertaking

activities likely to lead to malaria transmission; and when malaria is acquired, access to

health services is more mixed and varies considerable across different cultural settings.

Alternatively, if a household only has one bednet, priority may be given to the male head

of the household as he is often considered the primary breadwinner (Krause, et al 2000).

Before the ITNs project started in Bagamoyo, Tanzania, it was reported that it was mainly

the adult men who used the nets, followed by women and children under two who sleep

with their mothers, while elder children were frequently the last to gain access (Makemba

et.al.1995). ITNs availability and efficacy. The use of insecticide-treated nets is currently

considered one of the most cost-effective methods of malaria prevention in highly endemic

areas Tanzania being included. This has been achieved through free distribution of long

lasting insecticidal nets (ITNs) that has been conducted through campaigns, public health

facilities, faith-based organisations (FBO), and non-governmental organisations (NGOs)

with the goal of achieving universal access for the at-risk population of children under age

five and pregnant women. The use of ITNs in Tanzania has increased markedly over the

past few years. Statistics indicate that the proportion of households with at least one

untreated net has increased from 14% in 2001 to 58% in 2005.ITNs coverage is estimated

to have reached 63% of households with at least one ITN and 25%b and 26% of children

under 5and pregnant were respectively sleeping under an ITN. However, more effort is

needed to further increase this to reach the globally agreed target of 80(2007-2008

YHMIS). According to the (MoHSW 2006) report, Insecticide-treated mosquito nets

(ITNs) used for protection against mosquito bites has proven to be a practical, highly

effective, and cost-effective intervention against malaria. This was also supported by (Roll

Back Malaria, 2005) which reported that ITNs reduces human contact with infected

mosquitoes and have been shown to be an effective malaria prevention measure. In addition

to the direct benefit to the individual, ITNs use offers a protective benefit for the entire

community (Teklehaimonot et al., 2007). Studies examining ITN‘s efficacy suggest a

significant reduction in malaria episodes. If used universally, ITNs could prevent

approximately 7% of the global under-five mortality (Jones et al, 2003). The UNICEF

corroborates that under-five mortality rates could be reduced by about 25-30% if all young

children in malaria endemic areas were protected by treated bed nets at night. This was

also evidenced by (Lengeler‘s,2004) review which demonstrates the efficacy of ITNs in

both stable and unstable transmission areas where by it was documented the wide spread

use of ITNs resulted in an overall reduction in mortality of 19 percent, protected against

anemia, and had a substantial impact on mild disease episodes. Another One large-scale

rural study in Tanzania found that ITNs and untreated nets reduced mortality of children

one month to four years, with protective efficacies of 27 and 19 percent, respectively

(Armstrong and Schellenberg,2002). Hill et al wrote in 2006 that despite of all these efforts

and its efficacy, only 3% of African children sleep under these treated nets while only about

20% sleep under any other kind of nets. This however may account for the high rate of

mortality amongst children due to malaria and its related problems. Despite the evidence

that the use of ITNs decreases malaria-related morbidity and mortality, the use of ITNs in

sub-Saharan Africa remains relatively low.

2.6 ENVIRONMENTAL FACTORS/CLIMATE

Malaria is governed by a large number of environmental factors, which affect its

distribution, seasonality and transmission intensity (Snow et al, 1999). Climate and

environmental conditions greatly affect the transmission and incidence of malaria, by

influencing primarily the abundance and survival of vectors and parasites, and also

exposure of humans and other hosts. (Lafferty, 2009). The most important environmental

factors for malaria transmission have to do with conditions for Anopheles mosquito

breeding and survival water in which they can breed, and minimum temperatures and

humidity to allow them to survive long enough for the vector stage of the parasite‘s life

cycle to be completed usually about ten days. These factors are influenced by climate, as

well as by topography and soil conditions, drainage, vegetation cover, land use and water

all of which vary greatly depending on local conditions. As such, changes in climate and

land use such as water management, agriculture, urbanization, and deforestation can lead

to significant increases or decreases in malaria transmission, depending on local contexts.

(Reiter P.2001) Some agricultural practices facilitate the spread of vector-borne diseases.

Also, the presence of cattle in marshy areas results in the creation of hoof prints that

potentially offer ideal conditions for mosquito breeding. Within man- made malaria,

excluding the migration of non-immunes to endemic areas, the most important impacts on

transmission are probably brought about by water resource development and land use

change. Human modification to the environment also can create larval development sites

and malaria (Denise et al, 2003). This may especially be true for man- made malaria in

which man by his farming activity or any other activity may create the environments which

suit mosquito breeding and protective measures may be widely distributed. The

identification of predictors of malaria incidence could provide a useful means of

identifying targets for intervention of manmade malaria (Ghebreyesus et al., 2000).

Furthermore Utilization of ITNs has, however, been found to vary with Binka et al showed

seasons of the year and acceptability of the nets in terms of size, colour and shape. That

the time of the year during which the nets are delivered affects use. 99% of the net

recipients were found to use the nets during rainy season, while only 20% used it during

the dry season this was evidenced by a study which was done in Burkina Faso of which

reported a decreased use of bed nets during the dry season due to a perceived lower risk of

mosquito bites and the practice of sleeping outdoors (Frey et al, 2006). Malaria control

strategies need to consider how changing environmental conditions may be linked to an

increase or decrease of malaria transmission. Opportunities exist for integrating

environmental management interventions into vector control strategies in order to reduce

malaria risk.

2.7. CAUSES OF MALARIA

Malaria parasites belong to the genus Plasmodium (phylum Apicomplexa). In humans,

malaria is caused by P. falciparum, P. malariae, P. ovale, P. vivax and P. knowlesi. Among

those infected, P. falciparum is the most common species identified (~75%) followed by

P. vivax (~20%). Although P. falciparum traditionally accounts for the majority of deaths,

recent evidence suggests that P. vivax malaria is associated with potentially life-threatening

conditions about as often as with a diagnosis of P. falciparum infection. P. vivax

proportionally is more common outside of Africa (Okenul, 2003). There have been

documented human infections with several species of Plasmodium from higher apes;

however, with the exception of P. knowlesi—a zoonotic species that causes malaria in

macaques—these are mostly of limited public health importance (Okenul, 2003).

2.8 LIFE CYCLE OF PLASMODIM

All types of malaria have a similar life cycle. Sporozoites, the infectious form of the malaria

parasite, are injected into a human host through the saliva of an Anopheles mosquito. These

sporozoites enter the liver cells within minutes, take on a new form, and multiply. When

the liver cells rupture, blood stage parasites—known as merozoites—are released. Each

merozoite invades a red blood cell, and for two days multiplies into more merozoites. The

red blood cell full of merozoites ruptures to release more merozoites. It is this stage of the

life cycle that causes disease and, too often, death. Some merozoites change into the form

called gametocytes, which do not cause disease but remain in the blood until they are

cleared by drugs or the immune system, or taken up by the bite of a mosquito. In the

mosquito's stomach a "male" gametocyte fertilizes a "female" to form an egg, or oocyst,

which matures into thousands of sporozoites that swim to the mosquito's salivary glands to

be injected into another human at the next bite (Gallup, 2001).

2.9 PATHOGENESIS OF MALARIA

In humans, malaria is caused by four species of the plasmodium protozoa (single celled

parasites) – plasmodium falciparum, plasmodium vivax, plasmodium ovale and

plasmodium malariae. Of these species plasmodium falciparum accounts for the majority

of infections and is the most lethal. Several studies have been done on different aspects of

the disease, from parasitology to finding a cure with drugs (chemotherapy) and to

eradication of the disease by the use of insecticide treated net and insecticides. Rashed4

conducted a study which was aimed at determining the effect of Permethrin insecticide

treated nets (PITN) use on the incidence of febrile episodes and non-household malaria

expenses in Benin. The study found out that, the use of PITNs decreased the risk of

developing malaria by 34% in children in the rural areas; meanwhile, PITN use did not

reduce prevention and treatment expenses. In a parasitology laboratory, malaria was found

to be the major killer of paediatric illness and death in Kinshasa (Coene 1991).

In view of this, the treatment of fevers as malaria with chloroquine is no longer acceptable

because the plasmodium falciparum had a resistance to chloroquine. According to the

study, the differences in endemicity of malaria that existed between the various parts of

town had to be taken into consideration alongside the ecological and socio-economic

factors that underlie when planning for estimation of potential control methods. The

behavioural risk for malaria in the Machodinho resettlement area in the Amazonian forests

of Brazil was examined (Castilla and Sawyer 1993). Analysis of the study suggested that

economic status and knowledge of the importance and behavoiur of the mosquito in

transmitting malaria are significant factors in determining prevalence risk irrespective of

whether preventive precautions, for example, dichlorodiphenyl trichloroethane (DDT)

spraying of houses and cleaning of vector breeding sites are to be undertaken in the

endemic areas. However, the researchers found out that a higher economic status combined

with better knowledge of the vector and DDT spraying of houses decreased the risk of

infection. They suggested that a more positive implication is that control programmes must

work harder and more intensively on behalf of poorer people especially migrants in order

to diminish the disease burden for them. Sharma and colleagues (2001) carried out a study

on the socioeconomic factors as well as on the human behaviour towards malaria on cross

section of the Sundargarh district in India. They argued that poor socioeconomic status and

socio-cultural factors play an important role in maintaining high degree of malaria

transmission. They found that human behaviours such as location of hamlets, type of

malaria transmitted, sleeping habits, and outdoor activities after dusk, poor knowledge

about the disease and treatment seeking behaviour are of great significance as determinants

of malaria transmission.

Malaria is also a major problem in Papua New Guinea as it accounts for a high proportion

of sickness and death. This is because in addition to human suffering, it also put severe

stress on the health facilities and directly hinders economic growth. It has been suggested

that a malaria vaccine would be best, most cost effective and safe public health measure to

reduce the burden of malaria (Reeder 2001). Whitty and Allan (2004) contend that the

serious threat posed by the spread of drug-resistant malaria in Africa has been widely

acknowledged. Chloroquine resistant malaria is now almost universal and resistant to

successor drug, sulfadoxine-pyrimethamine (SP) is growing rapidly. If the question of cost

of treatment is not successfully addressed this could lead to adverse result from the

deployment of combination therapy as a first-line treatment. Adverse effect of costly

treatment ranges from increase in delays in infected individuals presenting themselves to

the health care facilities for treatment to exclusion of the poorest malaria sufferers from

receiving treatment altogether.

2.10. GENETIC RESISTANCE

According to a 2005 review, due to the high levels of mortality and morbidity caused by

malaria—especially the P. falciparum species—it has placed the greatest selective pressure

on the human genome in recent history. Several genetic factors provide some resistance to

it including sickle cell trait, thalassaemia traits, glucose-6-phosphate dehydrogenase

deficiency, and the absence of Duffy antigens on red blood cells (Kwiatkowski, 2005). The

impact of sickle cell trait on malaria immunity illustrates some of the evolutionary trade-

offs that have occurred because of endemic malaria. Sickle cell trait causes a defect in the

hemoglobin molecule in the blood. Instead of retaining the biconcave shape of a normal

red blood cell, the modified hemoglobin S molecule causes the cell to sickle or distort into

a curved shape. Due to the sickle shape, the molecule is not as effective in taking or

releasing oxygen. Infection causes red cells to sickle more, and so they are removed from

circulation sooner. This reduces the frequency with which malaria parasites complete their

life cycle in the cell. Individuals who are homozygous (with two copies of the abnormal

hemoglobin beta allele) have sickle-cell anaemia, while those who are heterozygous (with

one abnormal allele and one normal allele) experience resistance to malaria. Although the

shorter life expectancy for those with the homozygous condition would not sustain the

trait's survival, the trait is preserved because of the benefits provided by the heterozygous

form (Kwiatkowski, 2005).

2.11 CLINICAL FEATURES

The signs and symptoms of malaria typically begin 8–25 days following infection;

however, symptoms may occur later in those who have taken antimalarial medications as

prevention. Initial manifestations of the disease—common to all malaria species—are

similar to flu-like symptoms, and can resemble other conditions such as septicemia,

gastroenteritis, and viral diseases. The presentation may include headache, fever, shivering,

joint pain, vomiting, hemolytic anemia, jaundice, hemoglobin in the urine, retinal damage,

and convulsions (Sherman, 1998).

The classic symptom of malaria is paroxysm—a cyclical occurrence of sudden coldness

followed by shivering and then fever and sweating, occurring every two days (tertian fever)

in P. vivax and P. ovale infections, and every three days (quartan fever) for P. malariae.

P. falciparum infection can cause recurrent fever every 36–48 hours or a less pronounced

and almost continuous fever. Severe malaria is usually caused by P. falciparum (often

referred to as falciparum malaria). Symptoms of falciparum malaria arise 9–30 days after

infection.[4] Individuals with cerebral malaria frequently exhibit neurological symptoms,

including abnormal posturing, nystagmus, conjugate gaze palsy (failure of the eyes to turn

together in the same direction), opisthotonus, seizures, or coma (Sachs, 2001).

2.11.1. Complications

There are several serious complications of malaria. Among these is the development of

respiratory distress, which occurs in up to 25% of adults and 40% of children with severe

P. falciparum malaria. Possible causes include respiratory compensation of metabolic

acidosis, noncardiogenic pulmonary oedema, concomitant pneumonia, and severe

anaemia. Although rare in young children with severe malaria, acute respiratory distress

syndrome occurs in 5–25% of adults and up to 29% of pregnant women. Coinfection of

HIV with malaria increases mortality. Renal failure is a feature of blackwater fever, where

hemoglobin from lysed red blood cells leaks into the urine (WHO, 1999).

Infection with P. falciparum may result in cerebral malaria, a form of severe malaria that

involves encephalopathy. It is associated with retinal whitening, which may be a useful

clinical sign in distinguishing malaria from other causes of fever. Splenomegaly, severe

headache, hepatomegaly (enlarged liver), hypoglycemia, and hemoglobinuria with renal

failure may occur. Malaria in pregnant women is an important cause of stillbirths, infant

mortality and low birth weight, particularly in P. falciparum infection, but also with

P. vivax (WHO, 2005).

2.12 DIAGNOSIS OF MALARIA

Owing to the non-specific nature of the presentation of symptoms, diagnosis of malaria in

non-endemic areas requires a high degree of suspicion, which might be elicited by any of

the following: recent travel history, enlarged spleen, fever, low number of platelets in the

blood, and higher-than-normal levels of bilirubin in the blood combined with a normal

level of white blood cells. Malaria is usually confirmed by the microscopic examination of

blood films or by antigen-based rapid diagnostic tests (RDT) (Perking, 2007). Microscopy

is the most commonly used method to detect the malarial parasite; about 165 million blood

films were examined for malaria in 2010. Despite its widespread usage, diagnosis by

microscopy suffers from two main drawbacks: many settings (especially rural) are not

equipped to perform the test, and the accuracy of the results depends on both the skill of

the person examining the blood film and the levels of the parasite in the blood. The

sensitivity of blood films ranges from 75–90% in optimum conditions, to as low as 50%.

Commercially available RDTs are often more accurate than blood films at predicting the

presence of malaria parasites, but they are widely variable in diagnostic sensitivity and

specificity depending on manufacturer, and are unable to tell how many parasites are

present (WHO, 2004).

In regions where laboratory tests are readily available, malaria should be suspected, and

tested for, in any unwell patient who has been in an area where malaria is endemic. In areas

that cannot afford laboratory diagnostic tests, it has become routine to use only a history

of subjective fever as the indication to treat for malaria; a presumptive approach

exemplified by the common teaching "fever equals malaria unless proven otherwise". A

drawback of this practice is over diagnosis of malaria and mismanagement of non-malarial

fever, which wastes limited resources, erodes confidence in the health care system, and

contributes to drug resistance. Although polymerase chain reaction-based tests have been

developed, these are not widely implemented in malaria-endemic regions as of 2012, due

to their complexity (Gallup et al, 2001).

2.13 PREVALENCE, INCIDENCE AND DETERMINANTS OF MALARIA

It should be noted that epidemic malaria is derived from interactions of vectors, parasites

and various environmental and anthropogenic determinants. Malaria epidemic afflict

immunological vulnerable populations, straining the capacity of health facilities and

causing case fatality rates to increase five-fold or more during outbreaks. The demographic

profile may translate into larger economic consequences, although the full economic

impact of epidemic malaria remains undefined. A study was conducted in Benin on how to

conceive and establish the importance of economic factors that contributed to malaria

transmission (Mensah and Kumaranayake 2004).

According to the study, despite the endemic malaria situations, there was still little

understanding of the relative importance of economic factors that contribute to people

acquiring the disease in communities where malaria was endemic. The researchers

contended that, predisposing characteristics of household’s heads such as age, knowledge

of malaria, education and size of household significantly affect the incidence of malaria as

anticipated by economic theory. A study by Asenso – Okyere (1994) on malaria in 4

districts namely Kojo Ashong, Barekese, Barekuma and Oyereko all from the Greater

Accra Region of Ghana revealed that factors that were perceived as causing malaria are

malnutrition, mosquitoes, excessive heat, excessive drinking, flies, fatigue, dirty

surroundings, unsafe water, bad air and poor hygiene. Almost all the adolescents at that

time had no idea how the disease was spread from person to person, while the symptoms

of clinical malaria was also frequently considered to be yellowish eyeball, chills and

shivering, headache, a bitter taste, body weakness and yellowish urine, the study added.

2.14 MANAGEMENT OF MALARIA

Yeboah-Antwi and colleagues (1997) examined the extent to which district health teams

in Kintampo in the Brong Ahafo Region of Ghana could reduce the burden of malaria,

which is a major cause of mortality and morbidity in a situation where severe resource

constraints existed. It was found out that, compliance improve by approximately 20% in

both adults and children but there was improvement to care about 50% for example in cost

to patients, waiting time at dispensaries and drug wastage at facilities. Another case study

in Ghana sought to compare household’s data on acute morbidity and treatment seeking

behaviour in two districts with the use of health facility data (Agyepong and Kangeya-

Kayonda 2004). For every case of febrile illness seen in the health facilities there were

approximately 4-5 cases in the community, hence they concluded that every febrile

episodes especially in children be treated with an anti-malarial drug. Since several

countries extend malaria treatment to include the community and the home through public

and private, formal and informal sectors, the need for more comprehensive estimates

becomes urgent. Appawu and colleagues (2004) studied malaria transmission dynamics in

the Kassena Nankana District, a site in northern Ghana proposed for testing malaria

vaccines. Intensive mosquitoes sampling was done for one year using human landing

catches in three micro-ecological sites that is irrigated, lowland and rocky highlands.

Transmission was highly seasonal and the heaviest transmission occurred from June to

October. The intensity of transmission was higher for people in the irrigated communities

than the non-irrigated ones. Approximately 60% of malaria transmission in KND occurred

indoors during the second half of the night, peaking at daybreak between 04.00 to 06.00

hours.

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This section of the study looks at the study site, sample population, sample size and the

data collection as well as the mode of analysis.

3.1. POLITICAL BACKGROUND

Bosomtwe District is in the Ashanti Region of Ghana. It was formerly part of the

Bosomtwe-Atwima-Kwanwoma district, but carved out by Legislative Instrument LI 1853

of 29th February, 2008. Kuntenase, the district capital is about 28 kilometers from Kumasi,

the capital of the Ashanti Region. The district shares common borders with the Ejisu-

Juaben district and Kumasi Metropolis on the North; Asante-Akim North district on the

East, Atwima Kwanwoma District on the West and Amansie-East district on the South.

3.2 GEOGRAPHY

The land size is approximately 500 square kilometres which represents about 2% of the

total land area of the Ashanti region. The road network from Kumasi, the regional capital,

to Kuntenase and Abono at the Lake area is second class. Unfortunately, around the Lake

and in most parts of the district the roads are not motorable. There are mountainous areas

as well which are generally quite difficult to access. The district has the only Crater Lake

in Ghana, Lake Bosomtwe which is being developed as a resort to boost tourism in Ghana.

3.3 HISTORY OF THE STUDY AREA

Figure 3.1 shows the map of Bosomtwe-Atwima Kwanwoma district. The map shows the

major towns of the district. The map shows the major towns of the district, roads and the

Lake Bosomtwe.Lake Bosomtwe is one of the biggest lakes in Africa. It can be located in

Ashanti Region of Ghana. ‘Bosomtwe’ means "god of antelope’s. ‘Bosom’ in Akan is god

an antelope in Akan is ‘otwe’. The person who first saw the lake was a hunter. His name

was ‘Agya Bempe’. One day he went out to hunt and he saw an antelope and shot at it. The

antelope ran away, but later on it was found in the lake dead. It was a very small lake. Later

the people thought the antelope was a god so they name the lake after the antelope.

Another school of thought is that the lake came into existence through a volcanic action.

There was valley around the lake side and there were almost thirty villages in the valley

around the lake, but because the lake is getting larger and larger it has covered some of the

villages. The lake has become very big that is why Lake Bosomtwe is among the biggest

Natural Lake in West-Africa and it has now become a tourist attraction fetching Ghana

with foreign exchange.

Lake Bosomtwe was formed by a falling meteorite about 1.3 million years ago. This was

discovered by Rock analysis in 1965 in the USA. Fossils of many animals including lions,

elephants, tigers, black cobras, pythons, and alligators were also found along the rivers

banks indicating that these animals once inhabited the area around the lake. Two rivers and

ground water keeps the water volume of the lake constant. The lake is surrounded by a

peaceful and serene atmosphere (http://africannaturetours.com).

Lake Bosumtwi is a large crater lake formed in an impact crater some 32 km south-east of

Kumasi, Ghana. It is the largest natural lake in Ghana, approximately 8 km across. The

lake is popular as a recreational area.Bosumtwi is a sacred lake to the Ashanti. According

to traditional beliefs, the souls of the dead come here to bid farewell to their god Twi.

Because of this, they only considered it permissible to fish in the lake from wooden planks

(rather than the usual traditional canoes). There are about 30 villages in the lake area, with

a combined population of about 70,000 people.

Lake Bosumtwi is estimated to be 1.07 million years old, placing it in the Pleistocene

period. The crater was easy to find, however, there was a problem in distinguishing whether

it was or was not caused by a meteor impact. This was because it is in the middle of a

rainforest and filled with water to form the lake. The problem with this was that shatter

cones and other rocks and minerals would be deep under vegetation and many of the

features of an impact crater were eroded. However, scientists managed to confirm it was

an impact crater after a dome in the centre, which is common in impact craters, was

discovered buried beneath the lake's floor. The impact is believed to have been a very

powerful one too because tektites have been discovered as far away as the Côte d'Ivoire.

The tektites are believed to have been from the impact.

After the impact the landscape in the area went through several different stages caused by

climate changes. Sometimes periods of heavy rainfall filled the whole crater with water so

the lake level was up to the lowest points of the rim. These periods became obvious when

fossils of fish were found on the top of the hills. The water was even flowing out of the

basin through an overflow channel. But there were also times when the water level was so

low that that rain forest could come up inside the basin and the lake itself was only a small

pond. This period lasted until about 300 years before present.

There is a legend that in 1648 an Ashanti hunter named Akora Bompe from the city of

Asaman was chasing an injured antelope through the rainforest. Suddenly, the animal

disappeared in a small pond, as if the little water wanted to save the animal’s life. The

hunter never got the antelope but he settled close to the water and started catching the fish.

And he called the place “Bosomtwe”, meaning “god antelope”. This story also gives a hint

that by then the lake level was very low, and the dead tree giants standing offshore in the

lake are evidence for it as they are over 300 years old. The following centuries saw several

wars about the lake as both the Ashanti and the Akim people claimed the area to be theirs.

Finally, the Ashanti were victorious and secured Lake Bosumtwi for their kingdom. Each

village in the lake area has its own shrine or fetish grove. With the arrival of Christianity,

some of the people lost their belief in those, but still many are worshipping them for help

in bad times or against diseases. The spiritual centre of the lake is the Abrodwum Stone

(see map). Here, all the lake people will sacrifice a cow when an omen of bad fish harvest

occurs. This act is celebrated in the presence of his majesty, the Ashanti king, the

Asantehene himself. In the ceremony, the guts of the cow will be given to the stone and

the rest is thrown into the lake, so the crowd will rush into the water with cutlasses and

axes to take their share of the meat. This happening is surely worth seeing it, but as the

omen mentioned above depends on various different factors, it is hardly predictable.

3.4 POPULATION

Politically, there are 3 sub-districts, namely, Kuntenase, Jachie-Pramso and Amakom, but

for public health activities, the Jachie-Pramso sub-district has been divided into; Jachie

and Pramso. There are a total of 63 communities with an estimated 2000 population of

96,677.

3.5 STUDY DESIGN AND SAMPLE SIZE

The study was a descriptive cross-sectional study. With a population of 172, 599 and an

estimated 20% of the study population, 200 sample size was determined using EPI STAT

CALC software. Prevalence rate of 23% and a margin of 5% error and a power of 95%

confidence interval.

3.6 DATA COLLECTION AND TOOLS

Prepared questionnaires containing open ended in the form of probing questions and closed

- ended questions were used to interview the clients. The research assistants read out the

questions and interpreted them to the respondents in their local language (Twi) after which

their responses were recorded accordingly. The questions on malaria included the socio -

demographic characteristics such as the educational level, the occupation and the marital

status. Again, questions concerning the causes, prevalence and treatment of malaria were

asked.

3.7 PRE-TESTING

Before the start of the study, pre-testing of data collection tool was carried out at

Ejisu-Juaben, a community in the Ashanti Region of Ghana having similar demographic

characteristics to check for consistency, clarity and the acceptability of the study questions

to the respondents.

3.8 DATA HANDLING AND STORAGE

Questionnaires were numbered serially to allow for easy identification in the sequence in

which they were filled and collected. The identification numbers were kept throughout data

coding. Data were entered on SPSS spreadsheet. SPSS software was used to clean and

validate entered data and for performing the main analysis. Data were stored on laptop and

a backup on a pen drive and a compact disc as well as in the researcher’s electronic mail

inbox.

3.9 ETHICAL CONSIDERATIONS

Ethical approval was obtained from the Committee on Human Research Publication and

Ethics (CHRPE), School of Medical Sciences, SMS, of the Kwame Nkrumah University

of Science and Technology, KNUST and the District Health Management Team (DHMT),

Bosomtwe district. Informed consent was sought from the participants before they were

included in the study. Participants were assured of their privacy and non-participation if

they so wished. Confidentiality of the data and outcome of the study were kept only for the

purpose of the study.

3.10 LIMITATION(S) OF THE STUDY

The study had several limitation, which includes; limited time in collecting data, data

collection assistance were not consistence.

CHAPTER FOUR

RESEARCH FINDINGS

4.0 INTRODUCTION

This chapter analysis and describes the findings of the study. Lake Bosomtwe is Ghana’s

only natural lake. The area is prevailed by malaria. Malaria was defined by WHO (2005)

as a parasitic disease that involves infection of the red blood cells.

4.1 DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

Malaria is prevalence in the Lake Bosomtwe area. The area is often filled with people with

various background due to the nature of the lake and its historical beginnings. Thus, the

lake serves as a tourist attraction for the nation as a whole.

Plate 1: Overview of Lake Bosomtwe

Source: Microsoft Encarta, 2007

The respondents were grouped into non health official and health officials. The causes,

effects and preventions of malaria vary in terms of age and educational background.

TABLE 4.1 EDUCATION BACKGROUND OF RESPONDENTS

Education Frequency Percentage

No formal education 100 50

Primary 50 25

Secondary 30 15

Tertiary 20 10

Total 200 100

Source: Author’s Field Work, 2007

The educational attainment of the respondents varies greatly. As shown, out of the 200

respondents, both health and non-health official, 100 of the respondents constituting 50%

had no formal education, 50 respondents constituting 25% had primary education, 30

(15%) had secondary education and 20 (10%) had highest form of education.

From the table, it can be estimated that, most of the respondents had no form of education,

therefore have influence on the data collected. The respondents with no level of education

could not actually perceive the causes, effect and prevention of the malaria. As for the

treatment, they were able to contribute. Also, they find it difficult in detecting the

symptoms of malaria from other disease related to them. The respondents who had primary

level of education were able to contribute to the study though they were doubting. Finally

the respondents who had tertiary education contributed to the study greatly to the study.

Due to their level of education, they were able to examine clearly to support the study.

TABLE 4.2: AGES OF RESPONDENTS

Ages Frequency Percentage

18-30 48 24

31-40 32 16

41-50 44 22

51+ 76 38

Total 200 100

Source: Author’s Field Work, 2007

The survey results further shows that age is not fairly distributed among the inhabitants in

the area. The composition of the age structure among the respondents is dominated by the

aged who constitute 38%, within the age group of 51 and above. Also, those within 41-50

years constitute 22%, 31-40 years constitute 16% and 18-30 years constitute 24% of the

study population.

The above table indicated that, the highest age among the respondents ranged between 41-

50,51and above. They were able to contribute to the study. This was due to the fact that,

the old are responsible for the health expenses of their dependants. In addition, the age

range between 18-30 years is the next dominant. The people fall under this age group,

normally is supposed to know the endemic and epidemiology of diseases but this is not the

case. This is attributed to high dropout and low educational level. However, a few were

able to contribute to the study.

TABLE 4.3 OCCUPATIONAL OF THE RESPONDENTS

Occupation Frequency Percentage

Drivers 16 8

Fishermen 16 8

Farmers 98 49

Teachers 5 2.5

Unemployed 50 25

Tourist Attendants 4 2

Retired Government Workers 3 1.5

Nurses 5 2.5

Medical Assistant 3 1.5

Total 200 100

Source: Author’s Field Work, 2007

From the table above 16 (8%) were drivers, 16 (8%) were fishermen, 98 (49%) were

farmers, 5 (2.5%) were teachers, unemployed respondents were 50 (25%), tourist

attendants were 4 (2%), retired workers were3 (1.5%), 5 (2.5%) were nurses and 3 (1.5%)

were medical assistants from the Kuntanase General Hospital. It can be clearly seen that,

majority of the respondents were farmers and fishermen. This is due to the availability of

fertile soil and the lake for fishing. This is the major occupation of the study site.

TABLE 4.4: SEX OF THE RESPONDENTS

Sex Frequency Percentage

Male 120 60

Female 80 40

Total 200 100

Source: Author’s Field Work, 2007

In the Ghanaian society, women are poor, voiceless and vulnerable. As shown in Table 4.4

out of the total respondents, 120 (60%) were male and 80 (40%) were females. The males

are the bread winners in most of the households visited. They were willing to voice out

their perception about the study on behalf of their families. Most of the females who

contributes to the study were single parents who are the heads of their own families.

4.2 MALARIA PREVALENCE

TABLE 4.5: PREVALENCE OF MALARIA

Incidence Frequency percentage

Yes 160 80

No 40 20

Total 200 100

Source: Author’s Field Work, 2007

Table 3.5 shows the occurrences of malaria at the study area. The table shows that,

incidence rate of malaria is very high. This data clearly shows the need for the study in the

Lake Bosomtwe District.

4.3 CAUSES OF MALARIA

TABLE 4.6: RESPONSE ON THE CAUSES OF MALARIA

Causes Frequency percentage

Unsanitary Practises 190 95

Ignorance 10 5

Source: Author’s Field Work, 2007

Malaria like any other infectious disease has so many causes to its existence. At the study

site, unsanitary practises and ignorance were the major causes of malaria. Table 3.6 shows

ignorance which includes (less public education on malaria) constituted 10 (5%) whiles

unsanitary practises which also includes (improper disposed of sewages, weeds and

stagnant water in cans and gutters) constitute 190 (95%). From the table, unsanitary

practises were seen to be the major cause of malaria in the area. These unhealthy practises

help in the breeding of mosquitoes especially the Anopheles mosquito (female mosquito)

(see plate 2).

Plate 2: An Anopheles mosquito

Source: Miscrosoft Encarta, 2007

When the mosquito bites the inhabitants, the mosquito deposits some species of

plasmodium parasites which actually cause malaria in humans. When the inhabitants are

infected, they are characterised by chills and fever mostly.

4.4 EFFECTS ON MALARIA PREVALENCE

TABLE 4.7 RESPONSE OF EFFECT ON MALARIA

Effect Frequent Percentage

Poverty 90 45

Death 20 10

Low Production 40 20

Loss of Weight 50 25

Source: Author’s Field Work, 2007

With the table above, it could be ascertained that, the effects of malaria on the inhabitants

were poverty 90 (45%), death 20 (10%), low production at work 40 (20%) and loss of

weight due to low appetite constituted 50 (25%). From the table, it was deduced that

poverty has the largest effect on the respondents. When the inhabitants get infected, money

and time are wasted in the course of the treatment. More so, when symptoms like chills

and fever resurface the body’s immune system becomes weak leading to low production,

low profit hence poverty.

4.5 TREATMENT AND PREVENTION OF MALARIA

TABLE 4.8 RESPONSE ON TREATMENT AND PREVENTION OF MALARIA

Variables Frequency Percentage

Treatment

Orthodox 190 95

Herbal Medicine 10 5

Prevention

Use of treated mosquito Nets 40 20

Use of mosquito Repellants 50 25

Keeping the environment clean 110 55

Source: Author’s Field Work, 2007

From table 4.8, 190 (95%) of the respondents use orthodox medicine either prescribed by

a medical assistant or bought from the pharmacy. About 10 (5%) use herbal medicine. The

herbal medicine is either bought from the chemist shop or they get them from the native

doctors. The herbal medicine is mostly a mixture of roots, weeds, leaves and herbs from

their surroundings. As the sayings goes, ‘prevention is better than cure.’ This statement is

true because from the above 40 (20%) uses treated mosquito nets as a way to prevent

themselves of getting malaria. About 50 (25%) uses mosquito repellents at night to

prevented getting malaria. Majority of the respondents sought to cleaning and a healthy

environment as a way of preventing malaria from occurring. If all these precautions are

met, the respondents believe that the prevalence o0f malaria in the district would reduce

dramatically. In effect, there would be less death, weight gaining, high production at the

workplace, high income, all resulting to poverty reduction.

4.6 HEALTH OFFICIAL RESPONSES

Among the health officials, there were three (3) medical assistants and five (5) nurses at

the Kuntanse Government hospital. According to the health officials, unsanitary practises

are highly rated in contributing to the prevalence of malaria at the district. Lack of

concentration, poor attitude to work, preterm in babies, and anaemia in pregnancy and

death especially in children are the effects of malaria in the district. According to them,

complying with the treatment of malaria as prescribe by the medical assistant, good

hygiene practises, continue public education on malaria and the use of intercede treated

nets at night will help in the prevention of malaria in the district.

In conclusion the health officials indicated that, 30% of malaria cases are recorded daily,

40% cases recorded weekly, 50% recorded monthly and 60% cases recorded yearly.

According to the health officials, among all the villages, Obo recorded the highest

incidence of malaria cases constituting 62.1% yearly.

CHAPTER FIVE

SUMMARY, CONCLUSION, AND RECOMMENDATIONS

5.1 SUMMARY OF FINDINGS

This study reveals the prevalence of malaria in the Lake Bosomtwe Area in the Ashanti

Region of Ghana by using cross-sectional data collected in February, 2007. This study

specifically assessed the prevalence of malaria, its causes, effects, treatment as well as

preventions in the study areas. The study assed the causes of malaria in the Lake Bosomtwe

area as result of unsanitary practises and ignorance.

The study further reveals that, poverty and death are the effects malaria has on them. It was

justified that, the inhabitants of the study area use both orthodox and herbal medicine in

treating malaria. Also, the inhabitants prevent themselves from getting malaria by the use

of mosquito nets and repellents as well as keeping their surroundings clean.

The key to understanding the potential of the prevalence of malaria is for the government

and health officials to recognise the fact that malaria is a factor to poverty and death in our

societies. Again, malaria is both a preventable and curable. However, this can be done if

greater attention and educational strategies are strictly put in place.

5.2 CONCLUSIONS

The research reveals that, the major causes of malaria are unsanitary practises which

includes; improper disposal of sewage, weeds stagnant water in cans and gutters and

ignorance in terms of less publicity on malaria. That is, most of the inhabitants are not

aware of the causes and preventions of malaria. Therefore, they are not able to avoid the

getting malaria. Also the improper disposal of waste and stagnant water in cans serves as

a catalyst for breeding of mosquitoes.

It was revealed that, poverty, death, preterm in babies, anaemia in pregnancy and loss of

weight, low productivity at work, low concentration especially in children are the effects

of the occurrences of malaria at the study site. Finally the study shows that, inhabitants

seek orthodox and herbal medicines in the treatment of malaria. In addition, malaria can

be prevent by the use of mosquito nets and repellents as well as keeping their surroundings

clean.

5.3 RECOMMENDATIONS

According to Turkington (2006), malaria is a serious, infectious disease spread by certain

mosquito usually the Anopheles. Malaria ranks among the major health and development

challenges facing the world. The Lake Bosomtwe is a tourist area, of which day in and day

out a lot people visit and stay, therefore there is a need for appropriate measures to be taken.

Based on the research findings, particularly the constraints identified, the following

suggestions are made for the prevention of malaria at the Lake Bosomtwe district of the

Ashanti Region;

Incidence of malaria should be reported very early and patients should comply with

treatment as required by the medical assistants.

Homes and surrounding environment should be kept clean: sewages must be

properly disposed, weeds must be cleared often and stagnant water in gutters and

cans should be kept dried.

There should be communal labour in the village around Lake Bosomtwe district.

The use of treated mosquito nets and repellents should be used often at night and

day time as precaution against mosquito bites.

Government should give out free mosquito nets and implement policies to cater for

children who suffer from malaria.

Preventive medicines such as Daraprin and Malaprin should be taken weekly.

Also, inhabitants should be vaccine against the infection using CS antigens and

gametocyte antigens.

Lastly, government and other institutions such as non-governmental agencies

should make it their ultimate aim of publicizing the awareness of malaria, thus, it

causes, effects, treatment and prevention.

5.4 LIMITATIONS

The inhabitants of the villages were very busy at the time of data collection. Some were

running their business whilst most of them were at funerals either within or outside the

district. Due to these reasons, not all categories of people were interviewed, though

random sampling was used in the study.

5.5 SUGGESTIONS FOR FUTURE RESEARCH

Future research could consider the whole of Ashanti Region since the regions is noted

for high incidence of malaria cases.

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