SCHOOL OF PUBLIC HEALTH

COLLEGE OF HEALTH SCIENCES

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY

BARRIERS AND FACILITATORS TO THE UPTAKE OF MALARIA

INTERVENTIONS AMONG PREGNANT WOMEN IN YENDI

MUNICIPALITY, GHANA

BY

JAMILATU ZAKARIA

THIS DISSERTATION IS SUBMITTED TO THE KWAME NKRUMAH

UNIVERSITY OF SCIENCE AND TECHNOLOGY IN PARTIAL

FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTERS

OF PUBLIC HEALTH IN HEALTH EDUCATION AND PROMOTION

SEPTEMBER, 2019
 DECLARATION

This thesis is submitted to Kwame Nkrumah University of Science and Technology, School

of Graduate Studies through the School of Public Health, Department of Health Education

and Promotion. I hereby declare that this thesis has been composed by myself and has not

been accepted in any previous application for a degree here or elsewhere. This thesis presents

results of original research undertaken by me personally under the supervision of Mrs Rose

Odotei- Adjei. Information taken from other works has been specially and duly

acknowledged.

Jamilatu Zakaria ………………………… ………………………

(20610832) (Signature) (Date)

Mrs Rose Odotei-Adjei ………………………… ………………………

(Supervisor) (Signature) (Date)

Prof Anthony K. Edusei ………………………… ………………………

(Head of Department) (Signature) (Date)

ii
 DEDICATION

This work is dedicated to the Almighty Allah for his boundless mercies and guidance in all

my endeavours.

To my parents and family for their prayerful support and encouragement.

iii
 ACKNOWLEDGEMENT

My gratitude first goes to God Almighty for giving me life, strength and courage to complete

this work.

I wish to express my heart felt gratitude to my academic supervisor, Mrs Rose Odotei-Adjei,

School of Public Health, KNUST, for her immense support and guidance in making this work

possible.

My gratitude also goes to Professor Anthony K. Edusei, Head of Department (HEP) and all

the lecturers and staff of Department of Health Education and Promotion, School of Public

Health, KNUST, for their support to my successful completion of my course.

I further extend my warmest gratitude to my research respondents for availing themselves to

be interviewed.

My sincerest gratitude goes to my colleague students who supported me in one way of the

other.

And last but not the least, to my family for supporting me both financially and emotionally.

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 ABSTRACT

Introduction
In 2012, the WHO revised its recommendations and now necessitates that in addition to
LLINs, at least three doses of SP be given to all pregnant women at each scheduled antenatal
care visit (ANC) beginning as early as possible in the second quarter and given at intervals of
one month (Amankwah and Anto, 2019). These treatments are inexpensive and cost-
effective. However, access to and use of these interventions by pregnant women is extremely
low. The study therefore sought to ascertain the barriers and facilitators to the uptake of
malaria interventions among pregnant women in Yendi Municipality.

Methodology
This was a case study of 394 pregnant women within communities in three sub-districts in
Yendi Municipal. Structured questionnaires and Focus Group Discussions were used to
collect data on pregnant women‟s socio demographics, knowledge of malaria in pregnancy
and its interventions, and the barriers and facilitators to the uptake of these interventions.
Thematic presentations were used for manual analysis of qualitative data after tape recording
and transcription. Quantitative data was analysed using Stata12. Categorical variables were
presented as frequencies and associations were assessed using chi-square analysis with 95%
confidence intervals.

Results
A total of 394 pregnant women at 16 weeks or more gestational age were studied. This
research has shown that pregnant women are conscious of malaria, but they still lack
extensive understanding of the disease. Some barriers could be attributed to supply-side
problems and inadequate knowledge about the benefits of the recommended interventions,
especially IPTp-SP. There were reports of side effects which affect their perception about the
interventions. It was found that mothers participated in the uptake of the interventions
because they were fairly knowledgeable about their benefits, especially LLINs. Also, their
uptake of IPTp-SP was because SP is part of the ANC routine drugs.

Conclusion
There is the need for concerted behavioural communication intervention to improve the
knowledge of malaria regarding malaria prevention measures, causes and benefits of the
uptake of recommended interventions.

v
 TABLE OF CONTENTS
DECLARATION......................................................................................................................ii
DEDICATION........................................................................................................................ iii
ACKNOWLEDGEMENT ...................................................................................................... iv
ABSTRACT .............................................................................................................................. v
LIST OF TABLES .................................................................................................................. ix
LIST OF FIGURES ................................................................................................................. x

CHAPTER ONE ...................................................................................................................... 1

INTRODUCTION.................................................................................................................... 1
1.1 Background of the study ...................................................................................................... 1
1.2 Problem Statement ............................................................................................................... 2
1.3 Research Questions .............................................................................................................. 3
1.4 Objectives of the Study ........................................................................................................ 4
1.4.1 General Objective ............................................................................................................. 4
1.4.2 Specific Objectives ........................................................................................................... 4
1.5 Significance of the Study ..................................................................................................... 4
1.6 Scope of the Study ............................................................................................................... 5
1.7 Conceptual Framework. ....................................................................................................... 5

CHAPTER TWO ..................................................................................................................... 8

LITERATURE REVIEW ....................................................................................................... 8
2.0 Introduction .......................................................................................................................... 8
2.1 Malaria in Pregnancy ........................................................................................................... 8
2.2 Consequences of Malaria in Pregnancy ............................................................................. 11
2.3 Malaria in Pregnancy interventions ................................................................................... 12
2.4 Knowledge and perception ................................................................................................ 14
2.5 Socio-demographics and uptake of malaria interventions ................................................. 18
2.6 Barriers to access of malaria preventive measures during pregnancy. .............................. 19
2.7 Facilitators to uptake of malaria interventions among pregnant women ........................... 22

CHAPTER THREE ............................................................................................................... 24

METHODOLOGY ................................................................................................................ 24
3.0 Introduction ........................................................................................................................ 24
3.1 Profile of study area ........................................................................................................... 24
3.2 Research setting ................................................................................................................. 26

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3.3 Research design and approach ........................................................................................... 26
3.4 Population and sample size ................................................................................................ 27
3.5 Sampling Techniques ......................................................................................................... 29
3.6 Instruments for data collection........................................................................................... 30
3.6.1 Primary Data ................................................................................................................... 31
3.6.1.1 Questionnaires.............................................................................................................. 31
3.6.1.2 Focus group discussion ................................................................................................ 31
3.7 Data analysis ...................................................................................................................... 32
3.8 Inclusion criteria ................................................................................................................ 32
3.9 Exclusion criteria ............................................................................................................... 32
3.10 Ethical clearance .............................................................................................................. 32
3.11 Study variables ................................................................................................................. 33
3.12 Assumptions ..................................................................................................................... 33

CHAPTER FOUR .................................................................................................................. 34

RESULTS ............................................................................................................................... 34
4.0 Introduction ........................................................................................................................ 34
4.1 Social demographic characteristics of respondents ........................................................... 34
4.2 Knowledge and perception ................................................................................................ 36
4.3 Barriers and facilitators to uptake of malaria interventions ............................................... 40
4.6 Association between socio-demographics of respondents and knowledge on mosquito bite
as a cause of malaria. ............................................................................................................... 42
4.7 Association between socio-demographics of respondents and knowledge on malaria
intervention .............................................................................................................................. 44
4.8 Association between socio-demographics of respondents and uptake of SP .................... 46
4.9 Association between socio-demographics of respondents and use of LLINs.................... 47

CHAPTER FIVE ................................................................................................................... 57

DISCUSSION ......................................................................................................................... 57
5.0 Introduction ........................................................................................................................ 57
5.1 Knowledge and perception ................................................................................................ 57
5.2 Associations between socio-demographics and knowledge on mosquito bite as the cause
of malaria ................................................................................................................................. 59
5.3 Associations between socio-demographics and use of LLINs .......................................... 60
5.4 Associations between socio-demographics and uptake of SP ........................................... 61

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5.5 Barriers to the uptake of malaria interventions .................................................................. 61
5.6 Facilitators to uptake .......................................................................................................... 63

CHAPTER SIX ...................................................................................................................... 64

CONCLUSION AND RECOMMENDATIONS ................................................................. 64
6.1 Conclusion ......................................................................................................................... 64
6.2 Recommendations .............................................................................................................. 65

REFERENCES ....................................................................................................................... 66
APPENDIX ............................................................................................................................. 78
DATA COLLECTION TOOLS .............................................................................................. 78
QUESTIONNAIRE ................................................................................................................. 78
ETHICAL APPROVAL LETTER .......................................................................................... 84

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 LIST OF TABLES

Table 3.1: Number of expected pregnancy from YMHD. ....................................................... 28

Table 3.2: Sample of respondents from selected sub-districts. ................................................ 29
Table 4.1: Socio-demographic characteristics of the respondents ........................................... 35
Table 4.2: Respondents knowledge and perception on malaria and its prevention ................. 38
Table 4.3: Barriers and facilitators to uptake of malaria intervention ..................................... 41
Table 4.4: Association between socio-demographics of respondents and knowledge on
mosquito bite as a cause of malaria ............................................................................. 43
Table 4.5: Association between socio-demographics of respondents and knowledge on
malaria intervention ..................................................................................................... 45
Table 4.6: Association between socio-demographics of respondents and uptake of SP ......... 46
Table 4.7: Association between socio-demographics of respondents and use of LLINs ........ 48

ix
 LIST OF FIGURES

Figure 1.1 conceptual framework on health Belief Model(HBM) ............................................ 7

Figure 3.1 Geographical Map of Yendi Municipal .................................................................. 26

x
 CHAPTER ONE

INTRODUCTION

1.1 Background of the study

The mantra of 'one million malaria fatalities' has been spoken annually by lay and scientific

authors alike for over 50 years (Breman, 2001). Malaria is a huge global health issue that

primarily affects young children, pregnant women and adults with little or no immunity. It is

recognised in the world's tropical and subtropical regions as a severe health issue. As a result

of its elevated and alarming morbidity and mortality rates, it has far-reaching medical, social

and economic implications for the nations where it is endemic (Osei Tutu, 2009). The disease

has a ruinous economic growth effect and continuous vicious cycles of poverty. It costs

Africa US$ 10 – 12 billion in lost national product every year, even though it can be

monitored for a fraction of that amount (Mba and Aboh, 2006).

Malaria is a life-threatening condition induced by the Plasmodium falciparum (WHO, 2010)

and it is the most common malaria species in the WHO African region, representing 99.7% of

estimated cases of malaria in 2017 (World Health Organization, 2018). People with malaria

often experience fever, chills and flu-like diseases. If left untreated, serious complications

may develop which may result in death (CDC, 2019). Malaria also manifests in a variety of

disease forms. Acute infections can lead to cerebral malaria (CM), anaemia, respiratory

distress, or hypoglycaemia; acute CM infections sometimes have long-term neurological

consequences. Repeated infections contribute to severe anaemia (WHO, 2014).

The problem of Malaria infection among pregnant women was originally reported nearly 83

years ago. A number of descriptive research in sub-Saharan Africa from the 1950s to 1984

concentrated on infections with Plasmodium falciparum and outlined the frequency of

placental diseases and specific adverse effects (Steketee et al., 2001). Thirty million pregnant

1
women across Africa are susceptible to malaria every year (WHO 2003), and there is a risk of

malaria throughout Ghana. Malaria accounted for 19% of all fatalities reported in Ghana in

2015 (World Health Organization, 2015).

The World Bank estimates that malaria during pregnancy contributes 9.0% of maternal

deaths and is the single largest contributing factor to all OPD admissions among pregnant

women (197,017 cases). (Odjidja et al., 2018). An earlier systematic review and meta-

analysis of seven studies established that malaria during pregnancy (MiP) is associated with

serious maternal anaemia, low birth weight and cerebral malaria in females and that could

lead to premature delivery and eventually death (Odjidja et al., 2018). According to Turyakira

et al. (2013), several studies have explored the effects of malaria on maternal health and

birth-results during pregnancy. While anaemia dominates the effects of MiP on maternal

health, information and mortality related to malaria are scarce. For the foetus, an enhanced

risk of low birth weight is the most frequently reported adverse effect of MiP, which is a high

risk factor for both impaired growth and infant mortality (Turyakira et al., 2013).

1.2 Problem Statement

Malaria continues to be one of the most prominent global health issues despite huge efforts

put in by both private and public sectors over the past few decades (Okeibunor et al., 2011).

Since 2000, malaria has cost sub-Saharan Africa $300 million annually for case management

alone and is estimated to cost up to 1.3% of GDP in Africa (UNICEF, 2018). Malaria alone

accounts for 28.1% of OPD attendance, 13.7% of admissions, and 9.0% of maternal fatalities

among pregnant women in Ghana (Ghana Ministry of Health, 2010).

A significant percentage of individuals at risk of infection, including pregnant women and

kids in Africa, are not secured. The 2008 World Malaria Report shows that there is

2
inadequate access and use of lifesaving malaria tools and treatment (World Health

Organisation, 2018).

Malaria during pregnancy has significant negative effects on mothers, foetuses as well as

new-borns, but the harmful effects can be avoided. A study done by State et al.(2011),

indicates that the inclusion of community-based programmes can substantially increase

effective access to malaria prevention, and also increase access to formal health care in

general. They also suggested the inclusion of antenatal care in combination with supply side

interventions.

The World Health Organisation recommends a package of interventions for prevention and

control of malaria during pregnancy in areas of stable plasmodium falciparum (Masaninga et

al., 2016). The detrimental effects of malaria during pregnancy can be significantly decreased

using these interventions that have been in the system for over twenty. These measures are

inexpensive and cost-effective. However, access to and use of these interventions by pregnant

women is extremely low, representing a failure of the public health community (Hill et al.,

2013).

1.3 Research Questions

1. What is the level of knowledge and perception of malaria and its prevention among

pregnant women?

2. What are the facilitators to the uptake of malaria interventions among pregnant

women?

3. What are the barriers to the uptake of malaria interventions among pregnant women?

3
1.4 Objectives of the Study

1.4.1 General Objective

The general objective of this study is to ascertain the facilitators and barriers to the uptake of

malaria interventions among pregnant women in Yendi Municipal, Northern region.

1.4.2 Specific Objectives

The specific objectives of the study are;

1. To assess the knowledge and perception of malaria and its interventions among

pregnant women.

2. To determine the barriers to the uptake of malaria interventions among pregnant

women.

3. To determine the facilitators to the uptake of malaria interventions among pregnant

women.

1.5 Significance of the Study

The researcher therefore seeks to contribute to existing literature of malaria in pregnancy by

exploring the factors that affect the access and use of malaria interventions among pregnant

women in Yendi Municipal. Specifically, the study will be substantial in clarifying the

motivators and impediments to the uptake of malaria interventions during pregnancy.

The severity of the problem associated with malaria in pregnancy will be identified, thereby

strongly raising awareness to the general public about the seriousness of malaria in

pregnancy, and the importance of accessing and utilisating malaria interventions. It is highly

essential to identify the factors that influence the uptake of these established malaria

interventions. Moreover, to unveil the level of knowledge and perceptions among these

pregnant women, so as to take informed measures to clarify misconceptions and

misperceptions about malaria in pregnancy and its interventions.

4
The realization of the above mentioned goal will contribute significantly to reaching target

one of sustainable development goal three, which is to reduce the global maternal mortality

ratio to less than 70 per 100 000 live births by the year 2030.

1.6 Scope of the Study

Geographically, the study will take place in Yendi Municipal located in the Northern region

of Ghana. In this regard, the study will focus on analysing the factors that influence the

uptake of malaria interventions among pregnant women in communities within the Yendi

Municipality. The analysis of this study will be based on a cross-sectional study in the

communities.

1.7 Conceptual Framework.

The conceptual framework used for the study draws its strength from a Behavioral Model

specifically the Health Belief Model (HBM). The HBM contains several primary concepts

which predicts why people will take action to prevent, to screen for, or to control illness

conditions (Champion, 2008). The original HBM comprised of four constructs, namely:

perceived susceptibility, perceived severity, perceived benefits, and perceived barriers.

Nonetheless, HBM scholars later improved the model‟s validity by including three new

constructs, namely, cues to action, self-efficacy and modifying factors (Glanz et al., 2002).

Perceived susceptibility refers to beliefs about the likelihood of getting a disease or condition.

For instance, a pregnant woman will take malaria intervention if she believes that there is a

possibility of her getting malaria.

Perceived severity is a belief about how serious a condition and its sequelae are. That is to

specify consequences of risks and conditions of a health issue instigate a person to adopt a

behaviour. For instance a pregnant woman who beliefs that malaria can lead to loss of her life

and that of her unborn baby would take malaria interventions seriously.

5
Perceived benefits refer to belief in efficacy of the advised action to reduce risk or

seriousness of impact. It describes an individual‟s opinion about the usefulness of a behaviour

in decreasing the risk of contracting an infection. People tend to adopt healthier behaviours

when they believe that such behaviours will decrease their chances of developing a disease.

For instance a pregnant woman needs to believe that the benefits of malaria intervention such

as consistent use of LLINs or taking SP reduces her risk of getting malaria and hence

experiencing its associated consequences.

Perceived barriers is belief about the tangible and psychological costs of the recommended

action. It can be described as an individual‟s evaluation of potential negative aspects or

obstacles to the adoption of new health behaviour. For instance, barriers like bitterness or side

effects of SP may dissuade a pregnant woman from taking it. Therefore, in bid of promoting a

health behaviour or intervention, it is imperative to identify and reduce perceived barriers

through reassurance, correction of misinformation, incentives, assistance.

Cues to action also refers to strategies to activate “readiness” of adopting a behaviour. The

concept of cues as triggering mechanisms is appealing, and can be an event, a person or

merely a conscious perception of a poster. For example a relative, colleague or health

personnel‟s opinion about malaria intervention can move a pregnant woman to utilize such an

intervention.

Self-efficacy refers to confidence in one‟s ability to take action.

Modif

ying factors including age, occupation, religion, marital status, education level, number of

births/ children may influence knowledge and perceptions and, thus, indirectly influence

health-related behaviour. For example, socio-demographic characteristics, particularly

6
educational attainment, are believed to have an indirect effect on behaviour by influencing

the perception of susceptibility, severity, benefits, and barriers (Champion, 2008).

The conceptual framework underpinning this study has been designed based on certain

constructs of HBM. This is illustrated in Figure 1.1

Figure 1.1 conceptual framework on health Belief Model(HBM)

(Author‟s construct, 2019).

7
 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

In this chapter, literature relevant to the research is delved into for an explicit understanding

of the subject matter. This chapter, therefore, captures areas including overview of Malaria in

Pregnancy, MiP interventions, the knowledge and perceptions about MiP and its

interventions, the barriers to the uptake of MiP interventions and the facilitators to the uptake

of MiP interventions.

2.1 Malaria in Pregnancy

The global burden of malaria has declined in recent years, but more than 40% of the world's

population is still at risk of infection and more than 400,000 people die each year. (Rogerson,

2017). The worldwide count of fatalities from malaria was 445 000, about the same number

reported in 2015 (World Health Organization, 2016). In 2016, a total of 216 million malaria

cases were recorded by 91 countries, an increase of 5 million cases compared to the prior

year.

Although the incidence of malaria has dropped worldwide since 2010, the rate of decrease

has halted and even reversed in some areas since 2014. Mortality rates followed a comparable

pattern (World Health Organization, 2016).

An projected 219 million malaria cases were reported worldwide in 2017 compared to 239

million in 2010 (95% CI: 219–285 million) and 217 million in 2016. Although there were an

estimated 20 million fewer cases of malaria in 2017 than in 2010, data for the 2015–2017

period underlines that no significant progress has been made in this time period in reducing

global cases of malaria. The World Health Organization (2016) reported that majority of

cases of malaria in 2017 were in the WHO region of Africa (200 million or 92%), preceded

8
by the WHO region of South-East Asia with 5% and the WHO region of the East

Mediterranean with 2%.

Plasmodium falciparum is the most predominant malaria parasite in the African region,

accounting for 99.7% of projected cases of malaria in 2017, as well as in the South East

Asian (62.8%), Eastern Mediterranean (69%) and Western Pacific (71.9%) regions of the

WHO.

Malaria is a major public health problem in Ghana, and one of the major causes of morbidity

and mortality in children. It was responsible for 19% of all documented deaths in Ghana in

2015. Statistics report that, Malaria in Ghana accounts for 4% of the global burden and 7% of

the malaria burden in West Africa. (Knowledge sharing for severe malaria, 2019).

It is caused by Plasmodium parasites, and infected female Anopheles mosquito, called

„malaria vectors‟, spread the parasites to humans through their bites (Knowledge sharing for

severe malaria, 2019). Malaria is hyper endemic in Ghana and among pregnant women,

putting both the mother and the foetus at risk of adverse effects (Gamble et al., 2006). It

accounts for 17.6% of OPD attendance, 13% of admissions and 3.4% of maternal deaths

(Malaria in pregnancy, 2015). Maternal mortality is twice higher in pregnant women with

malaria than among non-pregnant patients with severe malaria (Okafor et al., 2019).

In areas with low and unstable malaria transmission, such as many regions in Asia and the

Americas, women do not have significant anti-malarial immunity and are vulnerable to acute

and sometimes severe malaria, and foetal and maternal death (Gamble et al., 2006). In

regions with constant transmission of malaria, such as most sub-Saharan Africa, Plasmodium

falciparum infection during pregnancy is largely low-grade, sometimes sub-patent, persistent

9
or recurrent parasitaemia. These often cause no acute symptoms but maternal anaemia and

lead to low birth weight, which can lead to early child mortality. (Gamble et al., 2006).

Women in stable regions of malaria have obtained a pro-active immunity that, although partly

decreased during pregnancy, remains powerful enough to avoid the onset of acute clinical

symptoms in infestation (Cot et al., 2002).

Pregnant women are particularly prone to infection with malaria. Severe malaria may develop

without established immunity requiring emergency treatment, and loss of pregnancy is

prevalent. In semi-immune females, the effects of malaria on the mother include anaemia

while stillbirth, premature delivery and limitation of foetal growth inhibit the development of

the foetus (Rogerson, 2017); (Amankwah and Anto, 2019).

Malaria control during pregnancy should be an essential component of maternal and perinatal

morbidity and mortality reduction attempts in Africa (Agboghoroma, 2014).

After analysing 32 national cross-sectional data sets, a research carried out disclosed that

prevention of malaria during pregnancy is connected with significant decreases in neonatal

mortality and Low birth weight based on the circumstances of the routine malaria control

program. (Eisele et al., 2012).

In 2012, the WHO revised its recommendations and now necessitates that at least three doses

of SP be given to all pregnant women at each scheduled antenatal care visit (ANC) beginning

as early as possible in the second quarter and given at intervals of one month (Amankwah and

Anto, 2019). In addition, it also proposes the use of long-lasting insecticide-treated nets

(LLINs) to prevent malaria during pregnancy (Hill and Kuile, 2018).

The WHO Global Technical Strategy for Malaria offers a technical structure for all malaria-

endemic nations working to control and eliminate malaria. It sets ambitious but achievable

10
worldwide objectives for 2030, including decreasing malaria incidence by at least 90%,

lowering malaria mortality rates by at least 90% in at least 35 nations, and preventing malaria

from resurging in all malaria-free nations. The 2016–2030 timeline is in line with the 2030

Sustainable Development Agenda, supported in 2015 by all member countries of the United

Nations (Okafor et al., 2019).

2.2 Consequences of Malaria in Pregnancy

Millions of women in malaria-endemic areas are at increased risk of contracting malaria

infection that threatens the outcome of pregnancy. The complication of this infection is

considerable for mother and baby (Okoko et al., 2003). During pregnancy, the symptoms and

complications of malaria vary, based on the region's intensity of malaria transmission and the

individual's level of immunity. (World Health Organisation, 2017); (Rogerson, 2017);

(Deleron, 2003). P falciparum infections during pregnancy in Africa rarely lead to fever and

thus stay undetected and untreated (Desai et al., 2007).

Low birth weight (LBW) is a leading global risk factor for death among neonates and infants.

Plasmodium falciparum infection during pregnancy is a notable cause of low birth weight

(Eisele et al., 2012). Many studies show a significant association between placenta or

peripheral blood malaria infection and haemoglobin levels, which confirms that this is a

leading cause of anaemia, even if there are other factors. (Desai et al., 2007). A study by

Singh et al., (1999) also indicates that cerebral malaria is one of the prevalent complications

of severe falciparum malaria, with high pregnancy mortality.

Malaria can also affect the progression of antimalarial immunity during pregnancy during the

first years of life. Children born to placenta-infected mothers were shown to be more

probable than those born to non-infected mothers to develop a malaria infection between four

11
and six months of life. (Briand et al., 2007). In addition, malaria increases sensitivity to other

diseases and retards children's growth and development. (Okafor et al., 2019).

Malaria adversely affects the health and economy of the country, increases the cost of care

and adversely affects family avenue (Taremwa et al., 2017). Meta-analysis of intervention

trials suggests that effective control of these infections decreases the likelihood of serious

maternal anaemia by 38%, low birth rate by 43% and perinatal death by 27% among

paucigravidae. The low birth weight connected with malaria during pregnancy is estimated to

result in 100,000 infant deaths each year in Africa (Desai et al., 2007).

2.3 Malaria in Pregnancy interventions

With more importance placed on community and individual involvement, the spectrum of

malaria control is evolving globally (Oladimeji et al., 2019).

The World Health Organization proposes a three-pronged approach to malaria in pregnancy

control that involves the use of insecticide-treated nets (LLINs) and antimalarial drugs, either

by intermittent preventive therapy (IPT) or case management (treatment) (Gamble et al.,

2006).

In 2012, it revised its recommendations and now requires that in addition to LLINs, at least

three doses of SP be given to all pregnant women at each scheduled antenatal care visit

(ANC) beginning as early as possible in the second trimester and administered at one month

intervals. (Amankwah and Anto, 2019).

LLINs have a positive effect on the outcome of pregnancy in malaria-endemic African

regions when used by households or by individual mothers (Gamble et al., 2006). On the

other hand, IPTp may have an impact on reducing the risk of placental malaria in high-

12
transmission regions, low birth weight, severe maternal anaemia, and perinatal mortality in

the first two pregnancies (Gamble et al., 2006); (Gutman et al., 2013).

LLINs have proved effective and should be included in policies aimed at reducing the

adverse effects of malaria in pregnant women in endemic regions of the world (Gamble et al.,

2006). However, in this environment, IPTp presents higher difficulties to deliver via ANC

than LLINs. It is estimated that there is a significant decrease in the public health effect on

LBW arising from unproductive delivery of IPTp. Urgent attempts are needed to enhance this

significant intervention's service delivery (Hill et al., 2013).

A research conducted in Tanzania disclosed that there is scope for enhancing IPTp first and

second dose coverage at domestic level within current systems by enhancing stocks at RCH

and revising current rules to recommend delivery of IPTp after acceleration, rather than

during a predefined antenatal visit. (Marchant et al., 2008).

The Ghana National Malaria Control Program also updated its policy and now recommends

a minimum of five doses of SP. Ghana's objective to achieve 55% intake of at least three

doses of SP by pregnant women in 2015 was not achieved as only 41.3% received three or

more doses of SP over the period (Amankwah and Anto, 2019).

Although pregnant women's coverage of intermittent preventive treatment and use of

insecticide-treated nets has grown in majority of nations, coverage falls well lower than

global objectives, regardless of relatively elevated attendance estimate in antenatal clinics.

The outcome of implementing the WHO's 2012 policy amendment on intermittent preventive

treatment, which sets to make the message more comprehensible and align preventive

treatment with the targeted antenatal care plan, should be evaluated to determine if it leads to

increase in coverage (Van Eijk, 2013).

13
A number of factors also influence the implementation and reception of suggested measures

for MiP prevention and care. In conjunction to cost and accessibility problems, deterrents to

LLIN use and IPTp uptake included discontent with and concerns about LLINs or re-

treatment of insecticides and concerns about the side effects of taking SP during pregnancy

(Pell et al., 2011).

In addition to their clinical efficacy, the effectiveness of these measures relies on the

knowledge, attitudes and behaviours of pregnant women and the wider society which are

shaped by social and cultural variables (Pell et al., 2011).

2.4 Knowledge and perception

Adequate understanding of prevention of malaria can aid to reduce this increasing malaria

among vulnerable groups, especially pregnant females and the under 5 children residing in

endemic environments of malaria (Oladimeji et al., 2019). According to Oladimeji et al.,

(2019), indication from malaria knowledge, attitudes and practices (KAP) studies stipulates

that there are still misconceptions about the spread of malaria and the risk factors with

detrimental effects on activities for control of malaria. Findings from research done by Singh

et al., (2014) support this. However, they deduced that knowledge of prevention methods

does not necessarily result in practices being improved.

Perceptions and opinions about the cause of malaria are strongly influenced by thoughts

about their prevention (Adongo et al., 2005). The practice of preventive measures for malaria

has been linked to people's level of understanding and belief. Perceptions and opinions about

the cause of malaria are strongly influenced by thoughts about their prevention (Adongo et

al., 2005).

Many respondents in some areas of Bulsa district attributed the underlying cause of malaria

to dirty or stagnant water. In the qualitative interviews, the participants indicated that

14
mosquitoes drank and injected the dirty water into their body, causing malaria. This implied

that participants linked water, mosquitoes and malaria but the causal relationships, however,

were not well established (Adongo et al., 2005). Oladimeji et al., (2019) also deduced that

there have been gaps in knowledge about breeding sites for malaria-borne vectors, malaria

symptoms and malaria prevention measures.

Some studies in Nigeria and other African countries also revealed false and misleading

sources including staying long in the sun, drinking poor water, living in a filthy setting,

consumption of unhygienic food, stress, among other malaria misconceptions (Oladimeji et

al., 2019).

With regard to the signs and symptoms of malaria, (Hot body) is by far the most significant

symptom used in malaria recognition. Malaria feber is diagnosed with a general rise in body

temperature, often linked with other circumstances such as headache, loss of appetite, sour

mouth, vomiting and tiredness. (Adongo et al., 2005). In Northern Ghana, most individuals

also recognize other minor symptoms such as chills as a symptom of malaria feber (Adongo

et al., 2005).

Obol et al., (2011) from their study reported that, most pregnant females in northern Uganda

have comparatively elevated understanding of transmission of malaria, signs, symptoms and

effects during pregnancy. However, most participants had misperceptions about the cause of

malaria, while some had wrong or inaccurate ideas about how malaria was transmitted.

Household ownership and use of LLINs by pregnant women is progressing with present

attempts to increase application of LLINs, but the gap between ownership and use remains

large. (Belay and Deressa, 2008). In LLINs use surveys undertaken in Tanzania and Nigeria,

only a few participants had extensive understanding of malaria, and few of the participants

used LLINs. The knowledge constraints associated with the use of LLINs for malaria

15
prevention and the presumed misconceptions and adverse attitude towards the use of ITNs as

a preventive measure have resulted in the misuse of LLINs. Moreover, the attitude towards

LLIN use is affected by socio-cultural expectations, and cultural views about symptoms of

malaria such as fever, back pain, nausea, loss of appetite and vomiting as indications of

pregnancy, thus inhibiting women from using those LLINs. (Taremwa et al., 2017).

A study by Heggenhougen et al. (2003) on the adoption of LLINs by the society has shown

that different variables affect the use of LLINs, including cultural, behavioural and

demographic factors, ethnicity, availability, gender relationships and malaria seasonality.

(Mbonye et al., 2005).

The knowledge of possible causes, methods of transmission and choice on preventive and

control measures varies from society to society and between households (Kimbi et al., 2014)

and can play a significant role in the access of malaria interventions during pregnancy. A

study done by Obol et al., (2011) revealed that, a large proportion of participants were

familiar with mosquitoes as a cause of malaria / fever though a very small percentage of the

respondents were confident that malaria could be transmitted by mosquito bites from person

to person (Legesse and Deressa, 2009). In addition, findings showed that nearly all research

respondents from the different communities knew that malaria was a severe disease for all

age groups. (Legesse and Deressa, 2009).

A research undertaken by Singh et al. in Northern Nigeria's country side regions disclosed

that while awareness of prevention of malaria procedures was substantial (90%), it was

weakly mirrored in their practices. (Oladimeji et al., 2019). Targeted instructional programs

are needed to enhance the attempts of the populations to create desirable malaria attitudes and

procedures and their involvement in malaria control (Singh et al., 2014).

16
Good malaria practices in combination with elevated level of respondent knowledge are quite

important for the sustainable implementation of malaria intervention programs. One of the

techniques for malaria control that contributes to decrease in morbidity and mortality is

instructional teaching on the comprehension of individual malaria awareness, attitudes and

procedures (Amusan et al., 2017).

The most significant problem that emerges here is that malaria health education is often

presented or conveyed in a manner that makes it unacceptable to individuals. Control

campaigners for malaria base their messages on premises that individuals do not recognize

local understanding and malaria definition. The individuals of Kassena-Nankana and Bulsa

may not have the precise local name for malaria, but everyday experience points to malaria

being known as an endemic disease. (Adongo et al., 2005).

While local individuals may not have a biomedical concept of malaria, they have developed

local definitions and views over the years that are used to deal with malaria. Its long-term

impact on understanding could lead to the synchronization of local and biomedical

information that could promote the implementation and use of suitable health behaviours and

LLINs (Adongo et al., 2005).

In addition, a more efficient way to communicate data to individuals residing in endemic

malaria regions is needed. It is not appealing to individuals to simply tell communities that

mosquitoes cause malaria; health education needs to go beyond that and tell individuals why

it is the mosquito that causes malaria and not other insects. The complexity of malaria

transmission will involve a thorough science explanation, for example Health educators will

need to communicate malaria entomology and epidemiology in a basic language to groups so

that they comprehend (Adongo et al., 2005).

17
Despite adequate understanding about malaria and its preventive measures, there is a need to

enhance information availability through appropriate community channels. Particular

attention should be provided to community members who are non-literate (Mazigo et al.,

2010)

2.5 Socio-demographics and uptake of malaria interventions

The results from a study done by Oladimeji et al., (2019) show that socio-demographic

variables such as marriage and educational status have a major effect on the prevention and

control policies of malaria. Findings from Aregbeshola and Khan, (2018) support this.

Yaya et al., (2017) also proposes that the level of education is a main factor in malaria

awareness and that the likelihood of accurate malaria knowledge improves as the level of

education increases. This is supported by Knowledge sharing for severe malaria (2019) as

they revealed that, malaria infection rate is higher in non-literate mothers (43%) than

secondary education or higher (5%).

Also, results from a reasearch conducted by Balami et al., (2018) discovered that there are

conflicting outcomes for relationship between level of education and use of LLINs. Whereas

a number of studies revealed greater use of LLIN with higher educational and revenue levels,

others showed the opposite. However, their study's findings tend to be in line with the former,

as its respondents also confirmed a higher use of LLIN. Moreover, there was no important

connection between age, educational level, source of income and use of LLIN, comparable

with a past research within the exact area of Nigeria (Balami et al., 2018).

It was also established that mothers with a greater number of preceding pregnancies have

higher likelihood of sleeping under an LLIN, because they are probable to have enhanced

knowledge of the threats of malaria and a higher chance of attending ANC clinics, thereby

elevaing their chances of accessing LLINs (Idris, 2018).

18
On the other hand, Rumisha et al., (2014) expressed that, though it is anticipated that marital

status, education level and occupation predicts more doses of SP, it was not noted in their

research. In another research conducted by Dako-Gyek and Kofie (2015), it was discovered

that approximately 90% of pregnant females in south western Nigeria refused to take the

drug because of their religious convictions.

2.6 Barriers to access of malaria preventive measures during pregnancy.

To decrease this burden of MIP, there is a need to reinforce Public Health (PHC) systems and

address obstacles to the use of SP-IPTp and LLINs (Ameh et al., 2016).

A systematic review recognized several obstacles to IPTp uptake, including an absence of

community awareness of the benefits of IPTp, the safety of SP use during pregnancy, the

suggested IPTp dosing schedule, and whether SP can be taken on an empty stomach (Chico et

al., 2015). Similar to this statement, Sangaré et al., (2010) also found that, the primary

reasons for not completing a full 2-dose course of IPTp among women who had received

only 1 dose included not being given IPTp from the ANC and lack of awareness about the 2-

dose schedule.

From their study, Barriers to IPTp uptake in Uganda (2015) found that, despite a number of

minor issues (such as taking IPTp on an empty belly), mothers and communities are mainly

positive about ANC and IPTp. IPTp's refusal levels are low and therefore, considering the

strong ANC attendance, the primary barriers to IPTp's provision are likely to be supply-side

problems. In support of this, Rassi et al. (2016) expressed that due to the current elevated

ANC participation levels in Uganda, supply side obstacles are likely to account for many

missed chances to provide IPTp in Uganda.

A study found that educated women were more at risk of missed opportunities compared to

those without education, which was contrary to Masaninga et al.'s study, where increased

19
IPTp-SP uptake was associated with high school. This is probable because educated females

are more likely to have a more busy schedule due to their jobs and therefore do not fully

maximize the benefits of the ANC visit (Olukoya and Adebiyi, 2017).

Another significant obstacle to IPTp is the insufficient expertise of health employees about

when and how to deliver IPTp. This is worsened by the inconsistent and outdated data

contained in many policy documents and work aids to guide health employees (Barriers to

IPTp uptake in Uganda, 2015).

Sangaré et al., (2010) found that the failure to offer SP during ANC was the reason not

completing the full course of IPTp-SP. These results show the significant role of health

workers in providing IPTp to mothers and the need to investigate challenges in providing this

treatment.

Other challenges to proper treatment include procedural problems from the demand side.

COMDIS-HSD (2016) discovered that sometimes mothers are charged for what should be

free treatment when visiting private facilities. Health seeking behaviour was also identified as

a problem, with some interviewees only seeking medical attention during their pregnancy if

they feel ill. From their study, it was observed that some mothers appeared negligent by not

adhering with the recommended ANC visits or taking SP for IPTp (Mubyazi and Bloch,

2014). They were primarily concerned about psychosocial and some systemic (primarily

supply-related) factors, however, which reduced the likelihood of eligible pregnant females

attending hospital and possibly taking IPTp with SP doses (Mubyazi and Bloch, 2014).

Late ANC registration by low- and high-parity mothers, lack of vital supplies such as

drinking water and water cups (e.g., use of affordable disposable cups), significance of child

spacing, as well as improving people's understanding of MiP and IPTp hazards in particular

(Mubyazi and Bloch, 2014).

20
In a study conducted by Rassi et al. (2016), several health workers reported that they

sometimes do not observe DOT, especially if their workload is high or if women ask to take

the tablets home because they did not eat and do not want to take the medication on an empty

stomach. Some pregnant women testified that, ANC staff sometimes allow them to swallow

SP tablets at home and that gives some women room to throw away SP tablets after leaving

the clinic.

Some of the causes are within the clients themselves (psychological), while others are

external because they stem in their respective society and from the setting around the

pregnant clients. (Mubyazi and Bloch, 2014).

Women who are pregnant may feel more comfortable if they can act freely, including when

deciding whether to seek pregnancy care, where and when. Consequently, subjecting these

women to take the medicine under DOT without their will may seem forceful and

disrespectful of their autonomy to choose to use or not to use health care, and this is

intolerable or inappropriate to some of them (Mubyazi and Bloch, 2014).

Interviewees also noted that some women would delay ANC attendance because their

partners were unable or reluctant to accompany them. While this was not confirmed by any of

the mothers studied, several stated that they were handled differently based on whether or not

their partners had attended with them. They stated, for instance, that females who attended

with their partners were first seen, while those who attended without their partners had to

wait (Rassi et al., 2016).

With regards to LLIN use, it was established by Singh et al. (2013) that some of the basis for

not using LLINs included discomfort, heat or inconvenience, inadequate perceived benefit or

preferential use of other preventive techniques for malaria. This is backed by a research

undertaken by Aluko and Oluwatosin (2012), in which many mothers who slept under LLINs

21
experienced at least one type of discomfort with the greatest distress being excessive heat.

(Idris, 2018).

Ameh et al., (2016) in their study discovered that the lack of independence or freedom to

receive SP-IPTp during ANC without consulting a family member, particularly the head of

the household, is a barrier to using SP-IPTp. Refusal of SP during ANC visits may also be

due to presumed adverse effects of SP on pregnancy as observed in Cross River State and

Southwest Nigeria. Iliyasu et al. reported similar findings in northern Nigeria, but attributed

cultural factors to pregnant women's reluctance to use SP without their husbands ' prior

consent.

2.7 Facilitators to uptake of malaria interventions among pregnant women

Early initiation and frequent visits to antenatal care centres encourage the optimal use of SP

doses (Amankwah and Anto, 2019).

It was found that the primary factor in determining preventive use of SP during pregnancy

was being offered IPTp during an ANC visit (Sangaré et al., 2010). Early first ANC is crucial

in order to receive ideal doses of SP. It is presumed that a mother who visits ANC early is

likely to receive more doses of SP if supported by frequent ANC visits. Also, given that SP is

accessible and DOT is practiced at the facility (Hajira, 2015).

Another encouraging finding was that water, jerry cans, clean cups, and water purification

tablets had been provided in sufficient quantities when SP was offered (Rassi et al.,

2016).

Ameh et al., (2016) also stated that informal health care providers such as drug vendors,

traditional birth attendants and adolescent peer mobilisers are capable of increasing access to

and compliance with SP-IPTp.

22
Health education programs are a significant requirement to prevent malaria. These programs

target mothers, household heads and a broad variety of health care suppliers, and this is

channelled into higher chances of MiP intervention uptake (Ameh et al., 2016). In line with

this statement, the results of the review by Owusu-Addo and Owusu-Addo, (2014) suggest

that health education interventions are beneficial and remain a valuable resource in the

prevention and control of malaria in the community. This review found reasonable

indications that interventions in health education influence community-based malaria

prevention and control interventions, enhance malaria awareness, and generally improve the

prevalence and mortality of malaria in pregnant women.

23
 CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter provides the available research methods that will be used to ensure successful

execution of the study. It explains the methods that are specifically important for the purpose

of the study and the data collection techniques that will be used. It is sub-divided into

research setting, research design and approach, population and sampling techniques,

instrument for data collection, procedure for administration of instruments, data analysis

procedure, validity and reliability, and ethical issues.

3.1 Profile of study area

Yendi Municipal is one of the twenty six (26) administrative and political Districts in

Northern Region. The Municipality is located in the eastern corridor of the Northern Region

of the Republic of Ghana between Latitude 9º – 35º North and 0 º – 30 º West and 0 º – 15 º

East. The Greenwich Meridian thus passes through a number of settlements – Yendi, Bago,

Laatam, Lumpua, Gbetobu, Gbungbaliga and Nakpachei.

The population of the Municipality is about 148,650 projected from 2010 population and

Housing Census and is varied in terms of ethnicity with the Dagombas constituting the

majority. The other ethnic groups include Konkomba, Akan, Ewe‟s, Basare, Chokosi, Hausa

and Moshie.

The centrality of the Municipality within the Eastern Corridor puts it in a better position to

sap the energies of the remaining districts. This is manifested by the concentration of major

development projects in the Municipality e.g. Hospital, Telecommunication facilities, Pipe

borne water and banking services. The advantages inherent in the centrality of the district

24
notwithstanding, undue pressure are often brought to bear on the facilities mentioned above

due to the large catchment area of the district.

The Municipality has 30 electoral areas but has 31 demarcated CHPS zones.

The Economy of the people is largely subsistence with Agriculture being their main

occupation. Over 80% of the people depend on Agriculture for their livelihood.

Other economic activities include weaving, agro-processing (Shea butter extraction), meat

processing, fish mongering, wholesale and retail of general goods, transport and many others.

These activities are on a medium and small scale.

The potential of the district in Agriculture is enormous. The land is suitable for the

cultivation of cereals, tubers and rearing of animals. Animals reared include cattle, sheep,

goats, pigs and poultry birds for domestic and commercial purposes.

A good number of the populace is engaged in small scale manufacturing business. They

include smock weavers, blacksmiths, bakers, mechanics, Shea butter and groundnut oil

extraction.

25
Figure 3.1 Geographical Map of Yendi Municipal

3.2 Research setting

Geographically, the study was designed to take place in communities within three (3) selected

sub-districts of Yendi Municipal, Northern Region of Ghana. Specifically the study was done

in Yendi central, Yendi east and Yendi west.

3.3 Research design and approach

The case study design was adopted for this study. In the view of Zainal (2007), granting that

case study methods continue to be a debated method of gathering data, they are extensively

known in many social science studies especially when thorough descriptions of a public

behaviour are required. She also argues that, through case study methods, a researcher is able

to go beyond the quantitative statistical results and understand the behavioural conditions

through the actor‟s perspective. By including both quantitative and qualitative data, case

study helps explain both the process and outcome of a phenomenon through complete

observation, reconstruction and analysis of the cases under investigation.

26
This study design is more suitable because it offers an efficient way of looking at

occurrences, collecting data, analysing information and reporting results. It is an empirical

inquiry that investigates a contemporary phenomenon within its real life context when the

boundaries between phenomenon and context are not clearly evident and in which multiple

sources of evidence are used (Alnaim, 2015).

To achieve the objectives of this study, a mixed approach of quantitative and qualitative was

used in the collection and analysis of data. The rationale behind the selection of the mixed

method approach was for the broad purposes of breadth and depth of understanding and

corroboration. This approach provides researchers with opportunities to compensate for

inherent method weaknesses, on inherent method strengths, and offset inevitable method

biases (Almalki et al., 2016). Based on the principle of triangulation, the mixed method

approach was ideal since all appropriate characteristics of this research would not be fully

captured by any single technique such as interview or questionnaire

3.4 Population and sample size

In this study, the Taro Yamane formula was used to determine the required sample size. The

Taro Yamane formula for calculating sample size is given as;

Where n is the required sample size,

N is the study population,

e is the margin of error.

A report from Yendi‟s Municipal Health Directorate reviews that the number of expected

pregnancies for the year 2019 is 3377. Therefore, using this figure in the Taro Yamane‟s

formula, the sample size (n) was

27
n = 358

Making provision for 10% non-response, 10% of 358

= 35.8

≈ 36

Therefore the total number of respondents was

= 358+36

=394

Table 3.1: Number of expected pregnancy from YMHD.

Expected Pregnancy

ADIBO BUMBON GNANI YENDI YENDI YENDI MUNICIPAL

G CENTRAL EAST WEST

689 944 742 1284 842 799 5301

2014

709 982 764 1321 870 810 5457

2015

732 1006 787 1335 915 842 5616

2016

757 1038 813 1375 926 870 5779

2017

780 1068 838 1412 953 895 5946

2018

795 1089 857 1486 979 912 6118

2019

Source: Yendi Municipal Health Directorate, 2019.

Using the number of expected pregnancy from the selected sub-districts, the sample of

respondents from each of these sub-districts is presented in Table 3.2 below.

28
Table 3.2: Sample of respondents from selected sub-districts.
Sub-district No of expected pregnancy Proportion (%) Sample

Yendi central 1486 44 173

Yendi west 912 27 106

Yendi east 979 29 115

Total 3377 100 394

The target population for this study consisted of pregnant women in communities within the

selected sub-districts in Yendi Municipal; Yendi central, Yendi west and Yendi east. The

sample size estimate for collection of quantitative data for this study was 394 pregnant

women. The study involved only women whose pregnancies are above 16 weeks, which is

the recommended period for the first ANC visit and the first dose of IPTp is not given in the first

trimester. This study therefore placed emphasis on pregnant women who have attended ANC

at least once in the course of their pregnancy where they have been introduced to the

recommended malaria interventions.

3.5 Sampling Techniques

In order to answer the research questions, it was crucial that researcher be able to collect data

from all cases. Thus, there was a need to select a sample. Since, researchers neither have time

nor the resources to analysis the entire population, they apply sampling technique to reduce

the number of cases (Taherdoost and Group, 2017).

The selected sub-districts were chosen through convenience sampling. The respondents,

pregnant women, were also selected through simple random sampling. Two Focus Group

Discussions with participants ranging between eight (8) and twelve (12) were also conducted.

29
The sampling techniques employed in this study have further been explained below.

i. Convenience sampling

Convenience sampling is a type of non-probability or non-random sampling where members

of the target population that meet certain practical criteria, such as easy accessibility,

geographical proximity, availability at a given time, or the willingness to participate are

included for the purpose of the study (Etikan, Musa and Alkassim, 2016).

For this study, convenience sampling was used to select the sub-districts; Yendi central,

Yendi east and Yendi west due to geographical proximity.

ii. Simple random sampling

The simple random sampling was used to select the required sample size from the population

as simple random sampling method purely based on chance or equal opportunity, which is

desirable due to the unsystematic nature and the degree of uncertainty related to it, and that

participants had equal chance of being selected for this study.

3.6 Instruments for data collection

Mixed method approach was used to collect data in this study. This type of research is one in

which a researcher or team of researchers combine elements of qualitative and quantitative

research approaches (e.g., use of qualitative and quantitative viewpoints, data collection,

analysis, inference techniques) for the broad purposes of breadth and depth of understanding

and corroboration (Almalki et al., 2016).

For this study questionnaire was used for obtaining quantitative data from the respondents.

On the other hand focus group discussions was used for obtaining the qualitative facts.

30
3.6.1 Primary Data

It is data collected and observed from first-hand experience. Primary data collection methods

that was employed for this study included the following;

3.6.1.1 Questionnaires

According to Bird (2009), the questionnaire is a well-established tool within social science

research for acquiring information on participant social characteristics, present and past

behaviour, standards of behaviour or attitudes and their beliefs and reasons for action with

respect to the topic under investigation.

The researcher administered questionnaires to obtain information from the respondents about

the subject matter. The questionnaire included close ended questions; checklist questions.

Administering the questionnaire involved the researcher asking questions and recording the

answers in the questionnaire. This was used to obtain data from the respondents.

The questionnaire was first pretested with a small sample of respondents before use. The pilot

checked respondents‟ understanding and ability to answer the questions, highlighted areas of

confusion and looked for any routing errors, as well as provided an estimate of the average

time each questionnaire was taken to complete. Any amendments highlighted by the pilot was

made to the questionnaire before issuing a final version.

3.6.1.2 Focus group discussion

The focus group discussion involved gathering the pregnant women to discuss the specific

topic of interest. Questions were asked about their perceptions attitudes, beliefs, opinion or

ideas. In the focus group discussions, participants were free to talk with other group. Focus

group discussions generally involves group interviewing in which a small group of usually 8

to 12 people (Dti, 2016). It was led by the moderator (researcher) in a loosely structured

discussion of the various topics of interest.

31
According to Nyumba et al. (2018), focus group discussion is regarded as economical and an

encouraging alternative in participatory study offering a platform for differing paradigms or

worldviews.

3.7 Data analysis

After the data collection, the questionnaires were reviewed, responses were coded and

analysed using STATA. The results obtained from the information were explicitly discussed

with appropriate references to literature where necessary.

The qualitative analysis was done manually. The data (recordings) gathered from the field

were transcribed and organised into themes.

3.8 Inclusion criteria

a. Respondent should be a Ghanaian who has resided in the selected sub-districts for a year or

more.

b. Respondent should be pregnant for more than 16 weeks.

c. Respondent should be willing to provide an informed consent.

3.9 Exclusion criteria

a. The study will exclude all pregnant women within the selected sub-districts who have

been pregnant for less than 16 weeks.

b. The study will again exclude pregnant women who are not residents of the selected

sub-districts.

3.10 Ethical clearance

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

Ethics, KNUST. Informed consent and permission to participate in the study was obtained

from each participant. Participants also had the liberty to withdraw from the study anytime

32
they deem necessary. Moreover, participants were at liberty to choose not to answer

particular questions they are uncomfortable with. Strict confidentiality of the identity of

respondents was maintained. Completed data collection tools were retained until the final

work had been submitted and approved.

The knowledge and information that stemed from the study was made available for public

consumption through appropriate channels.

3.11 Study variables

The study examined the extent to which some of the independent-variables such as age,

occupation and religion affected the dependent variable (barriers and facilitators towards the

use of malaria interventions).

3.12 Assumptions

The assumptions below were made for the study

a. The sample size will adequately represent the population under study.

b. Some participants will not decline in answering the questions.

c. Respondents will be truthful, honest and frank with responses they give to the

questions.

33
 CHAPTER FOUR

RESULTS

4.0 Introduction

This chapter entirely presents findings from the survey conducted. These findings are

presented under five sections. The various sections encompass socio-demographic

characteristics of respondents, level of knowledge and perceptions of respondents on malaria

and its prevention among pregnant women, the facilitators to the uptake of malaria

interventions among pregnant women, the barriers to the access to and use of malaria

prevention measures during pregnancy.

4.1 Social demographic characteristics of respondents

A total of three hundred and ninety four (394) respondents were engaged in the study. The

respondents were from communities within three selected sub-districts in Yendi Municipality

namely Yendi Central, Yendi East and Yendi West.

Pertaining to age distribution, the minimum and maximum age recorded from the study were

14 years and 45 years respectively. Moreover, out of the total respondents, 39 (9.9%) were

within the ages of 14 years to 19 years, 219 (55.6%) were within the ages of 20 years and 29

years, 120 (30.5%) were within 30 years and 39 years, whereas the minority, 16 (4.0%),

were 40 years and above. The median age of the respondents was 26 years, with a mean age

of 26.86 years. Also the standard deviation for the age of respondents involved in the study

was 6.16. In terms of occupation majority of the respondents, 148 (37.6%), engaged in the

study were into trading with quite a number of them, 104 (26.4), engaged as Housewives.

Others were also into farming, civil servants with the minority, 31(7.9%), engaged in other

lines of work. The study also found that majority of the respondents, 383 (97.2%), were

married and the remaining, 11 (2.8%), were single.

34
With regard to the number of children, majority of the respondents, 112 (28.4%) had just one

child as at the time of the study. Only a handful of the respondents, 4 (1.0%), making the

minority had eight children. The mean number of children was estimated as 1.95 with a

standard deviation of 1.77. Notwithstanding that 111 (28.4%) of the respondents had attained

a secondary or higher educational level, 140 (35.5%) making-up majority of the respondents

had no formal education. On data collated for religion, Muslims constituted the majority, 292

(74.1%) of the total respondents. This was proceeded by 90 (22.8%) and 12 (3.1%) Christians

and Traditionalists respectively. A detailed description of the socio-demographic

characteristics of the respondents is presented in Table 4.1 below.

Table 4.1: Socio-demographic characteristics of the respondents

Variable Frequency Percentage (%)
Age
14-19 39 9.9
20-29 219 55.6
30-39 120 30.5
40+ 16 4.0
Mean ± SD= 26.86± 6.16
Range = 14 - 45
Median = 26
Occupation
Farmer 82 20.8
Trader 148 37.6
Housewife 104 26.4
Civil servant 29 7.4
Other 31 7.9
Marital status
Married 383 97.2
Single 11 2.8
Divorced 0 0
Widowed 0 0

35
Number of children
0 90 22.8
1 112 28.4
2 65 16.5
3 46 11.7
4 46 11.7
5 15 3.8
7 16 4.1
8 4 1.0
Mean ± SD = 1.95 ± 1.77
Range = 0 – 8
Median = 1
Educational level
None 140 35.5
Primary 71 18.0
Middle/JHS 70 17.8
Secondary/higher 111 28.2
Vocational 2 0.5
Religion
Christian 90 22.8
Muslim 292 74.1
Traditionalist 12 3.1
Other 0 0
Source: Field survey, 2019.

4.2 Knowledge and perception

Most (86.8%) of these respondents were fully aware and knew that mosquito bites cause

malaria. However some respondents had misconceptions about the cause of malaria. Falsely,

61 (15.8%), 26 (6.7%), 18 (4.7%) and 7 (1.8%) of the respondents associated the cause of

malaria to not keeping the environment clean, eating unhygienic food, walking in the sun and

working too hard respectively. Moreover, 31 (8.0%) of the respondents also associated

malaria to other causes such as through unclean water, not washing hands after using the

36
toilet and consuming too much oily foods. Furthermore, when respondents were probed

about whether or not pregnant women are susceptible to malaria 95.1% indicated “Yes”,

1.8% indicated “No” and 3.1% indicated “I don‟t know”. Virtually all the respondents, 383

(98.2%), were of the view that malaria is a grave and life-threatening disease. Response given

by respondents when they were queried about the possible signs and symptoms of malaria

included high temperature/fever (58.7%), headache (32.6%), weakness (32.1%), loss of

appetite (30.0%), chills and rigors (24.9%), vomiting (24.4%) and looks pale (6.9%). Also

35.2%, 25.6, 18.5%, 17.6% and 14.5% of the respondents respectively indicated abortion,

anaemia, still birth, premature delivery and underweight baby as some effects of malaria on

pregnancy. However, 22.0% of the respondents had no knowledge about the effects of

malaria in pregnancy.

The study also ascertained that 240 (64.7%) of the respondents asserted that malaria can be

transferred from one person to another. Among these respondents 69.7% indicated

transmission occurs through mosquito bite from one with malaria to another whereas 17.5%

also indicated that the transmission occurs as a result of sleeping together. Malaria prevention

methods that were cited by respondents included use of LLINs (87.1%), use of mosquito coils

(35.5%), use of mosquito repellents (24.8%), keeping gutters clean (23.8%), use of mosquito

spray (16.6%) among others.

Interestingly, majority of the respondents, (94.0%), indicated that they would go to a health

facility when they develop malaria. Also majority of the respondents, 350 (90.7%) were

cognizant about malaria intervention for pregnant women which included LLINs (93.7%) and

SP (58.0%). Side effects which respondents associated with the use of LLINs included

catarrh (9.1%), inhaling too much chemicals (13.0%), body itching (42.8%) and body

inflammation (2.1%). Also the side effects which respondents associated with the use of SP

37
were found to include nausea (19.2%), dizziness (20.4%) and tiredness (10.9%). Table 4.2

illustrates respondents‟ knowledge and perception on malaria and its prevention.

Table 4.2: Respondents knowledge and perception on malaria and its prevention
Variable Frequency Percentage (%)
What causes malaria?*
Mosquito bite 335 86.8
Eating unhygienic food 26 6.7
Walking in the sun 18 4.7
Working too hard 7 1.8
Not keeping the environment clean 61 15.8
Other 31 8.0
Do you think pregnant women are susceptible to malaria?
Yes 371 95.1
No 7 1.8
Don‟t know 12 3.1
Do you think malaria is a serious and life-threatening
disease?
Yes 383 98.2
No 7 1.8
Don‟t know 0 0
How do you know a pregnant woman has malaria?*
Looks pale 27 6.9
High temperature/ fever 229 58.7
Chills and rigors 97 24.9
Weakness 125 32.1
Loss of appetite 117 30.0
Headache 127 32.6
Vomiting 95 24.4
Other 104 26.7

38
What are some of the effects of Malaria in Pregnancy?*
Anaemia 100 25.6
Still birth 72 18.5
Abortion 136 35.2
Premature delivery 68 17.6
Underweight baby 56 14.5
Don‟t know 85 22.0
Other 47 12.2
Can malaria be transferred from one person to another?
Yes
No 240 64.7
Don‟t know 116 31.3
15 4.0
If yes, how?
Sleeping together 40 17.5
Mosquito bite from one with malaria and to another 159 69.7
Other 29 12.7
How can malaria be prevented?*
Use of repellents 95 24.8
Keep gutters clean 92 23.8
Use of LLINs 336 87.1
Use of mosquito coils 137 35.5
Malaria prophylaxis (SP) 43 11.1
Use of mosquito sprays 64 16.6
Other 89 23.1
What will you do if you develop malaria?*
Chemical shop 23 6.0
Drug peddler 4 1.0
Health facility 363 94.0
TBA 0 0
Herbalist 4 1.0
Self-treatment 4 1.0

39
Do you know any malaria interventions for pregnant
women?
Yes 350 90.7
No 36 9.3
What are some of the malaria interventions for pregnant
women?*
LLINs 358 93.7
SP 222 58
What are some of the side effects? (LLINs)
Catarrh 35 9.1
Inhaling too much chemicals 50 13.0
Body itching 165 42.8
Body inflammation 8 2.1
Other 52 13.5
What are some of the side effects? (SP)
Nausea 74 19.2
Dizziness 78 20.4
Tiredness 42 10.9
Other 124 32.1
Source: Field survey, 2019. * Multiple response

4.3 Barriers and facilitators to uptake of malaria interventions

From table 4.1, respondents were more familiar with health facility as the source of accessing

malaria intervention as compared with other sources.

From the study, 314 (90.0%) of the respondents admitted to have taken SP in their pregnancy.

Reasons underpinning the intake of SP among these respondents were to prevent malaria

(71.7%) and also as part of ANC routine drugs (28.3%). Moreover, reason for not taking SP

by respondents in their pregnancy was shrouded under side effects (17.4%), too many drugs

(11.6%), bitter tastes (5.8%) and other reasons (65.2%) such as no knowledge about SP, SP

were not given during ANC, and G6PD deficiency. It was also divulged that 350 (90.7%) of

40
the respondents used LLINs during their pregnancy. Of the 350 respondents, 95.7% used the

LLINs to prevent malaria whereas the remaining 4.3% used it as part of ANC routine items.

It was found that 33.3%, 22.2% and 12.5% of the respondents do not use ILLNs because they

feel uncomfortable using it, its side effects as well as heat associated with its use respectively.

Detailed findings on the barriers and facilitators to uptake of malaria intervention is presented

in Table 4.3 below.

Table 4.3: Barriers and facilitators to uptake of malaria intervention

Variable Frequency Percentage (%)
Where can you access malaria interventions?*
Chemical shop 4 1.0
Drug peddler 0 0
Health facility 366 94.8
TBA 0 0
Herbalist 0 0
Have you taken SP in this pregnancy?
Yes 314 90.0
No 69 18.0
If yes, why?
To prevent malaria 225 71.7
Part of ANC routine drugs 89 28.3
If no, why?
Side effects 12 17.4
Too many drugs 8 11.6
Bitter taste 4 5.8
Other 45 65.2
Have you used LLINs in this pregnancy?
Yes 350 90.7
No 36 9.3

41
If yes, why?
To prevent malaria 335 95.7
Part of ANC routine items 15 4.3
If no, why?
Side effects 8 22.2
Heat 4 12.5
Feels uncomfortable 12 33.3
Other 20 55.6
Source: Field survey, 2019.

4.6 Association between socio-demographics of respondents and knowledge on mosquito

bite as a cause of malaria.

In Table 4.4 below, the association between socio-demographics characteristics of

respondents and their knowledge regarding whether mosquito bite causes malaria was

analyzed using chi-square test at 95% confidence interval (Significance level, α=0.05). A p-

value less than the significant level (α = 0.05) was obtained for educational level (p-value of

0.006) and number of children (p-value < 0.001) vis a vis knowledge on mosquito bite as a

cause of malaria. The analysis therefore indicates that there is a statistically significant

association between these variables. That is knowledge that mosquito bite causes malaria is

associated with the educational level and number of children of respondents.

However, no association was found between knowledge on mosquito bite as a cause of

malaria and age, occupation, marital status as well as religion of respondents. This is because

their respective p-values compared with the level of significance was not statistically

significant.

42
Table 4.4: Association between socio-demographics of respondents and knowledge on
mosquito bite as a cause of malaria
Variables Malaria is caused by mosquito x2 P value
bite
Yes No
Age
14-19 27 8
20-29 192 27 5.4583 0.141
30-39 100 16
40+ 16 0
Occupation
Farmer 67 11
Trader 122 26
Housewife 89 11 7.6816 0.104
Civil servant 29 0
Other 28 3
Marital status
Married 324 11 1.7237 0.189
Single 51 0
Number of children
0 83 3
1 94 18
2 52 13
3 35 11 19.8156 0.006
4 40 6
5 15 0
7 12 0
8 4 0
Educational level
None 111 25
Primary 62 5
Middle/JHS 61 9 19.9570 0.001
Secondary/higher 101 10
Vocational 0 2

43
Religion
Christian 83 7
Muslim 244 44 4.6074 0.100
Traditionalist 8 0

4.7 Association between socio-demographics of respondents and knowledge on malaria

intervention

Moreover, the association between socio-demographics of respondents and their knowledge

on malaria intervention was explored using chi-square test at 95% confidence interval

(Significance level, α=0.05). A statistically significant association was found to exist between

age, occupation, number of children as well a religion and knowledge on malaria

intervention. The association is statistically significant because the p-value obtained for age

(p-value < 0.001), occupation (p-value = 0.027), number of children (p-value < 0.001) and

religion (p-value < 0.001) are all less than the level of significance (α = 0.05).

On the contrary, no statistically significant association was established between marital status

and educational level against knowledge on malaria intervention since their p-value were all

greater then the level of significance. This test of association is demonstrated in Table 4.5

below.

44
Table 4.5: Association between socio-demographics of respondents and knowledge on
malaria intervention
Variables Do you know any malaria x2 P value
interventions for pregnant
women?
Yes No
Age
14-19 27 8
20-29 203 16 17.8166 0.001
30-39 112 8
40+ 8 4
Occupation
Farmer 64 12
Trader 132 16 10.9984 0.027
Housewife 96 4
Civil servant 25 4
Other 31 0
Marital status
Married 339 36 1.1646 0.281
Single 11 0
Number of children
0 78 8
1 100 12
2 61 4
3 42 4 38.6251 0.001
4 46 0
5 15 0
7 8 8
Educational level
None 120 12
Primary 59 12
Middle/JHS 66 4 6.7014 0.153
Secondary/higher 103 8
Vocational 2 7

45
Religion
Christian 78 12
Muslim 268 20 19.2911 0.001
Traditionalist 4 4

4.8 Association between socio-demographics of respondents and uptake of SP

Table 4.6 also represents analysis of the association between socio-demographics of

respondents and their uptake of SP. At the given significance level of 0.05, both occupation

(p-value < 0.001) and number of children (p-value < 0.008) were ascertained to have a

statistically significant association with uptake of SP. The rest including age, marital status,

level of education and religion had no statistically significant association with the uptake of

SP by respondents.

Table 4.6: Association between socio-demographics of respondents and uptake of SP

Variables Did you take SP in this x2 P value
pregnancy?
Yes No
Age
14-19 27 8
20-29 185 34 3.5951 0.309
30-39 94 23
40+ 8 4
Occupation
Farmer 71 7
Trader 109 36
Housewife 89 11 18.9592 0.001
Civil servant 25 4
Other 20 11

46
Marital status
Married 303 69
Single 11 0 2.4887 0.115
Divorced 0 0
Widowed 0 0

Number of children 64 22
0 90 22
1 62 3
2 40 6 17.4003 0.008
3 34 12
4 12 0
5 12 4
7 - -
8
Educational level
None 107 22
Primary 63 8
Middle/JHS 56 14 4.4223 0.352
Secondary/higher 86 25
Vocational 2 0
Religion
Christian 74 16
Muslim 232 53 1.8265 0.401
Traditionalist 8 0
Other - -

4.9 Association between socio-demographics of respondents and use of LLINs

Interestingly, as presented in Table 4.7 socio-demographic characteristics of respondents

including age (p-value < 0.001), occupation (p-value of 0.003), number of children (p-value

of 0.007) and educational level (p-value < 0.001) were all found to have a statistically

significant association with the use of LLINs. Only marital status and religion were having a

47
p-value greater than the level of significance and hence showed no test of association with the

use of LLINs.

Table 4.7: Association between socio-demographics of respondents and use of LLINs

Variables Have you used LLINs in this x2 P value
pregnancy?
Yes No
Age
14-19 35 0
20-29 187 32 17.1655 0.001
30-39 116 4
40+ 12 0
Occupation
Farmer 78 0
Trader 132 16 10.4069 0.034
Housewife 88 12
Civil servant 25 4
Other 27 4
Marital status
Married 339 36
Single 11 0 1.1646 0.281
Divorced - -
Widowed - -
Number of children
0 70 16
1 100 12
2 61 4
3 42 4 17.7249 0.007
4 46 0
5 15 0
7 16 0
8 - -

48
Educational level
None 132 0
Primary 59 12
Middle/JHS 54 16 34.3445 0.001
Secondary/higher 103 8
Vocational 2 0
Religion
Christian 86 4
Muslim 256 32 4.4441 0.108
Traditionalist 8 0
Other - -

49
 FOCUS GROUP DISCUSSION 1

Knowledge and perception

Participants were asked to point out their opinions about what causes malaria. However, the

following responses were obtained.

“In my view I think mosquitoes cause malaria. That is to point out that when you refuse to

close your door at night these insects can enter the room and bite you when you are asleep.”

“I also think cold food causes malaria”

“To me malaria is caused by too much intake of oily foods.”

Respondents engaged in the study agreed that malaria is a life-threatening disease and that

they expressed their views;

One respondent bemoaned that;

“Malaria makes one lose appetite hence prevents one from eating well which eventually has

negative effect on the foetus during pregnancy.”

Another respondent noted that;

“I see it to be life threatening because it makes one feel very weak and dizzy.”

A respondent also lamented that;

“The worst of malaria is that it can cause miscarriage”

“Malaria can also cause deformity to a child.”

Respondents when asked whether they have any knowledge on symptoms of malaria they

expressed their views as follows;

50
“I always suspect malaria when have high temperature, headache, cold and rigors.”

Another respondent added that

“To me per the observation of an individual when sick tells that the parson has malaria.”

Respondents involved in the discussion agreed to the fact that malaria cannot be transferred

from one person to another.

Respondents when asked how they can prevent malaria in pregnancy they indicated the

following

“In my view, to be malaria free during pregnancy is to sleep under treated mosquitoes net.”

Another respondent claimed that;

“The use of mosquitoes coil and mosquito repellent can be useful in the prevention of

malaria.”

Another respondent also indicated that;

“Proper preseveration of food and proper eating can health prevent malaria.”

Respondents when asked what they will do if they realised that they have malaria, they

responded as follows

“I think the hospital is the best place to report to when you suspect malaria.”

“In my view, you only go to hospital when you are pregnant and you suspect that you have

malaria, if not you can buy drugs from drug store.”

Respondents expressed their view on the interventions for malaria as below

51
A respondent voiced that;

“The best intervention for malaria is to sleep under treat mosquito nets. However, intake of

malaria drugs could be helpful.”

Respondents expressed their view on the side effect of malaria intervention

A respondent lamented that:

“There is heat when using mosquito nets and that is the only side effect I have experienced”

Some respondents claimed that:

“There is no side effect in the use of malaria intervention.”

“I have no view on the side effect of mosquitoes net since I have not used it before.”

“I just acquired a mosquito net but I have not used it before”

“In my view the side effects of the malaria drugs include vomiting, dizziness and weakness.”

“I usually experience body itching, weakness and dizziness after intake of malaria drugs.”

“I even felt dizzy after taking the malaria drug.”

“I also felt very weak after talking the drug at the health facility which caused me to vomit.”

Another respondent claim that;

“To me I don’t even feel anything after taking the drug.”

52
Barriers and facilitators to uptake of malaria interventions

Respondents were asked, whether they know where they can access malaria interventions

“I see the health facilities to be the best place to access malaria intervention.”

“We also get free mosquitoes nets during mass distribution in our community.”

Respondents were asked why they take sulfadoxin pyrimethamine during pregnancy.

A respondent stated that;

“For me, the intake of the drug during pregnancy prevents me from getting malaria.”

Another respondent added that;

“To give birth to a healthy child the intake of this drug during pregnancy stage is the best.”

However, respondents agreed that sleeping under mosquitoes net helps a lot.

They agreed by saying;

“It prevents us from getting malaria because if only you sleep under it during the night you

will not be bitten by the mosquitoes.”

53
 FOCUS GROUP DISCUSSION 2

Knowledge and perception

A respondent explained that;

“I can get malaria through mosquito bite because it can bite an animal and later bite me.”

Another respondent expressed that;

“One can also get malaria when he/she fails to sleep under mosquitos net.”

A respondent stated that;

“Open cans can serve as a bleeding grounds of mosquitoes.”

Also another respondent claimed that;

“Open pot with water can also breed mosquitoes when you leave it uncovered also uncovered

food cause malaria when contaminated.”

Respondents bemoaned why they see malaria as a life-threatening disease

They lamented that;

“Malaria can lead to miscarriage when it affects a pregnant woman.”

“It can also result in giving birth to unhealthy child or cause pre-mature delivery.”

A respondent was of the view that;

“Feeling of pains all over the body is a symptom of malaria.”

Another participant said;

“Dizziness, loss of appetite, body itching and feeling warm are symptoms of malaria.”

54
When respondents were asked whether malaria can be transferred, a respondent explained

that;

“Yes, malaria can be transferred with the view that where one fails to sleep under

mosquitoes net and get bitten by these insect it can easily affect other people.”

A respondent revealed that;

“Sleeping under mosquitoes nets prevent malaria.”

Another respondent claimed that;

“Washing your hand after visiting the wash room prevent you from getting malaria.”

Another participant added that;

“Taking proper care of yourselves will present you from getting malaria but refusing to sleep

under the mosquitoes net will cause one to feel sick all the time.”

Respondent when asked what they will do if they had malaria, they respond by saying the

following;

“Will go to the health center for diagnosis and if there is malaria they will give me drugs.”

“You can also use local herbs to treat malaria by boiling the pawpaw leaves and then add

milk.”

When the respondents were asked whether they have any view with regards to intervention

for malaria they explained that;

“Sleeping under treated mosquitoes net and intake of malaria drugs can help quit malaria at

once.”

55
However, respondents noted the side effects of the malaria intervention

“I feel body itching after sleeping under the mosquitoes net especially if I fail to hang it

under the sun.”

Another pregnant woman claimed that;

“I feel very uncomfortable sleeping under mosquitoes net due to the heat.”

Barriers and facilitators to uptake of malaria interventions

Respondents were asked, whether they know where they can access malaria interventions

“Personally I see the health facility to be the best to treat malaria.”

Respondents were asked why they take sulfadoxin pyrimethamine during pregnancy

A respondent response that;

“It prevents me and the unborn baby from getting malaria.”

However, respondents agreed that sleeping under mosquitoes net helps a lot because they see

it to be important in prevention of malaria.

With regard to what prevent them from taking sulfadoxin pyrimethamine during pregnancy.

A respondent expressed that;

“For me nothing prevents me from taking the malaria drug during pregnancy.”

With regard to what prevent them from sleeping under mosquitoes net during pregnancy. A

respondent lamented that;

“Heat prevent me from sleeping under the mosquitoes net.”

56
 CHAPTER FIVE

DISCUSSION

5.0 Introduction

The World Health Organisation recommends a package of interventions for prevention and

control of malaria during pregnancy in areas of stable plasmodium falciparum (Masaninga et

al., 2016). The detrimental effects of malaria among pregnant women will possibly be

significantly decreased using these preventive measures proposed and accessible for more

than twenty years. These preventive measures are economical and low-cost. However, the

utilisation of these preventive measures during pregnancy is extremely low, demonstrating a

failure of the public health community (Hill et al., 2013).

The present study aimed to enrich an existing database and fill gaps with findings of MiP in

communities within three sub-districts in Yendi, Ghana. Therefore, this chapter discusses the

results obtained based on the specific objectives of the study in relation to previous literature.

5.1 Knowledge and perception

The findings from this study indicated that though most of the respondents had adequate

knowledge about the cause of malaria, there were still some misconceptions and

misperceptions about MiP and its interventions.

In the case of the causes of malaria, some respondents expressed that mosquito bites were the

main cause of malaria, but could not identify them as just being the vector. They also

affirmed some misconceptions like eating cold food, walking in the sun, working too hard

and consuming too much oily foods. This resonates with reports from research done by Singh

et al., (2014) and indications by malaria knowledge, attitudes and practices (KAP) studies

(Oladimeji et al., 2019). An interesting finding from the study was that, some respondents

associated malaria with other causes such as drinking unclean water, eating unhygienic food

57
and not washing hands after using the toilet. From this, it is evident that, some respondents

mistake malaria for diarrheal diseases like cholera and typhoid. Also, Adongo et al., (2005)

implied that in his study, participants linked water, mosquitoes and malaria but the causal

relationships were not well established. A similar discovery was made as some participants in

a Focus Group Discussion correctly attributed the cause of malaria to mosquito bites (vector)

but explained that “I can get malaria through mosquitoes bite because it can bite an animal

and later bite me”.

Results clearly showed that the respondents knew that they are susceptible to malaria and

were aware that malaria is a serious and potentially fatal disease. This finding is in line with

the findings from a study done by Legesse and Deressa (2009), that participants are well

aware that malaria is a serious disease. With regards to the signs and symptoms of malaria,

respondents exhibited high level of knowledge as they mentioned symptoms like headache,

loss of appetite and high temperature. This finding correlates with outcomes from a study

done by Adongo et al., (2005) as the respondents exhibited adequate knowledge.

Pertaining to the effects of MiP, a good percentage the respondents had fair knowledge, but a

chunk of them had no knowledge at all regarding the subject matter. For the knowledge of

malaria, once again, there were some misconceptions as some respondents claimed that

malaria can be transferred by sleeping together, clearly mistaking malaria for an STI like

HIV. On the other hand, in contrast with findings from a study conducted by Legesse and

Deressa (2009), a good number of respondents were well aware that malaria can be

transferred through mosquito bites from an infected person to an uninfected person.

A positively interesting finding from this study is that, all respondents attend ANC and visit

health facilities when they develop malaria. On the other hand, some participants in a Focus

58
Group Discussion agreed that “You can also use local herbs to treat malaria by boiling the

pawpaw leaves and then add milk.”

With the MiP interventions, Majority of the respondents were cognisant with LLINs as they

were aware that utilising it prevents malaria. It is also important to note that, though most of

the women stated that they have and use LLINs, some of them did not acquire them from the

health facilities, but from mass distributions. As for IPTp-SP, though more than half of the

respondents take or have taken SP, most of them only did because it was part of the ANC

routine drugs.

The women also voiced out some side effects they experienced from using LLINs and taking

SP. These side effects included catarrh, body inflammation and body itching for LLINs, and

for SP, they experienced nausea, dizziness, tiredness, etc.

5.2 Associations between socio-demographics and knowledge on mosquito bite as the

cause of malaria

Results from a chi-square analysis revealed that there is an association between the

educational level of women and the knowledge about the cause of malaria. This result builds

on existing evidence divulged by Obol et al., (2011) as their findings stated that there is a

relationship between educational level and knowledge on the cause of malaria. Also, as

suggested by Yaya et al. (2017), education is a major factor in malaria awareness. They again

stated that the likelihood of having precise knowledge of malaria improves as the level of

education increases.

On the other hand, results also showed that knowledge about the cause of malaria is

influenced by the number of children. Possible explanation could be that mothers who

previously went through pregnancy had already acquired some level of knowledge or

59
experience to enrich their awareness about MiP. The higher the number of children, the more

enriched or exposed they were to knowledge about MiP.

In the domain of associations between socio-demographics and knowledge on MiP

interventions, a statistically significant association was found to exist between age,

occupation, number of children as well a religion and knowledge on malaria intervention.

As Tijani (2017) had found from his study, age plays a significant role in the knowledge and

practice of malaria prevention, a similar result was found in this study. Also, it was revealed

that occupation has an influence on the knowledge about malaria prevention. A possible

reason for this is that pregnant women with busy work schedules are more prone to missed

opportunities and at more risk of missing antenatal visits where they are educated more about

MiP and its interventions (Olukoya and Adebiyi, 2017). Again, number of children was found

to influence knowledge about MiP interventions. This, possibly, is because mothers who

previously went through pregnancy had already acquired some level of knowledge and have

been taught to use these interventions (Idris, 2018). Lastly, there was an association between

religion and knowledge about MiP interventions. This finding is parallel with the results of

the study conducted in Nigeria on the prevalence of malaria parasite infection among

pregnant women. The study found that about 90% of pregnant women in Southwest Nigeria

refused to take malaria drugs due to their religious beliefs (Dako-Gyek and Kofie, 2015).

5.3 Associations between socio-demographics and use of LLINs

Socio-demographic characteristics of respondents including age, occupation, number of

children and educational level were all found to have a statistically significant association

with the use of LLINs.

Inconsistent outcomes were conveyed regarding the relationship between level of education

and use of LLIN. Whereas a number of researches reported increasing utilisation of LLIN

60
influenced by higher educational level and source of income, some others revealed the

opposite. Nonetheless, the results from this study, just like a study conducted by Balami et

al., (2018) seems in line with the former, since increased utilisation of LLIN was stated by

their respondents.

It was also established that mothers with greater number of previous pregnancies have higher

chances of sleeping under an ITN. This has been attributed to the fact that they are likely to

have better knowledge about the perils of malaria and a better chance that they will attend

ANC clinics, thus boosting their chances of using ITN (Idris, 2018).

5.4 Associations between socio-demographics and uptake of SP

Both occupation (p-value < 0.001) and number of children (p-value < 0.008) were ascertained

to have a statistically significant association with uptake of SP. Contradictory to findings

from Rumisha et al., (2014), occupation as expected to be a predictive variable of uptake of

recommended doses of SP, was not observed in their study. Number of children on the other

hand influences the uptake of SP in sense that, with every pregnancy, a mother is exposed to

experiences, education and counselling about the benefits of taking SP (Idris, 2018).

5.5 Barriers to the uptake of malaria interventions

Some participants in the Focused Group Discussion expressed that “In my view, the health

facilities are the best place to access malaria intervention”. It is evident from this that

pregnant women are aware that the best point of contact to acquire MiP interventions is the

health facility. On the other hand, they also stated that, they acquire LLINs during mass

distributions in their various communities, and not necessarily the health facilities. Though it

pertains to SP, this can possibly be attributed to supply-side problems as reported by Barriers

to IPTp uptake in Uganda, (2015). This can be a barrier to access and use of MiP

interventions.

61
For the barriers to the use of LLINs among pregnant women, a respondent during one of the

Focus Group Discussions lamented that; “Heat prevenst me from sleeping under the

mosquitoes net.” Other side effects stated by the participants included body inflammation,

catarrh and body itchingSingh et al. (2013) discovered that some of the reasons provided for

not using ITNs included discomfort, heat or inconvenience, inadequate perceived benefit or

preferential use of other preventive techniques for malaria. This is backed by a research

undertaken by Aluko and Oluwatosin (2012), in which more than one-quarter of females who

slept under ITNs experience at least one type of pain with the greatest discomfort being

excessive heat. This could be due to Africa's typical hot weather and absence of electricity

(Idris, 2018).

For the barriers to the uptake of SP, it can also be noted that some mothers seemed negligent

by not complying with the recommended ANC visits or taking SP for IPTp (Mubyazi and

Bloch, 2014).

Though from the study, 90% of the respondents admitted to taking SP, a number of them said

they do not, because of side effects they experienced from previous intake. Some side effects

included nausea, dizziness and weakness. Similar results were obtained by Ashwood-Smith et

al., (2002) as some pregnant women said that they sometimes felt dizzy after they took SP.

Also, a reported barrier to the uptake of SP was that, the health workers did not provide

enough information about SP before administering the drug, hence, their refusal to take it.

The WHO (2018) in response to this has therefore reported that simplified IPTp messages

and training of health workers have been demonstrated to enhance coverage of IPTp.

62
5.6 Facilitators to uptake

The respondents expressed that they adhere to the uptake of SP because it will prevent them

from getting malaria and that it help to have a healthy baby, free of deformity. However, a

good number of them admitted to taking SP because it was part of the ANC routine drugs and

that it is DOT drug. This finding builds on results by Sangaré et al., (2010) as they stated that

the primary factor in determining preventive use of SP during pregnancy was being offered

IPTp during an ANC visit.

With regards to LLINs, the reported facilitators to its use is to prevent malaria. It is also

worthy to note that, regular ANC attendance contributes to the uptake of SP. Findings from

Amankwah and Anto (2019) supports this as they stated that early initiation and regular ANC

attendance resulted in a higher number of visits and uptake of SP.

Limitations of this research took account of recall bias on account of information made

available by respondents. This limitation notwithstanding this report gives a fair idea of the

level of knowledge and perceptions about malaria in pregnancy and its interventions, and the

barriers and facilitators to the uptake of these interventions.

63
 CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion

This study has revealed that pregnant women are conscious about malaria, though there is

still a deficiency in the extensive understanding of the disease. A good number of pregnant

women recognise various important malaria symptoms like headache, cold and fever. The

study also registered some level of misconception regarding malaria, which has to be entirely

lay bare by strengthening education about malaria among pregnant women (Oladimeji et al.,

2019).

Some barriers could be attributed to supply-side problems as there were reports that some

pregnant women were not given LLINs at the health facilities, but rather from mass

distributions within their communities. Other barriers included inadequate knowledge about

the benefits of the recommended interventions, especially IPTp-SP. Moreover, though most

of the women take SP and use LLINs, there were reports of side effects which affect their

perception about the interventions.

Pertaining to the facilitators to the uptake of the interventions, it was found that mothers

participated because they were fairly knowledgeable about their benefits, especially LLINs.

Also, the mother‟s participation, especially with IPTp-SP, was influenced because SP is part

of the ANC routine drugs.

There is therefore, the need for concerted behavioural communication intervention to

improve the knowledge of malaria regarding malaria prevention measures, causes and

benefits of the uptake of recommended interventions.

64
This insight will assist policymakers execute incessant tactical action as well as health

education and awareness activities to achieve the 2030 malaria objectives.

6.2 Recommendations

Just as Oladimeji et al., (2019) proposed, the problem of misconceptions and misperceptions

about MiP and its interventions all boils down to Health education.

1. Health promotion education to pregnant women should be done both at the community

level and at the health facilities during ANC visits, to change misconceptions of the causes of

malaria and its interventions among women. Health promoters and educators who work with

the pregnant women should also be knowledgeable.

65
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77
 APPENDIX

DATA COLLECTION TOOLS

QUESTIONNAIRE

Kwame Nkrumah University of Science and Technology

Department of Health Education and Promotion

Master of Public Health (Health Education and Promotion) 2018/2019 Thesis Field Research

This questionnaire is intended to gather data geared toward assisting Jamilatu Zakaria, a

Master of public Health student in the Department of Health Education and Promotion,

School of Public Health, Kwame Nkrumah University of Science and Technology for his

Research Thesis titled “the barriers and facilitators to the uptake of malaria interventions

among pregnant women in Yendi Municipal”

Declaration: Information supplied herein will be used only for academic purposes and will

be treated with utmost confidentiality.

Instructions to respondents

• Do not write your name or contact details on the questionnaire.

• Tick in the space provided for closed questions

• Fill in the space provided for open ended question

78
 SECTION A

Background Information

1. Age ……….

2. Occupation: a. Farmer [ ] b. Artisan [ ] c. Trader [ ] d. Housewife [ ] e. Civil

servant [ ] f. Other (please specify)………………

3. Marital status: a. Married [ ] b. Single [ ] c. Divorced [ ] d. Widow [ ]

4. Number of children…………..

5. Educational level: a. None [ ] b. Primary [ ] c. Middle/JHS [ ]

d. Secondary/higher [ ] e. Vocational [ ]

6. Religion: a. Christian[ ] b. Muslim [ ] c. Traditional [ ] d. Pagan [ ]

SECTION B

Knowledge and perception

7. What causes malaria? a. mosquito bite [ ] b. Eating unhygienic food [ ] c. Walking in

the sun [ ] d. Working too hard [ ] e. Not keeping the environment clean [ ] f. Other

(please specify)…………………………………………………………………………….

8. Do you think pregnant women are susceptible to Malaria? a. Yes [ ] b. No [ ]

c. Don‟t know [ ]

9. Do you think that Malaria is a serious and life-threatening disease? a. Yes [ ] b. No [ ]

c. Don‟t know [ ]

10. How do you know a pregnant woman has malaria? a. Looks pale [ ] b. High

temperature/Fever [ ] c. Chills and rigors [ ] d. Weakness [ ] e. Loss of appetite [ ]

f. Headache [ ] g. Vomiting [ ] h. Others (please specify)……………………………

79
11. What are some of the effects of malaria in pregnancy? a. Anaemia [ ] b. Still birth [ ]

c. Abortion [ ] d. Premature delivery [ ] e. Underweight baby [ ] f. Don‟t know [ ]

g. Others (please specify)………………………………………………………………

12. a. Can malaria be transferred from one person to another? Yes [ ] No [ ]

b. If yes, how is malaria spread from one person to another?

a. Sleeping together [ ] b. mosquito bite from one with malaria and to another [ ] c.

Other (please specify)…………………………………………………………………….

15. How can malaria be prevented? a. Use repellents [ ] b. Keep gutters clean [ ] c. Use

of mosquito nets [ ] d. Use mosquito coil [ ] e. Malaria prophylaxis (SP) [ ] f. Use

mosquito sprays [ ] g. Other (please specify)………………………………………………

14. What will you do if you develop malaria? a. Chemical shop [ ] b. Drug peddler [ ]

c. Health facility [ ] d. Traditional birth attendant [ ] e. Herbalist [ ] f. Self-treatment [ ]

16. Do you know any malaria interventions for pregnant women? a. Yes [ ] b. No [ ]

18. If yes, what are some of the malaria interventions for pregnant women? a. LLINs [ ]

b. IPTp (Sulfadoxine-Pyrimethamine) [ ]

19. What are some of the side effects? (LLINs) a. Catarrh [ ] b. Inhaling too much

chemicals [ ] c. Body itching [ ] d. Body inflammation [ ]

e. Others, please specify…………………………………………………………………

20. What are some of the side effects? (IPTp) a. Nausea [ ] b. Dizziness [ ]

c. Tiredness [ ] d. Weakness [ ] e. Others, please specify………………………………

80
 SECTION C

Barriers and facilitators to uptake of malaria interventions

21. Where can you access malaria interventions? a. Chemical shop [ ] b. Drug peddler [ ]

c. Health facility [ ] d. Traditional birth attendant [ ] e. Herbalist [ ]

22. Have you taken SP in this pregnancy? a. Yes [ ] b. No [ ]

23. If yes, why do you take SP? a. To prevent malaria [ ] b. Part of ANC routine drugs [ ]

c. Recommended by significant others [ ] d. Others (please specify)……………………………

24. If no, why don‟t you take SP? a. Side effects [ ] b. Too many drugs [ ] c.

Forgetfulness [ ] d. Bitter taste [ ] e. Other, please specify………………………………

25. Have you used LLINs in this pregnancy? a. Yes [ ] b. No [ ]

26. If yes, why do you use LLINs? a. To prevent malaria [ ] b. Part of ANC routine items [ ]

c. Recommended by significant others [ ] d. Others (please specify)……………………………

27. If no, why don‟t you use LLINs? a. Side effects [ ] b. Heat [ ] c. Feels

uncomfortable [ ] d. Others (please specify)………………………………………………

81
 FOCUS GROUP DISCUSSION GUIDE

Kwame Nkrumah University of Science and Technology

Department of Health Education and Promotion

Master of Public Health (Health Education and Promotion) 2018/2019 Thesis Field Research

This Focus Group Discussion guide is intended to gather data geared toward assisting

Jamilatu Zakaria, a Master of public Health student in the Department of Health Education

and Promotion, School of Public Health, Kwame Nkrumah University of Science and

Technology for his Research Thesis titled “The barriers and facilitators to the uptake of

malaria interventions among pregnant women in Yendi Municipal”.

Declaration: Information supplied herein will be used only for academic purposes and will

be treated with utmost confidentiality.

Section A

Knowledge and perception

1. In your opinion how can one acquire malaria?

2. Why do you think that Malaria is a serious and life-threatening disease? / What are some

of the effects of malaria in pregnancy? (if it is not treated early)

3. How will you know a pregnant woman has malaria?

4. Can malaria be transferred from one person to another? If yes, how?

5. How can you prevent malaria in pregnancy?

6. What will you do if you develop malaria?

7. Do you know any malaria interventions for pregnant women? What are they?

8. Do you think malaria interventions have side effects? What are some of them?

82
 Section B

Barriers and facilitators to uptake of malaria interventions

1. Where can you access malaria interventions?

2. Why do you think it important to take Sulfadoxine-Pyrimethamine (SP) in this

pregnancy?

3. Why do you think it important to use LLINs during pregnancy?

4. What prevents a pregnant women from taking SP?

5. What prevents a pregnant women from using LLINs?

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