Malaria control and prevention in pregnant women and children in Ghana: Policies and programs.
Malaria is a global life threatening disease, in Ghana malaria is hyper-endemic and undermines the health of all in the country (Ghana RBM report, 2003). Though it affects people of all ages, the effect of malaria is very serious in children and pregnant women due to their level of immunity, (Asante F and Asenso-okyere, 2003), when malaria is not properly treated in pregnant women it can lead to still births, anaemia, underweight babies and maternal deaths(Asante F& Asenso-Okyere,2003), In children apart from malaria been the major cause of class absence, complicated malaria resulting in cerebral malaria can lead to epilepsy, brain damage and learning difficulties (WHO/UNICEF,2001). It is also classed third among all childhood diseases (Ministry of Health, 2002). The main vector for malaria transmission in Ghana is the female Anopheles Gambiae and Anopheles Fenustus. Plasmodium Fulciparum is the predominant parasite, it accounts for 90% of malaria infection, Plasmodium Malariae accounts for 9% and plasmodium ovale accounts for the remaining 1% of all cases of infections (Ghana RBM report, 2003). Malaria is among one of the leading cause of morbidity and mortalities in Ghana, 45% of patient attending outpatient clinics daily and 13% of hospital deaths are due to malaria, 22% of children under five die from it every year and overall 9% of all deaths can be attributed to it. (De la Cruz et al, 2006).Malaria control has been identified as one of the major priorities of the ministry of health and the Ghana health service, it has also been given a lot of attention in the poverty reduction strategy paper due to its predicted effect on productivity and micro economic stability of the country.(Ghana RBM report, 2003). There has been a global initiative in fighting malaria which aims to halve the morbidity and mortality rate of malaria by 2010 worldwide; this is to be achieved through the roll back malaria initiative, in 2000 this initiative was endorsed by forty-four of the fifty-five African heads of states in Abuja (Abuja Declaration, 2000). The heads of states agreed on( for the purpose of this eassay) three most basic targets to combat the effects of malaria by providing 60% of people suffering malaria with affordable, appropriate and prompt treatment in 24hours of malaria attack, 60% 0f pregnant women and children under five years of age to be sleeping under insecticide treated nets (ITN) and access to other preventive measures. Also 60%pregnant women to have preventive intermittent treatment therapy (Abuja Declaration,2000), all these by 2005, using potent drugs, insecticides and nets as tools (Molyneux and Nantulya,2004). Designing a public health intervention program for malaria prevention the health belief mode(HBM) developed by Becker (1974) will be adapted to look at early detection, diagnosis and treatment for malaria control and prevention including vector control. The HBM suggests that for a person to adopt a preventive action they first have to feel susceptible and threatened by the consequences of the disease, perceive that the benefits of undertaking a preventive action outweigh the perceived barriers and there are cues to take action (Mbonye 2006, Pakhshani 1999,) The HBM is been used in this easy because it has a direct implication on health intervention programes as each of its components can be adapted to traditionally suit health intervention strategies in malaria prevention (Pakhshani, 1999). It under two broad areas of early detection, diagnosis and treatment as one aspect, the other aspect will be planning and implementing lasting preventive measures including vector control.
Perceived Susceptibility And Severity (Early Detection, Diagnosis And Treatment)
Malaria is mostly perceived as an illness which can be self limiting, not severe and hence does not require an immediate attention (weller et al 1997) also believed to be a normal sign of pregnancy (Mbonye 2006) as pregnant mother tend to get morning sickness and easy fatigability which is also a symptom of malaria. In Ghana it is uncommon for initial treatment and management of malaria to start at home either with herbs or over the counter drugs outside the healthcare facilities due to cultural beliefs and practises surrounding pregnancy, cost, time and lack of transportation (C J. Mba1 and I K. Aboh, 2003) people only seek health facility treatment mostly after their attempts to treat have failed (Adjapong, 1992) According to UNICEF (2008) in rural areas in Sub-Saharan Africa out of 100 episodes of malaria, 5 are treated in hospitals, 15 in dispensaries and 80 are self treated. Some of these treatments maybe appropriate and complete, whereas others can be inappropriate leading to clinical complications such as anaemia, cerebral malaria and other parasitological problems which can lead to drug resistance (C J Mbal & K Andoh, 2003). Treatment seeking practises is determined by factors such as previous pregnancies, perceived cause of a condition and cultural beliefs (Kogun and Kauna). health education and access to the different health care facilities are the main policies involved here. Health education is required to develop the knowledge of the mother in her ability able to recognise malaria and seek the appropriate treatment can, and based on the HBM if the mother is made aware of complications such as premature births, maternal mortality, still births, low birth weight and spontaneous abortions (kengeya-kayoundo, 1994) she will be take action. For the mothers to be able to do this they need to be educated on the consequences of not treating malaria properly.. One policy strategy is to address the treatment of malaria at house hold level and health facilities in the various cities, towns and villages. The key element in this is to use home management of malaria as a means of improving access to malaria treatment in areas where healthcare system is far to reach and self treatment is common and inappropriate.(Pagnoni F,2008) This based on UNICEF(2008) guidelines should include a pre-packed and user friendly unit-dose artemisinin based antimalaria drugs which are available close to the home of the individual and easily accessible through a network of trained community based providers. For this home management to be effective people should be educated on their ability to spot the signs and symptoms of malaria and behaviour change. Asenso-okyere(1994) conducted a study in Berekuma, Oyereko and Kojo Ashong (all these four districts are within Accra) found out that people perceived the causes of malaria to be drinking unsafe water, malnutrition, living in unhygienic environment, flies and polluted air. They also perceived the symptoms of malaria to be chills and shiver, headaches, and sour taste in the mouth, heat, generalised body weakness, yellowish urine and eyes. This is an indication that raises concern as people may not identify the symptoms proper and in effect musk the hidden symptom of other underlining diseases which may also exhibit the same symptom. De la Cruz et al (2006) Identifies that in planning a health intervention for a country like Ghana with a lot of deep seated believes its important to categorise these believes and also identify ways of reinforcing positive believes and incorporating them in the plan and also finding ways of amending others that can be detrimental to the people.
Choosing, planning and implementing lasting preventive measures including control of vector:(perceived benefits and barriers)
Prevention of malaria is a major public health challenge and a prority in the rollback malaria partnership which focuses on three areas in reducing the burden of malaria on the pregnant woman such as effective case management, the use of insecticide treatedd nets (ITN's) and intermittent preventive treatments with Sulfadoxine- pyrimethamine(SP) (Akinleye et al 2009). This involves administering a curative dose of SP to the mother at least three times during the period of the pregnancy at a routinely scheduled ante-natal clinics irrespective of whether the mother is parasitemic or not and to be administered under the direct observation of the clinic staff(Akinleye et al, 2009). Antenatal clinics are the main point of access since almost every mother at least attends the clinic once in the period of pregnancy (Aghoja et al, 2008). A study conducted by Akinleye in Nigeria found out that pregnant women uptake of ipti uptake in women was poor due to lack of knowledge To achieve this a protocol to aid health care workers to be able to administer the right doses at the correct intervals has to be set. This in collaboration with the multi-disciplinary team such as the pharmacist, the midwives and the nurses and doctors. A national training scheme will also be designed to train all staff to be able to administer and observer patients to take the drug and to be equipped with knowledge to be in the position to be able to demystify any fears and misconceptions perceived by the mothers. Also women within child bearing age will be targeted with campaigns and health promotion programs to update their knowledge to improve their acceptance to the use of SP when they become pregnant.
there is a nationally renowned interest in the use of insecticides in the control of malaria, (Anto et al, 2009) Molyneux and Nantulya (2004) suggest that these targets can be achieved by joint forces with other preventive programs such as vaccination programs which are already underway, by this the population that are underserved can be reached which could also drive the cost down, this they said has been evidenced by the a recent link of free ITN distribution to measles vaccination program in the Gambia and Ghana which achieved the Abuja target in one week, they also suggest control of mosquito vector as the most effective approach in controlling malaria and this can reduce the increasing resistance of vectors to the available drugs. A meta-analysis showed that ITN's reduce the incidence of malaria by 50% in children under five's and a combination of ITN's and antimalarial chemoprophylaxis can reduce the incidence of malaria by 97% (Chanddramohan et al,2005), it has also been proven to have a good impact on the outcomes of pregnancies in mosquito endemic areas and also as a form of vector control (gamble et al, 2006) this has been used effectively in the kessenan-Nankan district which first started as a trial intervention and now used as a national policy in combating malaria and also to support the roll back malaria campaign.(Anto et al 2009 ), but Anto et al identified in their study in Kassenan Nankana that, though the Anopheles funestus and gambiae are susceptible to the insecticides treated nets in the district, there has been recent reported cases of possible vector resistance to the insecticides used to impregnate these nets in neighbouring Burkina Faso and this was likely to have a negative impact on the success with the use of ITN's. the 60% target set for children under five and pregnant mothers to be sleeping under ITN's by 2005 appears to have not been achieved, yet these targets have been increased to 80% by 2012 to reach the most vulnerable (WHO,2005) countries have devised ways of increasing coverage in achieving these targets and in Ghana one method has been the use of voucher redemption scheme as a system of delivering ITN's to pregnant mothers and their children as it is known that mothers tend to share beds with their babies. These were to be distributed through antenatal clinics by the midwives from the first month of pregnancy or the first day of attendance to the facility, but Kwake et al (2007) conducted a study in Volta region, found some problems with the midwives in imposing an eligibility criteria on mothers by insisting they proved their ability to pay the difference on top of the voucher before issuing the vouchers to mothers who attended the clinics, also a high number of pregnant mothers failed to attend the antenatal clinics hence missing out on the benefit of the scheme, otherwise the voucher scheme could have been a good way of distributing ITN's to mothers and the midwives could have been useful in educating mothers on the importance and benefits of using these ITN's. Other reason resulting in poor usage of bed nets can be attributed to lack of knowledge on the side of mothers on the causes of malaria and the importance of the use of bed nets in malaria prevention. All though a considerable amount of efforts and campaigns has gone into the use of these ITN's, issues around affordable and accessibility are pretty obvious in Ghana, particularly those who live in the very remote areas of the country. Due to high temperatures in Ghana some parents may find it very uncomfortable sleeping under these bed nets, and some people have even described the bed nets as looking like shrouds for covering the dead. Some have even attributed the fever that is a symptom of malaria to the heat from the sun and therefore does not see the need to sleep in mosquito nets at night (WHO, 2005) these and other beliefs knock the use of these bed nets.
Intermittent prevention and treatment in infancy (IPTi) involves the administration of antimalarial drugs as a prophylaxis beside other immunization drugs as a form of malaria control, this is an approach to expand coverage by taking advantage of the well expanded infrastructure of immunization program (Mockenhaupt et al 2007), in this case a curatve dose of of antimalarial chemoprophylaxis is administered to a child at the time of routine vaccination irrespective of whether or not the child is parasitaemic. Continous administration of IPTi to children and pregnant mothers prevent incidence of anemia, mortality and outpatient attendance. A study conducted in Tanzania in administering ipti along side the expanded immunizaton program at ages 2, 3 and 9 months reduced the incidence of anaemia by 50% in the first 12 months of life irrespective of whether the child have malaria (chandramohan et all,2005).
As Ghana becomes champion in controlling malaria with programs and policies incidence will start to decline, hence a greater understanding of preventive coverage level is required to sustain control. It does not make it possible to relax due to lower transmission settings resulting from the good preventive coverage, we could assume that high levels of coverage would be sustained for a long period of time, but this can vary across the country. Therefore contingency plans should be put in place to combat outbreaks quickly and If lower coverage levels are adequate to maintain control, momentous costs can be saved.
it is a necessity to have evidence to be able to make policies and start programs in malaria control, these policies and programs needs to be specific to the country, city or town to be effective. The problem with the ongoing rate of resistance of the malaria parasites to drugs can only be dealt with through research to be able to come up with other policy drugs to tackle the parasites (WHO,2003) allocating resources to funding research in malarial is a very important part of controlling malaria it helps in defining the kind of programs and interventions that is needed in the country and its also able to trace the epidemiological changes resulting from better interventions, for Ghana to be able to sustain the delivery of ITN and vector control the knowledge gap in the cost involved and the projection into the future has to be researched into this has to involve the provider the user and the ministry of health point of view. It has already been established that due to the increased poverty rate of the people the most effective method of increasing coverage is by free distributing of malaria control agents, but this in effect can burden the resources and make it impossible to achieve any targets, hence researching into the most cost effective ways of delivery where the is a balance in delivery and acquisition, also the life span of the ITN should be considered. The policy should be to supply the cheapest with the longest life span of the treatment and control agents can be a way in the direction of achieving these targets set by WHO. Malaria control and treatment differs from country to country, and so does it even differ within a country due to urbanisation, a study by Baragatti et al (2009) found out that
According to peters, (1997) malnutrition is able to reduce the antipathgenicity of the human immune system.the risk of failure of antimalaria treatment in children in the northern part of Ghana seem to increase. Another study conducted in okomfo anokye teaching hospital (kath) in Kumasi on chloroquin resistance to P falciparum show that anemia is a long term complication from malaria and it increases the burden of malaria. Also before patiens presents themselves for treatment at the health center they would have already taken chloroquine but due to resistance will still remain parasitinemic.(evans et al,2005A prospective study by Evans et al (2005) conducted in Kumasi to investigate the resistance of plasmodium Falciparum to chloroquine in children found out that, there was an extensive use of chloroquine among the 189 patients recruited for the study who already had clinical symptoms or a history of malaria. In fact one of the participants had a very high chloroquine plasma level and a high parasitaemia,which could be an indication of recent chloroquin intake or sheer resistance to the drug. The study supports the current assertion that the use of chloroquine as a single therapy in the treatment of malaria has to be replaced or used in combination with other potent drugs in other to control and treat malaria. (Evans et al, 2005) In Ghana now the drug policy has changed from chloroquine been the first line of treatment for uncomplicated malaria to a combination of artesunate and amodiaquine due to the increased treatment failure of chloroquine
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