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Factors influencing utilization of a malaria prophylaxis programme in Ghana
Sot
SCI. & Med.. Vol. 9. pp. 241 to 24R. Pwpmon
Press
1975 Printed
in Great
Britam
FACTORS INFLUENCING UTILIZATION OF A MALARIA PROPHYLAXIS PROGRAMME IN GHANA D. W. BELCHER, D. D. NICHOLASand S. N. BLUMENFELD School of Public Health, University of California, Los Angeles, U.S.A. and S. OFOSU-AMAAHand F. K. WURAPA Department of Community Health, University of Ghana Medical School, Accra, Ghana Abstract-In 1973 an interview survey was done in rural Ghana to learn about factors affecting participation in a malaria prophylaxis programme and whether volunteer workers could effectively serve as medication distributors. Several maternal characteristics were associated with higher participation and continuation rates. Education was not a factor. but women over age 30 and those with larger families had better programme attendance. This was attributed to a greater sense of need in larger families and greater previous use of and satisfaction with health programmes by older mothers. In addition, mothers who knew about modern preventive actions to avoid fever had significantly higher entry and continuation rates in the programme. Village volunteers were more successful than trained health workers in creating initial awareness of the programme and in motivating mothers to start and remain in the programme. Special efforts will be made in this year’s (1974) malaria programme to motivate younger mothers to participate and to maintain improved information flow.
Malaria is the third most common cause of death in Ghanaian pre-school children. In June 1973, an anti-malarial programme for children 5 years of age and under was started in the 15.000 person Danfa district in Ghana. Each month for 6 months 2700 pre-school children in 61 villages were offered one dose of pyrimethamine to suppress malaria infections. The distribution of the malaria medication was one of the public health measures of the Danfa Comprehensive Rural Health and Family Planning Project,* a joint research project of the University of Ghana Medical School, Ghana’s Ministry of Health, other interested Ghanaian agencies, and the School of Public Health, UCLA, with the support of the United States Agency for International Development [l]. The effectiveness of this malaria chemoprophylaxis programme was measured by periodic malaria films and spleen examinations. The programme will be repeated annually for the remaining 5 years of the Danfa Project. This report describes a special study conducted in November 1973 to learn how many pre-schoolers participated in the prophylaxis programme and what factors influenced their attendance. In addition, the effectiveness of two methods for distributing malaria tablets was evaluated. To obtain this information, a survey interview schedule inquiring into the knowledge, attitudes and practices regarding the malaria programme was administered to a 25 per cent sample of households containing pre-school children in the Danfa Project area. Two distribution systems were organized to reach the target population of children aged 5 years and younger. The Danfa Health Centre staff covered all villages located within a one mile radius of its station* Supported in part by USAID Grant OCOP/AID/CM/ afr-IDA-73-14.
ary health centre or one of its three satellite clinics. Mothers in these villages were told to come to the health centre or a satellite clinic once each month. Such villages contain 48 per cent of the population in the Danfa district. All other villages in the Danfa district were served by village volunteers, primarily school teachers, under the supervision of the health centre sanitarian. Most of the volunteers were serving as part-time birth and death registrars for their communities. After an orientation session to describe the programme and distribution procedures, an initial tablet distribution session in the village was supervised by the sanitarian. Subsequent distribution to individual communities was then the responsibility of the volunteer who arranged an acceptable monthly distribution date with each community. A detailed report of the recruitment, training and supervision of the volunteer programme will be published later. METHODS (1) Sample. In April 1973, 2 months before the malaria programme started, the annual project household census was conducted in the Danfa district. A computer listing 2240 households grouped by village was prepared. The sample frame consisted of 892 households containing pre-school children. A systematic sample of every fourth household on the listing was used to select the initial sample of 223 households. Only those households which had been resident in the Danfa district for the entire JuneNovember 1973 period were considered eligible for participation. (2) Survey procedures. The households were contacted and interviewed during a l-week period in November 1973. Each interviewer had an assigned household list. with alternative households to use if assigned respondents were unavailable. Alternatives
242
D. W. BELCHERetal.
were used to replace i absent during three revisits, 11 per cent; and no longer eligible, 5 per cent. There were no refusals in contacted households. (3) Interviewers. Four full-time Danfa Project field interviewers were trained to administer the schedule. They had O-level educational backgrounds, were fluent in at least two local languages and had previous field experience in enumeration and KAP household interviewing. All completed forms were edited daily in the field by a supervisor. Interviewers averaged seven schedules per day. (4) Questionnaire. A preceded schedule was developed using previous experience with KAP surveys in the Danfa Project. The interview schedule required about 15 min time and included information about the mother’s age, parity, education, number of preschool children and number of living children. The bulk of the questions investigated beliefs about fever and its prevention, reasons for attending or not attending the programme, comprehension of instructions and recommendations to improve the programme. No crosscheck of mothers’ reported attendance was possible because only simple tally counts had been done by volunteers at village clinic sessions. The reported rates are felt to be reliable, however. A clinic visit is a major event for the rural household and the S-month recall period is not excessive. Recently, reported immunization in preschool children was compared with clinic records and vaccination scars in the same population, This showed that mothers’ reports of participation correlated very highly with results of the record and scar examinations. (5) Statistical analysis. While 223 households participated in the interview survey, only the 197 respondents who were mothers of the 0-5-yr-olds have been analyzed and presented in the subsequent findings. Information obtained from grandparents, aunts or nonrelatives (in 26 households) has been excluded from analysis. The study was designed to determine the characteristics of mothers and how these related to utilization of the services. Nonparametric analysis was employed throughout. In most cases, strength of association of two cross-tabulated variables was measured by means of Cramer’s statistic, 4’. This statistic has the advantage (in contrast with the more widely known coefficient of contingency) of having a closed range, namely O@Ofor complete independence and IXMIfor perfect dependence [2]. In addition, crosstabulated data were examined for predictive association using the Goodman and Kruskal index 1, [3]. This statistic is interpreted as the average proportional reduction in error in the prediction of which category of the dependent variable a particular case will fall into when the category of the case on the independent variable is known as opposed to when it is unknown. The value of & is the percentage reduction in error. (It should be noted that this index deals only with predictive association and not with statistical association in the more general sense.) In every instance of its use in this paper, “number of attendance? has been taken as the dependent variable. In certain cases, the Mann-Whitney U test was used to test a hypothesis of independence of two tabulated variables; this statistic is shown in the tables
as Z,. In appropriate cases. Kendal’s rank correlation coefficient T (modified for ties) was used to examine the data for correlation and in one or two cases. where only minimal analysis was possible due to the classificatory nature of the data. only x2 tests are shown. FINDINGS
Analyses were performed for four areas of survey inquiry. 1. Attendance. The 5-month period from JulyNovember 1973 was used for study purposes to allow for any start-up problems during June, the initial month of the malaria programme. One hundred and ninety-five of the 223 sampled households had attended the programme one or more times during the period (87.4 per cent). The per cent distribution of 223 households according to the number of attendances is shown in Table 1. Three or more visits out of the potential five were considered desirable, while families attending one or two times were defined as “low attenders”. Almost half (49.1 per cent) of the 223 sampled households attended three or more sessions, with 28.5 per cent attending four or more. The number of people reached by the programme (87.4 per cent) appears acceptable for rural Ghana; but since frequent programme attendance is needed to reduce malaria morbidity in vulnerable preschoolers, the rest of the findings assess factors related to low attendance. Subsequent programmes should strive to improve the continuation rate. (2) Factors associated with utilization of the programme. Education of the mother is not a significant variable affecting either entry into or continuation in the programme (see Table 2). The influence of age is clarified when age and education are tabulated jointly (Tables 3a and b) and when age is examined alone against attendance (Table 3~). From these tables it may be seen that there is a significant difference in attendance patterns between women under 30 and over 30. While the younger group seems just as likely to start the programme, they are more prone to dropping out after only one or two attendances. These tables also demonstrate that age is the determinant of participation and not education. Other maternal/family characteristics studied were the number of living children, the number of 0-5-yrolds in the family, and the average family size by the total number of attendances (Table 4a). Family size appears to be related in an unexpected way to total clinic attendance. Table
I. Distribution
of households for programme attendance
No. visits
No. households
0 I 2 3 4 5
28 40 46 46 30 33
Per cent of total households (223) 12.6 Il.9 20.6 20.6 13.5 1.5-o
The malaria prophylaxis programme Table 2. Relationship
of mother’s educational
243
status to attendance
Total programme attendances Characteristics (education) None Educated
1-2
None
No. respondents 110 87
3+
No.
”/n
No.
%
No.
I:?,,
17 IO
15.5 11.5
36 39
32.7 44.X
57 3x
51.8 43.7
4’ = 0.151. i,, = 0.02. 2. = 0.592 (P = 0,278).
Mothers with small (one or two living children) and large (7+) families had slightly higher rates of nonparticipation. Of those families participating, however. there was a trend toward higher continuation rates with larger family size. Mothers with only one pre-schooler were three times less likely to start the programme as mothers who had two or more preschoolers. About the same percentage of mothers with one child attended three or more clinics (565 per cent) as did mothers with two or more children (55.4 per cent). However, the 29 mothers with three or more children under 5 had the highest participation rate (96.4 per cent) and the highest rate of attending three or more clinics (65.5 per cent). Several speculations can be offered about the association of older maternal age and large family size with continued programme attendance. Older mothers undoubtedly had greater experience with illness in their children than younger women and presumably greater previous use of child health services. Such experience would tend to affect their behaviour when health services are offered in the community. In addition. mothers with larger families might be less mobile; increased child-care responsibilities for mothers with large families might keep them closer to home and more available for attending community-based programmes. Younger mothers may be more frequently away from a village. Finally, mothers with several children might perceive more tangible results if fever is prevented in several children. Maternal satisfaction with reduced family illness would serve to reinforce continued attendance in the programme. The tendency of older persons to be
Table 3. Relationship
more aware of sickness and more positive about services received has been described elsewhere [7]. (3) Beliefs about illness as determinants of’ programme participation. Attendances in the malaria chemoprophylaxis programme were also analyzed by maternal attitudes and beliefs about fever, as stated in the household interview. Even though the causal role of health beliefs in influencing health behaviour is still not clear, it is the best explanation so far for health behaviour undertaken by a person with no symptoms [4]. Table 5 demonstrates the relationship of total clinic attendance to maternal attitudes and knowledge about fever such as frequency, seriousness. cause and preventive action to take. Although almost all mothers stated that fever in children was commonplace, only a small portion ( 1I .9 per cent) felt fever could lead to death. However, there was a trend for mothers who thought fever a severe disease to attend a higher number of sessions. No clear pattern emerges between attendance in the malaria programme and the mother’s knowledge about the cause of fever in children. Mothers who gave modern explanations for the cause of childhood fever had a greater entry rate and slightly greater continuation rates than did mothers with traditional beliefs. The small number of mothers who did not know any cause for fever were 3 times as likely to stay out of the programme as the mothers holding either modern or traditional beliefs about the cause of fever. The main finding in Table 5 is that variation in attendance is almost exclusively due to the mother’s perceptions about what action can be taken to pre-
of mother’s age and educational
status to attendance
Total programme Characteristics (age and education)
No. respondents
1-2
None No.
attendances 3+
%
No.
%
No.
%
13.0 12.5 13.3
45 15 30
48.9 46.9 50.0
35 13 22
38.0 40.4 36.7
14.3 16.7 7.4
30 21 9
28.6 26.9 33.3
60 44
16
57.1 56.4 59.3
13.0 14.3
45 30
48.9 28.6
35 60
38.0 57.1
a
Under 30 92 I2 None 32 4 8 Educated 4’ = 0.044. iB = OGO 2, = -O?I3 (P = 0.366) b 15 30 and above 105 None 78 13 Educated 27 2 4’ = 0243. i., = O+K).Z, = -0558 (P = 0.288) c t30 92 12 2 30 105 15 I$’ = 0321. iB = 0.10. 2, = 2.104 (p = 0.018)
D. W. BELCHERer al.
244
Table 4a. Relationship of number of children to clinic attendance Total programme attendances Characteristics
No. respondents
1. No. of living children 1-2 3-4 5-6
61 58 36
4’ = @173:,I, = 0.04, T = 00324;
Table 4b. Relationship
(yr)
O0
No.
*0
II 5 4 7
18.0 8-6 11.1 16.7
21 24 13 11
443 41.4 36.1 26.2
23 29 19 24
37.7 50.0 52.8 57.1
19 7 1
21.6 8.8 3.4
30 36 9
34. I 45.0 31.0
39 37 19
44.3 46.3 65.5
4.2
3.7
4.7
of mother’s age and average number of living children to attendance
.
15-19 20-24 25-29 30-34 35-39 40+ Totals
3+
No.
197
Nu,mber of respondents
Age
1-2
a,/ ,o
= 0.225)
2. No. of O-S yr olds in family I 88 2 80 3+ 29 4’ = 0.173, I, = OGO.r = 0.031 (P = 0.226) 3. Ave. no. of living children
None No.
Average number of living children
12 41 39 45 28 32 197
Table 5. Relationships
at majority of clinics
3 + Total attendances Number “,
I .08 1.85 3.23 4.66 604 744 4.19
3 14 16 29 14 18 95
25.0 34.1 41.0 64.4 50.0 56.3 48.2
behveen health beliefs and attendance in the malaria programme Total programme attendance None
No.
Variable*
respondents
Overall 197 I. Frequency of fever Common 182 Uncommon 4’ = 0.070, Is = o@O, z, = -O-l:55 (P = 0.430) 2. Severity Causes death 21 Does not result in death 176 4’ = 0.176, I, = OQO,Z, = -0604 (P = 0.272) 3. Cause of fever Modern 90 Traditional 78 Does not know 29 (6’ = 0.176, I, = 0.04 4. Action to take to prevent fever Modern 115 Traditional 4’ = 0.232, Is = @IO, Z, = 3.4078:P = OGOO) * Only the first responses are used.
l-2
3+
No.
“/‘,
No.
%
No.
70
27
13.7
75
38.1
95
48.2
26 1
14.3 6.7
68 7
37.4 46.7
88 7
48.4 467
5
23.8
3
14.3
13
61.9
22
12.5
72
40.9
82
46.6
8 10 9
8.9 12.8 31.0
35 28 I2
38.9 35.9 41.4
47 40 8
52.2 51.3 21.6
II 16
9.6 19.5
37 38
32.2 46.3
67 ‘8
58.3 34.1
The malaria prophylaxis programme Table 6. Comparison of knowledge about malaria programme by type of delivery system
Aware of programme Delivery system Health centre staff Volunteers
No. respondents
No.
%
87 110
64 101
73.6 91.8
x2 = 10.595, d.f. = 1, P = OGOl.
vent fever from occurring. One hundred and fifteen mothers gave modern courses of action to take to avoid fever; use mosquito nets or coils (522 per cent), anti-malarial drugs (27-O per cent) or hygienic childcare practices (20.9 per cent), such as keeping the child’s environment and food clean and protected. Eighty-two mothers described traditional methods to prevent fever; keeping child out of the sun and prohibiting excessive exertion (46.3 per cent), herbal preparations (20.7 per cent), purgatives and enemas on a periodic schedule (15.9 per cent) and following prescribed food taboos (13.4 per cent). Mothers who believed in traditional preventive measures were twice as likely not to attend the programme as mothers promoting modern methods. Moreover, 57.6 per cent of traditional mothers attended only on& or twice, in comparison with a rate of 35.7 per cent for mothers with modern ideas of fever prevention. (4) Effect of type of delivery system on attendance. Recent studies about utilization of health services have tended to focus attention on the client’s demographic and behavioural characteristics [S, 61, but in some investigations attention has been directed at the delivery system as a determinant of attendance [7, S]. Barriers which can interfere with the use of existing health services include distance, travel time, cost and waiting time at the clinic. Cost was not a factor, since no fee was charged for the programme, but distance and waiting time may have affected attendance at the health centre and satellite clinic-based programmes. Some mothers had to travel one mile to the health centre or satellite clinics, whereas volunteer distribution was done in the village itself. However. distance alone does not explain the difference in attendance rates. Mothers living in the same village as the health centre and satellite clinics had lower participation and continuation rates than volunteerserved villages. Patients must spend several hours waiting at the medical clinic which might have discouraged attendance by some mothers, although there was some waiting time also involved at places where volunteers were used.
245
The village volunteer programme was experimental and there were initial concerns about the volunteers commitment and acceptability to villagers as alternatives to full-time health workers. We have analyzed the attendance by the type of person who distributed monthly medications and also by factors related to satisfaction with the programme. Participation in a new programme requires the development of awareness and interest in the programme in potential clients. There was a significant difference in initial knowledge about the programme by mothers who lived in villages served by volunteers when compared to programme awareness in health centre communities (Table 6). The volunteer programme was more effective than the health centre programme in developing initial awareness about the malaria programme. For the 61 villages involved in the programme, the community with the lowest percentage of mothers knowing about the programme was Danfa, where the main health centre is located. Mothers located in volunteer villages appeared to acquire information through a wider variety of sources than those residents in health centre communities (Table 7). Village volunteers continued to provide information about the programme and remind villagers about clinic dates, whereas health workers appear to have made initial contacts but did little follow-up. In general, the traditional leaders were apparently asked to initiate programmes but were not involved in efforts to motivate continuing participation. The need to provide continuing information about the programme is reflected in the reasons given by 77 mothers who explained why they failed to attend November 1973 clinics (Table 8). The health centre village nonattendance rate for November was 55 per cent compared to 264 per cent in the volunteer programme communities. Reasons given for nonattendance such as absence, work or involvement in other activities would presumably not be affected considerably by programme change. However, the most common reason for nonattendance was lack of information about the November clinic. Poor information was about twice as common in health centre villages as in the volunteer programme. The other organizational problem was failure to hold any clinic, reported by five persons in the volunteer system. To some extent this may be intrinsic to use of volunteers who have other responsibilities and who may have difficulty holding regular sessions. Mothers’ suggestions
The need to improve initial and continuing programme information is shown also in Table 9 which illustrates the mothers’ suggestions for improving programme usefulness and effectiveness.
Table 7. Sources of information about programme by type delivery system Source of information (%) Deliver) system Health centre Volunteers
No.
Health worker
Trad. leader
Teacher volunteer
87 110
50 32
39 21
0 30
Friends 9 11
Other 2 6
D. W. BELCHERet al.
246
Table 8. Reasons for non-attendance
in November 1973. by delivery system Reasons
Delivery system
No. respondents
Health centre Volunteers Totals
Did not know about clinic No. %
48 29 77
34 I1 45
70.8 31.9 58.4
Absent No. “; 8 6 14
16.7 20.7 18.2
Table 9. Recommendations
Clinic not held No. “<,
Working No. “0 1 3 4
2.1 IO.3 5.2
0 5 5
No. of respondents
Health centre Volunteers Totals
None
87 110 197
Table 10. Recommendations
Better information
:
6.5
9
0
IO4 13.8 11.7
(:;)
More convenient time
39. I 9.1 22.3
31.0 32.7 32.0
Il.2
to improve programme Recommendations
Delivery system
Other No. ,I,,
21.8 32.1 27.9
to improve the malaria programme
in relationship
Improved treatment
Expanded coverage 8.0 20.9
0.0 4.5 2.5
15.2
to the total number of attendances
No. of total attendances Recommendation Better information More convenient time Expanded coverage Improved treatment None
No. of respondents 44 55 30 5 63
t-2
None
3f
No.
Y/,
No.
“/;
No.
‘,,
17 2
38.6 3.6 3.3 0.0 II.1
22 18 4 3 28
50.0 32.7 13.3 60.0 444
3; 25 2 28
II.4 63.6 83.3 40.0 44.4
I 0 7
The most common recommendation made by mothers in health centre villages was to improve information flow. Mothers suggested that clinic attendees should be instructed to pass information on to neighbours and friends to enlist their attendance at subsequent clinics. They proposed that chiefs should be asked to regularly sound the village gong to announce the clinic every month. The recommendation to change the schedule and scope of the malaria programme was often proposed by mothers with high attendance rates, whereas the need to improve information techniques was characteristically proposed by nonparticipants or by mothers with few attendances (Table 10). Of the mothers recommending improved information flow, 386 per cent failed to start the programme (3 times the overall average) and a lower attendance rate prevailed. Twenty-two of 27 mothers (815 per cent) who wanted better information and who started the programme dropped out after only l-2 visits. Other. more convenient, clinic times were proposed including the local market day (when most mothers could be readily contacted), nonfarming days (Tuesday or Friday in the Danfa District) and Sundays. Several mothers asked that the coverage of medications be expanded to include themselves, older children’ and other adults. Five mothers recommended improved treatment such as physical checkups and more medications, however; they seemed to bc misinformed about the objectives of the malaria programme and wanted a general medical clinic.
The pattern of attendance in health centre villages compared with the pattern in communities regularly serviced by full-time health centre staff (Table 11) was particularly important in determining whether volunteers might be a feasible manpower resource for community-based programmes. It can be seen that mothers in volunteer villages were more likely to start the programme and twice as likely to attend three or more sessions. DlSCUSSlON The findings which have been presented above may be summarized as follows: 86.3 per cent of 223 interviewed households entered into a malaria programme at some time during a 5-month study period. About half of these attended a majority of the sessions. Several maternal characteristics were associated with higher participation rates and higher continuation patterns. Mothers above age 30 had similar initial participation as younger mothers. but were about twice as likely to attend three or more clinic sessions. In addition, mothers with large families and three or more children under 6 years had more regular programme attendance. Education was not a factor in either starting or continuing in the programme. These findings are interesting, since most studies about utilization of medical care have found that younger. more educated women had better attendance. From an administrative point of view. special educational effort should be made to interest younger mothers in pre-
The malaria prophylaxis programme Table 11. Total attendances
247
by type of delivery system used No. of attendances
No.
Delivery system
87 110 197
Health centre Volunteers Totals
l-2
None
respondents
3+
No.
%
No.
%
No.
“’ 10
19 8 27
21.8 7.3 13.7
42 33 75
48.3 300 38.1
26 69 95
29.9 62.7 48.2
4’ = 0.344. i, = 016. Z, = 4.740 (P = 0.000). Table 12. Comparison
between health centre and volunteer systems in a malaria chemoprophylaxis
System Health centre Volunteers * Knew about programme
Aware of programme* (%) 74 92
programme
Attended three or more clinics (%)
Started programme (%) 79 93
30 63
at start; some mothers heard about it later and attended.
ventive programmes, since fhey may not have developed the same sense of need apparent in older mothers. In this study maternal perceptions about susceptibility to fever and knowledge about its cause could not be correlated with programme attendance. However, maternal attitudes about actions to take to prevent the occurrence of fever were significantly related to programme involvement. Mothers who knew about modern preventive actions were twice as likely to bring their children to the programme and one and a half times as likely to continue to attend for three or more visits as mothers who described traditional methods to prevent fever. Distribution of the monthly malaria chemoprophylaxis for half of the villages was done by health workers from the Danfa Health Centre at either the health centre or a satellite clinic. Village volunteers distributed tablets in the other communities. The majority of volunteers were teachers or literate residents who were already helping to register community births and deaths. None had been trained in health work, but when asked if they would consider helping with a 6-month long programme to reduce childhood malaria, enthusiastic response was given. The use of these volunteers expanded the number of communities in which preventive malaria programmes could be offered, and the overall participation by mothers exceeded that achieved in villages being serviced by full-time health workers. The key to their success appears to have been their contacting mothers both at the start of the programme and throughout its duration, thereby creating and main-, taining a higher level of interest in the programme than was promoted in the health centre villages (Table 12). The potential of this programme in Ghana as a model for other volunteer-staffed health programmes needs additional study. This study’s finding that \,olunteer workers can be valuable resources to expand coverage of malaria programmes and to successfully motivate mothers’ attendance owes much to the enthusiasm of the volunteers themselves and to the supervision of the health centre sanitarian. Highly motivated lay workers are not easy to find. The initial
programme lasted only 6 months; a year-long programme might result in dwindling of interest or effort by the volunteers. However, the present study found no evidence of reduced interest or attendance with time in the volunteer villages. Another possible limitation to volunteer use would be that other target populations might resent the use of lay volunteers in place of trained health workers. It seems likely, however, that well-organized and regular volunteer health services brought into previously under-serviced villages would receive the same strong support as was found in this study. This study has proven very useful to programme planners. Several problems of programme contact and follow-through were identified and mothers with low attendance tendencies have been recognized. These findings have implications for the malaria programme about to begin this year. A wider network of channels for communication will be used, and particular efforts are planned to keep the community informed about scheduled dates and the long-term nature of the programme. Satisfied clients will be asked to recruit non-attending mothers, and special motivational efforts will be made to reach the younger mothers.
REFERENCES
1. Neumann A. K., Prince J., Gilbert F. F. and Lourie I. M. The Danfa/Ghana comprehensive rural. health and family planning project-a preliminary report. Ghana Med. 9. 11(l). 18, 1972. 2. Hays W. Statistics. Holt, Rinehart & Winston, New York, 1963. 3. Goodman L. and Kruskal W. Measures of association for cross classification. J. Am. Stat. Ass. 49(268), 732. 1954. 4. Haefner D. P. and Kirscht J. P. Motivational and behavioral effects of modifying health beliefs Publ. Hlth Reports 836). 478, 1970. 5. Weidman H. H. and Egeland J. A. k behavioral science perspective in the comparative approach to the delivery of health care. Sot. Sci. & Med. 7. 845. 1973. 6. Andersen R. and Newman J. F. Societal and individual determinants of medical care utilization in the United
248
D. W. BELCHERer u/.
States. Milbank Memorial Fund Quarterly 51(l). 95. 1973. 7. Anderson J. G. Health services utilization: framework and review. Healtll Services Research 8(3). 184. 1973.
S. Greenlick M. R. Proceedines of a Conference on Conceptual Issues in the Analyiis of Medical Care Utilization Behavior. U.S. Department of Health. Education and Welfare. 1969.
SCI. & Med.. Vol. 9. pp. 241 to 24R. Pwpmon
Press
1975 Printed
in Great
Britam
FACTORS INFLUENCING UTILIZATION OF A MALARIA PROPHYLAXIS PROGRAMME IN GHANA D. W. BELCHER, D. D. NICHOLASand S. N. BLUMENFELD School of Public Health, University of California, Los Angeles, U.S.A. and S. OFOSU-AMAAHand F. K. WURAPA Department of Community Health, University of Ghana Medical School, Accra, Ghana Abstract-In 1973 an interview survey was done in rural Ghana to learn about factors affecting participation in a malaria prophylaxis programme and whether volunteer workers could effectively serve as medication distributors. Several maternal characteristics were associated with higher participation and continuation rates. Education was not a factor. but women over age 30 and those with larger families had better programme attendance. This was attributed to a greater sense of need in larger families and greater previous use of and satisfaction with health programmes by older mothers. In addition, mothers who knew about modern preventive actions to avoid fever had significantly higher entry and continuation rates in the programme. Village volunteers were more successful than trained health workers in creating initial awareness of the programme and in motivating mothers to start and remain in the programme. Special efforts will be made in this year’s (1974) malaria programme to motivate younger mothers to participate and to maintain improved information flow.
Malaria is the third most common cause of death in Ghanaian pre-school children. In June 1973, an anti-malarial programme for children 5 years of age and under was started in the 15.000 person Danfa district in Ghana. Each month for 6 months 2700 pre-school children in 61 villages were offered one dose of pyrimethamine to suppress malaria infections. The distribution of the malaria medication was one of the public health measures of the Danfa Comprehensive Rural Health and Family Planning Project,* a joint research project of the University of Ghana Medical School, Ghana’s Ministry of Health, other interested Ghanaian agencies, and the School of Public Health, UCLA, with the support of the United States Agency for International Development [l]. The effectiveness of this malaria chemoprophylaxis programme was measured by periodic malaria films and spleen examinations. The programme will be repeated annually for the remaining 5 years of the Danfa Project. This report describes a special study conducted in November 1973 to learn how many pre-schoolers participated in the prophylaxis programme and what factors influenced their attendance. In addition, the effectiveness of two methods for distributing malaria tablets was evaluated. To obtain this information, a survey interview schedule inquiring into the knowledge, attitudes and practices regarding the malaria programme was administered to a 25 per cent sample of households containing pre-school children in the Danfa Project area. Two distribution systems were organized to reach the target population of children aged 5 years and younger. The Danfa Health Centre staff covered all villages located within a one mile radius of its station* Supported in part by USAID Grant OCOP/AID/CM/ afr-IDA-73-14.
ary health centre or one of its three satellite clinics. Mothers in these villages were told to come to the health centre or a satellite clinic once each month. Such villages contain 48 per cent of the population in the Danfa district. All other villages in the Danfa district were served by village volunteers, primarily school teachers, under the supervision of the health centre sanitarian. Most of the volunteers were serving as part-time birth and death registrars for their communities. After an orientation session to describe the programme and distribution procedures, an initial tablet distribution session in the village was supervised by the sanitarian. Subsequent distribution to individual communities was then the responsibility of the volunteer who arranged an acceptable monthly distribution date with each community. A detailed report of the recruitment, training and supervision of the volunteer programme will be published later. METHODS (1) Sample. In April 1973, 2 months before the malaria programme started, the annual project household census was conducted in the Danfa district. A computer listing 2240 households grouped by village was prepared. The sample frame consisted of 892 households containing pre-school children. A systematic sample of every fourth household on the listing was used to select the initial sample of 223 households. Only those households which had been resident in the Danfa district for the entire JuneNovember 1973 period were considered eligible for participation. (2) Survey procedures. The households were contacted and interviewed during a l-week period in November 1973. Each interviewer had an assigned household list. with alternative households to use if assigned respondents were unavailable. Alternatives
242
D. W. BELCHERetal.
were used to replace i absent during three revisits, 11 per cent; and no longer eligible, 5 per cent. There were no refusals in contacted households. (3) Interviewers. Four full-time Danfa Project field interviewers were trained to administer the schedule. They had O-level educational backgrounds, were fluent in at least two local languages and had previous field experience in enumeration and KAP household interviewing. All completed forms were edited daily in the field by a supervisor. Interviewers averaged seven schedules per day. (4) Questionnaire. A preceded schedule was developed using previous experience with KAP surveys in the Danfa Project. The interview schedule required about 15 min time and included information about the mother’s age, parity, education, number of preschool children and number of living children. The bulk of the questions investigated beliefs about fever and its prevention, reasons for attending or not attending the programme, comprehension of instructions and recommendations to improve the programme. No crosscheck of mothers’ reported attendance was possible because only simple tally counts had been done by volunteers at village clinic sessions. The reported rates are felt to be reliable, however. A clinic visit is a major event for the rural household and the S-month recall period is not excessive. Recently, reported immunization in preschool children was compared with clinic records and vaccination scars in the same population, This showed that mothers’ reports of participation correlated very highly with results of the record and scar examinations. (5) Statistical analysis. While 223 households participated in the interview survey, only the 197 respondents who were mothers of the 0-5-yr-olds have been analyzed and presented in the subsequent findings. Information obtained from grandparents, aunts or nonrelatives (in 26 households) has been excluded from analysis. The study was designed to determine the characteristics of mothers and how these related to utilization of the services. Nonparametric analysis was employed throughout. In most cases, strength of association of two cross-tabulated variables was measured by means of Cramer’s statistic, 4’. This statistic has the advantage (in contrast with the more widely known coefficient of contingency) of having a closed range, namely O@Ofor complete independence and IXMIfor perfect dependence [2]. In addition, crosstabulated data were examined for predictive association using the Goodman and Kruskal index 1, [3]. This statistic is interpreted as the average proportional reduction in error in the prediction of which category of the dependent variable a particular case will fall into when the category of the case on the independent variable is known as opposed to when it is unknown. The value of & is the percentage reduction in error. (It should be noted that this index deals only with predictive association and not with statistical association in the more general sense.) In every instance of its use in this paper, “number of attendance? has been taken as the dependent variable. In certain cases, the Mann-Whitney U test was used to test a hypothesis of independence of two tabulated variables; this statistic is shown in the tables
as Z,. In appropriate cases. Kendal’s rank correlation coefficient T (modified for ties) was used to examine the data for correlation and in one or two cases. where only minimal analysis was possible due to the classificatory nature of the data. only x2 tests are shown. FINDINGS
Analyses were performed for four areas of survey inquiry. 1. Attendance. The 5-month period from JulyNovember 1973 was used for study purposes to allow for any start-up problems during June, the initial month of the malaria programme. One hundred and ninety-five of the 223 sampled households had attended the programme one or more times during the period (87.4 per cent). The per cent distribution of 223 households according to the number of attendances is shown in Table 1. Three or more visits out of the potential five were considered desirable, while families attending one or two times were defined as “low attenders”. Almost half (49.1 per cent) of the 223 sampled households attended three or more sessions, with 28.5 per cent attending four or more. The number of people reached by the programme (87.4 per cent) appears acceptable for rural Ghana; but since frequent programme attendance is needed to reduce malaria morbidity in vulnerable preschoolers, the rest of the findings assess factors related to low attendance. Subsequent programmes should strive to improve the continuation rate. (2) Factors associated with utilization of the programme. Education of the mother is not a significant variable affecting either entry into or continuation in the programme (see Table 2). The influence of age is clarified when age and education are tabulated jointly (Tables 3a and b) and when age is examined alone against attendance (Table 3~). From these tables it may be seen that there is a significant difference in attendance patterns between women under 30 and over 30. While the younger group seems just as likely to start the programme, they are more prone to dropping out after only one or two attendances. These tables also demonstrate that age is the determinant of participation and not education. Other maternal/family characteristics studied were the number of living children, the number of 0-5-yrolds in the family, and the average family size by the total number of attendances (Table 4a). Family size appears to be related in an unexpected way to total clinic attendance. Table
I. Distribution
of households for programme attendance
No. visits
No. households
0 I 2 3 4 5
28 40 46 46 30 33
Per cent of total households (223) 12.6 Il.9 20.6 20.6 13.5 1.5-o
The malaria prophylaxis programme Table 2. Relationship
of mother’s educational
243
status to attendance
Total programme attendances Characteristics (education) None Educated
1-2
None
No. respondents 110 87
3+
No.
”/n
No.
%
No.
I:?,,
17 IO
15.5 11.5
36 39
32.7 44.X
57 3x
51.8 43.7
4’ = 0.151. i,, = 0.02. 2. = 0.592 (P = 0,278).
Mothers with small (one or two living children) and large (7+) families had slightly higher rates of nonparticipation. Of those families participating, however. there was a trend toward higher continuation rates with larger family size. Mothers with only one pre-schooler were three times less likely to start the programme as mothers who had two or more preschoolers. About the same percentage of mothers with one child attended three or more clinics (565 per cent) as did mothers with two or more children (55.4 per cent). However, the 29 mothers with three or more children under 5 had the highest participation rate (96.4 per cent) and the highest rate of attending three or more clinics (65.5 per cent). Several speculations can be offered about the association of older maternal age and large family size with continued programme attendance. Older mothers undoubtedly had greater experience with illness in their children than younger women and presumably greater previous use of child health services. Such experience would tend to affect their behaviour when health services are offered in the community. In addition. mothers with larger families might be less mobile; increased child-care responsibilities for mothers with large families might keep them closer to home and more available for attending community-based programmes. Younger mothers may be more frequently away from a village. Finally, mothers with several children might perceive more tangible results if fever is prevented in several children. Maternal satisfaction with reduced family illness would serve to reinforce continued attendance in the programme. The tendency of older persons to be
Table 3. Relationship
more aware of sickness and more positive about services received has been described elsewhere [7]. (3) Beliefs about illness as determinants of’ programme participation. Attendances in the malaria chemoprophylaxis programme were also analyzed by maternal attitudes and beliefs about fever, as stated in the household interview. Even though the causal role of health beliefs in influencing health behaviour is still not clear, it is the best explanation so far for health behaviour undertaken by a person with no symptoms [4]. Table 5 demonstrates the relationship of total clinic attendance to maternal attitudes and knowledge about fever such as frequency, seriousness. cause and preventive action to take. Although almost all mothers stated that fever in children was commonplace, only a small portion ( 1I .9 per cent) felt fever could lead to death. However, there was a trend for mothers who thought fever a severe disease to attend a higher number of sessions. No clear pattern emerges between attendance in the malaria programme and the mother’s knowledge about the cause of fever in children. Mothers who gave modern explanations for the cause of childhood fever had a greater entry rate and slightly greater continuation rates than did mothers with traditional beliefs. The small number of mothers who did not know any cause for fever were 3 times as likely to stay out of the programme as the mothers holding either modern or traditional beliefs about the cause of fever. The main finding in Table 5 is that variation in attendance is almost exclusively due to the mother’s perceptions about what action can be taken to pre-
of mother’s age and educational
status to attendance
Total programme Characteristics (age and education)
No. respondents
1-2
None No.
attendances 3+
%
No.
%
No.
%
13.0 12.5 13.3
45 15 30
48.9 46.9 50.0
35 13 22
38.0 40.4 36.7
14.3 16.7 7.4
30 21 9
28.6 26.9 33.3
60 44
16
57.1 56.4 59.3
13.0 14.3
45 30
48.9 28.6
35 60
38.0 57.1
a
Under 30 92 I2 None 32 4 8 Educated 4’ = 0.044. iB = OGO 2, = -O?I3 (P = 0.366) b 15 30 and above 105 None 78 13 Educated 27 2 4’ = 0243. i., = O+K).Z, = -0558 (P = 0.288) c t30 92 12 2 30 105 15 I$’ = 0321. iB = 0.10. 2, = 2.104 (p = 0.018)
D. W. BELCHERer al.
244
Table 4a. Relationship of number of children to clinic attendance Total programme attendances Characteristics
No. respondents
1. No. of living children 1-2 3-4 5-6
61 58 36
4’ = @173:,I, = 0.04, T = 00324;
Table 4b. Relationship
(yr)
O0
No.
*0
II 5 4 7
18.0 8-6 11.1 16.7
21 24 13 11
443 41.4 36.1 26.2
23 29 19 24
37.7 50.0 52.8 57.1
19 7 1
21.6 8.8 3.4
30 36 9
34. I 45.0 31.0
39 37 19
44.3 46.3 65.5
4.2
3.7
4.7
of mother’s age and average number of living children to attendance
.
15-19 20-24 25-29 30-34 35-39 40+ Totals
3+
No.
197
Nu,mber of respondents
Age
1-2
a,/ ,o
= 0.225)
2. No. of O-S yr olds in family I 88 2 80 3+ 29 4’ = 0.173, I, = OGO.r = 0.031 (P = 0.226) 3. Ave. no. of living children
None No.
Average number of living children
12 41 39 45 28 32 197
Table 5. Relationships
at majority of clinics
3 + Total attendances Number “,
I .08 1.85 3.23 4.66 604 744 4.19
3 14 16 29 14 18 95
25.0 34.1 41.0 64.4 50.0 56.3 48.2
behveen health beliefs and attendance in the malaria programme Total programme attendance None
No.
Variable*
respondents
Overall 197 I. Frequency of fever Common 182 Uncommon 4’ = 0.070, Is = o@O, z, = -O-l:55 (P = 0.430) 2. Severity Causes death 21 Does not result in death 176 4’ = 0.176, I, = OQO,Z, = -0604 (P = 0.272) 3. Cause of fever Modern 90 Traditional 78 Does not know 29 (6’ = 0.176, I, = 0.04 4. Action to take to prevent fever Modern 115 Traditional 4’ = 0.232, Is = @IO, Z, = 3.4078:P = OGOO) * Only the first responses are used.
l-2
3+
No.
“/‘,
No.
%
No.
70
27
13.7
75
38.1
95
48.2
26 1
14.3 6.7
68 7
37.4 46.7
88 7
48.4 467
5
23.8
3
14.3
13
61.9
22
12.5
72
40.9
82
46.6
8 10 9
8.9 12.8 31.0
35 28 I2
38.9 35.9 41.4
47 40 8
52.2 51.3 21.6
II 16
9.6 19.5
37 38
32.2 46.3
67 ‘8
58.3 34.1
The malaria prophylaxis programme Table 6. Comparison of knowledge about malaria programme by type of delivery system
Aware of programme Delivery system Health centre staff Volunteers
No. respondents
No.
%
87 110
64 101
73.6 91.8
x2 = 10.595, d.f. = 1, P = OGOl.
vent fever from occurring. One hundred and fifteen mothers gave modern courses of action to take to avoid fever; use mosquito nets or coils (522 per cent), anti-malarial drugs (27-O per cent) or hygienic childcare practices (20.9 per cent), such as keeping the child’s environment and food clean and protected. Eighty-two mothers described traditional methods to prevent fever; keeping child out of the sun and prohibiting excessive exertion (46.3 per cent), herbal preparations (20.7 per cent), purgatives and enemas on a periodic schedule (15.9 per cent) and following prescribed food taboos (13.4 per cent). Mothers who believed in traditional preventive measures were twice as likely not to attend the programme as mothers promoting modern methods. Moreover, 57.6 per cent of traditional mothers attended only on& or twice, in comparison with a rate of 35.7 per cent for mothers with modern ideas of fever prevention. (4) Effect of type of delivery system on attendance. Recent studies about utilization of health services have tended to focus attention on the client’s demographic and behavioural characteristics [S, 61, but in some investigations attention has been directed at the delivery system as a determinant of attendance [7, S]. Barriers which can interfere with the use of existing health services include distance, travel time, cost and waiting time at the clinic. Cost was not a factor, since no fee was charged for the programme, but distance and waiting time may have affected attendance at the health centre and satellite clinic-based programmes. Some mothers had to travel one mile to the health centre or satellite clinics, whereas volunteer distribution was done in the village itself. However. distance alone does not explain the difference in attendance rates. Mothers living in the same village as the health centre and satellite clinics had lower participation and continuation rates than volunteerserved villages. Patients must spend several hours waiting at the medical clinic which might have discouraged attendance by some mothers, although there was some waiting time also involved at places where volunteers were used.
245
The village volunteer programme was experimental and there were initial concerns about the volunteers commitment and acceptability to villagers as alternatives to full-time health workers. We have analyzed the attendance by the type of person who distributed monthly medications and also by factors related to satisfaction with the programme. Participation in a new programme requires the development of awareness and interest in the programme in potential clients. There was a significant difference in initial knowledge about the programme by mothers who lived in villages served by volunteers when compared to programme awareness in health centre communities (Table 6). The volunteer programme was more effective than the health centre programme in developing initial awareness about the malaria programme. For the 61 villages involved in the programme, the community with the lowest percentage of mothers knowing about the programme was Danfa, where the main health centre is located. Mothers located in volunteer villages appeared to acquire information through a wider variety of sources than those residents in health centre communities (Table 7). Village volunteers continued to provide information about the programme and remind villagers about clinic dates, whereas health workers appear to have made initial contacts but did little follow-up. In general, the traditional leaders were apparently asked to initiate programmes but were not involved in efforts to motivate continuing participation. The need to provide continuing information about the programme is reflected in the reasons given by 77 mothers who explained why they failed to attend November 1973 clinics (Table 8). The health centre village nonattendance rate for November was 55 per cent compared to 264 per cent in the volunteer programme communities. Reasons given for nonattendance such as absence, work or involvement in other activities would presumably not be affected considerably by programme change. However, the most common reason for nonattendance was lack of information about the November clinic. Poor information was about twice as common in health centre villages as in the volunteer programme. The other organizational problem was failure to hold any clinic, reported by five persons in the volunteer system. To some extent this may be intrinsic to use of volunteers who have other responsibilities and who may have difficulty holding regular sessions. Mothers’ suggestions
The need to improve initial and continuing programme information is shown also in Table 9 which illustrates the mothers’ suggestions for improving programme usefulness and effectiveness.
Table 7. Sources of information about programme by type delivery system Source of information (%) Deliver) system Health centre Volunteers
No.
Health worker
Trad. leader
Teacher volunteer
87 110
50 32
39 21
0 30
Friends 9 11
Other 2 6
D. W. BELCHERet al.
246
Table 8. Reasons for non-attendance
in November 1973. by delivery system Reasons
Delivery system
No. respondents
Health centre Volunteers Totals
Did not know about clinic No. %
48 29 77
34 I1 45
70.8 31.9 58.4
Absent No. “; 8 6 14
16.7 20.7 18.2
Table 9. Recommendations
Clinic not held No. “<,
Working No. “0 1 3 4
2.1 IO.3 5.2
0 5 5
No. of respondents
Health centre Volunteers Totals
None
87 110 197
Table 10. Recommendations
Better information
:
6.5
9
0
IO4 13.8 11.7
(:;)
More convenient time
39. I 9.1 22.3
31.0 32.7 32.0
Il.2
to improve programme Recommendations
Delivery system
Other No. ,I,,
21.8 32.1 27.9
to improve the malaria programme
in relationship
Improved treatment
Expanded coverage 8.0 20.9
0.0 4.5 2.5
15.2
to the total number of attendances
No. of total attendances Recommendation Better information More convenient time Expanded coverage Improved treatment None
No. of respondents 44 55 30 5 63
t-2
None
3f
No.
Y/,
No.
“/;
No.
‘,,
17 2
38.6 3.6 3.3 0.0 II.1
22 18 4 3 28
50.0 32.7 13.3 60.0 444
3; 25 2 28
II.4 63.6 83.3 40.0 44.4
I 0 7
The most common recommendation made by mothers in health centre villages was to improve information flow. Mothers suggested that clinic attendees should be instructed to pass information on to neighbours and friends to enlist their attendance at subsequent clinics. They proposed that chiefs should be asked to regularly sound the village gong to announce the clinic every month. The recommendation to change the schedule and scope of the malaria programme was often proposed by mothers with high attendance rates, whereas the need to improve information techniques was characteristically proposed by nonparticipants or by mothers with few attendances (Table 10). Of the mothers recommending improved information flow, 386 per cent failed to start the programme (3 times the overall average) and a lower attendance rate prevailed. Twenty-two of 27 mothers (815 per cent) who wanted better information and who started the programme dropped out after only l-2 visits. Other. more convenient, clinic times were proposed including the local market day (when most mothers could be readily contacted), nonfarming days (Tuesday or Friday in the Danfa District) and Sundays. Several mothers asked that the coverage of medications be expanded to include themselves, older children’ and other adults. Five mothers recommended improved treatment such as physical checkups and more medications, however; they seemed to bc misinformed about the objectives of the malaria programme and wanted a general medical clinic.
The pattern of attendance in health centre villages compared with the pattern in communities regularly serviced by full-time health centre staff (Table 11) was particularly important in determining whether volunteers might be a feasible manpower resource for community-based programmes. It can be seen that mothers in volunteer villages were more likely to start the programme and twice as likely to attend three or more sessions. DlSCUSSlON The findings which have been presented above may be summarized as follows: 86.3 per cent of 223 interviewed households entered into a malaria programme at some time during a 5-month study period. About half of these attended a majority of the sessions. Several maternal characteristics were associated with higher participation rates and higher continuation patterns. Mothers above age 30 had similar initial participation as younger mothers. but were about twice as likely to attend three or more clinic sessions. In addition, mothers with large families and three or more children under 6 years had more regular programme attendance. Education was not a factor in either starting or continuing in the programme. These findings are interesting, since most studies about utilization of medical care have found that younger. more educated women had better attendance. From an administrative point of view. special educational effort should be made to interest younger mothers in pre-
The malaria prophylaxis programme Table 11. Total attendances
247
by type of delivery system used No. of attendances
No.
Delivery system
87 110 197
Health centre Volunteers Totals
l-2
None
respondents
3+
No.
%
No.
%
No.
“’ 10
19 8 27
21.8 7.3 13.7
42 33 75
48.3 300 38.1
26 69 95
29.9 62.7 48.2
4’ = 0.344. i, = 016. Z, = 4.740 (P = 0.000). Table 12. Comparison
between health centre and volunteer systems in a malaria chemoprophylaxis
System Health centre Volunteers * Knew about programme
Aware of programme* (%) 74 92
programme
Attended three or more clinics (%)
Started programme (%) 79 93
30 63
at start; some mothers heard about it later and attended.
ventive programmes, since fhey may not have developed the same sense of need apparent in older mothers. In this study maternal perceptions about susceptibility to fever and knowledge about its cause could not be correlated with programme attendance. However, maternal attitudes about actions to take to prevent the occurrence of fever were significantly related to programme involvement. Mothers who knew about modern preventive actions were twice as likely to bring their children to the programme and one and a half times as likely to continue to attend for three or more visits as mothers who described traditional methods to prevent fever. Distribution of the monthly malaria chemoprophylaxis for half of the villages was done by health workers from the Danfa Health Centre at either the health centre or a satellite clinic. Village volunteers distributed tablets in the other communities. The majority of volunteers were teachers or literate residents who were already helping to register community births and deaths. None had been trained in health work, but when asked if they would consider helping with a 6-month long programme to reduce childhood malaria, enthusiastic response was given. The use of these volunteers expanded the number of communities in which preventive malaria programmes could be offered, and the overall participation by mothers exceeded that achieved in villages being serviced by full-time health workers. The key to their success appears to have been their contacting mothers both at the start of the programme and throughout its duration, thereby creating and main-, taining a higher level of interest in the programme than was promoted in the health centre villages (Table 12). The potential of this programme in Ghana as a model for other volunteer-staffed health programmes needs additional study. This study’s finding that \,olunteer workers can be valuable resources to expand coverage of malaria programmes and to successfully motivate mothers’ attendance owes much to the enthusiasm of the volunteers themselves and to the supervision of the health centre sanitarian. Highly motivated lay workers are not easy to find. The initial
programme lasted only 6 months; a year-long programme might result in dwindling of interest or effort by the volunteers. However, the present study found no evidence of reduced interest or attendance with time in the volunteer villages. Another possible limitation to volunteer use would be that other target populations might resent the use of lay volunteers in place of trained health workers. It seems likely, however, that well-organized and regular volunteer health services brought into previously under-serviced villages would receive the same strong support as was found in this study. This study has proven very useful to programme planners. Several problems of programme contact and follow-through were identified and mothers with low attendance tendencies have been recognized. These findings have implications for the malaria programme about to begin this year. A wider network of channels for communication will be used, and particular efforts are planned to keep the community informed about scheduled dates and the long-term nature of the programme. Satisfied clients will be asked to recruit non-attending mothers, and special motivational efforts will be made to reach the younger mothers.
REFERENCES
1. Neumann A. K., Prince J., Gilbert F. F. and Lourie I. M. The Danfa/Ghana comprehensive rural. health and family planning project-a preliminary report. Ghana Med. 9. 11(l). 18, 1972. 2. Hays W. Statistics. Holt, Rinehart & Winston, New York, 1963. 3. Goodman L. and Kruskal W. Measures of association for cross classification. J. Am. Stat. Ass. 49(268), 732. 1954. 4. Haefner D. P. and Kirscht J. P. Motivational and behavioral effects of modifying health beliefs Publ. Hlth Reports 836). 478, 1970. 5. Weidman H. H. and Egeland J. A. k behavioral science perspective in the comparative approach to the delivery of health care. Sot. Sci. & Med. 7. 845. 1973. 6. Andersen R. and Newman J. F. Societal and individual determinants of medical care utilization in the United
248
D. W. BELCHERer u/.
States. Milbank Memorial Fund Quarterly 51(l). 95. 1973. 7. Anderson J. G. Health services utilization: framework and review. Healtll Services Research 8(3). 184. 1973.
S. Greenlick M. R. Proceedines of a Conference on Conceptual Issues in the Analyiis of Medical Care Utilization Behavior. U.S. Department of Health. Education and Welfare. 1969.