The diagnosis and management of fever at household level in the Greater Accra Region, Ghana

Acta Tropica, 58(1994)317 330 Elsevier Science B.V.

317

A C T R O P 00440

The diagnosis and management of fever at household level in the Greater Accra Region, Ghana Irene A k u a A g y e p o n g a'*, L e n o r e M a n d e r s o n b aDangme West Health Research Centre, Ministry of Health, PO Box 1, Dodowa Accra, Ghana, bTropical Health Program, The Faculty of Medicine, University of Queensland, Herston Road, Herston, Qld 4006, Australia Received 17 June 1994; revision received 6 October 1994; accepted 12 October 1994

> Qualitative research methods were used in rural and urban areas of the Greater Accra Region to generate data to describe the folk diagnosis, etiology and management of malaria. Respondents defined as fever a set of symptoms loosely concordant with clinical malaria. Primary cause of fever as heat and particularly in rural areas, an understanding of the role of mosquitos in transmitting fever was limited. First- and second-line treatments adopted by caretakers, when either they or their children were sick, involved considerable self-medication with chloroquine and paracetamol. Ethnographic data were supplemented and tested for generalizability through a cross-sectional survey, and the paper discusses this methodological approach.

Key words: Malaria; Ethnographic assessment; Fever; Caretaker

1. Introduction Interest in behavioural interventions to reduce the incidence, morbidity and mortality of infectious disease in poor countries has led to recognition of the need to understand community beliefs and practices that may relate to the transmission, diagnosis and management of disease (Manderson, 1994). For a number of diseases, including diarrhoeal disease, acute respiratory infections and malaria, early diagnosis and treatment may be of critical importance in reducing mortality. However, we now know that caretakers may recognise, interpret and act on signs and symptoms of illness in ways that are not necessarily either concordant with biomedical understandings of the disease nor consistent with health education designed to encourage early treatment (Smith and Kane, 1970; Katon and Kleinman, 1981; Pattison et al., 1982; Olango and About, 1990; Pelto and Kendall, 1991; Nichter, 1993). We know too that caretakers' behaviour in response to signs of disease are influenced by a wide range of factors other than accessibility and availability of services, including social networks and socio-economic factors as well as perceptions of severity of illness (Safer et al., 1979; McKinlay, 1981; Sukkary-Stolba, 1989; Tupasi et al., 1989; Kendall, 1990). The experience of illness, including its prevalence in the community, *Corresponding author. Fax I.A.A.: 233-21-22.6739. E-mail: [email protected]. Fax L.M.: 61-7-365.5599. SSDI 0 0 0 1 - 7 0 6 X ( 9 4 ) 0 0 0 7 5 - 1

318

the frequency of infection of household members, the past history of episodes of illness in the affected individual, familiarity with and access to different treatment modalities and therapies, and a variety of social, structural and economic factors influence care and treatment (Pattison et al., 1982; Fitzpatrick et al., 1984; Csete, 1993). In addition, local diagnostic categories and local understandings of the etiology of disease affect timing of diagnosis, methods of home treatment, patterns of health seeking behaviour outside of the domestic domain (Kendall 1990), and compliance with treatment (Homedes and Ugalde, 1993; Jayawardene, 1993; or prophylaxis, see Helitzer-Allen et al., 1993). These social factors apply to malaria as they do to other infectious diseases, although compared to some other diseases, they remain poorly researched. In this paper, we are concerned with community understandings, diagnosis and treatment of malaria in Ghana. The research was conducted in the course of developing a manual for the rapid ethnographic assessment of social and cultural aspects of malaria, in which context we were interested in the triangulation possible from limited focused ethnographic research supplemented by a cross-sectional survey. In this paper, we first examine the diagnostic criteria used by urban and rural residents in two sub-districts of the Greater Accra Region for malaria ('fever'). We then explore the etiology of fever as understood within the community, and discuss the patterns of treatment and resort to care taken by caretakers in the event of sickness.

2. Background and methods This paper draws on research undertaken in August-September 1992 and November 1992 January 1993. Both qualitative and quantitative research methods were used to collect social, cultural and behavioural information relating to malaria. The qualitative methods used included focus groups, key informants and other in-depth interviews, and observations in the two rural and urban study sites, which were selected opportunistically on the basis of the investigators' prior familiarity with the areas. This approach is consistent with ethnographic methods but obviously raises questions of generalizability of data. A cross-sectional survey of the research districts was used to test the qualitative data for external validity, and in keeping with the methodological project of developing rapid assessment procedures, we used a standard EPI two-stage cluster-sampling frame (30 x 7) which did not correct for population size (Smith, 1989). By combining both qualitative and quantitative methods, notwithstanding the limitations with regard to sampling method and to rapid assessment approaches more generally (Manderson and Aaby, 1992a), we were able to collect detailed information about community perceptions, understandings and responses to illness and to enhance the validity of the ethnographic data. A full exploration of the context of diagnosis and treatment, and the testing of reported behaviour against specific cases, await further research however. Qualitative research was conducted in Duffo, Dangme West, and in the Odorna and Sahara areas of Osu-Clottey sub-district, Accra. Duffo is a village located on the Volta River, comprising of around 300 households (620 registered adults, ca. 2000 pop.) divided into three residential clusters. It is located in the Osudoku subdistrict of Dangme West, which had (in 1993) a mid-year population of 16,473.

319 The population is primarily Dangme, with some migrant Ewe. It is broadly characterised by village endogamy, patrilineality and patrilocal residence. The community has an agricultural subsistence base of corn and cassava, and individuals generate limited cash income from the sale of surplus crops, fish and prawns caught in the Volta River, and from the production of quick lime and charcoal, the latter sold to middlemen to meet the fuel requirements of Accra residents. Women also earn money by selling their labour (often in teams) to nearby rice farms: they are paid around 400 cedis (ca. 80 US dollarcents in 1992) per day for harvesting and threshing the rice. Other income generating activities include selling kenke (steamed corn dough) or other foodstuffs within the village, or buying small quantities of food or other items in the market for resale in the village. Most women are economically active. Immediate health care needs are met by two village health workers, who with around 4 weeks training operate a community clinic which provides primary palliative care and treatment of acute cases for a limited number of health problems (primarily management of diarrhoeal disease, ARI and fever, and dressing of wounds). They also refer community members to the rural health centres or the mission hospitals located in an adjacent district, the nearest of which are accessible by river. An outreach clinic visits the community on a sporadic basis (usually once per month, depending upon vehicle availability), and whilst its primary role is immunization and monitoring infant health (through weighing babies), it also provides some health education, for example for family planning and for oral rehydration therapy for the management of diarrhoeal disease. There is no government health centre or hospital in the subdistrict, which is served only by three nurses working out of an MCH centre, by five community clinics, and a midwife who runs a private clinic. Thus the ratio of private clinics to population at the time of the study was 1:16,473. The urban study was located in Odorna and Sahara, adjacent residential areas where around 10,000 people live, of an estimated total population of 162,704 of Osu-Clottey subdistrict, Accra. The study site includes established residential areas with reasonable quality housing, and squatters' huts which provide rudimentary shelter for in-migrants from all regions and ethnic groups. There is considerable crowding, and provisions for the disposal of both wet and dry waste is poor. Residents work for cash in both formal and informal sectors; for women, incomeearning activities include hairdressing, dressmaking, commercial sex work, trade stores and food stalls. The area is well served by biomedical services. These include a Polyclinic (urban health centre), a local smaller health centre which is a 'satellite clinic' of the Polyclinic, two dental clinics, one maternity and two general hospitals, private clinics and doctors, chemists selling pharmaceuticals and patent medicines, and various pedlars selling herbal and pharmaceutical concoctions, some of which are allegedly affective in treating fever. The urban health centre alone employs three doctors and 108 nurses of all grades, and the ratio of private clinics to population is 1:2805. A cross-sectional survey was conducted to gather quantifiable data from householders in these same subdistricts, using a structured questionnaire developed following preliminary analysis of the qualitative data. As already mentioned, a twostage cluster sampling frame was used, with systematic random sampling first to select 30 clusters from each of the urban and rural subdistricts, using for Osudoku

320 an official list of rural communities, and for Osu-Clottey, where natural communities do not exist, enumeration areas of the census office. The second stage was to select 7 households per cluster. Interviewers selected households by locating the approximate centre of the community and then choosing the nearest compound to identify the first household. If there were several households within a compound, all were included. The person with primary responsibility for the care of children less than five years old was interviewed in each sampled household. Some accidental oversampling occurred where there was more than one caretaker in a given household, and when all volunteered to be included in the study, to avoid individuals feeling slighted at being excluded. This was particularly the case in Osudoku, where 256 households were included, compared with 215 households in Osu-Clottey, but the oversampling was small enough to have little effect on findings. As noted, survey participants were caretakers of a child or children < 5 yrs. Most (96% rural and 92% urban respectively) were mothers. Urban respondents were more likely than rural women to have only one child < 5 yrs (70.7% cf. 54.3% of rural respondents with one child; 28.4% cf. 42.4% with two children < 5). The mean age of respondents in both study areas was 29. In Osudoku, 42.6% of women had no formal education and 21.9% had less than six years of schooling; among urban women in Osu-Clottey 1.2% had no formal schooling, 18.1% had < 6 years, 53.5% had 6-10 years of school, and 17.2% some post-secondary education.

3. Fever, asra and malaria

Residents in both rural and urban G h a n a use f e v e r as the predominant term for malaria. Only a few respondents recognised the term 'malaria' as one borrowed from clinic staff or doctors. Fever in this paper is understood to be a local term for a set of symptoms that approximate the biomedical disease defined clinically as malaria, hence its italicisation. As Agyepong (1992) has described, among G a Adangme speakers in Dangme West, in the same area in which this present study was conducted, f e v e r and asra are used interchangeably to refer to a number of symptoms including hot body and chills, headache, yellow urine, yellow vomit and yellow eyes, bitter taste in the mouth, bodily pains, certain behavioural changes such as dizziness, weakness and anorexia in adults, and loss of energy ('doesn't play') and refusal of food in children. In Duffo, asra was commonly used to refer to malaria-associated symptoms. Community members distinguished between asra and asraku or 'high fever', the latter term usually indicating severe and complicated illness which was due to untreated or inappropriately treated asra and was diagnosed by the ' m a d ' behaviour of the person ill (see Agyepong, 1992). Fever was also used coterminously with asra; the term hedola was used to refer to a rise in body temperature and was nearer in meaning to the English word 'fever'. Some respondents gave a fuller description of asra or fever, noting that with asra, one is 'alright in the morning but starts shivering the late afternoon or early evening'. Asra can also start with a headache, then shivering. In Odorna and Sahara, a variety of terms were used for malaria-type symptoms, not unexpectedly given the ethnic mix within the area. These included atridii (from G a and Akan speakers), eboum (Akan) and kuraye (Akan), although the t e r m f e v e r was the most commonly used. Here, severe illness was associated with

321 delirium a n d 'high fever'. As noted, asra or fever m a y be diagnosed in the event o f a n u m b e r of symptoms, a n d diagnosis o n the basis of a single s y m p t o m is rare. I n the survey, some 7% o f u r b a n respondents said that they w o u l d diagnose fever in either a n adult or child o n the basis o n one s y m p t o m only, a n d diagnosis was m a d e o n the basis of two s y m p t o m s only by 40% of r e s p o n d e n t s for children a n d 32% for adults. A m o n g rural respondents, 6.35% based their diagnosis of fever o n one s y m p t o m a n d 37.5% o n two s y m p t o m s only in their children; for fever in adults 5.5% used one s y m p t o m a n d 29% two symptoms. The majority, therefore, in the case of their own illness a n d that of a child, used a cluster of s y m p t o m s to arrive at a diagnosis, including general feeling of unwellness a n d malaise, changes in temperature, a n d other physical a n d b e h a v i o u r a l signs of illness (Tables 1 a n d 2). The assessment o f a child's condition, therefore, including the n a t u r e of the illness TABLE 1 Symptoms of fever in children by order of frequency Order of frequency

1 2 3 4 5 6 7 8 9 10

Rural respondents (n = 255)*

Urban respondents (n=205)*

Symptom

No

Symptom

No

Hot body Yellow eyes Vomiting Yellow urine Refusal of feeds Other Diarrhoea Child won't play Chills Bitter mouth

226 103 90 89 67 52 37 37 36 4

Hot body Refusal of feeds Other Vomiting Child won't play Yellow urine Yellow eyes Diarrhoea Chills Bitter mouth

181 93 82 55 53 39 25 20 16 3

* Total number of symptoms exceeds sample due to multiple responses. TABLE 2 Symptoms of fever in adults by order of frequency Order of frequency

1 2 3 4 5 6 7 8 9 10 11 12

Rural respondents (n =255)*

Urban respondents (n = 205)*

Symptom

No

Symptom

Bitterness in mouth Bodily pains Chills Hot body Headache Loss of appetite Yellow urine General weakness Other Yellow vomit Yellow eyes Dizziness

119 101 97 85 82 74 65 64 37 35 31 28

Headache Loss of appetite General weakness Bitterness in mouth Bodily pains Hot body Chills Yellow vomit Other Yellow urine Dizziness Yellow eyes

* Total number of symptoms exceeds sample due to multiple responses.

No 88 87 86 71 62 52 51 46 31 28 26 13

322 TABLE 3 Number of signs mentioned as indicatingfever in children Number of respondents giving:

Rural (n = 255)*

Urban (n- 205)*

1 sign of fever 2 signs of fever 3 signs 4 signs 5 signs 6 signs 7 signs

255 (100%) 240 (94%) 160 (63%) 68 (27%) 13 (5%) 5 (2%) 0 (0%)

205 (100%) 189 (92%) 122 (59.5%) 40 (19.5%) 9 (4%) 2 (1%) 0 (0%)

* The question was asked only to those who perceivedfever to be a health problem, slightly less than the total number of respondents. and its severity, and hence decisions relating to the management of the illness are based on various subjectively determined signs (see Nichter (1993) with respect to respiratory infections and diarrhoeal disease). Mothers included both physical and behavioural changes in their child's condition as indicators of illness, with the majority of women using three or more symptoms to make such an assessment. It is worth observing, however, that virtually all mothers used change in body temperature ('hot body') as one of the symptoms of fever. Rural mothers then looked for other physical signs of illness (vomiting, yellow urine, etc.) whilst urban mothers tended most often to assess the general condition of the child on the basis of behaviour (refusal to eat, won't play), rather than physical signs (Table 1 ). A m o n g adults, the coincidence of a number of symptoms also both denoted illness and the specific diagnosis. The symptoms in adults most likely to be associated with and thus leading to a diagnosis of fever varied slightly between urban and rural populations, with urban respondents diagnosing more often on the basis of headache and other diffuse perceptions of illness (loss of appetite, general weakness) whilst rural respondents were more likely to rely on physical signs and symptoms ('bitterness in mouth', pains, chills and hot body) (Table 2). Although women diagnose a child's or adult's illness on the basis of the clustering of symptoms, the clustering of particular symptoms does not appear to be systematic, but rather, the coincidence of any two, three or more symptoms might taken together to indicate fever. Neither was there an apparent hierarchy of clusters of symptoms; respondents simply usually mentioned more than one symptom indicating fever as it presented in both children and adults (see Tables 3 and 4).

4. Etiology There are several causes of fever, which include exposure to heat from sun or fire, eating oily or starchy food, mosquitos, or unhygienic surroundings, and in the survey, most respondents gave more than one cause. In the rural area, exposure to heat was the most important cause, and was mentioned by 79.6% of survey respondents as a sole or contributory cause of fever. Children were said to get fever 'because they play in the scorching sun'; adults 'by working in the sun' since 'the sun enters your body', or by heat from fire, such as that used to burn oyster shells to produce

323 TABLE 4 Number of signs mentioned as indicating fever in adults Number of respondents giving:

Rural (n = 255)*

Urban (n = 205)*

1 sign of fever 2 signs of fever 3 signs 4 signs 5 signs 6 signs 7 signs

255 (100%) 241 (94.5%) 181 (71%) 94 (37%) 35 (14%) 12 (5%) 0 (0%)

205 (100%) 190 (92.7%) 140 (68%) 71 (35%) 28 (14%) 7 (3%) 0 (0%)

* The question was asked only to those who perceived fever to be a health problem, slightly less than the total number of respondents.

quick lime or to burn charcoal. A few also mentioned that fever could be caused by not eating nutritious foods, by eating the same food over a long period of time (particularly fresh cassava, konkonte - dried cassava, and corn dough), by eating uncovered food, old food, or food prepared in unhygienic surroundings. Fever is generally not regarded as infectious, although focus group participants in Duffo felt that child-to-child transmission was possible. In in-depth interviews in Duffo, few respondents only mentioned the mosquito as the vector of malaria: one explained that mosquitos bit animals and therefore spread disease to humans, another that the mosquito sucks blood out, then injects it back into the body, causing disease. A few people mentioned that malaria was seasonal, although they could not specify times of year of greatest prevalence or explain the etiology of the disease in relation to seasonality. However, although the qualitative data suggested that in rural Ghana there was little association between mosquitos and malaria, in the survey 33% of respondents mentioned mosquitos as causing malaria. Views about the role of the mosquito as a vector held by Duffo community members were not dissimilar to those gathered in interviews and focus group discussions in Odorna and Sahara, where according to women 'mosquitos eat dirty water and inject you with it' or 'mosquitos bite others with a disease and biting you later, (they) can give you fever'. Again, in Odorna and Sahara, a number of women associated eating oily foods with malaria: 'If you take oily food, jaundice sets in. Palm oil is alright, it's not as fatty, so people prefer to eat palm oil to avoid fever. If you have fever already, oily food makes it worse'. Others also gave exposure to heat as a primary or contributory cause of malaria: 'sitting in the sun is the worse, it melts your blood' (Sahara resident). However, women more often recognised that mosquitos were the sole or primary cause of malaria, and associated the prevalence of fever in the community with environmental conditions, drawing our attention to the stagnant water in drains throughout the area. Survey responses replicated these findings. Virtually all respondents in both rural and urban areas said that fever caused them concern, but knowledge of the cause of malaria was a major point of difference between urban and rural respondents. Some 50% of rural respondents attributed fever to heat from the sun only, compared with only 16.6% of urban respondents. Some 10% of rural respondents stated that fever was transmitted by mosquitos as the primary cause, although as already noted a total of 33% included mosquitos as one of the causes of malaria. Among urban

324 respondents, 47.3% gave mosquitos as the primary cause of fever, and a total of 62.4% of urban respondents mentioned mosquitos as one of multiple causes of fever. In addition, 19.5% mentioned 'unhygienic surroundings' as a factor contributing to fever and around a third of those who mentioned mosquitos also attributed fever transmission to other factors.

5. Treatment

As noted above, health care is provided by a combination of government, private, charitable, traditional and self-help sources; Osu-Clottey is well-provided by these services whilst Osudoku has extremely limited government and private services. Provision of services does not appear to have direct influence on treatment-seeking behaviour, however. At onset of symptoms, fever tends to be treated in the home without resort to traditional or professional healers. Such treatment involves herbal medicine, herbal inhalations and herbal baths, various other home remedies, and self-prescribed western medicines administered by the caretaker or other family members. Among adults in Duffo, fever is treated at onset with either herbal preparations or with analgesics and antipyretics such as paracetamol, Aspirin, Daga (an aspirin + caffeine tablet) and sometimes with chloroquine. Urban respondents were less likely to use herbs as a primary or secondary treatment because 'those in the village feel better when they take the herbs since they are used to it, but with us here it does not work' and because 'we know the orthodox medicine, we don't know the herbs. Also the people in the house will say "take the child to the hospital" several times and this will make you go'. In the case of their own illness, informants took patented medicines which they knew either generically (paracetamol, chloroquine) or by trade name (Alagbin), used pharmaceuticals for symptomatic relief ('Give chloroquine to children when their bodies are hot'), took herbal medicines according to a fixed regime ('You drink a herbal preparation from neem tree, guava and lime leaves 3 times daily in total'), and combined both biomedical and herbal practice: '(In the event of fever) go to the hospital, then when you feel fine you can drink herbal preparations for three days'. Husbands, when present, usually purchased drugs for their wives, either from the local chemist (who sells chloroquine tablets and syrup over the counter) or from other local pedlars. The amount of drugs self-administered varied. Some respondents mentioned taking two paracetamol and one chloroquine; others one paracetamol and one chloroquine per day; one mentioned taking each twice a day. One supplemented paracetamol and chloroquine with 'B-co' (Vitamin B-complex). One informant in Odorno said that adults should take 2 paracetamol 3 times day, and 2 chloroquine tablets twice day; children should be given 1 teaspoon each of chloroquine and paracetamol syrup. Another gave the same dose to her children, using the smallest teaspoon she owned for the youngest child, and a larger spoon for the older children. Another woman would take 3 paracetamol 3 times per day, and present at hospital if there was no change after the third day. Most people ceased medication when the symptoms of malaria stopped ('I stop when I feel free'), and used any remaining tablets to suppress symptoms when they were sick again. Where a child was sick, it was often bathed in cold water to reduce body temperature, and medicated with paraceta-

325

mol to 'bring the illness down' (in Duffo, as advised by Outreach clinic staff to deal with a temperature following immunization). In the cross-sectional survey, the majority of respondents reported initially using some form of home treatment for both children and adults, either paracetamol alone, or paracetamol in combination with chloroquine or herbal medicine (53% of cases of adults and 60% of children with presumed fever among rural respondents; 72% of cases of adults and 76.5% of children among urban respondents). Significantly also, most people took more than one action. For example, 143 out of 256 rural respondents undertook two first actions concurrently (self-medicating with chloroquine and paracetamol, for instance), and 46 out of the 143 who took a second action took a third one at the same time, such as having an enema and taking a combination of drugs (Tables 5 and 6). The proportion reporting self-medication as a first treatment is relatively high TABLE 5 First treatment actions for a child with fever Treatment/action

Rural (n=255)*

Urban (n=205)*

Paracetamol Chloroquine Herbal drink Inhalation Enema Other drugs Go to clinic Go to hospital Nothing/wait and see Don't know: child has not had fever Other

153 99 59 8 27 10 12 12 6 2 68

156 111 7 0 7 5 6 6 10 1 33

* Total actions exceed number of respondents as respondents might undertake two or more actions concurrently.

TABLE 6 First treatment actions for an adult with fever Action

Rural (n = 255)*

Urban (n = 205)*

Paracetamol Chloroquine Herbal drink Herbal inhalation Enema Other drugs Went to a clinic Went to a hospital No action/waited to see Never had fever Other

140 85 93 46 19 14 7 3 2 0 49

147 102 37 3 6 11 5 3 4 1 25

* Total actions exceed number of respondents as respondents might undertake two or more actions concurrently.

326 compared with the other study available for Ghana and indicates greater selfmedication in urban rather than rural Ghana (see Wondergem et al., 1989). However, the general pattern is the same: that is, people treat symptoms themselves first, using either traditional remedies or pharmaceuticals, and seek outside advice only if symptoms persist. The difference in use in paracetamol between urban and rural areas may relate to its relative availability in the two areas. Among urban respondents, 52.7% of all respondents (76.5% of those administering paracetamol) also gave the sick child chloroquine. In rural areas, of those who reported giving a child with fever paracetamol, 65.7% also said that they would administer chloroquine; 13.8% would give the sick child herbs and an additional 9.2% would give herbs in addition to other medication. Other responses - giving enemas, inhalations, seeking immediate medical advice, or simply monitoring the sick child's condition - were relatively infrequent and equally common. Care of a sick person is a dynamic process. The caretaker diagnoses on the basis of a variety of symptoms, as described above, then treats, assesses treatment success, alters the treatment regime or seeks advice, and so on. There was no real difference in second and third line treatment between rural and urban respondents, despite the greater distance and relative cost for rural patients. In both cases, over 85% said that they would go to hospital if their fever did not respond to self-medication, and the difference related only to choice of service: some two-thirds of urban respondents said they would go to the clinic, one third to a hospital; the proportion was reversed for rural patients. A significant proportion mentioned that they would continue to self-medicate in the event of continuing symptoms, primarily using paracetamol and chloroquine, but also taking herbal drinks, inhalations and enemas (13.3% and 6.8% for rural and urban respectively for herbs and other traditional therapies). People sought medical attention for 'proper treatment' and 'proper examination' rather than because of the availability of chloroquine injections, and only 7% of rural and 1% of urban respondents did not mention proper examination and treatment as at least one of the reasons for using a clinic/hospital. Rural respondents seemed to put less value on clinics/hospitals for the sake of injections than urban residents, and 25% mentioned 'proper examinations and treatment' as their reason for seeking biomedical advice. On the other hand, many who presented to the clinic or hospital outpatients department expected as part of 'proper treatment' that they would be given an antimalarial injection (41.2% rural, cf. 52% of urban respondents in the survey). Findings were similar for children but fewer people mentioned that they would take their child to a clinic only or primarily because of the availability of injections alone. The association between biomedical treatment and injections, and a preference for injections over oral medication, is consistent with research related to medication practice and preference in other poor country settings (Wyatt, 1984; Kumar et al., 1985). Injections were preferred for the chemotherapautic treatment of malaria in adults by community members in both urban and rural areas. Among Duffo residents, herbs and tablets are said to 'put fear in the illness', but hospital treatment by injection is regarded universally as the most effective and tablets, in contrast, were perceived to have little effect on adult fever. In Duffo, people (correctly) pointed out that the tablets available through the community clinic were the same that they would use for self-medication, and that failure to respond to the tablets indicated the need for an injection: 'Injections work through the whole body and are more

327 powerful than tablets, they work through your veins'. Fever that recurred after three days, despite medication in tablet form, could be cured with an injection. (In general, those who said that tablets did not work for them used a very low dose, taking for example only 2 tablets of chloroquine (300 mg base), around 20% of the dose required; see Agyepong, 1992). One of the attractions of injections is its immediacy, and in interviews respondents emphasised that they could ill-afford the time taken to recover if they relied on chloroquine by tablet. For some people at least, cost of illness is assessed in terms of loss of income. According to a village health worker in Duffo: 'People... need to sustain economic activities for the sake of the family. If you're sick, you are all in trouble. People worry about loosing work time, so they'd rather have an injection and recover quickly, than be sick for a number of days while they take pills.' But community members also linked injections with proper treatment and medical practice: 'proper' health services included thermometers, blood pressure equipment, and injections, and staff examined people (for example, felt their stomach). The community clinic in Duffo provided none of these services. Again, in the words of a village health worker: 'People only feel they've been treated if they've been given injections, or if their BP is taken, so (here) they don't feel they've been treated they're not confident they think, these people are only fooling, they're not serious.' At the community clinic, only paracetamol and chloroquine, in syrup form for children and in tablet form for adults, can be prescribed. At the rural health clinic a boat-trip away, an injection of chloroquine is standard practice. In Odorna and Sahara also, clinic or hospital treatment is sought when fever is perceived to be 'serious' and when home treatment does not work. Here too injections are preferred, and urban residents in the survey were more likely expressly to seek an injection where self-medication failed. In the event of a child with fever not improving, 87.4% of urban and 90% of rural respondents said they would take the child to either a clinic or hospital, either as the sole second-line strategy or in addition to other actions such as the administration of herbs, paracetamol or chloroquine. Health-seeking behaviour for children was influenced less by the possibility of injection, although still 31.7% of rural and 30.4% of urban respondents expected this as the appropriate outcome of presenting for medical care. But many also emphasised that their decision was influenced by the provision of proper examination (49.7% rural, 86.7% urban) and proper medical treatment (83.9% rural, 93% urban), which was either independent of or in addition to the availability of injections. In addition, there were reported variations in behaviour depending on the individual who was sick. Women claimed that when pregnant, they would wait 'a few days' to see if the fever improved, but if not, they'd go straight to the hospital because 'when we are pregnant, we don't play with it. If we feel we are not well, we act. We don't tamper with pregnancy here', and maintained that 'you don't take any medicine at three months, you would wait until you were six months or more - otherwise you might spoil your pregnancy'. 6. Discussion and conclusions We noted at the outset o f this paper that this research occurred as part o f the development o f a field manual for the rapid assessment of social, economic and

328 cultural aspects of malaria. In the context, we were concerned to combine qualitative and quantitative approach since the research methods are designed to collect different kinds of data. Methods need to be determined on the basis of the research questions to be asked, and the qualitative methods used in this study were designed to collect detailed information about linguistic categories, folk taxonomies and the construction of illness (e.g. fever), diagnostic process, and treatment-seeking action and behaviour (see also Helitzer-Allen, Kendall and Wirima, 1993). However, the methodological approach - using a given community as a 'case study' - is not appropriate to describe the distribution of a behaviour or an illness, and not especially appropriate to extrapolate to a wider population or to give numeric value to this information. Further, since study sites for ethnographic research are sampled opportunistically, and since no one study site can be 'typical' in a statistical sense, then it is possible that the results are unrepresentative and they cannot be generalized to the population at large other than with caution. Probability sampling and survey methods come into their own, therefore, at the point at which frequency of knowledge and action is important (Manderson and Aaby, 1992a, 1992b). In this project we conducted a cross-sectional survey, which utilised an alternative quantitative rapid assessment approach. The results of this combined study provide an example of the value of methodological mixes for the purposes of triangulation (Jick, 1979; Mason, 1994). In this paper, we have described the diagnostic term fever, as used in the Greater Accra Region to refer to one or more symptoms which, taken together, approximate a clinical diagnosis of malaria. A number of symptoms may suggest fever diagnosis, although, as we have noted, the clustering of symptoms is not systematic and the term fever appears to be neither sensitive nor specific for malaria. Further we have noted differences between children's and adult's presentation of fever. Children's diagnosis is primarily based on observable and objective signs of illness (hot body, yellow urine, and so on), whilst the diagnosis of fever in adults depends in part on the individual's own perceived illness. The physical and behavioural signs of illness may in turn be interpreted according to an individual's own past experience of fever or of other episodes of illness in the household. Diagnosis may also be influenced by circumstantial evidence of exposure, linked to perceived cause, such as working in the hot sun. In describing the local etiology of fever, we note from the survey data that only 33% of rural and 62% of urban informants mentioned mosquitos as either a contributory or the sole factor associated with fever infection. The qualitative data suggested even lower association between mosquitos and malaria, suggesting some local variation (e.g. between communities) in terms of knowledge of malaria and possibly exposure to health education. The diagnosis of fever leads to a series of treatment actions in the case of both children and adults, which differs little by area of residence (rural or urban) or by education level of respondent. Primary first course of treatment is by self-medication, and this includes the use of pharmaceutical products such as paracetamol and chloroquine for symptomatic relief, which is of interest in the context of increased chloroquine resistance. Pharmaceuticals such as these are readily available in small quantities in the market place. Recourse to medical advice and treatment is delayed until it is clear that the fever cannot be managed in the home. At this point adults look for injection rather than oral treatment for fast cure for their own fever, and rediagnosis and 'proper' effective treatment for their children. The delay in treatment

329

is particularly significant in terms of the outcome for sick infants, for whom malaria remains a major cause of death in the first year. The research, whilst highlighting areas that suggest the need for more extensive social research, indicates also areas where health education and control program activities might be initiated.

Acknowledgements Field research was conducted by the authors with Bertha Aryee and Helen Dzikunu. The project was supported by the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Disease (Social and Economic Reseacch Programme). We are grateful to the Health Research Unit, Ministry of Health, Ghana, and particularly to its director, Dr Sam Adjei, for support.

References Agyepong, I.A. (1992) Malaria: Ethnomedical perceptions and practice in an Adangbe fanning community and implications for control. Soc. Sci. Med. 35, 131-137. Csete, J. (1993) Health-seeking behavior of Rwandan women. Soc. Sci. Med. 17, 1285-1292. Fitzpatrick, R., Hinton, J., Newman, S., Scambler, G. and Thompson, J., (1984) The Experience of Illness. London: Tavistock. Helitzer-Allen, D.L., Kendall, C. and Wirima, J.J. (1993) The role of ethnographic research in malaria control: An example from Malawi. Res. Sociol. Health Care 10, 269 286. Helitzer-Allen, D.L., McFarland, D.A., Wirima, J.J. and Macheso, A.P. (1993) Malaria chemoprohylaxis compliance in pregnant women: A cost-effectiveness analysis of alternative interventions. Soc. Sci. Med. 36, 403 407. Homedes, N. and Ugalde, A. (1993) Patients' compliance with medical treatments in the third world. What do we know? Health Pol. Plann. 8, 291-314. Jayawardene, R. (1993) Illness perception: Social cost and coping-strategies of malaria cases. Soc. Sci. Med. 37, 1169-1176. Jick, T. (1979) Mixing qualitative and quantitative methods: Triangulation in action. Admin. Sci. Quart. 24, 602 611. Katon, W. and Kleinman, A. (1981) Doctor-patient negotiation and other social science strategies in patient care. In The Relevance of Social Science for Medicine. L. Eisenberg and A. Kleinman, eds. Pp.253-283. Dordrecht: D. Reidel Publishing Company. Kendall, C. (1990) Public health and the domestic domain: lessons from anthropological research on diarrhoeal diseases. In: Anthropology and Primary Health Care. J. Coreil and D.J. Mull, eds. Pp.173 195. Boulder: Westview Press. Kumar, V., Clements, C., Marwah, K. and Diwedi, P. (1985) Beliefs and therapeutics preferences of mothers in management of acute diarrhoeal diseases in children. J. Trop. Paediatr. 31, 109-112. McKinlay, J.B. (1981) Social network influences on morbid episodes and the career of help seeking. In The Relevance of Social Science for Medicine. L. Eisenberg and A. Kleinman, eds. Pp. 77-111. Dordrecht: D. Reidel Publishing Company. Manderson, L. (1994) Social science research and tropical disease. Med.J. Aust. 160, 289 292. Manderson, L. and Aaby, P. (1992a) An epidemic in the field? Rapid assessment procedures and health research. Soc. Sci. Med. 35, 839-850. Manderson, L. and Aaby, P. (1992b) Can rapid anthropological procedures be applied to tropical diseases? Health Pol. Plann. 7, 46-55. Mason, J. (1994) Linking qualitative and quantitative data analysis. In: Analyzing Qualitative Data. A. Bryman and R.G. Burgess, eds. Pp. 89 101. London: Routledge. Nichter, M. (1993) Social science lessons from diarrhea research and their application to ARI. Human Org. 52, 53 67.

330 Olango, P. and About, F. (1990) Determinants of Mothers' Treatment of Diarrhea in Rural Ethiopia. Soc. Sci. Med. 31, 1245-1249. Pattison, C.J., Drinkwater, C.K. and Downham, M.A. (1982) Mothers' appreciation of their children's symptoms. J.R. Coll. Gen. Pract. 32, 149 162. Pelto, G.H. and Kendall, C. (1991) Behavioral aspects of acute respiratory infections in children. In: Acute Lower Respiratory Infection and Child Survival in Developing Countries. A. Gadomski, ed. Pp.145-151. Baltimore: Johns Hopkins University. Safer, M.A., Tharps, Q.J., Jackson, T.C., and Leventhal, H. (1979) Determinants of three stages of delay in health seeking care at a medical clinic. Med. Care 17, 11 29. Smith, G.S. (1989) Development of rapid epidemiologic assessment methods to evaluate health status and delivery of health services. Int. J. Epidemiol. 18, Supp.2, $2 S14. Smith, L. and Kane, R. (1970) Health knowledge and symptom perception: a study of a rural Kentucky county. Soc. Sci. Med. 4, 557 567. Sukkary-Stolba, S. (1989) Oral Rehydration Therapy: Behavioral Issues in Child Survival Programs. Washington, DC: USAID. Tupasi, T.E., Miguel, C.A., Tallo, V.L., Bagasao, T.M.P., Natividad, J.N., Valencia, L.B., de Jesus, M.E.G. Lupisan, S. and Medalla, F. (1989) Child care practices of mothers: implications for intervention in acute respiratory infections. Ann. Trop. Paediatr. 9, 82-88. Wondergem, P.W., Senah, K.A. and Glover, E.K. (1989) Herbal drugs in Primary Health Care. Ghana: An assessment of the relevance of herbal drugs in PHC and some suggestions for strengthening PHC. Amsterdam: Koninklijk Instituut voor de Tropen (Royal Tropical Institute). Wyatt, H.V. (1984) The popularity of injections in the Third World: Origins and consequences for poliomyletis. Soc. Sci. Med 19, 911 915.