Background
Data for this study come from the baseline component of a study designed to assess the impact of Freedom From Hunger's malaria educational model in Ghana. Freedom from Hunger (FFH) – an international non-governmental organization (NGO) – works in sixteen countries around the world. Their mission is to bring sustainable, self-help solutions to communities as they address chronic hunger and poverty and equip families with resources they need to build health, hope and dignity. The study was carried out in 13 communities in the Afram Plains District of the Eastern Region and 20 communities in the Asikuma-Odoben-Brakwa District of the Central Region. The Afram Plains District extends into the Volta Lake Basin and is among the most geographically disadvantaged districts in the country, as it can only be reached by ferries from the southwest and east. The Asikuma-Odoben-Brakwa District is located in the north-central portion of the Central Region and has a somewhat higher population density than Afram Plains. In both study areas, malaria remains the most common reason for attending a health facility.
Freedom from Hunger (FFH) uses Credit with Education to offer an integrated package of microfinance services combined with health education. Women within each credit association meet weekly, biweekly, or monthly to repay loans, to deposit savings and to participate in non-formal, dialogue-based learning sessions where they discuss better health, nutrition and family planning practices as well as sound business strategies.
In 2004, prior to introducing a new malaria education module developed for West Africa, FFH carried out baseline data collection as part of the first phase of a project intended to evaluate the impact of the module in Ghana. The purpose of the baseline assessment was to describe community members' knowledge and practices prior to the introduction of malaria education. Data for this study were drawn from the baseline assessment.
Instrument
The quantitative data collection instrument was adapted from a standardized tool (the Malaria Indicator Survey) developed by RBM partners and was designed to assess core household indicators. Several questions were also adapted from the 2003 Ghana Demographic and Health Survey. Prior to administering the survey, qualitative research was carried out to determine community perceptions of malaria and the survey was adapted accordingly.
Survey respondents included women of reproductive age (15–49) with a child less than six years of age. Each respondent was interviewed about sociodemographic and household characteristics as well as knowledge and practices regarding malaria transmission, prevention and treatment. Variables used for assessing respondents' knowledge included cause of malaria; steps in the transmission cycle; methods of protecting against malaria transmission; best ways to prevent malaria; stopping treatment before a full dose is completed; which groups are most vulnerable to malaria; and signs and symptoms of malaria in children and pregnant women.
Sample selection and data collection
A complete list of credit association members was used to randomly select clients from the 31 credit associations in the Eastern Region and the 51 credit associations in the Central Region. Prior to selecting clients, credit associations participating in the Credit with Education programme were randomly assigned to receive either the malaria or a standard diarrhoea module upon the completion of baseline data collection.
Non-clients were selected from the same communities as clients through two-stage cluster sampling. Each community was divided into four geographic segments, one of which was randomly selected. Non-clients were selected by systematically sampling the houses in the randomly chosen geographic sector. A starting point was randomly selected and every 5th household was then surveyed. The same eligibility criteria (women of reproductive age with a child less than six years of age) were used in the selection of clients and non-clients.
Trained interviewers collected data between September and October of 2004. Selection criteria for interviewers included the ability to speak the local dialects (Ewe, Twi and Fante) in addition to the national language (English); previous experience with data collection; and at least a high school education. Though the questionnaires were in English, the actual interviews were conducted in the local languages and each woman's responses were transcribed by the interviewer. In order to minimize variations between interviewers, during training, interviewers discussed and standardised how key questions would be asked in each language.
Interviewers briefly explained the research objectives and obtained written consent from participants. Because sociodemographic information and several other independent variables were only collected at the household level and because there were, on average, 1.5 women of reproductive age per household, only primary respondents – those women originally selected for interviews or the appropriate replacement that subsequently provided information on the other members of the household – were considered for the current analyses. Therefore, 1,051 women (n = 537 from the Central region; n = 514 from the Eastern region) were included in the analytic dataset, half (49.1%) of whom were clients of Credit with Education programmes.
Data from various subgroups of the original sample were analysed; however, this paper focuses exclusively on children less than five years of age. Though about 25% of women had more than one child under the age of five, only the youngest child in each household was included for analyses. Thus, the sample used for this study included 900 youngest children under the age of five. Before excluding older children (also less than five years of age) from analyses, it was confirmed that there were no significant differences in the behaviours of interest between the youngest child and other children in the household. Overall, 9.5% of all children less than five years of age slept under a bednet the night before the survey while only 1.4% slept under an ITN. Because only a very small percentage of all children under five slept under bednets that were verifiably insecticide treated, ITN use alone was not evaluated. Bednets that have not been treated with insecticide offer some protection against malaria, but the protection provided by bednets is maximized with treatment and regular re-treatment with insecticide [7]. In this paper, bednets refer to any bednet – insecticide treated or otherwise.
Data analysis
Data were analysed using SAS, version 9.1 (SAS Institute Inc., Cary, North Carolina, USA). Frequencies, percentages, Pearson chi-square tests and Fisher's Exact tests were used to compare the sociodemographic characteristics and knowledge of doers with non-doers in relation to bednet use. Differences between clients and non-clients were checked and found to be minimal. Logistic regression was then used to identify those factors most closely associated with bednet use among children less than five years of age. Variables were retained or dropped from the models through stepwise regression based on a 0.2 level of significance. Odds ratios and 95% confidence intervals were calculated for all retained variables.