In Ghana, it is the cultural norm for the female to be the primary caretaker (Ahorlu et al., 1997). Women are also the least likely to have received formal schooling, especially in the north region (GSS, 2008). As such, only 4 in 10 women are literate which significantly reduces the available methods of health education outreach (GSS, 2008). A direct implication of the lack of education, is the lack of knowledge surrounding malaria. Those who had not completed secondary school were much more likely to incorrectly identify the cause and risk factors for malaria (Attu & Adjei, 2018).
Alongside educational limitations are economical ones, the household income in the northern region is 130.00 Ghanaian Cedis or less per month, equivalent to 28 US dollars (GSS, 2008). Low socioeconomic status is closely associated with poor toilet facilities, and the unsanitary conditions of these facilities, whether communal or in the home, serve as additional breeding grounds for mosquitos and thus risk factors for malaria (Escribano-Ferrer et al., 2017).
Immediate Objective 1:To increase the proportion of residents who accurately report the modes of transmission for malaria to 90% within 3 months of program implementation.
The beliefs of those caring for children under 5 years of age will significantly impact the care they provide for the child and the preventative strategies they are willing to participate in. Although it is common to agree with scientific explanations for malaria, it is often cohabitated with beliefs of spiritual roots which may lead to inaction of recommended measures (Heggenhougen et al., 2013). This immediate objective would be carried out via an interactive educational workshop targeting the parents within the communities.
This workshop, spanning only one day in length, would focus on transmission, signs and symptoms, as well as preventative measures with a focus on insecticide treated bug nets (ITN’s). This objective would be measured with a comparison between scores on a pre and post exam taken that day.
Immediate Objective 2: To increase the proportion of residents who know where to gain access to an insecticide treated bug net (ITN) to 90% within 3 months of program implementation.
Explanations as to why families did not have bed nets was often attributed to not knowing where to access the ITN’s (Nyavor et al., 2017). Incorporated into the workshop described under immediate objective 1, there would be a section on where to access ITN’s during which times of the year, at what cost (often free), and what transportation would be available. In order to quantify this data, we will conduct a survey throughout the community at the time of the workshop as well as 3 months after the workshop.
Behavioral Objective: To increase the usage of insecticide treated bug nets (ITN’s) by parents inside the home by 75% within 1.5 years of program implementation.
Insecticide treated bug nets have been found to reduce malaria infections by 48% (Adongo et al., 2005). More specifically, ITN’s can reduce mortality in children under five years of age by 18.8% (Afoakwah et al., 2018). The immediate objectives will provide the knowledge and resources needed to allow participants to fulfill this behavioral objective successfully. This can measured quantitatively by conducting a household survey at the beginning of the program as well as 1.5 years into the program.
Health Objective: To decrease the incidence of malaria in children under 5 years of age in Northern Ghana by 50% within 3 years of program implementation.
If the immediate objectives are successful, then the usage of ITN’s within then northern region of Ghana will increase, and as a result will decrease the incidence of malaria in children under 5 years of age. Decreasing the incidence of malaria in this target population is the only way to reduce the rates of morbidity that coincide this infection. This can be measured quantitatively by comparing the publically available epidemiological data on malaria incidence by region in Ghana before and 5 years after program implementation.
This intervention is based upon the social cognitive theory, first proposed as the social learning theory by Albert Bandura in the 1960’s (LaMorte, 2018). The construct of the present theory is centered upon the idea of reciprocal determinism; that environment, individual cognition, and individual behavior all interact within a loop (LaMorte, 2018). The utilization of such a holistic theory allows for a topic as complex as malaria prevention to be combatted from a multifaceted approach. The SCT has been used to develop a similar program, which focused on reducing the mortality of children under 5 years of age in Ghana (Abbey et al., 2017). They did this successfully by increasing appropriate treatment seeking behaviors using the SCT constructs, which aimed to change their target population’s environment, knowledge base, and associated behaviors (Abbey et al., 2017). Having seen prior success, we can be confident that when utilized correctly the SCT will produce results in this target population.
The previously defined construct of reciprocal determinism will encompass the entirety of our intervention, and can thus be seen in each of the 5 remaining constructs we will be utilizing. Our first immediate objective relies on the constructs of behavioral capability, expectations, and self-efficacy.
Behavioral capability can be defined as a person’s ability to perform the behavior of interest based upon their knowledge and skill set (LaMorte, 2018). 90.0% of people using ITN’s and only 77.0% of those not using ITN’s believe that they are an effective measure for preventing malaria (De La Cruz et al., 2006). Alongside this data, a study done in the upper east region of Ghana found that the absence of knowledge regarding a mosquito’s role in malaria infection was related to low ITN ownership and usage (Adongo et al., 2005). There are several similar studies which show this association between an increase in knowledge and an increase in ITN use, hence the focus on knowledge for this objective.
This objective will be fulfilled by a series of educational presentations and discussions during the interactive workshop. It is important to incorporate the traditional knowledge of malaria present within the community with the knowledge you are hoping to integrate. If the traditional knowledge is not incorporated into the new information and intended knowledge base, they will often consider the information being presented in competition with their own (Tynan et al., 2011). This has been observed in a variety of communities where malaria is present, but success has been achieved using an integrative educational model (Tynan et al., 2011). As such, the interactive workshop will incorporate the traditional thoughts on malaria within their presentations as much as possible. However, it is important to note that some traditional beliefs cannot be encouraged as they decrease the likelihood of our suggested behavior. For example, bed net usage is often foregone due to the belief that they may infect the air and cause harm to children (Heggenhougen et al., 2013). This belief is obviously counterproductive to our objective and would not be able to be incorporated into the educational presentations. Alternatively, a common aspect of traditional knowledge is the role of spirits in causing illness (Adongo et al., 2005). This belief can be incorporated in to the accurate transmission of malaria and could greatly increase our chance of creating a sustainable and medically accurate knowledge base (Tynan et al., 2011). Assuming our integrative method of knowledge presentation is successful, the spread of this altered knowledge base throughout the community is inevitable and with it our intended effect. Behavioral tendencies are heavily influenced by receiving knowledge from others within one’s community, often portrayed as community perception (Tynan et al., 2011).
The second construct of immediate objective 1 is expectations. Expectations can be defined as the benefits of participating in a behavior, or alternatively the consequences of not participating in a behavior (LaMorte, 2018). The decision to or to not participate is heavily reliant upon prior experience as well as education (LaMorte, 2018). The interactive educational workshop will include, alongside accurate information on malaria and its prevention, the outcome one can expect if one were to utilize preventative methods, specifically ITN’s. For example, the data on the use of ITN’s in a similarly rural region of Ghana could be presented as they found children under 5 years of age had a 45% lower risk of malaria infection when ITN’s were used (Afoakwah et al., 2018).
Lastly, immediate objective 1 also utilizes the construct of self-efficacy, which can be defined as a person’s confidence level in their ability to perform a behavior successfully (LaMorte, 2018). Only 50% of the total population use ITN’s (De La Cruz et al., 2006). Alongside this, there is a gap between ITN ownership and ITN usage of about 33.0% (Tweneboah-Koduah, 2012). This gap can be explained by a lack of self-efficacy in performing the behavior at hand. As such, integrated within the post exam of this workshop will be an activity portion which requires the successful modeling of ITN use from start to finish.
Our second immediate objective relies on the constructs of behavioral capability and reinforcement. The construct of behavioral capability is used similarly to that of immediate objective 1, focusing on the increase in knowledge. However, as opposed to knowledge on malaria and its prevention, the focus is instead on educating participants on where to access ITN’s. They will receive an overview on what organizations provide free ITN’s, specifically stating the location, the time of year, and the circumstances under which they are available.
The second construct being utilized for immediate objective 2 is reinforcement. Reinforcement can be defined as a factor which affects a person’s likelihood of behavior participation, or alternatively behavior discontinuation (LaMorte, 2018). It has been found that communities which have visual cues/reminders have a higher usage rate of ITN’s (Nyavor et al., 2017). As such, following the discussion of this information in the interactive workshop, there will be a handout dispersed to every participant with the information listed. To offset the ratio of those who are illiterate, we will also disperse a diagram version. Alongside this, the diagram version of this handout will be displayed throughout the communities as a reminder/cue. The exposure within one’s environment of campaign messages, such as posters or flyers, has been associated with a 68% increase in bed net usage in children under 5 years of age (Adjah & Panayiotou, 2014).
Immediate objectives 1 and 2 rely upon recruitment of residents to participate in the interactive workshop being offered. The social cognitive theory is not inclusive of recruitment, but we include recruitment into our program as it is extremely necessary in the achievement of our objectives. The health of Ghanaians relies upon the national medical system which provides free treatment for malaria via a 3 day prescription of Malarone (Drislane et al., 2014). Our recruitment method would require collaboration with the Ghana Ministry of Health to highly encourage attendance to this workshop upon the request of this drug. It is most frequently requested at local clinics and is distributed to them on the spot. However, we would suggest that they attend the workshop and receive the prescription following successful completion.
Upon successful recruitment to and participation in the interactive workshop, one will have developed the knowledge and skills required to fulfill our behavioral objective. Studies done on the communication methods of malaria prevention have found that the most effective method is through dialogue with a health worker, which is the core of this program and the basis of our workshop (Adjah & Panayiotou, 2014). Alongside this, it has been found that utilizing multiple methods of communication outreach can increase their effects and produce greater results in reaching the target population, hence our additional method of communication via environmental cues/reminders (Adjah & Panayiotou, 2014).
In addition to utilizing all previously mentioned constructs, the behavioral objective also incorporates the construct of observational learning. Observational learning can be defined as the phenomena by which those who observe a behavior are more likely to reproduce that behavior themselves (LaMorte, 2018). This was originally seen through Albert Bandura’s research, where children who observed violent behavior by their parents also chose to participate in violent behavior (LaMorte, 2018). Behavioral modeling can be present in two scenarios of this program and its effects. Firstly, participants of the workshop will serve as a behavior model to others within the community thus encouraging further participation. Secondly, parents who attend this workshop are more likely to use ITN’s themselves. These individual will serve as behavioral models to their children encouraging ITN use as well as contribute to its normativity within the household.
This program has utilized previously implemented programs to incorporate successful interventions and eliminate those which were not successful. In doing so, we have developed a unique and innovative program. In addition to education about malaria and its transmission, we also include specific educational presentations on how to use ITN’s, why to use them, and where to access them. Our partnership with the clinics of the Ghana Ministry of Health is unique and has the potential to produce fruitful results in terms of recruitment. Our program utilizes all constructs included in the SCT, which in reference to previous studies using the SCT, is innovative in itself (Abbey et al., 2017).