Towards a Sociology of Health Care Utilisation in the Case of Children with Malaria in Nigeria

TOWARDS A SOCIOLOGY OF HEALTH CARE UTILISATION IN THE CASE OF CHILDREN WITH MALARIA IN NIGERIA

ALI ARAZEEM ABDULLAHI

A THESIS SUBMITTED TO THE FACULTY OF HUMANITIES, UNIVERSITY OF JOHANNESBURG IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY [PHD] IN SOCIOLOGY

PROMOTERS: PROFESSORS ANTON SENEKAL AND CECILIA VAN ZYL- SCHALEKAMP

DECEMBER, 2011

DECLARATION

I, Ali Arazeem Abdullahi, declare that this thesis is my handwork. It is being submitted to the Faculty of Humanities, University of Johannesburg in fulfilment of the requirements for the degree of Doctor of Philosophy in Sociology. It has not been submitted before for any degree or examination at this or any other University.

DEDICATION To my wife (Mrs. Khadijat Abdullahi) and my sons (Adam and Abdul-Basit)

ABSTRACT Background: Most recent data have shown a slight reduction in the incidence of malaria in Nigeria. However, cases of malaria in children younger than five years of age have continued to escalate amidst ‘simple’ and ‘effective’ treatment options. The realisation of the Millennium Development Goals (MDGs) – to halve the burden of malaria by 2015 – is becoming increasingly unrealistic in Nigeria following the alarming rates of malaria in children. Apart from the ecological and environmental factors, socio-cultural and behavioural factors might be responsible for the staggering cases of malaria in children in local communities in Nigeria. It was against this background that a sociological study of health care service utilisation was conducted among caregivers of children with malaria. The study investigated the perceived threat of malaria; how the local understanding of malaria affects the recognition of signs and symptoms, perceived aetiology, treatment-seeking patterns and the use of insecticide treated nets (ITNs). The socio- generational changes in the healthcare seeking behaviour between young and older mothers as well as differences in the patterns of health care service utilisation between rural and urban subjects were also interrogated.

Method: This study adopted a qualitative research design using complementary methods. A total of 40 semi-structured interviews, 20 in-depth interviews and four focus group discussions (FGDs) were conducted with caregivers and health workers. The respondents included young and older parents between the ages of 25 and 80 years whose children or wards below the age of five had manifested malaria symptoms at one time or another. A purposive sampling procedure was used to select sample for the study. The study was conducted in two selected rural areas; Okanle and Fajeromi; and one urban centre; Ilorin, Kwara State of Nigeria.

Findings: The research indicated that the perceived aetiology, symptoms and treatment of malaria in children were largely influenced by the socio-cultural patterns of the communities studied. The study found that the first line of treatment for children with malaria in the communities of study was usually home treatment using traditional herbal medicines. The use of modern health care facilities is usually seen as the last resort. The traditional beliefs about causes of malaria, affordability and trust in herbal medicines, on the one hand, were found to be responsible for the widespread use of herbal medicines in the treatment of malaria in children. On the other hand, poor service delivery, lack of money, attitudes of medical personnel, mixed feelings about the efficacy of modern medicines and lack of trust in the community health centres

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were some factors found to be responsible for delays in seeking modern health care services when children have malaria. More importantly, the decision to seek treatment from either traditional or modern sources was largely influenced by the network of informal social interaction and social support at household and community levels. In addition, the study also found some changes in the patterns of health care seeking behaviour of young and older caregivers but generally found no differences in the patterns of health care seeking behaviour between rural and urban participants. Finally, the study found that the majority of the respondents were not aware of the effectiveness of the ITNs. Consequently, there was a high dependence on the use of traditional preventive measures which included a local leaf known as “ewe-efon” translated as “mosquito leaf”. Apart from the perceived corruption and mismanagement at the level of distribution of the ITNs, lack of appropriate knowledge about the effectiveness of the ITNs was discovered to be responsible for the widespread non-acceptance of the ITN in the prevention of malaria in children.

Conclusions and Recommendations: Unless the socio-cultural issues surrounding knowledge, treatment and correct use of the ITNs are resolved, malaria will continue to affect local communities and the entire Nigerian society. This study has therefore suggested the implementation of community friendly and culturally sustainable health policies aimed at empowering the communities in the prevention and management of malaria in children. The foundation and the cardinal principles of such programmes should be built upon the understanding of the local dynamics in response to malaria in children. A mutual cooperation between traditional and modern medicines is highly recommended since the majority of the local people still depend on traditional herbal medicines. Such cooperation should help to minimise the disruption of lives in Nigeria and beyond. There is the need for pharmaceutical companies to investigate and confirm the efficacy and effectiveness of herbal medicines used in the local management of malaria. Finally, the community social capital and social structures are potential areas for effective distribution of treated bed nets to reduce malaria infections in children. This shall also require constant political will and the desire to fight against corruption at the level of distribution and disbursement of the bed nets.

ACKNOWLEDGEMENTS

I appreciate everybody who has contributed to the successful completion of this project in one way or the other all of whom cannot be listed here. First of all, I appreciate and thank the Almighty God who gave me the innermost enthusiasm and inspiration, direction and good health from the beginning of the programme to the end. To Him I give the glory.

I would like to express my sincere gratitude to my first and second supervisors, Professors Anton Senekal and Cecilia Van Zyl-Schalekamp for their kindness, understanding and constructive advice. I profoundly appreciate their kindness, unrelenting effort and constant advice. I wish them both the best of luck in their future endeavours.

My heartfelt gratitude also goes to the Head of the Department of Sociology, Professor Tina Uys. I thank her for recommending me for the National Research Foundation [NRF] bursary and the UJ Supervisor- Linked Bursary. Without her good leadership role during this period this project would not have been possible. I pray to God to continue to guide her everyday activities as she pilots the affairs of the Department. By extension, I would like to thank the NRF and the University of Johannesburg for the financial assistance rendered during the course of this study. Without the financial assistance from these organisations this work would not have taken off let alone be completed.

I would like to thank and acknowledge the contributions of all the respondents that participated in this study; from the semi-structured to the focus group discussions (FGDs). I specifically thank the incumbent Olokanle of Okanle and Baale of Fajeromi and the Staff of the Children Specialist Hospital and Okanle/Fajeromi Health Centre for their support and assistance rendered during the course of this study.

I wish to express my sincere appreciation to my lovely wife and the mother of my lovely children. I thank her for her prayers, patience and moral support. Thank you for giving the children the right and appropriate answers each time they asked about my whereabouts. Your contributions are absolutely immeasurable.

I would like to thank my home university, the University of Ilorin, for awarding me the Staff Development under supplementation categorisation - as a matter of policy - that allowed me access to my salary while on the programme. In addition, I would like to thank my colleagues in the Department of Sociology, University

v of Ilorin, for their moral support, particularly Dr OA Fawole, Dr (Mrs) Adekeye, Dr B. Salawu, Dr N. Yusuf and Mr Ridwan Yousouph. I wish them luck in their callings. My gratitude also goes to my good friend Mr Shegun Adelodun of the Zenith Bank, Nigeria for his financial support at the most crucial time.

I would like to thank my first and second cousins Mr Yusuf Dauda and Mr Suleiman Yusuf for their financial and moral support. They gave me the initial moral and financial backings that encouraged me to leave Nigeria for South Africa. I pray to God Almighty to continue to bless them and their families.

I thank the family of Engineer Abdul-Kareem Saka (PhD) for moral and spiritual support. I specifically thank the wife for preparing sumptuous meals for me both day and night throughout her stay in Johannesburg. I appreciate the love and bond we shared while in South Africa. I pray that God answers their prayers and grants them their heart’s desire. I also acknowledge the contributions of Jimoh Sikiru to this project.

I would like to thank the research assistants who assisted me in collecting and collating data for the study. They include my very good friend Tunde Orisankoko as well as Dolapo, Dayo and Yemi. Their contributions were huge and are highly appreciated.

I would like to thank Carol Leff of the Institute for the Study of English in Africa, Rhodes University, Grahamstown, South Africa for assisting me to proofread the thesis. Her contribution in this regard is highly appreciated.

Finally, I appreciate the contributions of everybody to the success of this project - many of whom cannot be mentioned. I wish everybody success in his future endeavour.

Ali Arazeem Abdullahi Johannesburg, 2011

TABLE OF CONTENT DECLARATION ...... i DEDICATION ...... ii ABSTRACT ...... iii-iv ACKNOWLEDGMENTS ...... v- vi TABLE OF CONTENT...... vii LIST OF TABLES...... xii LIST OF FIGURES...... xiii LIST OF ABREVIATIONS AND ACRONYMS ...... xv

CHAPTER ONE 1.1 INTRODUCTION ...... 1 1.2 THE BURDEN OF MALARIA DISEASE: STATEMENT OF THE PROBLEM ...... 7 1.3 OBJECTIVES OF THE STUDY ...... 12 1.4 INTENDED CONTRIBUTIONS OF THE STUDY TO SCIENTIFIC KNOWLEDGE ...... 13 1.5 SCOPE AND STRATEGY ...... 14 1.6. CONCEPTUALISATION ...... 15 1.6.1 Distinction between Rural and Urban...... 15 1.6.2 Socio-Economic Status and Poverty ...... 16 1.6.3 Caregivers ...... 16 1.6.4 Young and Grandparents...... 17 1.6.5 Disease and Illness ...... 18 1.6.6 Health Care System ...... 18 1.6.7 Illness and Health-Care Seeking Behaviour ...... 19 1.6.8 Informal Social Network and Social Support ...... 19

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1.7 RELIABILITY AND VALIDITY OF TECHNIQUES ...... 20 1.8 CONCEPTUAL FRAMEWORK ...... 22 1.9 THE STRUCTURE OF THE STUDY ...... 24

CHAPTER TWO DISEASE, HEALTH AND ILLNESS DIMENSIONS: A REVIEW OF THE LITERATURE 2.1 INTRODUCTION ...... 27 2.2 DISEASE AND ILLNESS CAUSATION: A MULTIDIMENSIONAL APPROACH...... 28 2.3 CULTURE, DISEASE, ILLNESS AND HEALTH ...... 36 2.4 SOCIAL DETERMINANTS OF HEALTH AND HEALTH SERVICES ...... 38 2.5. PSYCHOLOGICAL DIMENSIONS ...... 39 2.6 SOCIOLOGICAL AND ANTHROPOLOGICAL DIMENSIONS ...... 41 2.6.1 Barriers to Health Care Utilisation ...... 41 2.6.2 The Pathways to Health Care Utilisation ...... 47 2.7 AN OVERVIEW OF NIGERIA AND THE HEALTH CARE SYSTEMS ...... 52 2.8 AREAS OF STUDY ...... 59 2.8.1 A Brief Description of the City of Ilorin ...... 60 2.8.2 A Brief Description of Ilorin South ...... 61 2.8.2.1 The Children Specialist Hospital ...... 62 2.9 OKANLE AND FAJEROMI ...... 63 2.10 SUMMARY ...... 72

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CHAPTER THREE EXPOSITION OF RELEVANT THEORETICAL FRAMEWORKS 3.1 INTRODUCTION...... 74 3.2 THE HEALTH BELIEF MODEL (HBM) ...... 77 3.3 BEHAVIOURAL THEORY OF HEALTH SERVICE UTILISATION ...... 81 3.3.1 The Predisposing Factors ...... 81 3.3.2 The Enabling Factors ...... 82 3.3.3 The Need Factors ...... 83 3.4 GENERATIONAL COHORT THEORY (GCT) …………………………………………………………...... 85 3.5 TRANSTHEORETICAL MODEL OF CHANGE …………………………………………………………… 89 3.5.1 Stages of Change …………………………………………………………………………………. 90 3.6 RATIONAL CHOICE THEORY …………………………………………………………………………….. 93 3.7 SUMMARY ...... 97

CHAPTER FOUR RESEARCH METHODOLOGY

4.1 INTRODUCTION ...... 100 4.2 METHODOLOGY ...... 100 4.2.1 The Research Design: A Qualitative Approach ...... 100 4.2.1.1 Ethnography ...... 106 4.2.1.2 Case Study ...... 106 4.3 QUALITATIVE INSTRUMENTS OF DATA COLLECTION ...... 108 4.3.1 Semi-structured Interview ...... 109 4.3.2 In-depth Interview ...... 109 4.3.3 Focus Group Discussions ...... 110 4.3.4 Visual Methods ...... 112 4.4 POPULATION OF STUDY AND SAMPLING ...... 113 4.5 GAINING ENTRANCE INTO THE STUDY AREAS: ...... 114

4.6 DATA ANALYSIS ...... 114 4.7 ETHICAL CONSIDERATIONS ...... 116 4.8 PROBLEMS ENCOUNTERED ...... 117 4.9 SUMMARY ...... 118

CHAPTER FIVE DATA ANALYSIS AND DISCUSSION 5.1 INTRODUCTION ...... 119 5.1.1 The Research Questions Restated...... 119 5.2 DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS ...... 120 5.3 LOCAL KNOWLEDGE, PERCEIVED THREAT, AETIOLOGY AND SYMPTOMS OF MALARIA..... 123 5.3.1 Local Knowledge of Malaria ...... 123 5.3.2 Perceived Threat of Malaria ...... 126 5.3.3 Perceived Aetiology: Where Culture and Biology May Disagree ...... 129 5.3.4 Perceived Symptoms: Where Culture and Biology Converge ...... 137 5.4 THE USE OF HERBAL MEDICINES: A COMMON PHENOMENON ...... 138 5.5 GENERATIONAL CHANGES IN THE USE OF HERBAL MEDICINES ...... 146 5.6 PATHWAYS TO TREATMENT OF MALARIA ...... 152 5.7 ISSUES AFFECTING TREATMENT ...... 157 5.8 DECISION MAKING PROCESS: WHO SAYS WHAT? ...... 166 5.9 PREVENTIVE MEASURES ...... 169 5.10 DISCUSSIONS ...... 174

CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.1 INTRODUCTION ...... 184 6.2 SUMMARY OF FINDINGS ...... 186

6.3 THEORETICAL UNDERPINNINGS AND JUSTIFICATIONS ...... 188 6.4 CONCLUSIONS AND RECOMMENDATIONS...... 194 6.5 POLICY IMPLICATIONS ...... 194 6.6 FUTURE RESEARCH ……………………………………………………………………………...... 201

LIST OF REFERENCES...... 203

APPENDIXES

Appendix I: The Interview Guide (Semi-Structured and In-depth interviews and FGD Guide) ...... 240

Appendix II: Letter of Introduction ...... 246

Appendix III: Interview in Progress ...... 247

Appendix IV: Sample of the Consent Form ...... 248

LIST OF TABLES

Table 4.1 Number and Categories of Respondents...... 112

Table 5.1 Socio-Demographic Profile of the Respondents ...... 122

Table 5.2 Actual and Perceived Causes of Malaria in Children as Reported by the Respondents ...... 136

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LIST OF FIGURES

Figure 1.1 Health Field Model: Determinants of Health ...... 23

Figure 2.1 An Image of Mosquito Plasimodium Falciparum ...... 30

Figure 2.2 The Socio-Environmental Approach to Health ...... 32

Figure 2.3 The World Map Showing the World Poverty Estimates ...... 35

Figure 2.4 The World Map Showing an Estimate of the World Malaria Burden ...... 35

Figure 2.5 The Interplay between Individual, Significant Others and Treatment Seeking Behaviour ..... 50

Figure 2.6 Summary of Pathways to Health Care Utilisation in Nigeria ...... 51

Figure 2.7 Map of Nigeria Showing the 36 States including Abuja and International Boundaries ...... 54

Figure 2.8 Structure of Health Care System in Nigeria ...... 55

Figure 2.9 Map of Kwara State Showing the Study Areas ...... 61

Figure 2.10 The Children Specialist Hospital in Ilorin ...... 63

Figure 2.11 A Sample of Modern Building in Okanle ...... 65

Figure 2.12 Sample of Modern Structure in Fajeromi ...... 65

Figure 2.13 The Entrance to the Palace of the Olokanle of Okanle ...... 66

Figure 2.14 The Palace of the Olokanle of Okanle ...... 67

Figure 2.15 The Only Primary School at Okanle/Fajeromi ...... 68

Figure 2.16 Okanle/Fajeromi Community High School (the Newly Constructed Classroom of two) ... 69

Figure 2.17 Okanle/Fajeromi Community High School (Staff Building) ...... 69

Figure 2.18 Okanle/Fajeromi Community High School (One of the Old Two Blocks of Classrooms) .. 70

Figure 2.19 Okanle/Fajeromi Basic Health Centre (from the Outside) ...... 70

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Figure 2.20 Okanle/Fajeromi Basic Health Centre from inside (Abandoned Room at the Centre) ... 71

Figure 2.21 The Health Centre from inside (Abandoned Store Owing to Poor Management) ...... 71

Figure 2.22 The Two Beds Available at the Centre ...... 72

Figure 3.1 Health Belief Model ...... 79

Figure 3.2 The First Phase of Behavioural Model ...... 83

Figure 3.3 Andersen’s 2nd Phase of the Health Service Utilisation Theory ...... 84

Figure 4.1 Approaches to the Study: Ethnography and Case Study ...... 105

Figure 5.1 Environmental Characteristics of the Rural Communities ...... 142

Figure 5.2 The Natural Environment ...... 142

Figure 5.3 Environmental Challenges in the Fight against Malaria 1...... 165

Figure 5.4 Environmental Challenges in the Fight against Malaria 2 ...... 165

Figure 6.1 A Social Ecology Model of Behaviour Change ...... 193

Figure 6.2 A Framework for the Integration/Cooperation between Traditional and Formal Health Care System ...... 200

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LIST OF ABBREVIATIONS AND ACRONYMS

ACT – Artemisinin-based Combination Therapy

AIDS – Acquired Immune Deficiency Syndrome

BCC – Behavioural Change Communication Strategy

Cf – Copied from

DFID – Department for International Development

DHF – Haemorrhagic fever

FCT – Federal Capital Territory

FES – Focused Ethnographic Studies

FGD – Focus group discussion

FHI – Family Health International

FMoH – Federal Ministry of Health

FRN – Federal Republic of Nigeria

GCT – Generational Cohort Theory

GDP – Gross Domestic Product

HAI – Health Action International

HBM – Health Belief Model

HFM – Health Field Model

HIV – Human Immunodeficiency Virus

IMR – Infant Mortality Rate

ITN – Insecticide treated bed net

KAP – Knowledge, Attitude and Practice

MDGs – Millennium Development Goals

MM – Modern medicine

MMV – Medicines for Malaria Venture

N.d – No date

NCH – National Council on Health

NCI – National Cancer Institute

NGO – Non-Governmental Organisation

NHIS – National Health Insurance Scheme

NRF – National Research Foundation, South Africa

NTA – Nigeria Television Authority

NYSC – National Youth Service Scheme

ODU – Okanle Descendants Union

OOP – Out of Pocket Payment

PHC – Primary Health Care

PNMR – Perinatal Mortality Rate

QDA – Qualitative Data Analysis

RBM – Roll Back Malaria

SDH – Social Determinant of Health

SES – Socio-economic status

SRA – Social Research Association

SSA – Sub-Sahara Africa

TB – Tuberculosis

TBA – Traditional Birth Attendant

TM – Traditional medicine

U5MR – Under 5 Mortality Rate

UNICEF – United Nations Children and Education Fund

UNECOSOC – United Nations Economic and Social Council

WFSF – World Future Studies Federation

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WHO – World Health Organisation

ZIHP – Zambia Integrated Health Programme

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CHAPTER ONE

1.1 Introduction

The familiar saying that “health is wealth” has brought to the fore the significance of sound health not only for the individual, but also the society. On the individual level, “good” health1 is required for the effective execution of both official and unofficial responsibilities and duties. It is also a prerequisite for social and psychological development. Without sound health life can become frustrating and unpleasant to the individual. On a social level, a “good” state of health is one of the important parameters used to measure how a nation and its people are faring in the sense that a healthy population is taken to be a reflection of a healthy society and vice-versa. A healthy society is often characterised by low disease profiles, low infant morbidity and mortality rates as well as high life expectancy. “Good” health is a hallmark of and a yardstick for measuring economic as well as social advancement. Indeed, “good” health is both a consequence of and a vehicle for achieving economic growth, prosperity and poverty reduction (Adeyemi and Raheem, 2008: 340). The Department for International Development [DFID] (2007: 2) noted that the good state of health of a people is intimately bound up with the world's prosperity in the sense that “the healthier the people, the less likely they are to be poor and the more poverty is deep-rooted in a society the more people are likely to become sick and die”.

The importance of “good” health to the survival of the individual and society and the need to avoid unwanted sickness have compelled different people in different cultures and societies to conceive the idea of initiating and developing enduring health care systems to cater for human health needs. This was to enable the people to cope and deal with the persistent disruption of lives caused by ill-health and to maintain stability and social order. Indeed, the evolution and development of a health care system in any society is closely connected with and shaped by the socio-cultural context as well as the technological

1 Health is a relative term, the reason why it lacks a precise definition. Quite a significant number of people think of good health in terms of the absence of disease, pains, disability and discomfort (Sohn, 2002: 3). Others think of health in terms of physical appearance. However, the definition of health goes beyond these components and variables. One of the most acceptable definitions of health has been put forward by the World Health Organisation (see chapter two page 34 of this thesis). However, even WHO’s definition has been adjudged to be deficient because it fails to recognise the spiritual and emotional dimensions of health (Sohn, 2002: 3). An articulate and generally acceptable definition of health must therefore be holistic such that it takes cognisance of the multicultural dimensions of health.

frameworks of the society in question (Amzat and Abdullahi, 2008: 153). This may explain the disparity in the conception of health care systems across the world e.g. between Western and non-Western societies.

Some discourses about health care systems, particularly in health sociology2, have been centred around two contending themes: modern and traditional health care systems. Modern health care (also known as biomedicine, allopathic medicine, formal health care system or cosmopolitan medicine) is conceived of as the most dominant approach in disease prevention and management in contemporary society. Its discourse is centred around the fundamental principles of science based on rigorous, reliable and valid clinical analysis which has evolved from the West3 (Richter, 2003: 7). In the domain of Western medicine (known as ‘Whiteman’s medicine’ among local people across Nigeria), emphasis is usually placed on pathological agents such as germs as the causes of ill-health. A distinction is also made between the mind and the body in the conceptualisation of disease and its management (Clarke, 2001: 2). This is largely because the philosophical foundation of the MM discourse is premised on the assumption that human beings are physiologically identical and may respond to the germs that cause diseases in the same way (Chi, 2002: 1).

As a result, treatment and management procedures are determined by the outcomes of scientific investigations (i.e. tests and experiments) carried out in laboratories. The heavy reliance of MM on science, modern technology, verifiable clinical procedures and the support it enjoys from government officials and international health agencies across the world reflects its “superiority” posture over other treatment models or procedures like traditional medicine or spiritual healing. Consequently, remarkable achievements and

2 Sociology is a social science discipline whose major concerns are the societies and the social relations or actions in them, health being one of them. Health sociology is therefore that aspect of sociology that is concerned with people, health and illness. It is concerned with how people perceive and react to disease and ill-health. The subject matter of sociology of health includes the social production and distribution of disease. Health sociology interrogates the idea that medical knowledge is not purely scientific, but shapes and constantly being shaped by the society (Stacey, 1991: 13). Health sociology also stresses the role of social factors in the production and distribution of disease (White, 2002: 1). Examples of these social factors are the environment, culture, social class, gender and ethnicity. In summary, the sociological analysis of health takes into account the historical development of medical knowledge, occupations and facilities, as well as comparative health practices and institutions over time and space (Stacey, 1991: 13).

3 Any usage of this term must be conscious of its ambiguity and heterogeneity. The ‘West’ or ‘Western culture’ or ‘Western world’ comprised of different countries with different ideological, historical, political, cultural, technological and economic exigencies. The term became firmly established in Africa during the balkanisation process of the continent in the late 1884 and early 1885 at the Berlin Conference in Germany. To differentiate the developed from developing countries, African and other developing countries’ scholars have tended to use the term ‘West’ especially with regard to Western hegemony.

2 breakthroughs have been recorded in biomedicine over the years which include enhanced drug production to reduce the threat of a variety of diseases (Medicines for Malaria Venture [MMV], 2000: 1).

However, the tremendous increase in the number of people without adequate access to modern health care services and drugs and the simultaneous increase in the prevalence of diseases across the world have raised a very serious concern. For instance, more than half of the world’s population has been without adequate access to ‘Whiteman’s medicine’ (to borrow the language of the locals) to treat the world’s most common diseases (Naidoo, 2004: 6). The biggest number of this population is found in the so-called low and middle - income countries (LMICs) where Nigeria belongs. Indeed, Nigeria is the second largest economy in Africa after South Africa and the 6th largest oil producing country in the world. Paradoxically, more than 70% of the Nigerian population live on less than $1 per day (Duggan, 2009: 2) with over 1/3 of the population without adequate access to modern health care services (Amzat, 2011: 43).

Inadequate access to modern health care services in LMICs like Nigeria has been supported by the World Health Organisation and Health Action International’s (HAI) recent study in 36 LMICs. It appears that although medicines are free in most public hospitals in LMICs, they are often way beyond the reach of large sections of the populations. Where health services are available for free “patients might still need to purchase medicines from private sector where they are frequently unaffordable” (Cameron et al. 2008: 6). Consequently, LMICs are engulfed by a steady increase in preventable diseases and deaths. In 2001 alone, preventable infectious and parasitic diseases accounted for more than 50% of all deaths in Africa, compared to only 2% in Europe (Carr, 2004: 3). Jamison et al. (2006: 59) mentioned that tuberculosis (TB), Human Immunodeficiency virus and Acquired Immune Deficiency Syndrome (HIV/AIDS), diarrheal diseases, vaccine-preventable diseases of childhood, malaria, respiratory infections, maternal conditions, and neonatal deaths account for more than 25% of all deaths in low- and middle-income countries.

On the other hand, the ontology and epistemology of traditional medicine (TM) (also known as herbal medicine, native healing, ethno-medicine, or complementary/alternative medicine) is rooted in indigenous knowledge of plants, minerals, and animal parts in the management of ill-health (Amzat and Abdullahi,

2008: 154). TM is an ancient and culture–bound medical practice which had existed in human societies in different capacities before the application of modern science to health (WHO, 2000a: 11). The multifaceted nature of TM has thus rendered a singular universally accepted definition almost problematic and practically impossible4. TM includes a combination of rituals and religion as well as the use of herbs and plants in medicine which are often transmitted via oral traditional and observation (Waldram, 2000: 603- 604). Although TM is diverse (there are Chinese, Indian, European and African traditional medicines), there could exist unity in this diversity.

In Nigeria, traditional medicine specialists and practitioners comprised of the diviners, Traditional Birth Attendants (TBAs), bone setters, herbalists, oracle men, massagers, and traditional social psychiatrists (Owumi, 2002: 229; Pearce, 1989: 924; Rinne, 2001: 47). These practitioners are generally “recognised as experts on community attitudes and beliefs related to physical, mental and social well–being and the causes of disease and disability” (WHO, 2000a:11-12). Unlike the MM, the philosophical foundation of TM is firmly based on the belief that diseases are not just the result of germs, but also involve an examination of the socio-cultural and supernatural factors in disease causation and management. Some descriptions of TM in Nigeria have included some religious organisations in Christianity and Islam (Erinosho, 1998: 58; 2005: 39-40; Pearce, 1993: 155; Rinne, 2001: 47). TM emphasises and adopts a holistic approach in the whole process of health management. The healers provide healing in accordance with the socio-cultural context of the people by attempting to re-establish and reconnect the social and emotional equilibrium of patients based on the prevailing traditional community rules and relationships (Hillenbrand, 2006: 2-3).

However, debate is still on-going about the usability, effectiveness and safety of TM. Some scholars especially in modern medicine have challenged the use of TM in the management of disease and illness believing that TM is dominated by the ‘illiterates’ who lack ‘scientific’ and ‘proper’ knowledge of medicine. In spite of these controversies, studies have suggested that TM enjoys considerable levels of accessibility,

4 Indigenous communities like that of Yoruba in Nigeria also have a comparative distinction between traditional and alternative medicines, however in a reversed way. What could be described as traditional medicine in the Western world is indeed an “alternative” medicine in non-Western societies and vice-versa (Abimbola, 2006: 77). Thus, Abimbola suggests that the best way to distinguish between traditional and orthodox medicines is to juxtapose and excavate the “stark contrast” between the “principles” and “methods” of both medicines (Abimbola, 2006: 78). That is, the differences between traditional and modern medicines are matters of principles and methods.

desirability and acceptability among the majority of the people in developing countries (WHO, 2000a: 4; 2000b: v) and this has taken centre stage in the academic discourses in the recent time. It has been reported that about 80% of the population in Africa (UNECOSOC, n.d: 1; WHO, 2002a: 1) as well as Asia use TM (UNECOSOC, n.d: 1). In South Africa, more than 25 million consumers out of more than 50 million population use TM (Mander, et al. 2007: 190). Indeed, scientific studies of medicinal plants and their potency in the management of diseases in Nigeria and the rest of Africa have been documented. Weintritt (2007: 119) identified more than 500 medicinal species used in the management of numerous ailments in Nigeria, many of which are used by traditional healers. A considerable number of studies have also shown that traditional healers are important players in health care delivery system (Rinne, 2001: 47) and that many Nigerians usually seek “the services of assorted traditional healers before seeking care from Western style workers and facilities” (Erinosho, 2005: 38). In some instances, patients use TM simultaneously with modern medicine in order to ease sufferings associated with diseases (Ellis et al. 2007: 701). Perhaps, an important question to ask is why the widespread desire for, acceptance and use of TM exists in Nigeria and elsewhere? In other words, why has TM continued to gain momentum or attract wide users? Could wide use of TM be attributed to its effectiveness and the trust that people have therein?

For years, there was an interdisciplinary academic quest to investigate and understand individual illness and health care seeking behaviour and improve knowledge in that regard. Initially, this curiosity prompted studies and investigations in social psychology. At that time and even now, most social psychological studies consider an individual actor as a pioneer agent in promoting ‘good’ health (MacKian, n.d: 1; Postnote, 2007: 2). A health seeker is assumed to be a ‘rational’ thinker who takes ‘rational’ decisions about his/her health status because he/she is believed to be in control of his/her health condition. Such decisions to respond to ill-health would further depend on the demographic characteristics, information provided to and possessed by that individual about causes of ill-health and the availability of diverse choices and resources (MacKian, n.d: 1; Postnote, 2007: 2). This line of thought has given birth to more than 30 theories to predict possible health behaviour (see Munro et al. 2007; Conner and Norman, 1996) thereby complicating their usability in health intervention programmes (Munro et al. 2007: 2).

However, the provision of information and resources may not be enough in predicting health and illness behaviour and promoting “good” health. Sociological and anthropological studies in both Western and non- Western societies have shown that decisions to seek health care from any of the health care channels (modern, spiritual or native healers) are complex. This may involve several steps and a constellation of several socio-cultural and demographic factors (Pokhrel and Sauerborn, 2004: 231-232). For instance, gender role may not only affect illness reporting, it could also affect the decision to choose a health care provider and how much to spend (Pokhrel et al. 2005: 107). Other factors include some affection and respect for “significant others” in decision making process (White et al. 2006: 831).

Against this background, this study goes beyond the prevailing discourses and notions in bio-medicine and social psychology about individual health care seeking behaviour. It includes an attempt at understanding the influence of cultural practices and beliefs on communities’ overall perception and response to malaria in children below the age of five in both rural and urban communities of Nigeria. This is important against the background that children are more vulnerable to malaria infections and the associated complications than adult populations. In addition, although malaria used to be seen as a rural phenomenon, it is increasingly becoming an urban problem in developing countries like Nigeria. The study also investigates the socio- generational changes in the pattern of health care utilisation of caregivers to be able to establish trends in health care seeking behaviour of caregivers. A study of this nature has become necessary considering the dearth of literature (especially in Nigeria) on the inherent differences in health care utilisation in rural and urban areas and the socio-generational changes thereto in spite of the fact that both settings and the people who live in them are exposed to different levels of service delivery, health information and other social amenities. The study has been conducted among caregivers including grandparents in selected rural and urban communities in Kwara State, Nigeria. This study has described how the local understanding of malaria affects the perceived threat of malaria, recognition of signs and symptoms, perceived aetiology, treatment-seeking patterns and the use of insecticide treated bed nets (ITNs) sometimes referred to as the bed nets.

1.2 The Burden of Malaria Disease: Statement of the Problem

Malaria is one of the most recent top global health challenges and has taken centre-stage in local and international health discourses. Stratton et al. (2008: 854) consider malaria as a ‘global killer’ and “one of the most persistent and pressing global public health problems of our time”. This is not to suggest, however, that malaria is a new form of disease. Malaria is one of the oldest diseases in human history and has constituted a threat to human population from time immemorial (Dalrymple, 2009: 1). However, in the past decade, unprecedented global attention has been devoted to controlling and eradicating the spread of the malaria scourge worldwide (Crawley et al. 2010: 1468). Foregrounding the recent global attention is the fact that more than 40% of the world’s population is at risk of malaria in more than 100 malarious countries (Crawley et al. 2010: 1468; Medicines for Malaria Venture [MMV], 2000: 1) with more than 400 million clinical cases of malaria reported every year (Crawley et al. 2010: 1468; Sadiq et al. 2009: 116). Although global commitments to the fight against malaria have begun to yield results (WHO, 2010: v) malaria remains a ‘global killer’ especially among the children younger than five years of age.

Disabilities and deaths associated with malaria in children are staggering. For instance, millions of children have been subjected to unacceptable difficult and appalling neurological conditions due to malaria. Reports have shown that of more than 20% of children with cerebral malaria (malaria infections affecting the brain) 7% suffers from learning impairments or neurological complications (Ogbodo et al. 2010: 131; Roll Back Malaria [RBM], 1998: 1). Other critical health conditions attributed to severe malaria in children are anaemia (moderate or severe), convulsions, kidney failure, jaundice (yellow colouring of the skin and eyes) and coma (Jamison et al. 2006: 73). An association between malaria and diarrhoea has also been documented where children with dehydration are found to manifest malaria parasites (Ibadin et al. 2000: 117). Retinopathy has also been reported in children with severe malaria (Essuman, et al. 2010: 4).

There are strong indications that many of the people affected by malaria and its attendant consequences live in the continent of Africa5 especially, Sub-Saharan Africa (SSA) where plasmodium falciparum is responsible for the highest number of malaria cases. Epidemiological studies (Oshikoya, 2007: 51; Rogier and Trape, 1993: 265) have consistently shown that morbidity and mortality due to malaria have continued to occur mainly among infants and children. This usually happens during the first and second year of life given children’s biological dispositions; when children are yet to acquire adequate clinical immunity like the adult to protect themselves against the parasite that causes malaria (Crawley et al. 2010: 1468; Sadiq et al. 2009: 115). Of the approximately 1 million deaths recorded in SSA, more than 80% took place in children less than five years of age (Crawley et al. 2010: 1468).

Indeed, the highest number of deaths and disability associated with malaria in children are recorded in the rural areas where the level of poverty is relatively high coupled with limited access to information, modern preventive and curative measures among low income earners. As a result, some previous studies on malaria have assumed that malaria is concentrated in rural communities where the majority poor reside (Sadiq et al. 2009: 117; Uzochukwu and Onwujekwe, 2004: 2). Most of these studies have tended to sideline or neglect the urban areas altogether especially in terms of health and policy issues concerning malaria (Oguonu et al. 2005: 409-410). However, a growing number of studies have produced a corpus of

5 Africa is often seen as “a diseased continent” because the continent is believed to have the largest share of global disease burden. But to what extent is this submission true? If it is true at all, why is the continent so engulfed with diseases most of whom are preventable? These questions have attracted academics over the years leading to the formulation of diverse diagnostic theoretical apparatuses. Some have searched for an answer outside the continent using a combination of both contemporary and historical exigencies. To this group of scholars, inadequate access to health care services is the major reason why Africa shares the largest burden of global disease burden, the genesis of which is traced to colonialism. Owumi (2002: 230) argues that post colonial political elites in Africa inherited a biased medical system that discriminated against the local people. Unfortunately, the status-quo has continued to linger more than 50 years of political independence. Others have argued that the widespread of diseases like malaria cannot be disconnected from the entrenchment of Western models of disease management instead of indigenous or home-grown models. Others have mentioned the exaggeration of health statistics and figures upon which biomedical institutions, local and international donor agencies feast on. However, some scholars have expanded the debate to include some internal trajectories in trying to investigate health conditions in Africa. These include home-grown social vices like corruption and gross mismanagement of public health care funds (again, some have suggested that these social vices have their roots in colonialism). Also related to home-grown factors is low per capita income as well as limited capacity for domestic revenue mobilisation (African Union [AU], 2009). Reports have shown that health care funding from government tax revenue is less than 10% of the total government expenditure as a result of which more than 30% of SSA countries depend on donor agencies (McIntyre and Gilson, 2005: 2). Health care funding is also characterised by out of pocket payments (OOP) which account for more than 25% of total health care expenditure in more than three-quarters of SSA countries (McIntyre and Gilson, 2005: 2). Greg Mills (2010) has added a more controversial but candid opinion to internal trajectory debate. He suggests that in the on-going globalisation process, poverty and diseases are a matter of choice. He believes that African leaders, in a ‘globalised household’, have consistently followed wrong paths to development and the masses (with the exception of the North Africa and the Maghreb) seem to have refused to stand up against years of injustices melted on them by their leaders (Mills, 2010: 16).

8 evidence to suggest that malaria is both a rural and urban problem (Ogbadoyi and Tsado, 2009: 1; Oreagba et al. 2004: 300). A sporadic increase in unreported cases and treatment of malaria has been reported in rural as well as urban Nigeria (Ogbadoyi and Tsado, 2009: 1). A study found that of the 410 blood donors in Onitsha, Nigeria (an example of urban centre) 74.1% were infected with malaria parasites (Ekwunife et al. 2011: 23).

Although, the endemicity of malaria scourge in SSA varies from one country to another, malaria remains a dreaded disease in Nigeria where more than one million clinical cases are reported annually (FMoH, 2009: 9). Reports have shown that more than 90% of the Nigerian population is exposed to malaria out of which over 40% suffers from at least one episode of malaria annually (Abdullahi et al. 2009: 7102). Malaria is responsible for more than 50% outpatient visits, 40% of hospital admission, and 10% of maternal mortality (Okafor and Amzat, 2007: 156). Like other affected countries, malaria is ranked as one of the leading causes of morbidity and mortality in children less than five years of age in Nigeria (Olasehinde et al. 2010: 159; Oshikoya, 2007: 49). Reports have shown that between 250 000 and 300 000 children below five years of age die from malaria every year in Nigeria (FMoH, 2009: 10) representing 30% of infant mortality (Malaria Byte, 2007: 2; Okafor and Amzat, 2007: 156) and 25% of the global malaria deaths in children within this age-bracket (Okeke et al. 2006: 491). An estimated N100 billion6 (approximately $666.7 Million) is said to be lost to malaria annually in the form of treatment costs, prevention and loss of man hours (FMoH, 2009: 9).

In the past decade, however, an extraordinary and remarkable effort has been seen at both international and national levels to curtail and stem the scourge of malaria in order to avoid any further catastrophic scenario. For instance, the international funding for malaria increased from $200 million in 2004 to $1.5 billion in 2009 (Crawley et al. 2010: 1478; WHO, 2010: xiii). Similarly, there has been tremendous increase in the production of ITNs from 30 million in 2004 to more than 60 million in 2006 (UNICEF, 2007: 2). More than 200 million ITNs were disbursed to SSA at the end of 2010 (WHO, 2010: xiii). This was expected to cover over 60% of persons at risk of malaria (WHO, 2010: xiv). The invention of treatment arsenals such as

6 The Nigerian local currency is denoted with N to mean Naira.

artemisinin-based combination therapy (ACTs) and vector controls are also indications of global malaria interventions. However, as the search for anti-malaria vaccines continues, the alternative drugs are not only increasingly becoming harmful there are increasing concerns that they are not within the reach of the most vulnerable and poor populations in developing countries like Nigeria where the burden of malaria is mostly felt (Alaii, 2003: 11). For instance, of the 34 African countries that have updated their national drug formularies to reflect WHO’s recommendations (Stratton et al. 2008: 859), only eleven of them are distributing ACTs through the public health sector - one on which many people depend (WHO, 2010: xi).

The global commitments to fighting malaria seem to have boosted domestic responsibilities in the affected regions. For instance, the Nigerian governments at the Federal, States and Local Government levels have increased socio-political and financial commitments to fighting malaria head-on. To face some of the challenges posed by malaria and other health problems, in 2009, the Federal Government of Nigeria signed the $669.3 million Global Fund grant for the control of malaria and TB and for strengthening the health care system (The Punch, 2009). The Federal Executive Council of Nigeria in 2009 also approved more than N21 billion ($140 million) for the execution of 166 Millennium Development Goals (MDGs) projects in 31 States of the Federation (Nigeria Television Authority7 [NTA] News, 2009). Furthermore, the governments at all levels have also initiated and started implementing programmes and policies that could facilitate the broad fight against malaria one of which is the National Malaria Control Programme under the auspices of the Federal Ministry of Health, Abuja. This particular programme provides a strategic plan and a road map to intensify efforts on malaria control during its 5-year planning cycle (FMoH, 2009: 9). Correspondingly, there have been remarkable health sector reforms such as change in treatment policy from chloroquine to ACTs; increased coverage of the bed nets from 0% in 2003 to more than 6% in 2005; and the distribution of more than five million doses of ACTs to the 36 States of the Federation including the Federal Capital Territory [FCT] (Lambo, 2006: 285). While these are seen as responses to the reality of the menace of malaria, they are equally seen as responses to research findings which have consistently attributed high infant morbidity and mortality essentially to the incidence of malaria.

7 The Nigeria Television Authority is a government owned television station in Nigeria.

In spite of these efforts, however, malaria has continued to ravage the Nigerian society unabated, particularly among the children. Following the incidence of malaria and other childhood diseases, Nigeria is rated as one of the countries in SSA with the worst child survival indicators in Perinatal Mortality Rates (PNMRs), infant mortality rates (IMRs) and under-5 Mortality Rates (U5MR). The PNMR measures the risk of dying from the 28th week of pregnancy until the end of the first week of life; IMR measures the possibility of a child dying before his or her birthday; while U5MR measures the probability of death before the age of five years (Okonofua, 2006: 30). The IMR among the poorest segment of the population was put at 102 per 1000 live births in 2001 (Ogbolu, 2007: 358) compared to 32 and 36 per 1000 live births in Romania and Georgia respectively (United States Department of Health and Human Services, 2003). The U5MR increased from 140 per 1000 live births in 1999 to 197 per 1000 live births in 2004 (Okonofua, 2006: 30- 31).

Apart from dwindling health care funding resulting in a general collapse of the local primary health care systems, coupled with the growing resistance of parasites to anti-malarial drugs and increasing resistance of mosquito vectors to insecticides, the persistent increase in the incidence of malaria and its associated morbidity and mortality in children below the age of five might be an indication that knowledge about how and when families in these societies respond to malaria infections and prevention is lacking in government policies and the biomedical arena. As a matter of fact, health care seeking behaviour of caregivers in most traditional societies is organically intersected with cultural beliefs as well as social and environmental factors which are still apparently being neglected in the bio-medical as well as psychological discourses in Nigeria. Studies have shown that in most traditional communities of Nigeria, particularly in rural areas, modern preventive and curative measures in childhood diseases such as malaria can be neglected or are perceived to be ineffective where such measures conflict with local knowledge, traditional and religious beliefs (Feyisetan et al, 1997: 221). In such instances, rather than utilising these measures, most caregivers would prefer to opt for the use of traditional measures passed on to them by previous generations. The central research question is then: What are the dominant cultural beliefs that influence the choice of health care systems and how have these changed over time and places, with particular reference to malaria in children under the age of five? Other specific research questions which have also emanated from the main research question include the following:

• How do caregivers in the communities of study perceive the threat, aetiology and symptoms of malaria in children below the age of five? How does this correspond to biological construction and does it matter?

• To what extent does local knowledge and attitudes about preventive measures affect their utilisation in the communities of study and does it matter?

• What are the routes or pathways to health care utilisation in the management of malaria in children in both the rural and urban areas? In other words, does the pattern of health care utilisation differ between the rural and urban dwellers in response to malaria in children? If yes, why, and if no, why not?

• Is there any difference in the patterns of health care utilisation among young parents and grandparents in the treatment of malaria in children under the ages of five? If yes, what factors could be responsible for the difference and do they actually matter?

• What socio-cultural factors in the communities of study enhance or constrain the use of modern health care facilities in the management of malaria in children and why?

The current study aimed at providing scientific answers to the above questions that stemmed from the statement of the problem. The research questions served as guidelines in the search for answers to the problem statement. They also served as tentative hypotheses in this qualitative research. To search for scientific answers, the most appropriate qualitative instruments of data collection were adopted and relevant theoretical perspectives applied to substantiate data gathered from the field.

1.3 Objectives of the Study a. To examine local knowledge and perceptions about the threat, causes and symptoms of malaria in children under the age of five in communities of study.

12 b. To explore local knowledge and attitude towards modern preventive measures (e.g. treated bed nets) in the prevention of malaria in the communities of study. c. To understand the pathways to the management of malaria in children in both the urban and rural communities of study. d. To explore the inherent disparity (if any) in the patterns of health care seeking behaviour between young biological parents and grandparents with a view to investigate the socio-generational changes and the factors responsible therefore. e. To explore socio-cultural factors such as poverty, proximity to health care service, informal social networks that enhance or constrain health care seeking behaviour in the communities of study.

1.4 Intended Contribution of the Study to Scientific Knowledge

Health care service utilisation process has attracted scholars in the field of social sciences where economists seem to have taken dominance. Thus, serious and deep ethnographic exploration of health care service utilisation has been given minimum attention especially with regards to malaria in children younger than five years of age. This accounts for the obvious scarcity of qualitative scholarly literature in health care seeking behaviour with regards to malaria in Nigeria and the public domain. This study has provided deep sociological as well as anthropological dimensions of health care service utilisation that seem to have been neglected over the years.

Furthermore, most studies have paid little attention to the socio-generational changes in the pattern of health care utilisation among caregivers in local communities. While some studies have accounted for the cultural influence in the conception and management of ill-health, they have failed to demonstrate the obvious changes that are taking place in the pattern of health care utilisation among a ‘new’ generation of caregivers. They have also failed to look into the factors that could be responsible for such changes. This study has attempted to close this gap by probing into the socio-cultural dynamics influencing health care

13 seeking behaviours of both the young and grandmothers with a view to exploring the continuity and/or discontinuity in cultural beliefs associated with malaria.

Finally, this study hopes to make a significant contribution at both policy and theoretical levels. On the one hand, at policy level, this research could serve as a contribution to the on-going discourses about general notions in overhauling and reconstructing health delivery systems in Africa particularly in Nigeria. It could thus provide useful insights into the formulation of health policies that would include effective and dynamic systems that incorporate community strategies including cultural beliefs, knowledge and practices. This study is coming at a time when international health organisations like the WHO is calling for the recognition and incorporation of cultural beliefs into the mainstream of health delivery system. On the other hand, theoretically, the study intends to represent a contribution to a more robust theory of health care seeking behaviour in Health Sociology. It also provides empirical evidence that would expand knowledge about health care seeking behaviour beyond the dominant biomedical and psychological understanding. The study could also serve as a database or reference point not only to policy makers and educators in Nigeria, but also future researchers in the area of health sociology or public health who might develop and navigate their research around and within the scope and parameters of this study.

1.5 Scope and Strategy

Using a qualitative research design, this study focuses attention on the cultural influence on health care utilisation and the socio-generational changes in the pattern of health care seeking behaviour of caregivers in both rural and urban areas of Kwara State, Nigeria. The study was conducted in two selected rural areas and one urban centre. The two rural areas are Okanle and Fajeromi in Ifelodun Local Government and the urban centre is Ilorin specifically in Ilorin-South Local Government. The study covers both young biological parents and grandparents whose children or wards below the ages of five had manifested malaria symptoms at one time or another and who had reported or failed to report such cases at the available health centres. The health centres are the Okanle/Fajeromi Communities Health Centre in Okanle and Fajeromi and the Children Specialist Hospital at Centre Igboro in Ilorin-South Local Government.

The selected communities of study are characterised by diverse socio-cultural contexts with possible influence not only the availability of socio-amenities such as health care services and information but also their utilisation. Like many countries, the urban and semi-urban areas are usually characterised by diverse and mixed cultures as against rural areas with a more uniform culture and strict adherence to cultural practices. Therefore, living in an urban or semi-urban area ideally places an individual in an advantaged position of a ‘high degree’ of accessibility of formal health care services such as the Children Specialist Hospital, Teaching Hospital, General Hospital and a host of other government and private clinics situated in the State capital as against an individual in the rural areas with extreme disadvantage in this regard. Kwara State was chosen for the study because it is believed to be one of the poorest states in Nigeria where childhood diseases like malaria are rampant. (More about the study settings is provided in Chapter two).

1.6 Conceptualisation In this section, some basic concepts used in this study are clarified. These include a distinction between rural and urban areas, the meaning of socio-economic status and poverty, caregiver, malaria disease, health care system. Others are clarification of traditional medicine and healers, young and grandparents, health care seeking behaviour, informal social network system and social support.

1.6.1 Distinction between Rural and Urban ‘Rural’ and ‘urban’ are nebulous concepts. They lack precise definitions. The use of various definitions reflects the multidimensionality of the two concepts. Some of the defining criteria are population size, population density, administrative boundaries, proximity to urban settings, accessibility or proximity to social amenities and economic activities. The more of these criteria or features the more urban is the setting and the less of the features the more rural is the area. One of several definitions denotes rural setting as an area in which there is a small population and the most important economic activities are the production of foodstuffs, fibers, and raw materials. In this study, the rural settings are characterised by their adherence to farming as a way of life. They are not goal or achievement oriented. Members of the communities seek subsistence and not surplus; marked by a high regard for intimacy and traditional values. In such societies, the community way of life is often regulated by kinship customs and ritual, and, in particular, the ownership and care of productive land is strictly regulated by traditional ethos. Urban society on the other hand is

characterised by the opposite attributes of the rural: it is goal oriented; community members seek surplus; and there is less regard for intimacy and traditional values.

1.6.2 Socio-Economic Status and Poverty

Socio-economic status is a concept used to describe the social and economic positions of individuals within the larger society. What most studies have found is that the disadvantaged people in the society often have limited access to health care services and as such are more likely to engage in risky health behaviour; live in a dirty or less healthy social and physical environment; and have weaker social support with serious impact on health care service utilisation (Robert, 2002: 4). According to Robert (2002: 2) socio-economic status encapsulates a broad range of socio-economic resources on which people are hierarchically stratified. The most common indicators of socio-economic status are an individual’s income, assets, residential patterns, educational level, occupation, or a constellation of these variables.

Like socio-economic status, poverty is a broad and multi-dimensional concept. It embodies “lack of resources, limited ability to meet basic needs, and a range of other dimensions of vulnerability and security” (Worrall et al. 2005: 1048). Poverty can, therefore, be seen as one of the variants of the socio-economic resources. However, in this study, like Worrall et al. (2005: 1048), socio-economic status is used interchangeably with poverty. They both describe the economically disadvantaged caregivers in the society and the way in which their health status or health inequalities are affected by the social and economic conditions of life (Robert, 2002: 1). In other words, the concepts are used to describe and understand the relationship between the individual caregivers and access to health care services. An individual with higher socio-economic status is assumed to have higher access to health care services and the modern preventive and curative measures in the management of malaria and vice-versa.

1.6.3 Caregivers

Within the context of this study, a caregiver is someone involved in providing care for the children. In the communities looked at in this study, a caregiver goes beyond the biological parents to include members of

the extended family such as grandparents and cousins. The concept of caregiver is used interchangeably with caretaker and/or parents. It must be noted that a caregiver is not the same as care provider. A care provider is a health or medical professional trained to provide care for patients. They include doctors, nurses and other professionals within the medical parlance.

1.6.4 Young and Grandparents

Differentiating between young and grandparents could be problematic considering the fact that every society defines who constitute a particular age group; the same way societies differentiate between the old (grandparents) and the young. In some societies, these differences are explained based on chronological age disparity; if you are of a certain age you can or cannot belong to a particular social group. However, in most societies, chronological age is just one of the dimensions of this definition. Other factors may also hasten or prevent one from becoming a member of a particular age or social group. For instance, the acquisition of Western system of education, early marriages and religious belief are important determinants of membership in a particular social context8. For instance, in Nigeria, like other places, while most professional women celebrate the arrival of their first child at about the same age (say thirty-one to thirty- five) some lower-income women celebrate their first grandchild at the same age. Therefore, it should not be a surprise to find a 40 year old respondent in this study grouped under the categorisation of the grandparents. This may have been precipitated by virtue of early marriage which is culturally and religiously entrenched among the lower-income people in Nigeria. Within this context, apart from age factor, an important parameter used to define a grandparent in this study is a grandchild. Respondent between the ages of 18 and 49 were categorised as a young mother (except if has a grandchild) while those above 49 were categorised as older or grandparents.

8 It would be recalled that family system theory developed by McGoldrick (1989) was meant to explain differences in family systems. The theory emphasises religion (McGoldrick, 1989: 70), ethnicity and culture as important factors shaping family’s beliefs, practices and values rather than bio-ecological factors. See McGoldrick, M. (1989). ‘Ethnicity and the Family Life Cycle’. In Carter, B and McGoldrick, M (eds.). The Changing Family Life Cycle (2nd ed.). Needham Heights, MA: Allyn & Bacon.

1.6.5 Disease and Illness

From a medical point of view, a disease is a malfunction of biologic and psycho-physiologic processes in an individual (Kleinman et al. 2006: 141). It is a physiological and psychological process of malfunctioning of the human organism manifested in specific symptoms recognised by the medical profession and professionals who gave it its meaning and identity (Herselman, 2007: 62). It therefore refers to an objective condition. Illness on the other hand is the human experience of disease and therefore refers to subjective condition. However, beyond the biological construction, disease and illness can also be viewed from a cultural perspective (Kleinman et al. 2006: 141). Therefore, in this study, the terms disease and illness are used within the context of both biology and culture with special emphasis on cultural construction.

1.6.6 Health Care System

In contemporary society, when the health care system is mentioned, what comes to mind is the modern health care system. This suggests the mental primacy of the modern health care system in contrast to other forms of treatment such as traditional and spiritual healing. However, in countries like Botswana and China where traditional medicine and its practitioners are an integral part of the health delivery process and system, the concept of the health care system is incomplete without mentioning traditional medicine or complementary and alternative medicine as it is called in Europe and America. Therefore, in this study, the concept of the health care system shall include both the traditional and modern health care facilities.

According to the World Health Organisation (WHO), traditional medicine is “the sum of all knowledge and practices whether explicable or not, used in diagnosis, prevention and elimination of physical, mental or social imbalance and relying extensively on experience and observation handed down from generation to generation, whether verbal or in writing” (Amzat and Abdullahi, 2008: 155). It includes “a diversity of health practices, approaches, knowledge, and beliefs incorporating plant, animal, and/or mineral-based medicines; spiritual therapies; manual techniques and exercises, applied singly or in combination to maintain well-being, as well as to treat, diagnose, or prevent illness” (Amzat and Abdullahi, 2008: 155; WHO, 2002a: 7). A traditional healer is “a person who is recognised by the community where he or she lives as someone competent to provide health care by using plant, animal and mineral substances and other methods based on social, cultural and religious practices” (WHO, 2000a:11-12).

1.6.7 Illness and Health Care Seeking Behaviour

The researcher is aware of conceptual confusion embedded in the health behaviour discourses. Some of the confusing concepts include health behaviour itself, health directed behaviour, preventive health behaviour, sick-role behaviour and illness behaviour. In this study, the most important concepts are illness and health care seeking behaviours. Illness behaviour on the one hand is a concept broadly used to describe the process of how a particular people or individuals interpret symptoms and signs, and evaluate possible responses. It also includes the decision to respond to those symptoms or not. Harding and Taylor (2002: 526) note that illness behaviour is an active rather than perceive process. It includes “interpreting symptoms, evaluating possible responses, and, finally, deciding on whether to try to alleviate those symptoms or simply to ignore them” (Harding and Taylor, 2002: 526). In this study therefore, illness behaviour includes how an individual caregiver perceives, evaluates and reacts to symptoms of malaria in children younger than five years of age. Health care seeking behaviour on the other hand is used to describe health actions undertaken by individual caregivers to treat or cure malaria in children younger than five years of age. Therefore, sometimes the two concepts are used interchangeably simply because the decision to seek treatment from government approved facilities or not is influenced by the prevailing norms and values of the society, as well as other social factors and not simply related to the severity of the symptoms experienced by the caregivers.

1.6.8 Informal Social Networks and Social Support

In this study, informal social networks and support stands for the way and manner in which people are linked to one another through social ties and the ways in which these ties influence our own lives and those of others (Raab and Milward, 2003: 413) including the importance or otherwise they may have in how people engage with health systems in local communities. The involvement of ‘significant others’, especially grandparents in this study, was informed by the important role they also play in children’s health and the fact that the extended family system is still predominant among the people studied. El-Safty (2001: 3) contends that the extended family structure has remained very important to African people. The family structure may include husband, wife, children and blood relatives. In simple terms, the social ties that exist among the community members and neighbours and the possible impact on health care utilisation is referred to as social networks in this study.

1.7 Reliability and Validity of Techniques

The issues of validity and reliability in qualitative research have been at the centre stage of academic debate since the inception of qualitative research paradigm into mainstream social science research. This became important considering an age-long belief in social science research that validity and reliability testing were only central to experimental research where predetermined ‘standards’ are set and means of measurement firmly established. As a result, some proponents of quantitative research have been engrossed with challenging and criticising qualitative research on the basis of lack of “standardised” means of validating research findings as commonly found in quantitative research, such as quantitative measurement for hypotheses testing (Maxwell, 1992: 279).

On the contrary, contemporary qualitative research literature has been inundated with different approaches and perspectives regarding the position of validity and reliability (Creswell, 2007: 202). These include a number of scholars who have borrowed and introduced quantitative terminologies into validation and reliability discourses in qualitative research paradigm. A good example is LeCompte and Goetz, 1982 (Creswell, 2007: 202). This category of researchers has attempted to compare and equate the issues of validity and reliability with quantitative paradigm. They have “applied threats to internal validation in experimental research to ethnographic research ... and identified threats to external validation as effects that obstruct or reduce a study’s comparability and translatability” (Creswell, 2007: 202).

However, other qualitative researchers have shared contrary opinions. They have taken a more radical approach to establishing validation and reliability in qualitative research approaches. They have even questioned and challenged the methods used to introduce quantitative terminologies into qualitative research with regards to validity and reliability. To these researchers, such action is counter-productive and capable of damaging the image of qualitative research. Their argument is based on the fact that the ontology and epistemology of qualitative research are completely different from quantitative, hence, the ‘methods’ and/or ‘standards’ used to establish ‘trustworthiness’ should be different as well. To establish the ‘trustworthiness’ of a study, scholars have constructed alternative terms such as ‘credibility’, ‘transferability’, and ‘dependability’ to replace terms such as validation (both internal and external validations), ‘reliability’ and ‘objectivity’ commonly found in quantitative research (Creswell, 2007: 202). There is a strong belief in

20 qualitative research that the quality, plausibility, reliability and to some extent the validity of research can be enriched using triangulation (Bloomberg and Volpe, 2008: 72-73; Miller and Fredericks, 1996: 28) because qualitative researchers are more inclined towards providing a ‘thick description’ of social events under investigation.

To this end, this study employed qualitative research design using a combination of techniques. Triangulation allowed issues to be observed from different viewpoints in order to substantiate findings that would enhance the validity and reliability of the study. Within the context of qualitative research methodology, reliability is when a specific technique is applied repeatedly to the same situation and then gives the same results, consistently. It is thus the stability and consistency of information when a technique is used more than once as shown in the current study. Often, reliability in qualitative research depends on the researcher’s insight, awareness, questions and suspicions; when events are critically looked into from different angles (Neuman, 2007: 294). Besides, the credibility of the participants and their statements also form an integral part of reliability in qualitative research (Neuman, 2007: 294). Validity of the field work on the other hand was obtained through in-depth information and meanings regarding caregivers’ behaviour. Validity is the degree to which a technique measures what is supposed to be measured, thus the interview schedule used to conduct the interview with caregivers (see appendix for the interview schedule). Often, validity in qualitative research is the confidence placed in a researcher's analysis and data as accurately representing the issue under scrutiny (Neuman, 2007: 294).

Furthermore, Maxwell (1996: 91) notes that qualitative research is not all about removing variance between researchers in the values and expectations they bring to the study, “but with understanding on how a particular researcher’s values influence the conduct and conclusions of the study”. Based on this, careful thought was devoted to ways in which limiting factors were accounted for and thereby minimising their influence on the outcome of the study. Certain measures were also taken up front to reduce the researcher’s bias. For example, to reduce potential bias during data analysis, the researcher removed all participant names and coded interviews and focus group transcripts in order not to associate any material, data or statement with any particular respondent. In other words, anonymity of the respondents was guaranteed. Most importantly, the researcher consciously made an effort to create an environment

21 conducive to honest and open dialogue and discussion as much as possible. As observed by Neuman (2007: 294) reliability in a field research such as this is often guaranteed by internal and external consistencies where “internal consistency” is the plausibility and accuracy of data obtained from the field work. This is ensured by removing all forms of human deception. “External consistency” on the other hand is obtained when observations are verified with other sources of data (Neuman, 2007: 294).

Finally, although, qualitative researchers “rarely make explicit claims about the generalisability of their accounts” on the ground that they usually study a smaller number of individuals, Maxwell (1996: 97) distinguishes between internal and external generalisability. According to Maxwell (1996: 97) “internal generalisability refers to the generalisability of a conclusion within the setting or group studied, whereas external generalisability refers to its generalisability beyond that setting or group”. Therefore, the descriptive, interpretive, and theoretical validity of the conclusions drawn from a particular study setting depend largely on their internal generalisability to the case as a whole (Maxwell, 1996: 97). However, the strength of this study lies on the provision of detailed information regarding the research questions stated and the objectives of the study.

1.8 Conceptual Framework The conceptual framework for this study is health field model originally developed by Evans and Stoddart (1990). HFM was launched by these scholars to understand and explain the factors that affect disease and health distribution in human populations with a view to providing strategies for intervention. The model emphasises general factors affecting diseases in the overall large segments of the population, rather than specific factors that account for small changes in health at the individual level (Ratzan et al. 2000: 12). The model sees both health behaviours and factors that influence them as extremely complex. It combines bio- geo-physical and sociological variables in understanding disease distribution and their impact on health outcome. The model interrogates how social, environmental, economic, and genetic factors contribute to differences in health status in human population thereby presenting an opportunity for health intervention at all levels: individual, community and international levels. The model seeks to describe the relationship between “global factors” also known as the structural variables, the health care system, disease and injury and individual health status. On the one hand, the model demonstrates how “global factors” such as

22 community and social environment, physical environment, and genetic factors directly affect disease distribution, injury, health and wellbeing in human population (Ratzan et al. 2000: 12-13). The social and community environment emphasises the social status or class, social networks, government policies on health and wellbeing. The physical environment includes the physical hazards at home, community and work environment, natural health threats (e.g. natural disasters), and chemical agents to which individuals are exposed. The family and individual environment includes human behaviours and lifestyle, family support, access to and use of the medical system. On the other hand, it examines the impact of the risk factors or vulnerability which includes age and exposure to health risks (such as malaria-transmitting mosquitoes), education and income and health care system on health and wellbeing. This is illustrated diagrammatically below:

Figure 1.1: Health Field Model: Determinants of Health

______

Social Physical Genetic Environment Environment Endowment Individual Response

-Behaviour

-Biology Health and Disease Health Care Function

Wellbeing Prosperity

Source: Evans, RG. And Stoddart, GL. 1990. “Producing Health, Consuming Health Care”. Social Science and Medicine, 31: 1359.

The above model is concerned with what can be done at individual, community and global levels to influence and enhance health. These are divided into three broad levels: the primary, secondary and tertiary prevention levels (Ratzan et al. 2000: 12-13). The primary prevention concerns the question of “how do we keep ourselves well?” In other words, how do we prevent the occurrence of disease like malaria? Secondary prevention relates to questions such as “if we are getting sick, how can we detect these conditions?” In other words, if children have malaria how can we detect these conditions and respond adequately? The tertiary prevention is concerned with “if we are sick, how do we get the best care?” These questions have direct bearing on the question of how to prevent and treat malaria in children below five years of age at individual, community and national levels. At global and community levels, these aspects include formulating and enforcing health policies that affect health such as private and social health insurance. At individual or family level, this can include personal decisions to make the “right” or ‘rational’ choices such as using the mosquito bed nets regularly to prevent mosquito bites. However, all of these may not be possible without adequate knowledge and education about prevention and treatment of malaria.

1.9 The Structure of the Study

This thesis is divided into six chapters covering the introduction to the research problem, literature review, research methodology, data analysis and discussion. However, it should be borne in mind that each of the chapters is not distinct in itself. Rather, all chapters are chronologically interrelated aimed at answering the research questions and arriving at a logical conclusion. Chapter two reviews the works of academic authors and commentators that have focused attention on issues related to the study. The review of literature includes an examination of academic commentaries from both African and non-African authors. This follows a patterned structure that allows an examination of different streams of argument supported by empirical evidence in the analysis of health care utilisation and the local perceptions of health and illness. Some of these authors have focused attention on the biomedical issues in health and illness without emphasising the importance of social and cultural factors. The desire to incorporate socio-cultural issues into research on health seeking behaviour has prompted sociological and anthropological studies in both developing and developed countries. The background information about the communities of study is also provided in this chapter. It provides an overview of Kwara State as a whole, the city of Ilorin and Ilorin- South Local Government Area. A description of the Children Specialist Hospital located at Centre-Igboro is also provided.

A theory of health seeking behaviour is a necessity. This is because it could promote an understanding of health behaviour, direct research and facilitates “the transferability of an intervention from one health issue, geographical area or healthcare setting to another” (Munro et al, 2007: 1). The third chapter of this thesis examines the most relevant and useful theoretical models in health care utilisation. These models are extracted from social, psychological, anthropological and medical sociological studies. They include: Health Belief Model (HBM), the transtheoretical model (TTM), the Theory of Health Care Utilisation, the Rational Choice Theory (RCT) and the Generational Cohort Theory (GCT). These theories were reviewed and applied to the understanding of the research questions and objectives of the study.

Chapter four entitled “Research Methodology” provides an overview of the methodological approach adopted for the study. This chapter deals principally with the methodological issues that have relevance to the study. An attempt is made in this chapter to make an overview of the research design as well as providing insights into the various strategies adopted for the qualitative research adopted. Discussions here include how the research was planned and followed through. The chapter is compartmentalised into the research design (qualitative approach), the population of study and sampling procedures, description of qualitative instruments used to gather data, a description of how the researcher was able to gain entrance into the study areas, the methods of data analysis, ethical considerations and the problems encountered during the research process.

Chapter five presents a qualitative analysis of the data collected from the field. An attempt has been made to provide answers to the research questions and objectives of the study. The analysis and discussions were based on the research questions and objectives outlined above. These include: the description of the characteristics of the respondents, local knowledge of malaria; the perceived threat of malaria; perceived aetiology of malaria in children; perceived symptoms of malaria in children; treatment of malaria in children, socio-generational changes in treatment patterns, socio-cultural and economic factors affecting treatment of malaria in children, decision making process, pathways to treatment of malaria, as well as local knowledge and attitude towards modern preventive measures. Data interpretation and analysis were done using ‘emic-nonreflexive’ approach.

Chapter six, the “Conclusion and Recommendation” concludes the study by presenting the research findings and locating the contribution of this study to the mainstream of health care seeking behaviour discourses. This chapter also identifies areas for future research and provides contributions to the current cross-national and cross-country debate and a comparison is made to the academic discourses about health delivery systems. The chapter also offers a number of policy recommendations towards the formulation of health policies that would recognise local dynamics in response to childhood diseases such as malaria with a view to minimise the disruption of lives at the local levels particularly among children below the ages of five. These recommendations generally focus on suggestions on how to move the traditional medicine practice forward, rather than concentrating on the so-called “woes” and “inadequacies” which have characterised the discussion between traditional and modern medicines over the years. The study also provides important measures to be put in place in order to overcome the barriers to modern health care utilisation in some traditional societies. It is concluded that if these measures are followed it would not only benefit the individual, but also the entire health delivery systems in developing countries like Nigeria.

CHAPTER TWO

DISEASE, HEALTH AND ILLNESS DIMENSIONS: A REVIEW OF THE LITERATURE

2.1 Introduction

From the point of view of biology, exposure to germs, bacteria, viruses or parasites could cause a disease. When disease occurs, the expectation from the medical cycle is that the individual consult with a medical doctor for prompt treatment. This, perhaps, is because authority concerning health matters is believed to reside in the doctor’s expertise and dexterity especially as shown in diagnosis and treatment (Bury, 2005: 5). In spite of this, certain people often defy the use of modern health care facilities when they are sick. While some depend on spiritual healing others rely on self-medication with some elements of traditional and modern treatment. Nyamongo’s (2002: 370-379) study found out that a significant number of patients relied on multiple sources of care when malaria occurs in rural Kenya. A study has also found that 52.9% of pregnant women in rural and urban areas of Enugu, Nigeria rely on traditional health institutions for delivery (Onah et al. 2006: 1870). The questions are: why do some people fail to report to and access the modern health facilities when they are ill? Could non-use of modern health facilities be attributed to culture or distance? How is the local conception of disease, health and illness different from biological notions and how does it influence the choice of health care provider for effective management?

Therefore, in this chapter, the contributions of academic commentators to the disease and illness are broadly examined. The review follows a patterned structure that allows an examination of different streams of argument supported by empirical evidence in the analysis of health care service utilisation and the biological and local perceptions of health and illness. While some of these authors have focused attention on biomedical issues others have emphasised the importance of social and cultural factors in health and illness. The desire to incorporate socio-cultural issues into research on health care seeking behaviour has prompted sociological and anthropological studies in both developing and developed countries. This was borne out of the fact that socio-cultural and ecological issues in disease, health and illness are germane to an effective health system response and disease management.

A comprehensive literature review was conducted by means of relevant published journal articles on the research topic and related topics using an English language search. The journal articles included local, national and international studies. Published books were also consulted. The search for journal articles was primarily carried out by using the electronic databases of the University of Johannesburg library via JSTOR, Science Direct, SAGE Publications, EBSCO Host and so on. An extensive Google scholar search was also conducted using Medline, PubMed, malaria.com and others. Quite a number of relevant journal articles, reports and working papers were retrieved from the World Health Organisation and World Bank databases. Some of the following key search terms and concepts were used to locate relevant articles; “causes of disease; cultural and biological analysis”, “distinction between disease and illness”, “social production of disease”, “determinants and/or factors of health care seeking: psychological and social factors”, “malaria and: poverty, socioeconomic status; burden, treatment seeking”. The majority of the reviewed studies were conducted and published in 2000 and later.

2.2 Disease and Illness Causation: a Multidimensional Approach

Human beings are wonderful creatures. They are dynamically complex and sophisticated; they are biological, chemical, spiritual and social beings. As biological beings, human organs often malfunction. The question is why do people fall sick? Over the years, this simple but deep-rooted question has attracted the attention of scholars in both humanitarian and biomedical sciences and triggered academic debate spanning through the 19th and 20st century. The earliest attempt to study disease causation and distribution in human population was professionally and academically confined within the boundary of biomedical sciences. Indeed, understanding disease causation in human population was the principal reason why medicine came into existence as both a science and an art. The emergence of the germ theory in the 19th century as a principal ideological framework to dissect disease causation particularly, infectious diseases, marked a significant turning point in the history of biomedical sciences (Clarke, 2001: 2). The theory was later extended to explain all kinds of human diseases and this lasted for a long period of time.

One of the basic assumptions of germ theory is that human organs malfunction when humans are exposed to bacteria which can be manifested through certain specific pathological conditions or symptoms. Consequently, drugs were invented to counter the threat posed by diseases. Drugs became to be seen as

magic bullets capable of ameliorating or averting the devastating consequences of diseases (Cockerham, 1992: 2). A number of studies were conducted in the 19th century that supported and elevated the biological determinism of diseases inherently embedded in the germ theory. Inspired by the theory, Ehrlich, Koch and Pasteur, during the second half of the 19th century investigated the causes of prevailing health problems and concluded that diseases were caused by germs which ought to have penetrated human body through food, water, air or the bites of insects or animals (Locker, 2008: 19).

Although the biomedical model to disease causation has been subject to criticism, some of its basic assumptions and principles have continued to linger on in contemporary health discourses especially with respect to malaria. Recent studies have found that the mosquito species that cause malaria could be up to as many as five: Plasmodium vivax, Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale and Plasmodium knowlesi (Crawley et al. 2010: 1486). Of these five species, Plasmodium falciparum is the most destructive (MMV, 2000: 12) and is commonly found in the tropics and subtropical regions of the world that include SSA (Jamison et al. 2006: 72). Thus, malaria is believed to be transferred through infected female Anopheles bites which must have drawn blood of an infected person (Oshikoya, 2007: 49).

Based on the predominance of the parasites responsible for the transmission of malaria (malaria endemicity), the distribution of malaria has been divided into three zones. In the first zone are many parts of Central, East and West Africa, Papua New Guinea, Solomon Islands and Vanuatu regarded as stable endemic malaria areas. In this zone, malaria disease is a common phenomenon and occurs at alarming rates. Some level of immunity against malaria might even be developed in this zone. For instance, more than 80% of the Nigerian population (Abdullahi et al. 2009: 7102) and 95% of the Ugandan population (Kampala Ministry of Health, 2001: 3) are exposed to malaria infections. Of the 90% in Nigeria, more than 40% have at least one episode of malaria every year (Abdullahi et al. 2009: 7102). In the second zone are parts of Southern Africa, Central Asia and America, highland and desert fringe areas, plantations and irrigation schemes areas where malaria is unstable. The third zone is regarded as the free malaria zone. It is comprised of parts of Southern and North Africa, Seychelles, Ethiopian and Eritrean highlands and Transcaucasia (Nduga et al. n.d: 1). Below is an image of mosquito falciparum commonly found in SSA; the reason why millions of people including women and children are said to be dying from malaria. Using this

29 approach, the body is believed to be isolated from the person where “the social and material causes of disease are neglected, and the subjective interpretations and meanings of health and illness are deemed irrelevant” (Nettleton, 1995: 3).

Figure 2.1: An Image of Mosquito Plasmodium Falciparum

However, germ theory has been adjudged to be insufficient in understanding the epidemiology of diseases in human population. The theory neglects the socio-ecological and psychological dimensions of disease causation. Thus, it is increasingly becoming a common belief that a better understanding of disease causation and management cannot be achieved except by looking beyond the domain of biomedical science to include a multi-causal explanation. This became important against the backdrop that not all those exposed to germs or pathogens become ill (Locker, 2008: 20) and that not everybody that is sick that has pathogens. The limitations inherently embedded in the germ theory has therefore led to the formation of what is known as the epidemiological triangle or multi-causal approach which sees disease as the

30 product of an interrelationship between an agent, a host and the environment. In this sense, agents are biological, chemical or physical factors whose presence is necessary for a disease to occur; the host factors include personal characteristics and behaviours as well as genetic predisposition which influence susceptibility; while environmental factors are external conditions other than the agent that influence the cause of disease (Locker, 2008: 20).

The critics of the mono-causal or biomedical construction of disease have been polarised into two ideological camps or spectrums known as the ‘pragmatic’ and ‘fundamental’ approaches (Clarke, 2002: 3). On the one hand, are those critics inspired by pragmatic approach who still retain the biomedical model of disease causation but believe that the model does not sufficiently account for aetiology of diseases. Those who adopt the fundamental approach, on the other hand, challenge, repel and condemn the basic assumptions of the biomedical model altogether. They are more inclined towards social causes by social forces rather than biological determinism of diseases. They argue that medical concepts are not the natural outcome of the application of objective methods of scientific discovery to the study of the human body. Rather, there is an important socio-cultural dimensions to the creation of medical knowledge that must be recognised (Clarke, 2002: 3). The upsurge in the “stress related diseases” in the 21st century such as cardiovascular diseases has justified the need for a multi-causal explanation of disease (Weiss and Lonnquist, 1994: 1). This position has further been demonstrated in MacFarlane and Keller’s (2002: 1393) study. The study was designed to understand disease causation and attitudes toward health care among older people in the Republic of Ireland. The study discovered that although there was still a strong allegiance to biomedical concepts and practices, causes of disease were believed to be multi-dimensional in nature which included behavioural and psychosocial explanations. Figure 2.2 below indicates that disease and ill-health can be caused, aided and exacerbated by a myriad of risk factors ranging from social factors such as poverty and poor housing; physiological risk factors such as genes; behavioural factors such as smoking; and psycho-social factors such as loneliness and lack of social support.

Figure 2.2: The Socio-Environmental Approach to Health

Risk Conditions

• Poverty • Low education/Occupational Status • Dangerous, stressful work • Dangerous, polluted environment • Discrimination, etc.

Physiological Behavioural risk risk factors factors

• Hypertension • Hypercholesterolaemia • Compromised immune system • Genetic factors Psychosocial risk factors *

• Isolation • Lack of social support • Low self-esteem • Self blame, etc.

Health Status

Adapted from Locker, David (2008: 24).

The conclusion drawn from studies like these has moved the debate further to include the contributions of scholars in the field of social sciences, particularly anthropologists and sociologists. This concern was borne out of the fact that people’s modes of behaviour including how and where they live have profound impacts not only on disease causation but on health outcomes in general (Gilbert et al. 1998: 5). From a

Figure 2.2: The Socio-Environmental Approach to Health

Risk Conditions

• Poverty • Low education/Occupational Status • Dangerous, stressful work • Dangerous, polluted environment • Discrimination, etc.

Physiological Behavioural risk risk factors factors

• Hypertension • Hypercholesterolaemia • Compromised immune system • Genetic factors Psychosocial risk factors *

• Isolation • Lack of social support • Low self-esteem • Self blame, etc.

Health Status

Adapted from Locker, David (2008: 24).

geographical point of view, Smith and Easterlow (2005: 173) made a strong case for the effects of places or environment in health divide and inequalities. In sociology, an understanding of disease causation revolves around “the social causation of diseases” (Cockerham, 2007: 1) which might include the impact of belief system, social structure, socio-economic inequalities, social network and social status as well as environment on health and distribution of diseases (Jegede, 1996: 54). Although the mosquito believed to cause and transfer malaria parasite from one human being to another thrives in warm, humid climates where pools of water provides perfect breeding conditions (UNICEF, 2000: 1), there are solid and increasing evidence to suggest that environmental factors provide a favourable terrain for malaria transmissions (Simsek and Kurcer, 2005: 203). A relationship between malaria and poverty has also been reported. The concentration of malaria in the poorest continents and countries around the world could justify the claim that a relationship between malaria and poverty exists. A cursory look at figures 2.3 and 2.4 below shows that the burden of malaria is endemic in countries where poverty is highly entrenched. According to the Earth Institute of the University of Colombia:

Malaria and poverty are intimately connected. As both a root cause and a consequence of poverty, malaria is most intractable for the poorest countries and communities in the world that face a vicious cycle of poverty and ill-health (European Alliance against Malaria, 2007: 1).

Onwujekwe et al. (2010: 19) have argued that the high levels of household income depletion caused by malaria treatment often contribute to the vicious cycle of poverty and disease in malaria endemic regions especially in poorer households. In Malawi, a high economic burden of malaria is borne by lower-income households. In this country the direct and indirect costs of treatment of malaria gulps more than 30% of annual household income, compared to 4.2% in the middle to high income categories (cf. Yusuf et al. 2010: 5). Deressa’s et al. (2007: 1152) study found that malaria poses a daunting economic burden on rural households in rural Ethiopia. This is often manifested in high amount of out-of-pocket (OOP) payment and person-days lost. In Ghana, malaria swallows more than 30% of a poor household income (Hunt 2007: 1; European Alliance against Malaria, 2007: 2).

However, Worrall et al. (2002: 4) argued that the empirical evidence that suggests a causal link relationship between poverty and malaria is limited, contradictory, inconsistent and of questionable quality. Based on household Demographic and Health Survey data gathered in the 1990s from 22 African countries, Filmer (2001: 3) found a weak association between reported fever and poverty across space. However, the results showed associations between poverty and the type of care sought (or not sought) for an episode of fever. The study found that treatment from the modern sector was more likely to take place in Eastern and Southern Africa than in Western and Central Africa. In both regions, the percentage of people who seek treatment in the modern sector is larger in the richest than in the poorest quintile. In Western and Central Africa those from richer households are more likely to seek treatment or advice from both higher-level public facilities (such as government hospitals) and lower level public facilities (such as health clinics), than those from poorer households. In Eastern and Southern Africa, on the other hand, the rich are equally as likely as the poor to seek treatment from lower level public facilities but they are significantly more likely to seek care from private facilities. Therefore, conflicting report findings suggest that a better understanding of the connections between malaria and poverty is required in order to guide the design of coherent and effective policies to tackle malaria and poverty concurrently (Worrall et al. 2002: 4).

Figure 2.3: The World Map Showing the World Poverty Estimate

Adapted from European Alliance against Malaria (2007:2).

Figure 2.4: The World Map Showing an Estimate of the World Malaria Burden

Adapted from European Alliance against Malaria (2007:1),

2.3 Culture, Disease, Illness and health

In their book, The Cultural Context of Health, Illness, and Medicine, Loustaunau and Sobo (1997: 1) succinctly argue that the way and manner in which people react to disease and illness are intrinsically connected with their cultural norms, belief system as well as social structure and environmental conditions. In most indigenous communities in Africa, perception of the causes of disease is porous, ambiguous and sometimes overlapping. It might include natural, magical and spiritual underpinnings. A study by Govere et al. (2000: 613) in Mpumalanga, South Africa for instance showed that more than 90% of the respondents believed that mosquitoes were the causative agents of malaria. Yet, in most indigenous African communities such this natural causation of disease can later reflect supernatural dimensions “depending on the characteristic features such disease exhibits at a point in time” (Jegede, 1998: 32). In traditional Yoruba societies for instance, the presence of measles in young children is sometimes attributed to breaching family taboos or is perceived as the handwork of the witches and enemies (Feyisetan et al. 1997: 222). Such perceptions about disease causation often influence the choice of health care provider. Teshome- Bahiru (2004:30) found out that while both medical and traditional doctors are consulted for diseases perceived to be rooted in natural causes in Addis Ababa, only native healers are consulted for spiritually related health problems. In rural Tanzania, complicated malaria manifesting in convulsions (locally known as degedege) is often attributed to witchcraft or evil spirits and as such traditional healers are often consulted (Foster and Vilendrer, 2009: 3). Nevertheless, traditional healers are important reasons why treatment of degedege is delayed in Kilosa and Handeni Districts of Tanzania (Makundi et al. 2006: 8).

Some academic commentators have attempted to differentiate between disease and illness. According to Jennings (1986: 866) “disease is a matter of physics and chemistry whose presence is betrayed by physical signs” while “illness is experience whose presence is often communicated by complaint”. Martinez (2005: 797) asserts that disease corresponds to some form of bio-physiological change in the body while illness is the social phenomenon of meaning and experience that surrounds disease. For Helman (1981: 544), disease is something an organ has while illness is something a man has. Research has further shown the possibility of “the borderlands” of health, disease, and illness where a disjuncture may occur between what one’s body feels and reveals while the individual still continues with daily activities (Martinez, 2005: 798). Studies have shown that illness may occur without a corresponding biophysical state of disease and vice versa. The belief in the existence of Abiku Omo (children from the spirit world who can die at will)

among the Yoruba speaking people of Nigeria or Ogbanje among the Igbo speaking people is evidence of illness without a specific cause and which further justifies the cultural construction of disease (Feyisetan et al 1997: 222; Ogunjuyigbe, 2004: 45). Among these people, the abikus are believed to have come from the spirit world and could die at will after a short period of life. The incidence is usually attributed to having transgressed certain cultural taboos or “superstitions” by mothers especially during pregnancy. Ogunjuyigbe’s (2004: 47) study revealed that abiku-omo is usually identified from the evidence of past death, frequent indisposition, non-responsiveness of illness to modern medicine and repeated death. More than 70% of the population studied by Ogunjuyigbe (2004: 51) among the Yoruba speaking people of Nigeria had faith in traditional methods of treatment for abiku-omo.

Based on this notion, illness is seen as a subjective interpretation of disease “in which individuals perceive themselves as not feeling well” (Gilbert et al, 1998: 8). It is “personal, interpersonal and cultural reactions to discomfort” (Kleinman et al. 2006: 141) which is further “shaped by cultural factors governing perception, labelling, explanation, and valuation of the discomforting experience, processes embedded in a complex family, social, and cultural nexus” (Kleinman et al. 2006: 141). El-Safty (2001: 3) is convinced that the strong interrelationship between culture and the health status of the population “creates an inseparable bond that is tightly intertwined and overlapping in such a way that makes it impossible to understand one without understanding the other”.

Ironically, while numerous researchers have addressed the social and cultural dimensions of disease and illness, less attention has been devoted to the meaning of ‘‘health’’ (Martinez, 2005). Levin and Browner noted that since 1946 when the World Health Organisation has defined health as “the state of complete physical, social and mental wellbeing, not merely the absence of disease or infirmity” (Jegede, 2002: 214), “little has changed, and research in the ‘health’ sciences remains principally concerned with the characteristics and consequences of pathology” (Levin and Browner, 2005: 745). Anthropological and sociological studies in Africa have shown that for most people in this region health is conceived as a balanced relationship between human and other fellow human beings; human and nature; and human and the supernatural world (Helman, 1994: 544) because it is believed that every single object reflects a dualism of life (Iwu, 1993: 310). That is, both the physical and spiritual worlds are fused together in such a

37 way that they constitute an indivisible and inseparable entity (Iwu 1993: 310). This was demonstrated by Herselman (2007: 63) when he tries to explain the perception of impilo among indigenous Xhosa people in South Africa. According to Herselman, impilo represents not only physical health but a “fullness of life”. It includes harmonious relationships between human, nature and the ancestors. Therefore, impilo cannot only be destroyed or distorted by disease or sickness, some other adversity such as loss of property or relatives can also obliterate it (Herselman, 2007: 63).

Broadly speaking, therefore, the socio-cultural dynamics of health, disease and illness attests to the fact that how people perceive, experience, and respond to illness is intersected with the societal norms and explanations (Clarke, 2001: 2; Kleinman, 2006: 142-143) and that the state of health can only be measured and analysed in terms of the interconnectedness between physical, cultural, psychosocial, economic and spiritual attributes of the people (Naidoo, 2004: 5). Therefore, the underlying message in cultural studies of health and disease is:

An epistle call to look at the social and cultural influences on health that reside squarely within our view, but that too often get bracketed by health researchers in favour of more seemingly straightforward measurable data. Social and cultural forces matter not only for understanding the societal valences of causal factors of disease, but also for comprehending disease aetiology itself (Fullwiley, 2008: 14).

2.4 Social Determinants of Health and Health Services

In the past few decades, there has been an increasing emphasis on the social determinants of health (SDH). This is borne out by the fact that SDH shapes individual health behaviours; whether people know about, have access to, can afford and are motivated to engage in health-enhancing behaviours (Phelan et al. 2004: 267). The outcome of most of these studies is that the impact of SDH varies from one setting, region, community and country to another (Ompad et al. 2007: 43-44) particularly in terms of direction, severity and the kind of specific results they produce (Iyayi, 2006: 74). Hence, there are a number of approaches that can be adopted in reviewing studies in health and treatment behaviour. According to

Hausmann-Muela et al. (2003: 3) the adoption of these approaches in presentation of health and treatment behaviour studies “is not a chronological order of how these approaches have been developed, but rather follows a logic from ‘simple’ to ‘complex’, showing how factors have been added, replaced and reformulated in different approaches”.

Thus, Hausmann-Muela et al. (2003: 3-5) used KAP surveys (Knowledge, Attitude and Practice) and focused ethnographic studies (FES) and rapid assessment in health and treatment behaviours. MacKian (n.d: 4), on the other hand, divided health and treatment behaviours studies into two distinct clusters: those that emphasise the ‘illness response’ rooted in social psychological studies and those that emphasise the ‘end points’ i.e. utilisation of formal health care system or health care seeking behaviour that spread across anthropological and sociological studies. In the former, emphasis was placed on the influence of human behaviours in disease causation, health and illness behaviour while in the latter emphasis was shifted to include socio-cultural and economic factors in health care seeking behaviour.

2.5. Psychological Dimensions

Individual behaviour contributes very significantly to the burden of disease (Postnote, 2007: 1). The familiar saying that “smokers are liable to die young” might have been conceived based on scientific investigations that connect smoking (human behaviour and lifestyle) with cancerous related illnesses and untimely death. Indeed, studies have associated smoking with more diseases than any other health related lifestyle behaviour (Cockerham, 2006; 2007). Another aspect of health related behaviour that has aroused interest among researchers particularly in the field of social psychology is the issue of non-adherence to treatment as well as health promoting behaviours. For instance, studies have shown that non-adherence to treatment procedures (Munro et al. 2007: 2) and nonchalant attitude towards infectious diseases like TB and HIV/AIDS have continuously provided an atmospheric terrain for these diseases to thrive. Therefore, social psychologists have probed questions like: why do people indulge in lifestyles practices or activities knowing their lives is in danger and why do some HIV/AIDS positive and TB patients reluctant to adhere to treatment knowing that adherence to treatment can elongate their lives?

Consequently, social psychologists have investigated these questions and have come up with fascinating answers. In the course of investigation, psychologists emphasised the role of the individual actor in health decision making. The individual health consumer is believed to be consistently and continuously making rational decisions about his health. Most of these studies assumed that individual actors undertake actions that most likely lead to positive health outcomes (Munro, et al. 2007: 4) usually based on knowledge and information. Hence, factors that enable or prevent individuals from making healthy decisions or choices in either their lifestyle behaviours or regarding the use of medical treatment have been identified (MacKian, n.d). They have also proposed the development of health behaviour strategies capable of promoting positive health behaviour using a number of models. The applicability of these models is discussed in the next chapter.

However, many of the cognitive studies of health behaviour have been criticised on many grounds. Most of these studies give little attention to the origin of health beliefs and its impact on human health behaviours (Munro et al. 2007: 4). The studies also see the individual as a rational decision maker who is systematically reviewing available information that could propel health behaviour change (MacKian, n.d: 8). Yet, very few of these studies specifically streamlined the pathways or processes involved in behavioural change based on empirical evidence (Munro et al. 2007: 1). According to MacKian (n.d: 8) the psychological studies:

do not allow any understanding of how people make decisions, or a description of the way in which people make decisions… the central problem remains that these models focus on the individual and the centrality of cognitive processes (‘I know, therefore I act’). This loses the sense that we are all rooted in social contexts that affect, in a far more complex manner, the way we process and act on information.

2.6 Sociological and Anthropological Dimensions

To fill the gaps in social cognitive studies, sociologists and anthropologists have consistently maintained that people’s response to health and illness as well as access to and use of health services is often influenced more by multifarious and interwoven factors which can include social, cultural, demographic and economic factors (Ha et al., 2002: 61). Thus, Kroeger (1983, quoted from MacKian, n.d: 4)) divides these studies into those that categorise the types of barriers or determinants that stand in between health care seekers and health facilities and those that attempt to categorise the type of processes or pathways in an attempt to get well. MacKian (n.d: 4) argues that the difference between these studies is that the use of modern health care facilities is promoted in the former while the latter emphasise and encourage different channels of care that include traditional and modern health care systems.

2.6.1 Barriers to Health Care Utilisation

In the past decades, substantial overall improvement in human health has been reported. However, this improvement has not been evenly distributed across the human population. Studies have revealed that certain barriers often stand in-between the users and the health systems. A large body of research and literature in local and international studies have consistently shown that socio-economic status (SES) is an important factor in health and health care service utilisation. What studies have steadily found is that households with higher socio-economic status have better health and longer life expectancy than those with lower SES. Ahmed et al. (2004: 109) found that socioeconomic status supercedes age and gender in determining health care seeking behaviour in rural Bangladesh. However, Worrall et al. (2002: 11) have argued that studies examining the relationship between malaria and SES on a micro scale have tended to provide inconsistent results compared to those examining macroeconomic data. This, according to them, was partly due to the ambiguity in the concept of SES and the way it used to be operationalised. Therefore, “even if access to high quality medical care were made truly available to everyone, the unequal economic and social conditions of life would still produce socioeconomic disparities in health” (Robert, 2002: 4).

Dubale and Mariam’s (2007: 146) study buttresses the fact that age, gender, marital status, size of household and belief systems are important predisposing factors for utilisation of modern health services

41 among the northeast Ethiopian pastoralists. In a French population-based study conducted by Monnet et al (2008: 1054), geographic proximity to a general practitioner appeared to be the main factor that hampered the detection of hepatitis C. In South Africa, Romani and Anderson, (2002: 5) argue that skin colour and geographical proximity were important determinant factors in health care seeking for children. The authors argued that fewer than 20% of coloured children lived in the rural areas compared to 69% of black children. Hence, some 43% of the black households walked not less than 5km to seek modern health care service as against 14% among the coloured households (Romani and Anderson, 2002: 6). The existence of these differences reflects unevenness in the levels of economic and social development among various segments of a society and the differential impact of programmes and policies on particular groups within those societies (Romani and Anderson, 2002: 2).

In rural Haiti, longer travel times and greater distances to health centers constitute barriers to repeated visits by pregnant women for prenatal care use (Alexandre et al. 2005: 84). In Alexandre’s study logistic models were used to identify which factors explained the decision to seek prenatal care and negative binomial models used to determine how many prenatal visits were conducted by the subgroup of women who did make prenatal care visits. The expected probability of using prenatal care services among the rural respondents was found to be 77.16%, compared to 85.83% in urban Haiti (Alexandre et al., 2005: 90). In the same vein, Amaghionyeodiwe’ (2008: 225) study in Nigeria revealed that both distance and cost were important factors that could prevent individuals from seeking modern health care services, but cost was less important than distance. However, Duong et al (2004: 2593) found that geographical proximity to health facilities may not be an impediment in the utilisation of delivery services at the primary health care level in rural Vietnam since consumers were closer to primary health care facilities.

Studies in health decision process have also followed the line of gender some of which have produced different results. When the issue of gender is mentioned in SDH, it is generally referred to in terms of women’s social status in the society and reduction of gender inequalities in health outcomes, access to health services, educational and employment activities (Ompad, et al. 2007: 44). In a study conducted in Cape Town, South Africa, Skordis-Worrall et al. (2007: 2) found out that men and women chose different health care providers. The study showed that women tended to be more aware of the role of clinics as

42 health care service providers while men usually associated clinics only with babies and children. As a result, women were more likely than men to seek help at a clinic first when accessing the public health sector. This attitude explains why men were more likely to delay seeking treatment. This indicates that female respondents seemed to be more effective monitors of their own health and that of their children and were more sensitive to small changes in body systems.

However, results of the study conducted by Buor (2004: 386-387) in the Ashanti region of Ghana showed that although females have a greater need for health services than males, they were not using health care services as much. The study found that while health status, service cost, level of education and quality of service have greater impact amongst males than females, distance and income have a higher impact amongst females using health care services. Other studies have found that where levels of education and income are higher in women they are more involved in the family decision making process particularly regarding health decisions, but where treatment cost is high the husband was expected to contribute significantly to treatment costs (Orubuloye et al., 1991: 203-204). In other studies, gender roles are often seen to require that women seek advice from the husband and other relatives in the household before pursuing external treatment (White et al. 2006: 834). To understand health care seeking behaviours during pregnancy, satisfaction with services, reliance on social networks, and management of pregnancy-related illness in rural Haiti White et al., (2006) interviewed eighty-two pregnant women. The study found that because the majority of women had no steady income they tended to rely on their husbands or male partners in order to seek care in formal health care facilities (White et al. 2006: 831-832)..

In rural Burkina Faso, Mughisa et al (2004: 576) discovered that different factors can influence both medical treatment initiation and retention. The study shows that while household income, level of education, urban residency and expected competency of health care providers are important predictors of initiation of treatment, only the patient’s perception of the quality of care influenced the retention of treatment. This has been corroborated by a study by Hall and Dornan (1988: 937). Although patients may have limited capacity to correctly evaluate the technical competence of a doctor (Mechanic and Meyer, 2000: 657) they often recognise training and a facility’s technical capacity and can make subjective judgments about quality of care (Amaghionyeodiwe 2008: 222). According to Amaghionyeodiwe (2008: 225) this could be the result of

43 an image of the provider that has been built over the years through the societal definition and sub-cultural expectations or the conceptions formed by the patient himself through previous experiences or experiences of others. Also important in this image formation is the general attitude of the health provider.

In addition, Mechanic and Meyer (2000: 662) attempted to examine conceptions of trust among three groups of patients diagnosed with breast cancer, Lyme disease or mental illness using interviews as methods of data collection. They discovered that patients perceived trust as a continuous process and commonly tested their physicians against their knowledge as well as expectations. Most patients in the study identified interpersonal competence, involving caring, concern and compassion, learnable skills and not necessarily the physical attributes of the physician, and technical competence as the most common attributes of trust in doctor-patient relationships, with listening as a cornerstone. According to one respondent interviewed by Mechanic and Meyer (2000: 662):

I need understanding, empathy, concern about me as a total person, not just about my disease. I need concern about my fears, how I'm managing with my life, my family life, my work life, and how I'm able to keep it all together. I need the doctor to express some level of empathy; ask some questions that are not necessarily medical… “how is this affecting your work”? “How are you handling your family responsibilities?''

Another respondent said:

I fired a doctor not long ago because he was an alarmist and I don't need that. I had a lump that I discovered…and he said, “well, it can be pancreatic cancer or liver cancer''. And I thought, “Geez, that means I'm dead between the next six months''. It turned out to be an umbilical hernia. And that's the last time I ever went to see him. He's a fool. They don't always graduate at the top of their class in medical school (quoted from Mechanic and Meyer: 2000: 662).

The idea that professional competence or behaviour can influence health retention and satisfaction has been well established in a multi-racial environment. Reports have shown that residential segregation which is one of the characteristics of a racially segregated environment often shape socio-economic status (SES) with serious impact on health. This is made possible through restriction on access to educational and employment opportunities; discounts the economic value of a given level of SES; and concentrates health- damaging conditions in residential environments (Ahmed et al., 2007: 320). Thus, research on differences in utilisation of health care among ethnic and racial groupings has become a top priority of health services research in multi-racial societies with an increasing concern for reducing racial/ethnic disparities in health and health care utilisation. In a South African study, skin colour and SES were found to be intrinsically connected with patients’ level of satisfaction with health care providers though findings like these might have been influenced by the location and time of the study. Myburgh et al. (2005: 475) argue that significant relationship exists between race and SES. Using an unadjusted logistic regression analysis, both SES and race were significantly related to levels of satisfaction with the health care provider. The White participants in the study were 3.38 times more likely and Coloured and Indian participants 1.35 times more likely than Black respondents to have reported the treatment provided by the health care provider as being excellent. The study also found that high SES respondents were 3.4 times more likely and middle SES respondents 1.53 times more likely than low SES respondents to have reported the treatment provided by the care provider as being excellent (Myburg et al., 2005: 475).

Recently, more and more studies are investigating the influence of social capital or what Trevino (2005: 13) called “social currency” on health and health care seeking behaviour and many of these studies have found that social capital has a positive impact on individual health. Social capital has the possibility of not only increase members’ awareness about the need to seek treatment, it also allows members to participate in the processes of financial solidarity for accessing the health care services at both the community and family levels (Aye et al. 2002: 1929). Sund et al., (2007: 62) examined the relationship between social capital and self-rated health and depression among a total of 42 571 individuals using multi-level modelling. While geographical variations in self-rated health and depression were largely due to the socioeconomic characteristics of individuals, the contextual social capital, expressed as the level of trust, was found to be associated with depression and self-rated health at the level of individual. Thus, “a society with high levels

of social capital is characterised by high levels of social participation, trust in other people and reciprocity that enhance interactions with other people” (Nyqvist et al. 2006: 92).

In the same vein, Gaede et al, (2006: 367) discovered a positive relationship between social support system and health care seeking behaviour among rural and urban women living with HIV/AIDS in Kwazulu- Natal, South Africa. According to these researchers, a good social support system usually promotes the use of a condom, support group attendance and adherence to treatment. D’ Hombres et al. (2007) investigated the impact of social capital on individual self-reported health for eight countries from the Commonwealth of Independent States of Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Ukraine. Although results varied from one country to the other, in many of these countries an individual degree of trust is positively and significantly correlated with health (D’Hombres et al., 2007: 11). It is on this note that MacKian (n.d: 16) is of the opinion that:

Social capital actually serves an extremely useful purpose in the area of health seeking behaviour as it provides a means of shifting the focus from individuals to social groups, and the social embeddedness of the actions of individuals. In relation to the health of individuals there is growing evidence that high levels of social capital in themselves may have a positive effect on health. The point to stress is that this sort of benefit is an attribute of social structures, and therefore cannot be read off the individual alone as most health seeking behaviour studies attempt to do.

With specific reference to malaria, previous studies have identified the ability to pay for treatment (Kofoed et al. 2004: 17), perceived severity of malaria (Morey et al., 2003: 164) and quality of care (Akin, et al. 1995: 1536) as important factors that influence malaria treatment as well as the choice of health care provider. However, Kamat (2006: 2957) discovered that user fees as an impediment to prompt treatment at a public health facility for children with febrile in Tanzania. Delay in seeking health care was attributed to caretakers’ lack of education to differentiate between simple and severe fevers. Hence, studies have linked level of Western education with knowledge of malaria (Dike et al. 2006: 103) as well as use of maternal

health care services (Elo, 1992: 18). Tarimo’s et al. (2000: 182) study in Tanzania found that the perceived symptoms of malaria were significantly associated with having at least primary education. Western education is often linked to people’s SES and ability to afford the use of modern healthcare services (Carme, et al. 1992: 320). Yet, like all diseases, the extent to which these factors influence treatment behaviour and choice of health provider in the episode of malaria may differ from one place, social group, community or society to another. In other words, as much as these factors are important factors influencing health care seeking behaviour, they cannot be generalised across boards.

In short, three main alternative interrelated etiological theories have been proposed by Dutton et al. (2005) as narrated in Zhang (2007: 3) in his PhD thesis to understand health care seeking behaviour. They are “materialist”, “behavioural or lifestyle” and “psychosocial explanations”. According to Zhang (2007: 3) the materialist conception agrees that people with higher incomes are more able to purchase better food and housing, live in healthy social and physical environment and consequently have better access to health care services. The behavioural aspect points to those health behaviours including smoking, diet and use of health care services, which are invariably influenced by cognitive factors such as belief and attitude. Lastly, psychosocial explanation “emphasises the importance of factors such as the control, empowerment, and social integration that may result from low social standing and low autonomy in important areas of life, such as work” (Zhang, 2007: 3). In addition, Andersen and Newman, (2005: 2) have divided the factors affecting health care utilisation into societal and individual factors. The societal characteristics are broadly divided into type of health service delivery (organisation, resources, policies, and financial arrangements), changes in medical technology and social norms regarding the definition and treatment of illness. The individual factors are divided into predisposing, enabling and need factors. Details about the theoretical frameworks are provided in the next chapter.

2.6.2 The Pathways to Health Care Utilisation

In pluralistic medical systems, where different ways of perceiving and treating illness co-exist (Gilbert et al. 1998: 49), people have liberty to choose from a variety of treatment options when it comes to dealing with health problems (Bello, 2006: 323). This is the concern of the pathway studies. Pathway studies emphasise the routes taken by individual health seekers towards health recovery which sometimes involves moving

47 forward and backwards among the available health care systems which may or may not involve consultation with modern medical practitioners (Kleinman et al. 2006: 140) especially in indigenous communities where fatalistic or mythological views about certain diseases and illness are very common (Feyisetan and Adeokun, 1992: 145; Gyimah, 2002: 45). Most importantly, studies that are rooted in pathway analysis emphasise home treatments use of traditional medicine, the role of patent medicine stores as well as significant others (extended groups of kith and kin) in the management of disease and illness. Espino and Manderson (2000: 1314) used a combination of qualitative and quantitative methods of investigation to understand choices and pathways in treatment seeking behaviour for malaria in Morong, Battan, Philippines. In spite of the common belief among the people that “only a doctor can cure malaria”, it was discovered that treatment choice ranges from self-treatment with Western medicines and traditional remedies to not doing anything to relieve symptoms (Espino and Manderson, 2000: 1314-1315). In 68% of cases of diarrhoea in Enugu, Nigeria, Ene-Obong et al (2000: 99) reported that 30% of mothers prescribed drugs on their own with another 23% prescribed by the patent medicine stores.

There is evidence in pathway studies that significant others are active players in health and treatment behaviours. This is evident in most African communities where the extended family system provides some kind of succour that helps to minimise and prevent psychosocial and spiritual problems usually linked to illness (Adegoke, 1990: 3). In these communities, members of the families are usually involved in identification, negotiation and management of sickness (Hausmann-Muela et al. 2003: 15). A relatively recent study in rural Haiti found that a significant number of pregnant women relied on relatives including husbands and grandmothers for health care utilisation during pregnancy (White et al. 2006: 837). Sometimes this causes a delay in seeking treatment at the conventional clinics and hospitals. Yet, members of family including extended families remain very important players in the whole system of sickness. Erinosho (2006: 35-36) succinctly puts it this way:

The career of patients starts right from the moment they openly express physical and psychological discomfort… The expression of physical or psychological discomfort sets into motion a series of actions and activities, some of which involve next of kin and significant others who are interacting with the patient.

Furthermore, pathway studies also emphasise the pivotal role of the indigenous medical system in disease management. This is particularly important in traditional societies where there is a general belief in the traditional medical system. Although some “passionate ambivalence” towards traditional medicine in Africa has been noted (see Feierman, 2002), some studies have shown that a significant number of people have continued with the use of traditional medicine not only in Africa but across the world. Figure 2.5 below describes the interplay between the individual, significant others and treatment seeking behaviour. The diagram depicts that the decision to seek health (self-treatment, traditional health care provider or modern health facilities) does not only lie with one person. It involves friends, relatives and social support groups. This is a common phenomenon in African setting where extended family system is commonly practised. This idea, according to Hausmann-Muela (2003: 15) challenges a common belief in some societies that decision to seek health lies with the individual.

Figure 2.5: The Interplay between Individual, Significant Others and Treatment Seeking Behaviour

Traditional Practitioner

Self-treatment: Home remedies; shop Perception of “Significant Therapy medicines; chemist; Illness others” Choice market herbalism; clandestine sources of

injection antibiotics etc.

Biomedical Practitioners;

Government or Private

Note: The green arrow on the extreme right indicates movement from one sector to another.

Adapted from Hausmann-Muela et al. (2003: 15):

Like the figure 2.5, figure 2.6 below describes channels of care in Nigeria. The channels of care in Nigeria often consist of traditional healers, spiritual churches known as Aladura among the Yoruba speaking people, pharmacies, and the patent medicine stores. Others include primary health care providers, general and specialist hospitals. These channels of care are broadly divided into the pre-hospitalisation, hospitalisation and post-hospitalisation categories. However, self treatment is likely to precede the utilisation of the services of any of these agents of care (Erinosho, 1998: 48). In the pre-hospitalisation categories are traditional healers, faith or spiritual healers which may include the services provided by the

Aladuras and Islamic clerics. The services provided by the patent medicine stores or pharmaceutical companies also fall under this category. The utilisation of these services depends on the success or failure of self-treatment originated at home. Should symptoms persist, a patient may proceed to utilise the services of formal health establishments including the primary, secondary and tertiary health institutions (this is discussed further in the next section). During the last stage, Erinosho (1998: 48; 2006: 44) argues that some patients or families may go back to the native or faith healers for final cleansing or as a mark of appreciation. At this stage, final sacrifices are made. However, it should be noted that whether or not these processes would take place often depends on the severity and persistence of the health problem.

Figure 2.6 Summary of Pathways to Health Care Utilisation in Nigeria

Pre Indigenous/ Native Christian Faith Islamic Faith Hospitalis- Healers Healers Healers ation

Nurse Patent Medicine Pharmacists Store/vendours

Hospitalis- General practitioners Hospital/Specialists ation

Post hospi- Native Healers Christian Faith Islamic Faith talisation Healers Healers

Source: Erinosho (1998: 48; 2006: 44).

According to Hausmann-Muela et al (2003: 16) one of the strengths of the pathway studies is the fact that they portray treatment seeking as a dynamic process where factors affecting health care service utilisation are sequentially organised according to symptoms recognition, decision making, medical encounter, evaluation of outcomes, all of which describe the steps taken in the course of treatment. Generally, recent studies in health care seeking behaviour are increasingly coming to a realisation that traditional practitioners are important players in healing processes especially in developing countries. Native healers may contribute to promoting positive health behaviour and could serve as a good referral point to modern health care system as well as providing a lead to scientific breakthrough in modern medicine (Osowole et al. 2005: 338). Osowole et al. (2005: 338) investigated the pattern of treatment practices for febrile illnesses among 185 traditional healers from the Nigerian Middle Belt Zone and found out that more than 50% of the healers had once referred clients to modern facilities for further treatment. Among reasons mentioned for referral were non-improvement in patient’s condition (41.1%), inability to diagnose the type of illness (17.6%) and illness not being in their specialty area (10.5%). Of the cases that were referred, 41.0% were referred to the hospital, 2.0% to senior colleagues while the remaining 57.0% did not specify place of referral. Based on this, Osowole et at., (2005: 343) call for the integration of traditional medicine practice in modern health care services.

2.7 An Overview of Nigeria and the Health Care Systems

Governments across the world (whether capitalist or socialist) are important players in the provision of social security and protection including health security. They have consistently participated in transforming health care systems with a view to achieving quality, efficiency, and professionalism through performance management and state-sponsored policies. The government of Nigeria is a signatory to local and international health treaties and legislations. As a result, the government of Nigeria “recognises the right to health and has committed itself to its protection by assuming obligations under international treaties and domestic legislations mandating specific conduct with respect to the health of individuals within its jurisdiction” (Nnamuchi, 2008: 1). The role played by government including the government of Nigeria, however, does not rule out or downplay the pivotal role of service users and professional groups in shaping the nature and dynamics of the public health care system (Kuhlmann et al. 2009: 513).

Nigeria lies on the Coast of West Africa, along the Gulf of Guinea. It is bordered by Chad and Niger Republics in the North, Cameroon in the East and the Republic of Benin in the West (see figure 2. 7 below). Nigeria is one of the most populous countries in Africa with more than 140 million people divided along 250 ethnic groups, three of whom are accorded the status of majority groups. They include the Hausa/Fulani in the North, the Yoruba in the South/West and the Igbo speaking people in the East. The Niger Delta region occupies important economic position within the Nigerian landscape. However, years of oil exploration with limited growth and development coupled with perceived abandonment and widespread poverty have combined to make the region volatile and a flashpoint of conflict (Saliu et al., 2007: 277).

As a former British colony, the official language in Nigeria is English. The heterogeneity of the Nigerian State in terms of people, geography, history and culture informed the adoption of a Federal System of Government as the most ‘appropriate’ and ‘sustainable’ system of administration. Although the Nigerian Federalism has been questioned (Abdullahi and Saka, 2007: 29), the political power is purportedly shared between the Central or Federal, State and Local Government authorities. Thus, there are 36 States in Nigeria including the FCT, Abuja and 774 officially recognised Local Government Councils.

Nigeria is further divided into six geo-political zones for political and administrative conveniences: North- East, North-West, North Central, South-South, South-West and South-East. Abuja which falls in the North Central is the political capital of Nigeria while Lagos remains the commercial centre and the biggest city with more than 18 million people (Duggan, 2009: 2). Although Nigeria is the second largest economy in Africa after South Africa and the 6th largest oil producing country in the world, more than 70% of Nigerians live on less than $1 per day (Duggan, 2009: 2) with over 1/3 of the population without access to modern health care services for various geographical and economic reasons (Microsoft Encarta Premium, 2009).

Figure 2.7: The Map of Nigeria showing the 37 States and International Boundaries

The Nigeria health care system is structurally organised. The system operates at three interrelated levels of care known as the primary, secondary and tertiary health institutions, perhaps in line with the country’s political arrangement. The primary health care institutions handle minor health injuries and are usually under the management of the Local Government Councils. The secondary health institutions handle some major health problems and are under the management of the State Governments. The tertiary health institutions comprise of Federal Medical Centres and Teaching hospitals. Apart from handling complicated health problems, these institutions are also training grounds for potential medical doctors. They are directly under the management of the Federal Government.

A cursory look at health services in Nigeria shows that there are 59 Teaching Hospitals and Federal Medical Centres in Nigeria; 37 State Ministries of Health including Abuja; 774 Local Government

Departments of Health; 3 303 General Hospitals; and 20 278 Primary Health Centres and Health Posts (see Omoruan et al. 2009: 106). Although there is a National Council on Health [NCH] at the centre that shapes the health policy, the bulk of health sector performance lies with the State Governments (Olaniyan and Lawanson, 2010: 2) with more than 50% of the public health expenditure occurring at that level, 15% and 33% at Local Government and Federal levels respectively (Bello, 2006: 326). The private health practitioners are also important players in health care service provision in Nigeria with more than 60% of health services provided by them (FMoH, 2004a quoted from Omoruan et al. 2009: 106). Figure 2.8 below shows health care structure in Nigeria.

Figure 2.8: Structure of Health Care System in Nigeria

Cabinet

National Advisory Council on Health

Inter-sectoral Federal Ministry of Health Collaboration

Private Sector, NGOs,

Teaching Hospital, Traditional and Faith Healers Federal Medical Centre State Ministry of Health

Local Government Department for Health General Hospitals

Primary Health Centre & Health Posts

Adapted from Omoruan et al. (2009: 106).

Studies have persistently shown that the Nigeria health care delivery system is in a very deep crisis. Ayeni (2002: 17) argues that health care system in Nigeria is generally weak and rudimentary. This argument has been corroborated by numerous research findings. The 2002 studies show that of the 101 041 communities in Nigeria only 14% have access to some form of modern health care system (Orubuloye and Ajakaiye, 2002: 1). The health system is also being constantly threatened and hampered by severe lack of skills, aggravated by the ‘brain-drain’ syndrome, shortages of drugs and inadequate health infrastructures (Ayeni, 2002: 17-18). Reports have shown that Nigeria has one of the lowest health practitioners-to-patient ratios with 0.3 physicians per 1 000 persons, 1.7 hospital beds per 1000 persons, as well as 1.7 nurses, 0.02 dentists, 0.05 pharmacists, 0.91 community health workers, 1.696 nurse midwives per 1,000 persons (WHO, 2006 cited from Ogbolu, 2007: 359).

Regional variations as well as rural/urban disparity in terms of access to health care service have also been reported in Nigeria. In most parts of Nigeria, the availability of healthcare facilities is asymmetrically distributed among urban and rural settings with massive impact on health outcomes. In most rural areas, modern health care facilities are either lacking or inadequate with dilapidated structures unlike urban centres where modern health care services could be available but may be unaffordable to a significant number of people. This has consistently resulted in increased patronage of quack doctors, patent medicine stores or spiritual healers particularly in the rural areas. Following the overwhelming challenges faced by the health sector, Nigeria is rated one of the countries in the world with the lowest level of child survival and one of the highest levels of maternal mortality (Orubuloye and Ajakaiye, 2002: 1). The Nigerian health care system performance was ranked 187th position among the 191 Member States of the World Health Organisation in 2000 (Olaniyan and Lawanson, 2010: 1-2).

Aside from the deep-rootedness of corruption in the Nigerian political system and culture, the frightening state of health care system has been attributed largely to poor funding. Reports have indicated that health care financing is heavily dependent on out of pocket (OOP) payments which represent more than 60% of the total health care expenditure (Olaniyan and Lawanson 2010: 16). Despite being the 2nd largest economy in Africa and one of the leading oil producing countries in the continent, Nigeria contributes one of the lowest percentages of Gross Domestic Product (GDP) to the health sector in the continent. In spite of

56 the promises to commit 15% of GDP recommended by the African heads of state to the health sector, in 2003 government’s contribution to the health sector as a percentage of GDP fell to 1.3%, from 2.2% in 2000 (Nnamuchi, 2008: 4) compared to more than 8% in South Africa, 5% in Kenya and Senegal respectively within the same year (Scheil-Adlung et al. 2006: 3).

The government of Nigeria has instituted certain measures to increase accessibility to health care services. These include the social health insurance policy popularly known as the National Health Insurance Scheme (NHIS). However, this has had minimum impact on accessibility to health care systems because the scheme only covers the employees of the Federal Government and large bureaucratic organisations like banking. The majority of the rural poor and employees of the State government are left out from the scheme with serious health consequences. Consequently, the NHIS is increasingly facing threats. These include lack of access to quality health care by the poor, severe budgetary constraints, uneven distribution of resources between the urban and rural areas, as well as across the geographical regions of the country, inequitable financial systems resulting in increasing dependency on OOP spending (Olaniyan and Lawanson, 2010: 2) with more and more people depending on traditional medicine and the services provided by the private drug shops.

A widespread use of traditional medicine has been reported in Nigeria. Apart from inadequate access to modern treatment, traditional medical system usually conforms to the cultural values of the people. Offiong (1999: 118) argued that the decision to consult traditional healers among the Ibibio community was not conditioned by lack of modern health care facilities. Rather, traditional healers were generally trusted by the people and many of the clients used to pass by hospital facilities to get to native healers. Erinosho (2005: 38) observed that the utilisation of traditional therapeutic system hinges on i) the confidence people have in traditional medicine and their practitioners ii) accessibility; and iii) widespread belief in witchcraft. Bello (2006: 333) has observed that:

… traditional and modern health care workers are not directly comparable; patients often do not perceive the services provided by the two traditions as substitute for each other but rather, as complement… there are certain diseases that go beyond the diagnoses of modern medicine but which are recognised by the traditional healers. They are only managed by the modern method but not cured because these diseases are believed to be connected with some deities.

Following the growing demand for traditional medicine and the contributions of the medicine to the overall health delivery system in Africa, some authors have suggested that the traditional medical system be integrated into the mainstream of health care services to improve accessibility to health care. This was borne out of the conviction that traditional medicinal plants have potency in curing a whole range of ailments. For example, Obute (2005: 9) asserts that traditional medicine in Nigeria can be properly organised and formally integrated into the mainstream healthcare delivery system. This, according to Odebiyi (1990: 341), would improve health care services in two folds: enhancement of quality of care and supply of low-cost primary health care.

However, the on-going mistrust between the practitioners of modern and traditional medicines has, to a large extent, hampered the process of integration or cooperation between traditional and modern medicines in most African countries (Nevin, 2001: 16). Also important is the difficulty in regulating traditional medical properties and practices. On the whole, Western-trained physicians appear unwilling to allow TM and their practitioners included in the official system of medical care in Africa. This is an indication that not much is being done in medical schools to encourage the teaching of TM in African medical schools as they keep unfolding in some parts of the world. The general belief in medical cycle is that TM defies scientific procedures in terms of objectivity, measurement, codification and classification.

In broader terms, the relationship between modern and traditional medicine has been divided into four broad spectrums. These are: monopolistic or exclusive, tolerant, integrative and inclusive systems (Sambo, 2003: 8-9). In a monopolistic system, only the medical doctors are allowed to practice medicine. The

practice of traditional medicine is illegal and can be punished under the law. This was the situation under the colonial tutelage in most African societies. In contemporary African society, according to Sambo (2003: 8) there is no single country that falls under this categorisation. In a tolerant system, although the traditional medicine is not legally recognised, it is tolerated and allowed to co-exist with modern medicine. In this system, there are no legal frameworks that forbid the practice of traditional medicine, yet, “there is no provision for it in the health scheme” (Amzat and Abdullahi, 2008: 155). African countries with this kind of system are also rare. In an integrative system, traditional medicine and its practitioners are officially recognised and are incorporated into the overall national health care system. There is no single African region that falls under this category. According to Sambo (2003: 9) there are only four countries in the world that meet this standard. They include the Democratic Republic of Korea, the Republic of Korea, China and Vietnam. In an inclusive system, both the modern and traditional medicines are seen as separate components of the national health care system. Although the national authority officially recognises traditional medicine and its practitioners, some aspects of the art are yet to be incorporated into the national health care system. In most cases, the national government is preparing to develop the legal framework that guides and regulates the traditional practice. Most African countries including Nigeria fall under this categorisation. Although, the inclusive and tolerant systems are related, they can be differentiated on the basis that in an inclusive system effort is being made to officially recognise traditional medicine which is not the case in a tolerant system (Amzat and Abdullahi, 2008: 155).

2.8 Areas of Study This study was conducted in Okanle/Fajeromi in Ifelodun Local Government Area and Centre Igboro in Ilorin South Local Government Council of Kwara State. Created in 1967, the State has a population of more than two million based on the 2006 census (Federal Republic of Nigeria, 2009: 34). It occupies a land area of about 32 500 sq kilometres. The indigenous people of the State are divided along four major ethnic groups with four corresponding languages: Yoruba, Nupe, Baruba and Fulani. Kwara State is popularly referred to as the “State of Harmony”. Islam and Christianity are the dominant religions with some elements of traditional religion particularly in the rural areas. The State is bounded in the north by Niger state, Osun and Ondo in the south, Kogi in the east and Oyo in the west. It shares an international boundary with the Republic of Benin. There are two main climate seasons in the State: the dry and wet seasons with an intervening cold and dry harmattan (windy) period usually experienced between December and January. A

total of 62 state owned health facilities are built across the nooks and crannies of the state out of which five are specialist hospitals, 38 comprehensive health centres or cottage hospitals, seven prototype hospitals and 12 general hospitals (Saraki, n.d: 2). There are other thousands of privately owned health establishments many of which are concentrated in the State Capital, Ilorin.

2.8.1 A Brief Description of the City of Ilorin Politically, Kwara State is divided into 16 local government councils with the headquarters in Ilorin. Ilorin lies 306km northeast of Lagos and 500km southwest of Abuja. It is commonly known as “Ilorin Garin-Alimi” (Ilorin the city of Alimi). It is not only regarded as the political capital of the State, it is also a commercial, manufacturing and transportation centre. Describing the culture and people of Ilorin is usually done with care given the diverse historical and political idiosyncrasies embedded in the life and history of the people. According to history, the community was established in the late 18th century and captured by the British in 1897 (see Microsoft Encarta, 2008). The core indigenes of the town are Muslims with a significant number of immigrant Christians. The topography of the city of Ilorin is generally undulating. The elevation of the land on the western side ranges from 273m to 330m (900ft-1000ft), while the eastern part varies from size 273m to 364m (900ft-1200ft). The people speak the Yoruba language in spite of their historical antecedents while the majority of the immigrants retain their cultural identity. For political and administrative convenience, the city is further divided into three local governments one of which is Ilorin South. Figure 2.9 below is the map of Kwara State and the studied communities.

Figure 2.9: Map of Kwara State indicating the Study Areas

2.8.2 A Brief Description of Ilorin South Ilorin South Local Government was created in 1996 with the headquarters located at Fufu; a drive of about 30km from the State Capital. In terms of people, history, culture and geography, Ilorin South is highly complex and heterogeneous. The Local Government occupies a land area of about 174 km² with a population of about 209 251 based on the 2006 census (Federal Republic of Nigeria [FRN], 2009: 34). It is made up of urban, semi-urban and rural settlements with three districts (Akanbi, Balogun Fulani and Okaka/Oke-Ogun) and ten wards. The two major languages are Fulani and Yoruba (see www.kwarastate.gov.ng for more information). Living in an urban or semi-urban area in this Local Government ideally places the inhabitants in an advantaged position of a ‘high degree’ of accessibility to formal health care services that include both private and public health facilities located within these areas as against those in the rural regions who are extremely disadvantaged in this regard. Even then, there is strong evidence to suggest that most of the public health facilities are in appalling conditions; most are ill- equipped, short staffed and lack basic health facilities that could enhance treatment of diseases. The Children Specialist Hospital from where the urban respondents were drawn is located in Centre Igboro in Ilorin south local government area.

2.8.2.1 The Children Specialist Hospital

The Children Specialist Hospital is a symbol of the colonial legacy in Nigeria. It has been in existence for more than eight decades. Owned and managed by the State government, it provides both primary and secondary levels of care particularly for children. It became a fully-fledged children specialist hospital in 1997 when it was upgraded. It comprises of the ante-natal unit, the maternity wing, the family planning unit, the X-ray unit, children’s wards, surgical unit, intensive care unit, and mini theatre. It is headed by a medical director supported by nurses as well as youth corps members (medical doctors) of the National Youth Service Corps (NYSC).

At the time of the study, the hospital had a staff contingent of about 65 nurses with only two permanent medical doctors [a consultant and a general practitioner] assisted by at least four medical doctors of the NYSC. The laboratory scientist is supported by a lab technician; two X-ray technicians with two supportive staff; a pharmacist with about four supporters and a nutritionist. Despite the fact that the hospital is one of the highest revenue-generating hospitals in the State, according to one of the staff interviewed, the hospital is faced with numerous challenges. At the time of the study, the hospital did not have oxygen cylinders or refrigerators. The weighing scale and suction pump were non-functional. There was erratic power supply and insufficient medical doctors. Recently, a non-governmental organisation (NGO) known as the Wellbeing Foundation9 came to the rescue of the hospital. The NGO helped to give the hospital its present new look when it undertook the renovation (see figure 2.10 below) with the provision of a borehole for water supply, a children's ward, a doctor’s consulting room, nurses’ bay and bathrooms in the maternity unit, an ambulance and mosquito netting throughout the facility.

9 There were concerns in some quarters (especially among the opposition parties) that the assistance rendered through the Wellbeing Foundation was politically motivated. The NGO belonged to the wife of the Governor of the State at the time. It was believed by some people that the ‘good’ gesture was an attempt by the then Governor and the ruling party to earn political points. This allegation could not be substantiated, investigated or confirmed because it fell outside the jurisdiction of this thesis.

Figure 2.10: The Children Specialist Hospital

2.9 Okanle and Fajeromi Okanle and Fajeromi10 are typical examples of rural communities in Nigeria under the Omupo district in Ifelodun local government area of Kwara State. Based on the 2006 population census, the total population of Ifelodun local government is about 204 975 people (Federal Republic of Nigeria, 2009: 4). The Okanle Village Area Council was established in 1956 with other seven villages that included Fajeromi (Okanle Descendant Union [ODU], 2009: 3). Okanle is less than 2km away from Fajeromi. The villages are about 30km from Ilorin along Offa/Ajase Ipo Road and exactly 6km from Idofian town. The number of households in Fajeromi is less than 40 while that of Okanle is more than 60. Before the introduction and acceptance of Islam and Christianity in the community, the people were predominantly traditional believers. As a result, there is still widespread traditional belief in metaphysical powers wrapped in witchcraft and sorcery.

10 The researcher was familiar with Okanle and Fajeromi communities in the 1990s during his secondary school days. Based on this familiarity, the researcher possessed some knowledge about the history and culture of the people. More so, the researcher was aware of the fact that people often suffer from malaria in communities with limited access to modern health care facilities.

Similar to other rural communities in Nigeria, the majority of the people in Okanle and Fajeromi depend on subsistence farming as a means of livelihood. A number of people engage in buying and selling as well as craftsmanship and other unskilled labour. Yet, farming remains the primary source of livelihood. Based on this, both communities can be described as agrarian in nature. They are also labour-producing areas, with most of the youth leaving the areas after secondary school qualifications in search of greener pastures in various parts of Nigeria and abroad, seldom returning to pay visits during festive periods (ODU, 2009: 4). Food items such as grain, tuber and fruit are very common in the community. Farm produce are usually sold during the market days (ojo-oja) in Idofian town. Generally, household income is usually generated from farm produce, buying and selling and money sent from relatives in big cities. Although, the use of income as a yardstick for measuring poverty in communities such as these has been challenged because poverty to the people means more than just lack of income (Carr, 2004: 1), the elements of poverty can include the inability to educate children beyond primary school level or not at all, poor clothing and lack of access to health care services, inability to feed the family well and lack of shelter (Okunmadewa et al n.d). By all economic and socio-development standards, therefore, Okanle and Fajeromi can be described as poverty-stricken areas where the majority of the people depend on traditional medicine for the treatment of diseases.

One of the most common characteristics of rural communities in Nigeria is communal life where the basic residential units are compounds and an extended family structure. They are also generally patriarchal in nature where men are seen as the heads of the households and are expected to be responsible not only to themselves and families but the entire community. The family head is known as the “olori-ebi” who is culturally expected to provide financial, moral and spiritual responsibilities to members of his family. This is not to suggest that women are prevented from playing active roles in the day-to-day activities of the communities. They make concrete and significant contributions to the sustainability of the family. The majority of women engage in farming activities. Some of them engage in buying and selling in order to support or augment the family income to meet certain important family demands like education and health. However, culturally, domestic responsibilities like cooking, washing and taking care of the children are considered to be women’s roles. Housing in these areas varies. Most old buildings in the communities are constructed with mud and bricks and roofed with corrugated iron sheets many of which are giving ways to modern structures. Modern buildings in Okanle include the completed Oluode and Idera (uncompleted)

64 estates. Figure 2.11 and 2.12 showcase examples of modern structures in Okanle. The first is called the Oluode Estate.

Figure 2.11: A Sample of Modern Building in Okanle

Figure 2.12: Sample of Modern Structure in Fajeromi

In most indigenous communities in Nigeria, traditional institutions remain to be seen as an embodiment of cultural identity and tradition and the traditional rulers as catalysts and symbols of these institutions. Each of the rural communities studied is headed by a traditional village head. Okanle is headed by a King (Oba or Kabiesi) popularly addressed as “Olokanle of Okanleland”. The Olokanle is a member of Ifelodun Traditional Council with the headquarters in Igbaja. In Fajeromi, on the other hand, the traditional title of the village head is Baale. In traditional hierarchy, the Baale is lower than the Oba mostly because of historical antecedents. The Baale does not attend the traditional council meetings. Indeed, in both communities, the traditional rulers are conceived as the representatives of the community in matters affecting the people at all levels of governance: district, local and state levels. The village heads are assisted in running the day-today activities of the community by the council of chiefs especially in Okanle. The Oluode (head of the hunters) is an important traditional title in Okanle. The succession to the throne of the King or “Baale” is by ascription through the male line. Figures 2.13 and 2.14 below show the entrance and the palace of the Olokanle of Okanle respectively.

Figure 2.13: The Entrance to the Palace of the Olokanle of Okanle

Figure 2.14: The Palace of the Olokanle of Okanle

Okanle and Fajeromi are like many rural areas in Nigeria where people have very limited access to basic social amenities. The roads leading to both communities from both Arugbo and Idofian are not tarred and as a result difficult to traverse. Although the communities have just received electricity from the government (as shwn in the picture above), the researcher hardly saw electricity in use throughout his visits to both communities. Almost every household had a transistor radio to listen to news. The only primary school was facilitated by the Methodists Ludlow and Omrad in the 1950s (ODU, 2009: 5). It is known as Wesley LGE School (see figure 2.15). The communities also have one Secondary School that caters for high school education. It is known as Okanle/Fajeromi Community High School. The facilities, like others, are in deplorable condition. It contains 4 main blocks of buildings one of which is a newly constructed two classrooms. One of the buildings is for the staff members. The 3 other blocks of buildings are for the Junior and Senior classes (see figures 2.16, 2.17 and 2.18 below).

The community health centre was established in 1978 through the initiatives of both communities. The facility is situated in-between the two communities (see figures 2.19, 2.20 and 2.21 for the characteristic

67 features of the Okanle/Fajeromi Basic Health Centre). However, the management of the health centre has since been taken over by the State government. As a result, it is in a deplorable condition due to poor maintenance. As at the time of the study, the community health centre had no single medical doctor. Health matters [mild or severe] were handled by a nurse. Sometimes when the nurse was absent, the health attendant handled “uncomplicated” health matters especially malaria related problems since it is a common disease in the area. Indeed, the hospital lacked basic health facilities with just two beds in a dilapidated building (see figure 2.22). Most of the rooms in the health centre have been abandoned because the roofs were collapsing. The people sometimes travel to Idofian or Ilorin to consult with medical professionals where health problems are beyond herbal medicines and the capacity of the village facility or where health providers are not available for consultation. Figures 2.19, 2.20 and 2.21 are characteristic features of the Okanle/Fajeromi Basic Health Centre.

Figure 2.15: The Only Primary School in Okanle and Fajeromi

Figure 2.16: Okanle/Fajeromi Community High School (The Newly Constructed Classroom of Two)

Figure 2.17: Okanle/Fajeromi Community High School (the Staff Building)

Figure 2.18: Okanle/Fajeromi Community High School (One of the Old Two Blocks of Classes)

Figure 2.19: Okanle/Fajeromi Basic Health Centre (from the outside).

Figure 2.20: The Basic Health Centre from Inside (Abandoned room at the Health Centre).

Figure 2.21: The Health Centre from Inside (Abandoned store Owing to Poor Management).

Figure 2.22: The Two Beds Available at the Health Centre

2.10 Summary

In this chapter, the works of academic authors and commentators were reviewed using empirical evidence. Disease and illness were observed from the points of view of biologists and social scientists. From the biological point of view, disease including malaria is believed to be caused by parasites or viruses. However, recent events in sociological and anthropological research have shown that a better understanding of disease and illness requires looking beyond the context of biology to include a multi- causal explanation of disease and health. Hence the spotlight of sociological enquiry on disease and health spread across the social causation of diseases which include the impact of belief system, social structure, social class, social networks and social status and environment on disease causation and outcomes. On this note, it has been argued that sociological and anthropological research placed more emphasis on the role of culture in the conception and management of disease. This became highly relevant in indigenous African communities where notions of disease are ambiguously construed. In Africa, certain diseases are believed to have natural, magical, spiritual and supernatural underpinnings with massive impact on the choice of health care services and providers. Where diseases are perceived to have been naturally induced, the modern doctors can be consulted. However, where diseases are believed to have a

supernatural influence, native healers are consulted. An overview of the health care system in Nigeria was also provided.

Furthermore, in social determinants of health care services a distinction was made, from the existing literature, between “illness response” based on social psychological studies and “utilisation of formal health care system” based on sociological and anthropological research. The former studies were further divided into the “barriers” or “determinants” and “pathway” streams. The pathway studies have shown that recent studies in healthcare seeking behaviour are increasingly coming to a realisation that traditional practitioners are important key players in healing disease management especially in developing countries that include African. The native healers have contributed very significantly to health promotion and can serve a good referral point to the modern health care system. Hence the need to foster good relationships between traditional and modern medicines to achieve universal health coverage in developing countries especially in Africa where the majority of the people have limited access to health care services. While this process has been considered in health care structure in Nigeria, the Nigerian government is yet to formulate a structured policy that guides the activities of the traditional medicine and their practitioners.

Finally, the descriptions of the study settings were also provided. This became necessary against the backdrop that the environment and the culture of a people often influence the overall behavioural patterns including health behaviours. Thus, a general overview of the specific communities where the study actually took place was provided. The people and communities described fall under the Ifelodun and Ilorin-South local government areas of Kwara State respectively. Okanle and Fajeromi were presented as typical examples of rural communities in Nigeria while Ilorin-South was described as being heterogeneous comprising examples of rural, semi-urban and urban communities. The description of the Children Specialist Hospital was also provided despite the fact that urban participants were drawn from this health facility.

CHAPTER THREE

EXPOSITION OF RELEVANT THEORETICAL FRAMEWORKS

3.1 Introduction

Health educators have been most concerned about health behaviour changes that take place at the individual, community and societal levels (Sohn, 2002: 1). At the centre of this concern is the need to understand health behaviour and transform knowledge about behaviour into effective strategies for health enhancement. This chapter deals with the theoretical frameworks that guide the course of this research and provide the foundation upon which the research is construed and constructed. A theory - in the social domain - is an embodiment of a set of ideas and a decisive tool used to explain the workings of the society or the social world. Neuman (2007: 24) asserts that a social theory is a “system of interconnected abstractions or ideas that condenses and organises knowledge about the social world”. For Corbetta (2003: 60) it is “a set of organically connected propositions that are located at a higher level of abstraction and generalisation than empirical reality and which are derived from empirical patterns and from which empirical forecasts can be derived”. Maxwell (1996: 32) sees theory as “a statement about what is going on with the phenomena that you want to understand. It is not simply a framework, although it can provide that; rather it is a story about what you think is happening and why”.

An examination of the relationship between theory and model has been at the centre stage of academic debate over the years, the resolution of which is beyond this thesis. However, it is important to briefly touch on this topical issue in order to justify the application of the health care models adopted in this study. Some scholars are of the opinion that theory and model are the same. Others disagree. What is however certain is that a kind of relationship or connectivity exists between a theory and a model. McKenzie and Seltzer (2001: 138) noted that a model is “a subclass of theory”. According to McKenzie and Seltzer (2001: 139), “models provide the vehicle for applying the theories”. For Khan (2002: 9) a model - whether economic, physical or sociological model - is not just an analogical device, it is a simplification of an empirical reality. Models are used to explain, describe and possibly predict human actions but in a formal way. Even though a theory does the same, according to Khan (2002: 9) “it need not be always formal”. For DeBarr (2004: 74) theories are organised around ideas, concepts, and constructs but models are representations of theory.

Based on this notion, it follows that both models and theories of health care seeking behaviours can serve as important instruments of exploration to understand the interconnectivity between certain economic, political, individual and environmental variables and health care utilisation. According to Reeding et al. (2000: 180) models and theories of health behavior change are intrinsically connected to the measurement of health behaviour. In other words, models of health behaviour contain certain properties and variables that explain the subject-matter of health and health care utilisation. Hence, the Health Belief Model (HBM), the transtheoretical model (TTM), the Behavioural theory of Health Care Utilisation, the Generational Cohort Theory (GCT) as well as the Rational Choice Theory (RCT) provide the theoretical foundation and frameworks for this study. The adoption of these theories is premised on the assumption or common belief in social research that no single theory can provide ultimate answer to a research problem. This means that a combination of theories is required to understand, design, deliver, evaluate and implement programmes aimed at understanding and addressing the problem of malaria in homogenous (rural) and/or heterogeneous (urban) socio-cultural contexts as is the case in this study.

It needs to be mentioned that the research design adopted in the current study is aligned with exploratory model (see the section under research methodology) as the enquirer intends to operate (as conditioned by the questions and problem of the study) within the above mentioned theories rather than gathering evidence that tend to refute or support their basic tenets and assumptions. This is because some of these theories inherently contained some key factors, concepts or variables and presumed relationships that have direct bearing on the current study. Some of these theories were originally designed by the intellectuals to understand either health as a phenomenon or health care seeking behaviour or both. For instance, from a psychological point of view, the HBM assumes that there exists a close knit relationship between the cognitive mechanisms and response to disease. The theory identifies perceived threat and perceived barriers and a host of other deterministic cognitive variables in health behaviour. With regard to the present study, the theory is used to understand the perceived threat and response to malaria in children younger than five years of age by those socially and culturally positioned to give care to them. Like other cognitive theories, HBM proposes that individuals faced with alternatives will choose the action that will lead most likely to positive outcomes (Munro et al. 2007: 4).

The transtheoretical model of health behaviour change on the other hand moves the debate beyond the cognitive variables and focuses more on the process of change in health behaviour (Brewer and Rimer, 2008: 5). It stresses that health behaviour change is not automatic. Rather, it is gradual and procedural. The theory proposes at least six stages of change individual passes through before the change becomes part of their lifestyle (details provided below). This model could be used to understand observed health behaviour changes in the management of malaria especially among young caregivers in the communities studied. It could serve as a useful tool for policy intervention aimed at changing behaviour regarding management of malaria in children younger than five years of age.

The behavioural theory of health care utilisation is a sociological construct designed to account for the individual forces (predisposing, the enabling and need factors) and social factors (organisation, policies, resources, financial arrangement, medical technology and social norms relating to the treatment of diseases) that influence the utilisation of health care services. The theory is specifically used within the context of the current study to juxtapose the myriad of factors that enhance or impede health care service utilisation in management of malaria in the communities studied.

The generational cohort theory critically looks at the differences in attitude formation between the old and the young people with regards to a particular burning socio-economic issues and change. The theory helps the current research to understand generational differences and attitude towards the use of health care systems in the management of malaria in children younger than five years of age.

Finally, although RCT is deeply rooted in economic studies, it has been widely utilised by other social scientists including sociologists to understand human behaviour in different contexts. The rational choice theory assumes that an individual consumer has a well-defined manner of ranking alternatives according to desirability, and among collection of feasible alternatives, chooses an item that he/she ranks highest (OK et al. 2007: 2). RCT is used, within this assumption to explain caregivers’ desirability and preference for a particular method of treatment to other methods especially in management of malaria in children younger than five years of age.

An exposition of these theories is therefore structured using the following guidelines:

• An examination of the origin of the framework with particular emphasis on the originators and the rationale behind its development;

• Making explicit the basic assumptions and tenets of the framework;

• An examination of the limitations of the framework; and

• The relevance of the framework to the assumptions and propositions of the study.

3.2 The Health Belief Model (HBM)

The health belief model (HBM) is one of the many streams of social cognition models of health behaviour. It is rooted in psychological research. Generally speaking, the social cognition models assume that “people possess relatively consistent sets of beliefs concerning their health and that these reflect underlying, relatively consistent ‘models of illness’” (Kinderman et al. 2006: 1901). Of all social cognition models, the HBM is one of the oldest (Nejad et al. 2005: 65) and perhaps, the most extensively utilised and applied frameworks in trying to understand and predict human health behaviour (Hazavehei et al. 2007: 2). The model was originally developed in the 1950s by Godfrey Hochbaum and his colleagues in the United States Public Health Service to explain people’s participation in health screening exercise (cf. Nejad et al., 2005: 64). This was to determine whether individuals choose to engage in a healthy action with the primary aim of reducing or preventing the chance of disease or premature death (Nejab et al., 2005: 64). The assumption is that health behaviour is more often influenced by attitudes and beliefs, as well as established mechanisms to minimise the occurrence of disease within the social system. Initially, the HBM was designed using perceived susceptibility, perceived seriousness, perceived benefits, and perceived barriers (Parsa et al. 2008: 898). While these four dimensions provide consistent analysis of health behaviour, they are generally believed to be weak in predicting health behaviour. As a result, the HBM has been consistently updated. Health motivation, cues to action (Becker et al. 1979) and self-efficacy (Rosenstock

et al 1988) have been added and illuminated. However, the cue to action has not been sufficiently corroborated with systematic and empirical studies (Family Health International, 1996: 2).

Health belief model believes that perceived threat of a disease, i.e. the beliefs about the burden of disease, often depends on both the perceived susceptibility to the disease i.e. the beliefs about how vulnerable a person considers him or herself to be in relation to disease, and perceived seriousness or severity of the disease (Hausmann-Muela et al. 2003: 9). Also, the perceived benefits (i.e. perceived positive attributes or advantages of an action) and barriers (i.e. the perceived costs or constraints of the specific action) also influence perceptions of the effectiveness of health behaviour (Munro et al. 2007: 5) and these are known to be modifying variables (Nejad et al. 2005: 64). Therefore, according to this model, high-perceived threat, low barriers and high perceived benefits to action often increase the possibility of taking positive health actions (Munro et al. 2007: 5). With regard to the current study, an individual mother’s perceived susceptibility to malaria disease; the perceived severity of malaria; the perceived benefits in taking certain actions to reduce risk (i.e. the use of treated bed net to prevent mosquito bites); the perceived barriers and “cues to action” are important factors that influence the decision to taking health related actions when malaria strikes in children.

Therefore, with particular reference to malaria, HBM would assume that if an individual does not perceive malaria as a serious disease to children and does not see children susceptible to it he or she is not likely to feel threatened by the disease and hence not likely to take health related actions to prevent the occurrence of the disease and vice versa. In other words, an individual’s perceived susceptibility to malaria disease; the perceived severity of malaria; the perceived benefits in taking certain actions to reduce risk (i.e. the use of treated bed net to prevent mosquito bites); the perceived barriers and “cues to action” are important components that influence the decision to taking health related actions when disease strikes. Studies which found that mosquito bed nets were not perceived as effective in the prevention of malaria infection simply because mosquitoes bite day and night underscores the relevance of the perceived threat as contained in this model (Hausmann-Muela, 2003: 10) perhaps, because the respondents did not feel threatened by mosquito bites so they did not consider bed nets as effective preventive measures (see figure 3.1). In a study of caregivers’ acceptance of using Artesunate suppositories for treating childhood malaria in Papua

Guinea, Hinton et al. (2007) observed that 29% of caregivers refused to accept the use of this alternative care for fear of side effects (i.e. perception of effectiveness of health behaviour). Respondents in this study mentioned lack of spousal approval as well as concerns about safety and the practical challenges of administering to a reluctant child as reasons for rejection (Hinton et al., 2007: 639).

Figure 3.1: Health Belief Model

Perceived Susceptibility

Belief in a personal health threat Perceived Severity

Health

behaviour

Perceived Benefit

Belief in the effectiveness of Health behaviour

Perceived Barriers

Source: Munro et al. (2007: 5)

However, HBM has limitations in predicting certain health problems. Kinderman et al. (2006: 1910) in a study of illness beliefs in schizophrenia succinctly argue that HBM is less applicable to predicting or understanding schizophrenia. Munro et al. (2007: 5) have thus compressed the weaknesses of the HBM into two different clusters. The first has to do with the fact that the relationships between the so-called

variables (perceived threat, susceptibility, seriousness, barriers and benefits, health motivation, cues to action) are too ambiguous and not clearly spelt out. That is, their connection has not been explicitly elucidated and expatiated. The second weakness has to do with the exclusion of the social variables from health behaviour considering the fact that human beings are “social animals” whose behaviours including health related behaviours are more often influenced by social variables and characteristics. In other words, the theory fails to account for the cultural construction of disease, ill-health and health care seeking behaviour, hence, the need for an alternative theory.

In spite of these challenges, HBM has gained significant recognition among researchers in trying to explore and predict a variety of health behaviours. It remains the most widely used theory in health behaviour studies (Hazavehei et al. 2007: 2; Nejad et al. 2005: 66) which includes HIV and AIDS (Family Health International [FHI], 1996: 2), food handling behaviours (Hanson and Benedict, 2002: 25), breast cancer (Parsa et al 2008: 897), as well as prevention and control of haemorrhagic fever [DHF] (Phuanukoonnon et al. 2006: 6). The validity and reliability of HBM has been carried out in diabetic patients’ health behaviour (Kartal and Ozsoy, 2007: 1447). Hazavehei et al (2007: 4) applied the HBM to understand the prevention of osteoporosis (bone disease usually in women after menopause) among middle school girl scholars in Garmsa, Iran. It was used by Schafer et al (1995: 422) to predict fat in diets of marital partners in the State of Iowa. Nejad et al (2005: 65) used the HBM together with the theory of reasoned action to predict dieting and fasting among female university students in Australia. Indeed, there is increasing evidence that HBM is being used in combination with other theories by sociologists and anthropologists in understanding health care seeking behaviour. This follows increased emphasis on an interdisciplinary approach. Therefore, in this study, the HBM is used to understand the relationship between the perceived threat of malaria in children below the ages of five and health actions of caregivers. These include awareness and use of mosquito bed-net for children below the ages of five in the communities of study.

3.3 Behavioural Theory of Health Service Utilisation

The behavioural model of health care utilisation was developed in the 1960s by Andersen. The model was meant to predict and explain the use of health care services based on a series of empirical studies. This was informed by the need to understand why families use or fail to use health services, the need to define

80 and measure equitable access to health care services, and the need to develop health care policies that promote equitable access to health care facilities (Andersen and Newman, 2005). The development of this model was influenced by the prevailing belief in behavioural sciences at that time particularly in the field of sociology that individual behaviour is the function of both individual and societal forces (Andersen and Newman, 2005: 2). In other words, societal characteristics such as health services delivery system (organisation, policies, resources and financial arrangement), prevailing changes in medical technology and social norms relating to the definition and treatment of illness often interact with individual actors to influence decisions to seek health care services (Andersen and Newman, 2005; Hagewen, 2006). The individual factors are grouped into predisposing, enabling and need factors such that “each component might be conceived of as making an independent contribution to predicting use” (Andersen, 1995: 1). The complex relationships between individual and societal variables are explained in phases (see figures 3.2 and 3.3).

3.3.1 The Predisposing Factors

This spectrum of factors attests to the fact that the way and manner in which individuals and families utilise health care facilities is different, both in terms of propensity and volume. Usually, the predisposing factors exist before the onset or experience of disease and the decision to seek treatment. They include demographic (age, gender and family size), cognitive (attitudes or beliefs) and social structural variables (employment, social class or status, education and occupation). It is assumed that people with more of the predisposing characteristics have more chances of using health services than those with less, even though the characteristics are not directly responsible for health care use (Andersen and Newman, 2005: 2). For instance, as shown earlier in the review of literature, age, gender, marital status, size of household and belief systems were found to be important predisposing factors for utilisation of modern health services among the pastoralists in northeast Ethiopia (Dubale and Mariam, 2007: 146). A study by Buor (2004: 386) in the Ashanti region of Ghana shows that although females have a greater need for health services than males, they were not using health care services as much as men. Also connected to demographic factors are cognitive variables such as attitudes and beliefs. This suggests that what an individual thinks about disease, physicians and medical system as a whole sometime influence the decision to seek health. In other words, individuals with positive thinking and attitudes toward the health care system and who believe that illnesses require medical attention are more likely to seek health care than those without such thinking.

This can be influenced by previous illness experience. If people experienced disease in the past, there is a tendency to seek health care services should it arise in the future. The social structural characteristics emphasise individuals’ social positions, level of education, type of occupation, ethnic and religion affiliation as important factors that may affect health and the use of health facilities. They also include social networks, social interactions and culture (Andersen, 1995: 2).

3.3.2 The Enabling Factors

This aspect suggests that even though an individual may have predisposing characteristics, health service use may not occur unless the individual has the resources or means to do so. Therefore, the enabling factors are those factors that allow or disallow the family or individual to use health care services. Where they are present, they usually facilitate the use of health facilities. Where they are not, they usually impede the use of health services. Enabling factors are measured in terms of family or household characteristics such as the socio-economic background and resources like the disposable incomes, the availability and type of health insurance and closeness to health care facilities where they can be conveniently accessed by the people (US Department of Health and Human Resources, 2004: 6). Beyond the family characteristics, certain environmental variables such as where people live (rural or urban) as well as the local social norms are closely linked to health care utilisation. They could facilitate or impede the use of health care services. They are capable of making utilisation easier or extremely difficult. For instance, local norms concerning how medicine is practiced can influence individual health behaviour in the community (Andersen and Newman, 2005: 16). The rural/urban differences largely influence accessibility to and availability of health care facilities, personnel and resources. Andersen and Newman (2005: 16) are of the opinion that “if resources are reasonably plentiful and can be used without queuing up, they might be used more frequently by the population”. Similarly, a revised model of health care utilisation has incorporated social support and competing needs as important factors that enable or disable a person to use health services (Gilberg and Andersen, 1997).

3.3.3 The Need Factors

The need factors are regarded as the most important predictors of health care utilisation. This is closely related to the HBM earlier explained. They represent the most immediate cause of health care service utilisation because “if all people could obtain unlimited health care, perceived need…might be the only determinant of health care utilisation” (US Department of Health and Human Resources, 2004: 6). These include individuals’ perception of disease and professional evaluation. The former has to do with “how people view their own general health and functional state, as well as how they experience symptoms of illness, pain, and worries about their health and whether or not they judge their problems to be of sufficient importance and magnitude to seek professional help" (Andersen, 1995: 3) while the latter has to do with “professional judgment about people’s health status and their need for medical care” (Andersen, 1995: 3). To seek treatment, therefore, individual or family’s perceived symptoms and professional evaluation combine to influence the decision to seek treatment. Without this, health care services may not be used even where the predisposing and enabling factors are apparently present. The figure below describes the interaction between the predisposing, enabling and need factors and the use of health care services.

Figure 3.2: The First Phase of Behavioural Model

Health Service Use Predisposing Enabling Factors Need Factors Factors

Sources: Hausmann-Muela et al. (2003: 12); Andersen (1995: 2).

In the second phase of this model, the importance of health care system in the utilisation of health care system was explicitly emphasised. According to Andersen (1995: 6):

The health care system was explicitly included in this phase, giving recognition to the importance of national health policy and the resources and their organisation in the health care system as important determinants of the population’s use of services, as well as changes in those use patterns over time. Other developments in this period include elaboration of the measures of health services’ use, including those representing type, site, purpose, and coordinated services received in an episode of illness. Also added in phase 2 was an explicit outcome of health services- consumer satisfaction.

Thus, the health care utilisation model chart was modified in phase 2 to include type, site purpose of consumption as well consumer’s level of satisfaction.

Figure 3.3: Andersen’s second phase of health services utilisation theory.

Population Characteristics

Predisposing, Enabling, and Need factors Consumer Satisfaction Use of Health Services Convenience, Quality, Availability, Financing, and Type, Site, Purpose and Time interval Provider Characteristics Health Care System

Policy, Resources and Organisation

Source: Andersen, (1995: 6)

The behavioural model of health care utilisation is widely acknowledged as one of the most well researched and most widely used models of access to health services (Goldsmith, 2002) especially, the individual components of the model (see Abu-Mourad et al. 2008; Alexandre et al. 2005). Abu-Mourad et al (2008) have used the individual component of the model to examine the extent to which patients use the primary health care services in Gaza Strip, Palestine. Zhang (2007) applied the model to the understanding of utilisation of preventive health services among adults in the general population in Australia in his doctoral thesis. Recently, the health care utilisation model has been modified, expanded, and applied to the understanding of the utilisation of the traditional medicine and home treatments particularly in non-Western environments (Weller et al. 1997). Most importantly, scholars have also proposed the application of the health care utilisation model to the understanding of malaria related behaviour (Rauyajin, 1991 quoted from Hausmann-Muela et al. 2003: 12).

The criticism against the health care utilisation model has been moderate. The chunk of the criticism, according to Hagewen (2006), has little to do with the model itself but rather focuses on how researchers have used the theory over the years. According to him, very few researchers have examined Andersen’s model in full. Most researchers’ have tended to neglect the societal aspect of the model. Therefore, the health care service utilisation model fits this study. It is used to understand and predict health care seeking behaviour of caregivers in children with malaria within the context of government policies and resources to boost the treatment of malaria (societal characteristics) as well as predisposing, enabling and need factors (individual characteristics) with particular emphasis on cultural construction of malaria in children.

3.4 Generational Cohort Theory (GCT)

The concept of generation is becoming increasingly popular. It is more popular in the political, policy and academic domains. For instance, politicians often claim to safeguard “the older” and “future generations” through their policies and programmes (Johnson, 2007: 4). The emergence of the concept of sustainable development at policy and political realms is to protect the “next generation” from what is perceived as the excessiveness of the “present generation”. The on-going rapid advances or transformations in communication, information and technology nestled in globalisation discourses have given rise to a “new generation” of young people with its own unique set of experiences, values, persona, thinking and world

view. The concept of generation is most popular among students and teachers of sociology and anthropology especially with regards to discourses surrounding culture and socialisation. Sociologists and anthropologists often describe socialisation or acculturation as a process through which people’s culture is transmitted from “one generation” of people to the other. Although a very popular concept indeed, there is a great deal of argument surrounding the constitution of a generation; how to dissipate one generation from the other; and why such demarcations or differentiations are demographically, economically and sociologically significant (Johnson, 2007: 4).

Generational cohort theory (GCT) or generational theory as it is sometimes called is an important framework developed to understand the diverse attitudinal differences and behaviours embedded in different generations of people. However, it is not the intention of this thesis to give a detailed account of the GCT in this work given the inherent controversial issues embedded in the categorisation of the cohorts of generation. Rather, the researcher is concerned with the very essence of the theory and the important message carried by it with a view to explain intergenerational patterns of health care seeking behaviour in the communities of study.

Many scholars in various fields have contributed to the development of the GCT. However, the contributions of Karl Mannheim11 (1893-1947), a German sociologist, cannot be overemphasised. In his book entitled “The Problem of Generation” Mannheim propounded the basic and core tenets of the GCT. Mannheim asserted that cohorts within populations are bound together around shared experiences rather than the traditionally established lines of social class, geography gender and other social constructs. In other words, a cohort is a people born about the same time and who are coalesced and profoundly influenced by the events of their formative years (Foley, 2000: 1). Mannheim posited that “simple generational separation performed on the basis of so many calendar years did not furnish a sound foundation for the analysis of social process and change” rather, “chronological cohorts experiencing the same cultural events, interpreted through a similar lens based on their life-stage of sociological development, would forever share a sense of a common perspective” (Taylor, 2008: 4).

11 Mannheim, K. 1952. "On the Problem of Generations" In Essays on the Sociology of Knowledge, trans. Paul Kecskemeti. London: Routledge & Kegan.

In his analysis, Mannheim developed the concepts of “generational location”, “generation as actuality” and “generation units” to extrapolate his proposition on the matter. These concepts subscribe to the idea of intergenerational and socio-generational differences, illustrated by the unique traits and belief systems prevalent in various generations (Pendergast, 2009: 3). Generational location, according to Pendergast, is a passive category based on the chronological span of time for the birth years of a cohort of individuals which often affects the potential of the generation (Pendergast, 2009: 3). Generational actuality goes beyond the passive designation to include the way and manner in which a generation reacts to social transformations and how these reactions form an integral part of their existence and personality formation (Pendergast, 2009: 3). Also, Mannheim mentioned the generation units represented by pockets of sub- groups located within a particular location or region (Pendergast, 2009: 3). According to Mannheim:

belonging to the same generations or age group endows the individuals sharing in [it] with a common location in the social and historical process, and thereby limit them to a specific range of potential experiences, predisposing them for a certain characteristic mode of thought and experience, and a characteristic type of historically relevant action (quoted from Pendergast, 2009: 3).

Nevertheless, it was not until the 1990s that William Strauss and Neil Howe popularised the theory in their book “Generations, the History of America’s Future, 1584 to 2069”. Strauss and Howe posit that society often alternates between a cycle of growth, conformity, decay, and divisiveness and that each cycle is driven by the changes in the values and attitudes of each new generation (Drago, 2006: 2). The authors contended that there are four patterns of reoccurring phases, generational types and a persistent cycle of spiritual awakenings and secular crises and that each generation has its own unique and distinctive characteristics.

Therefore, GCT has emerged as a dynamic and broad socio-cultural approach that attempts to understand and characterise cohorts of people based on their birth generation (Pendergast, 2009). However, cohort categorisation is beyond sharing birth generation. It includes an understanding of the socio-political and economic dimensions that have shaped the feelings, attitudes and views of the generation in question. In other words, belonging to the same age group does not necessarily link people into any meaningful compartment, rather, it is the events that occur at various critical points during the group’s lifetime that create cohorts and define their core values (Foley, 2000: 1). While age brackets may have some usefulness (horizontal aspect of generation) Gaspar and Ramos (2005: 419-420) noted that the term ‘generation’ “should highlight the thinking and behaviour pattern of a given part of a society that is highly concentrated at an age group, but which can cross many age groups vertically”. GCT has therefore attempted to provide a form of generational identity and serves as a measuring rod into a period of time that produces people who tend to think and act in the same way in a particular time (Codrington and Grant- Marshall 2004). Bontekoning (2011: 1) contended that a generation is characterised by the following:

• Common life history and time spirit with serious impact on the upbringing and education which may further creates an enabling environment for the collective development of a new generation.

• The most important source being shared reaction to the actual time spirit based on vital sensitivity (i.e. the ability to feel where the culture of organisations and/or society needs to be renewed and expressed in a very strong propensity to add vital practices to an organisational or societal culture.

• The feeling of a shared collective destination combined with shared development of mental, emotional and physical attitudes and dexterity. It is known as a shared entelechy.

On this basis, young and old generations tend to view unfolding events (socio-political and economic issues) differently. The differences in opinions and attitudes are usually conditioned by a broad variation in values that have developed based on contrasting environmental and social dynamics each generation experienced as they were growing up (Notter, 2007: 1). Today, such differences can be noticed between young and older people with respect to coping in the current information-centric society (Sutton, 2005: 4). It is good to note that GCT does not preclude or contest the psychological, sociological, and other constructs

88 or variables that have direct or indirect impact on individual and group behaviours, rather it seeks to complement these frameworks in the understanding (Pendergast, 2009: 4).

The generational cohort theory has been criticised for prioritising the American society in its analysis especially with respect to Strauss and Howe’s exposition. Nevertheless, it has become a useful academic research tool in explaining and accounting for differences in opinions, responses and attitudes in different generations from different dimensions. Gaspar and Ramos (2005) have suggested a generational approach to help articulate how youth and the World Futures Studies Federation (WFSF) may relate to each other. Specifically, in health care studies the theory has been used to develop effective allied health recruitment and retention practices (Schoo et al. 2005) as well as understanding the physical therapy workforce (Schofield and Fletcher, 2007).

Therefore, GCT is adopted in this work to help shed light on the socio-generational changes in the patterns of health care seeking behaviour of young and older parents with particular reference to the issue of the treatment of malaria in the communities of study. The theory allows the researcher to reflect on intergenerational human health care patterns in local communities and use the insights gained to predict and strategise a plan that would accommodate age discrepancies with regards to treatment and prevention of malaria in the communities of study.

3.5 Transtheoretical Model of Health Behaviour Change

Behaviour change is one of the issues that have continued to interest scholars within and outside the social science arena for a long period of time. Many of these scholars and researchers have shed-light into the complexity of behaviour change. Specifically, scholars in health behaviour studies have shown that health behaviour change is a highly complex and dynamic process (Humphreys et al. 1998: 331). A number of theories have thus been developed to demystify the complexity in health behaviour change. One of the most dominant health behaviour change models is the transtheoretical model (TTM). The model was postulated and developed by James Prochaska and Carlo DiClemente in the early 1980s. Both were motivated to systematically review some of the existing major theories of psychotherapy and behavioural change. The outcome of this review is the transtheoretical model (Sohn, 2006: 220). Unlike previous models that focussed attention on cognitive variables (for instance, the HBM) TTM is a model of intentional

change that focuses attention on the decision-making abilities of the individual (Brewer and Rimer, 2008: 5). TTM has thus emerged as one of the most prominent and popular conceptual resources in the mainstream health behaviour and promotion discourses (Whitelaw et al. 2000: 707).

One of the basic assumptions of the TTM revolves around the fact that people tend to go through change as a process over time. That is, people are in different stages of preparedness to switch health behaviour, and that these stages are different with respect to the processes that move people closer to a new behaviour (Brewer and Rimer, 2008: 5). The model suggests that individual wanting to change health behaviour work through cognitive and affective processes leading to adoption of a new behaviour and then move to using behavioural strategies to stabilise the new status. These processes may take place in a linear form or moving back and forth (Lach et al. 2004: 89). The dimensions of behaviour change include stages of change, processes of change and decisional balance (Humphreys et al. 1998: 331-332). The model assigns individuals to one of five stages of change (explained below) based on their location in the behaviour change continuum. The processes of change include 10 strategies for moving through the stages of change and constitute experiences and behaviours that individuals engage in during behaviour transformation. TTM lucidly indicates that movement between the stages of change occurs as the benefits of a new behaviour (pros) outweigh the costs of a new behaviour (cons). The stages and processes of change are combined to define the decisional balance scale and enhance behaviour change (Kelly, 2008: 150). Other constructs include the strong and weak principles and self-efficacy (Kelly, 2008: 149). Below is the sketch of the stages and processes of change as identified in the TTM.

3.5.1 Stages of change

Contemporary researchers who have utilised TTM in their studies have reported conflicting stages of health switching behaviour, sometimes within time limits. Some have reported four stages (Reid et al. 1996: 334), some reported five (DeBarr, 2004: 78; Humphreys et al. 1998: 332) while others reported six (Communication for Governance and Accountability [CommGAP], n.d: 4). What then is responsible for this? At the beginning, Prochaska called his theory the ‘Stages of Change’ (Kelly, 2009: 4) however, with limited variables. As time progressed, new concepts, variables, stages and measuring instruments were added (Kelly, 2009: 4). This informed the disparity in the changes of change. In this study, six stages of change are considered and enumerated in the following order.

• The pre-contemplation stage: When a person does not intend to consider changing behaviour. • The contemplation stage: When a person intends to change behaviour but not acting upon the intention (also defined within a specific period of six month). People in this stage are aware of the prons and cons of change. • The preparation stage: When a person plans to make behaviour change (often defined within a specific period of one month). • The action stage: When a person initiates behaviour or takes action to change behaviour. • The maintenance stage: When a person’s new behaviour is well nurtured and maintained. At this stage, people work to prevent relapse. • The termination stage: When a person permanently adopts a desirable behaviour. That is, when a new behaviour is integrated into someone’s lifestyle.

The transtheoretical model further suggests that the above mentioned stages of change are driven by a series of 10 processes. They include the following:

• Consciousness raising: This Involves providing information regarding the nature and risk of unsafe behaviour and the value and drawbacks of the safer behavioural alternatives. The rationale is to raise awareness. • Dramatic Relief: This includes fostering the identification, experiencing, and expression of emotions related to the risk and safer alternatives in order to work toward adaptive. • Environmental Control (or Environmental revaluation): It allows persons to reflect on the consequences of their action vis-à-vis others. It may include reconsideration of perceptions of social norms and the importance of people’s opinion towards them. This may include the awareness that one can serve as a positive or negative role model for others. • Self Reevaluation: This entails the reappraisal of one's problem. It combines both cognitive and affective assessment of one’s self image with and without an unhealthy lifestyle. • Commitment (or Self-liberation or reevaluation): This encourages the person to consider their confidence in their ability to change and their commitment to doing so. • Social Liberation: Seeking to help others with similar problems. It requires an increase in social opportunities or alternatives, especially with respect to people who are relatively deprived.

• Stimulus Control: this helps to remove cues for unhealthy habits and adds prompts for healthier alternative. Avoidance, environmental reengineering, and self-help groups can provide stimulus packages that enhance healthy behaviour and reduce risks for relapse. • Helping Relationships: It assists the person in a variety of ways, including providing emotional support, modeling a set of moral beliefs, and serving as a sounding board. • Reward (Reinforcement management): Developing internal and external rewards and making them readily available to improve the probability of the new behaviour occurring or continuing. • Countering: Weighing the "pros" and "cons" of the behaviour change.

Some studies have organised the ten processes into two main clusters in which the first five processes are used in the early stages and classified as ‘experiential processes’ (they include consciousness raising, dramatic Relief, environmental re-evaluation, self-re-evaluation and social liberation); while the last five are classified as ‘behaviour processes’ used in later stages (they are: helping relationships, counter conditioning, reinforcement management, stimulus control, and self liberation (see Reeding et al. 2000: 189). The experiential set of processes are most often emphasised during the early stages in order to trigger intention and motivation; the behavioural set of processes are utilised in later stages as observable behaviour change efforts are imminent and needed to be sustained (Reeding et al. 2000: 189).

Like other theories, the transtheoretical model has been criticised. One of such criticisms came from the founder of social learning theory, Albert Bandura who argues that the model neglects a substantial body of intervention research. It is also criticised for being ‘too constrictive to explain change in human functioning’ (quoted from Kelly, 2008: 150). These challenges notwithstanding, TTM has continued to be a very useful resource to understand wide range of health behaviours. Kelly (2008: 150) argues that the TTM has attracted large crowd among the clinicians largely due to its simplicity and clarity. Humphrey et al. (1999) adopted TTM and theory of reasoned action to assess breastfeeding intention among breastfeeding mothers. How then can this model be applied to the current study? How effective is the model in predicting and understanding health switching behaviour among caregivers in the current study? It needs to be mentioned that the current study is not designed to change health seeking behaviour of caregivers. Rather, it intends to understand health switching behaviour among the caregivers of children in the communities studied. TTM therefore becomes a dependable and useful tool that can be used by health educators and

planners to understand and stimulate health switching behaviour from a traditionally oriented system to a more modern system of care should there be the need.

3.6 Rational Choice Theory Among alternative choices, why and how do people arrive at making a decision? What is the rationale behind reaching a certain decision? Is there a benchmark for taking or arriving at a decision? Are people ‘rational’ in choices they make? Why would a particular method of management be preferred to other alternatives? Could this be explained using the rationality in the rational choice theory?

The rational choice theory is rooted in economic studies (Green, 2002: 1; Scott, 2000: 1). RCT is held tenaciously in economics to understanding and predict market behaviour. Beyond economic studies, other variants of the RCT have emerged in other disciplines. The theory has gained widespread acceptance among contemporary disciplines ranging from political science to sociology such that predictions made using RCT are valuable guide to the formulation of public policy (Ulen, 1999: 794). Like in economics, RCT is adopted in other fields to comprehend different dimensions of social interactions and human behaviours (Green, 2002: 1). Indeed, even though it has generated argument and controversies, “no other well articulated theory of behaviour commands so large a following in so wide a range of disciplines” than the rational choice theory (Herrnstein, 1990: 356).

To understand the basic tenets of the RCT and its relevance to sociology and the current study, a brief analysis of the economic dimension of the RCT is indeed a prerequisite. From economic point of view, RCT addresses the following fundamental questions:

i) Exactly how does the buyer choose how much of his disposable income to be spent on a particular product?

ii) Exactly how does a seller choose the quantity of a product to be produced and at what price? (see Green, 2002: 4).

To answer these questions some basic assumptions have been sketched by Green (2002: 5) upon which RCT is built:

• That an individual consumer is faced with a known set of alternative choices. • That for any pair of alternatives (say X and Y), the consumer either prefers X to Y, prefers Y to X, or is indifferent between X and Y. • That these preferences are transitive in nature. That is, if a buyer prefers X to Y and Y to Z, then he/she prefers X to Z. If an individual is indifferent between X and Y and indifferent between Y and X, then he/she is indifferent between X and Z. • That consumer chooses the most preferred alternative. • In addition, individual actor is believed to have adequate information about how to make the most of their preferences.

Hedstrom and Stern (n.d: 1) see rational-choice sociology as a branch of sociology influenced by the above economic assumptions. From these axioms, rational choice sociology believes that economic principles can be applied to the understanding of social interactions where time, information and prestige are involved (Scott, 2000: 2). However, RCT in sociology is not simply an adaptation of economic axioms to the understanding of human actions and social phenomena. Rather, rational choice sociology consists of a number of propositions, predictions and assumptions adapted from other fields of study. Based on different models and outlooks of rational choice, some scholars have argued that rational choice is not a theory but consists of many theories conjured in one umbrella.

In sociology, rationality has been one of the sociological concepts that have attracted classical sociologists. The idea that people act ‘rationally’ has been discussed by Max Weber. In Weber’s sociology, human subjects are considered as free who constantly and consciously project meanings and seek ends (Labinjoh (2002: 22). The achievement of ends and the means are thus defined and dictated by the values and norms of the society respectively. However, a classical sociologist like Weber has seen human actions from both ‘sides of a coin’ (so to speak) containing rational and irrational actions. For instance, Weber built his typology of social action theory around traditional and affectual actions, and other forms of value-laden

actions alongside the purely rational types of action (Scott, 2000: 1). However, the rational choice sociology is different from the classical construction of social action theory like that of Weber simply because rational choice sociology only recognises ‘purely rational and calculative’ human actions (Scott, 2000: 2). George Homans’ contributions to sociology paved way for the rational choice sociology though he could not be seen as the founder of rational choice sociology (Headstrom and Stern, nd: 2). Modern rational choice theorists have tried to build their theories around the belief that human actions are fundamentally 'rational' and that people calculate the likely costs and benefits of any action before deciding what to do. From this point of view, human actions are rationally motivated however how much it may appear to be irrational (Scott, 2000: 1). The rational choice sociologists are united on the basis of the following principles:

• Human beings are seen as rational beings who behave rationally;

• Human beings are conscious decision makers whose actions are significantly influenced by the costs and benefits of different action alternatives;

• Most rational choice sociologists focus on social rather than individual actions. However, to make sense of social actions, these theorists focus on the actions and interactions that brought about them (see Headstrom and Stern, nd: 1-2).

However, some sociologists have maintained some reservation in the use of rational choice theory. Quite a number of sociologists are skeptical about the rationale behind the formation of the rational choice theory. The tenets of the theory have therefore been at the centre of hot debate. For instance, one of the criticisms that have been levelled against the rational choice sociology is “lack of realism in its assumption that human beings calculate the expected consequences of their options and choose the best of them” (Hechter and Kanazawa, 1997: 192). Everyday experience has shown that people often make certain ‘irrational’ choices that endanger their lives and lives of others (for instance, the so-called suicide bombers). Why do people smoke when they know the health implications of their actions? Why do some people refuse to use condom and consistently indulge in delicate sexual intercourse knowing the implications? Besides, critics maintain that people rarely have clear sets of preferred goals and that their actions are not often directed towards the pursuit of ultimate benefits since a significant number of people volunteer to participate in

social obligations and commitments even where there are no clearly defined benefits attached. Since chunk of human actions, decisions and choices are made instinctually how rationally constructed are they? Based on these weaknesses, the critics have concluded that the theory produces inaccurate predictions and their utilities as a research tool should be checkmated. In the words of Herrstein (1990: 356) RCT may be “normatively useful but is fundamentally deficient as an account of behaviour”.

However, proponents of RCT have simultaneously debunked the criticisms against RCT and upheld the validity, plausibility and rationality in the rational choice theory. Some have argued that even though the results generated by the RCT often sound like basic common sense it can also arrive at plausible and unexpected conclusions. One of the strongest defenders of the rational choice theory is Quackenbush (2004). Although a political scientist, Quackenbush (2004) is convinced that the critics of RCT have misunderstood the basic tenets of the RCT altogether. Such misunderstanding, he argues, often stems from lack of understanding of the differences between what he called procedural and instrumental rationality and ‘hatred’ for the concept of ‘rationality’. Quackenbush (2004: 94) relates procedural rationality to everyday usage of rationality where actors are said to make a constructive calculation of end-means while considering available options and choosing best of them. This, according to Quackenbush, falls short of the standards in the definition of rationality in the rational choice theory.

For him, the rational choice theory is rooted and strictly concerned with instrumental rationality. Quackenbush (2004) quoting the works of Luce and Raiffa (1957: 50) argues that an actor is rational when he is confronted with “two alternatives which give rise to outcomes” and decides to choose any one that yields the more preferred outcome. In addition, rational choice demands that a rational actor must have intertwined and transitive preferences as enumerated in the basic assumptions of the economic based rational choice theory earlier. That is, if A is preferred to B and B prefers to C then A is preferred to C. RCT requires that all the conditions and assumptions of the rational choice must be met for the adaptability and usability of the rational choice theory. More importantly, he argues that instrumental rationality is less concerned about whether or not some behaviours are “evil” or not, “bad” or “good”, “Godly” or “un-Godly”, “expressive” or “instrumental” (Quackenbush, 2004: 94). He, therefore, concludes that the most important

thing in rational choice “is understanding that a variety of motivations and behaviours are consistent with instrumental rationality, which is after all the rationality of rational choice theory” (Quackenbush, 2004: 102).

In spite of the criticism again the RCT, rational choice has continued to hold sway in predicting and understanding human actions. Based on the principles and assumptions of the RCT, RCT is a useful construct and a valuable resource in the current study especially regarding weighing the costs and benefits of the available health care channels in the communities studied before making a final decision to use them.

3.7 Summary

In this chapter the theoretical frameworks for the study were explored and discussed. They include the Health Belief Model (HBM), transtheoretical model (TTM), the Theory of Health Care Utilisation, the Generational Cohort Theory (GCT) and the rational choice theory. Each of these theoretical frameworks - except the GCT and RCT - alludes to the fact that health behaviour is a complex process and influenced by numerous but interrelated variables. Each of them has also helped in exploring different dimensions of issues in the current study using diverse parameters and variables. According to the HBM, health behaviour is more often than not influenced by attitudes, beliefs and established mechanisms in the society to minimise the occurrence of disease. It is assumed that health behaviours are influenced by the perceived threat, perceived susceptibility, perceived seriousness, perceived benefits and barriers, health motivation and cues to action. It is believed that high perceived threat, low barriers, and high perceived benefits to action are important factors in the decision to take health related actions. This model is used to explain health behaviour in the case of malaria in children younger than five years of age. Where an individual caregiver does perceive malaria as a serious health problem and sees her or himself prone to it, she or he is likely to take positive health actions by taking health precautions such as using treated bed nets or insecticides. The question is, what happens where an individual feels threatened by malaria but does not have access to control vector or treated bed nets as a result of structural or organisational problems that hinder access to these modern preventive measures?

The second theory adopted is the transtheoretical model. TTM has suggested that people are in different stages of readiness to make health behaviour changes and that intervention programmes aimed at improving health behaviour should take cognisance of these differences in order to achieve the desired results. Malaria intervention programmes designed to improve positive health behaviour with regard to improved awareness about the use of modern medicine in the management of malaria and correct use of insecticide treated bed nets should be structured to reflect the stages and process of change identified in this model. Once stage of change is assessed, people can be provided with therapist-guided, self-initiated, or other interventions suited to their respective needs.

The health care utilisation theory takes into account the social variables in health-care seeking behaviour. The theory assumes that both individual and societal forces function to influence an individual’s decisions to make use of health care services or not. The societal forces include the state of health care services delivery, the prevailing changes in medical technology and social norms that are directly linked to definition and treatment of disease. The individual factors include the predisposing, enabling and need factors. Each of these components makes an independent contribution to predicting use of health care facilities. Of all the individual factors, the need factors are considered as the most important predictors of health care utilisation. This theory is applied to understand health care seeking behaviour of caregivers in children with malaria within the context of government policies and resources to prevent malaria infections and boost the treatment of malaria (societal characteristics) as well as predisposing, enabling and the need factors (individual characteristics).

The GCT assumes that there are attitudinal differences in different generations of people. It was developed to understand diverse attitudinal differences and behaviour embedded in different generations of people each of which is known as a cohort. It is argued that each generation comprised of a cohort seen as people born about the same time and who are bound together and profoundly influenced by the events of their formative years. Belonging to the same age group does not necessarily link people into any meaningful cohort, rather, it is the events that occur at various critical points during the group’s lifetime that create cohorts and define core values. GCT is found relevant to this work with reference to the socio-generational

98 changes in the patterns of health care seeking behaviour of young and older parents especially as it regards the changing issues in the treatment of malaria.

Lastly, the rational choice theory has been used to understand the complex nature of human actions. The theory suggests that an individual actor is a rational thinker who aims to maximise satisfaction all costs. It is used in this study to understand the ‘rational’ calculation often make by caregivers in the communities studied in their choice for methods of treatment given certain institutional, economic and structural challenges beyond their control.

CHAPTER FOUR RESEARCH METHODOLOGY

4.1 Introduction Research methodology involves enduring activities directed towards answering certain intriguing questions about the social world or specific social issues or problems using scientific tools and techniques as a means of collecting, analysing and interpreting data. This chapter deals primarily with methodological issues that have relevance to the study. It details the research design adopted and subsequently demonstrates how a qualitative research methodology is preferred to other research designs. An attempt is made to make an overview of the research design as well as providing insights into the various strategies adopted for a qualitative research in this study. It also describes how the research has been planned and followed through. The chapter is thus compartmentalised into the research design (qualitative approach), the population of study and sampling procedures, description of qualitative instruments used to gather data, a description of how the researcher was able to gain entrance into the study areas, the methods of data analysis, ethical considerations and the problems encountered during the research process.

4.2 Methodology

4.2.1 The Research Design: A Qualitative Approach Social life and human actions are highly complex. The basic sense of curiosity to understand this complexity has therefore laid the foundation for social science research (Marvasti, 2004: 1). Over the past few years, enquiry in social science research has been polarised into two dominant ideological camps: the positivist or quantitative approach where ‘inquiry from the outside’ is usually conducted and the interpretive or qualitative approach, where ‘inquiry from the inside’ is usually perfected (cf. Ospina, 2004: 4). Quantitative research holds that the goal of knowledge is simply to describe the phenomenon under investigation; that the object of study is observed independent of the researcher; that knowledge can only be verified through direct observations; and that data can be collected through figures. These assumptions are rooted in the 19th century philosophy known as positivism, where human society is believed to be governed by natural laws and that the central aim for the study of human society is to unearth these laws (Okeke and Ume, 2004: 19). For many years, quantitative research paradigm dominated and unilaterally

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monopolised research processes in the social sciences. Evidence abounds that early and a number of contemporary qualitative researchers had received training in quantitative research methodology before their experience of qualitative research methodology. A good example is Irving Seidman12 (2006).

The naturalist or constructivist’s view on the other hand is a relatively new paradigm compared to quantitative approach. It consists of a group of researchers who tend to question and challenge the core tenets or assumptions of the quantitative research paradigm mentioned earlier. They have brought new argument into the fundamental principles of how research is to be conducted in social sciences. Qualitative research paradigm houses diverse lines of thought in micro-sociological traditions (symbolic interactionism, the interpretive tradition, phenomenology and ethnomethodology), whose focus of study is the individual as a social actor (Corbetta, 2003: 21). Quantitative researchers are obliged to discovering natural laws that govern human behaviours. However, such is not the case in qualitative studies. The goal of a qualitative researcher “is to describe a specific group in detail and to explain the patterns that exist, certainly not to discover general laws of human behaviour (Schofield, 1993: quoted from Henn et al. 2006: 178). According to Guba and Lincoln (1989: 175) ‘whereas positivists begin an inquiry knowing (in principle) what they don’t know’, constructivists typically face the prospect of not knowing what it is they don’t know”.

Given that the inquirer does not know what he or she does not know, it is impossible to be very specific about anything. But as the design proceeds, the constructivist seeks continuously to refine and extend the design – to help it unfold” (Guba and Lincoln, 1989: 179–80).

Axiologically, qualitative research holds that all kinds of research (quantitative or qualitative) are value- laden. They are often subject to the value systems (norms and culture) of both the researcher and the subjects as well as the theory used (Creswell, 2007: 247). Specifically, qualitative research is a participatory research paradigm where the researcher is physically immersed in the study (Ehigie and

12 In one of the editions of “Interviewing as a Qualitative Research: a Guide for Researchers in Education and the Social Sciences”, Seidman, (2006) makes a case for how he became inspired by “the impact of social and cultural forces on individual experiences in education” and began to challenge the basic assumptions of positivism and behaviourism that formed large part of his background in research methodology.

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Ehigie, 2005: 621) to understand the stories of their subjects because “when people tell stories, they select details of their experience from their stream of consciousness” (Seidman, 2006: 7) and that “every word that people use in telling their stories is a microcosm of their consciousness” (Vygotsky, 1987: quoted from Seidman, 2006: 7). This forms an integral part of the epidemiological assumptions in the qualitative research paradigm. Usually, qualitative research uses various methods known as triangulation to answer intriguing research questions (Wicks and Whiteford, 2006: 3), the essence of which is to produce a more comprehensive description of the social phenomenon and to achieve an in-depth understanding of the subjects under investigation (Hesse-Biber and Leavy 2004: 9). The common belief in qualitative research is that human experiences, feelings, opinions and their very existence are too complex to be presented and represented in numerical terms as portrayed in a quantitative, positivist or empiricist paradigm. In other words, qqualitative research method is less inclined towards rigorous statistical analysis commonly found in quantitative research paradigm (Eghie and Eghie, 2005: 621). “Thick descriptions” are required in understanding human experiences and only qualitative research can provide such thickness and informative analysis (see Geertz, 1973). Thus, the subjective dimensions such as motivations, intentions and free-will which have eluded quantitative researchers have become the primary focus of qualitative tradition; the very reason why qualitative enquiry addresses meaning centred questions that are difficult to quantify (Gysels et al. 2008: 2). As a method of investigation, qualitative researcher “relies on views of participants, and discusses their views within the context in which they occur to inductively develop ideas in a study from particulars to abstractions” (Creswell, 2007: 248).

During the early stage of qualitative research, most conservative quantitative researchers appeared to be skeptical, apprehensive and pessimistic about the authenticity, validity and reliability of qualitative research paradigm. Hence, qualitative research was relegated to the secondary status (Creswell, 2007: 5). The resultant effect was what appeared to be an ‘academic battle’ where supporters of each of the paradigms providing dazzling argument to justify the ontological and epistemological positions of their research. The battle for survival for each of the paradigms especially qualitative research has been reported across the world. Bruni and Gobo (2005: 1) maintained that early development of qualitative research in Italy was characterised by what they called the hegemony of Crocean idealism and deliberate attempt by survey researchers to condemn, discredit, dishonour and disrepute qualitative research methodology.

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Unfortunately, the tension or stalemate between the qualitative and quantitative research, characterising the early years of qualitative research, was perceived as ‘non-progressive’ in some quarters. This led to the emergence of the third methodological movement that challenged the supremacy of one single method over the other (Gorard and Taylor, 2004: 1). The new movement emerged to unite both methods and to suggest that both methods of enquiry can be merged together within a particular research context (Gorard and Taylor, 2004: 2; Schulze 2003: 8). This argument is contained in the mixed-methods of investigation. The methodology believes that the union between quantitative and qualitative methodology could accommodate the strengths of each of these paradigms and cover up their weaknesses at the same time. Some have structured models or approaches for the integration of qualitative into quantitative methodology. One of these is the phase-model approach which proposes qualitative study then quantitative. Here, qualitative methodology is seen as a benchmark or avenue for the formulation of hypotheses which can then be sufficiently tested using quantitative statistical models (see Kelle and Erzberger, 2004: 173). Others are qualitative then quantitative and qualitative and quantitative approaches concurrently (see Darlington and Scott, 2002: 121-124). However, even argument like this is implicitly or explicitly motivated by the belief that one method of research is again superior to the other. For instance, in the understanding of the phase- model approach, the quantitative research is still believed to be superior to qualitative research with respect to validity of the results and findings in qualitative studies (Kelle and Erzberger, 2004: 173).

There are, however, a growing number of qualitative researchers who have continued to twit the argument that suggests the integration of qualitative into quantitative studies suggesting further that each of these approaches can stand independent of one another. Such an independent approach could also help to preserve the integrity and dignity of each of these methods of research. Creswell (2007: 11) contends that “qualitative inquiry represents a legitimate mode of social and human science exploration, without apology or comparisons to quantitative research”. Byrne (2004: 182) argues that the qualitative approach is widely honoured “by those who come from an ontological position which values people’s knowledge, values, and experiences as meaningful and worthy of exploration”. These researchers explore the underlying meanings attached to everyday lived experiences by the people because human actions are best understood only when they are studied from the very “own eyes” of the subjects. Qualitative methods have become to be perceived as major tools in the quest for a deeper understanding of social and cultural phenomena (Denzin and Lincoln, 2003: 18-29). It examines issues in-depthly and provides answers from the point of view of the

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participants. Qualitative research method studies the why and how of things such as disease, health and illness in this study and not just what, where, and when? It focuses more on smaller rather than large samples to enable in-depth analysis. A qualitative researcher “builds a complex, holistic picture, analyses words, reports detailed views of informants, and conducts the study in a natural setting” (Creswell, 2007: 249). Some contemporary qualitative researchers have taken a more controversial position arguing that qualitative research is more ‘superior’ to quantitative research paradigm because “it provides a ‘richer’ and ‘more valid’ basis for social research than simply dealing with numbers and measures” (Yates, 2004: 139).

Indeed, classical and contemporary qualitative researchers who are passionate about qualitative research and subscribe to its basic principles and “rules of engagement” have produced a corpus of theoretical and empirical evidence that support their beliefs and orientations, all of which have proven qualitative research to be an important paradigm shift to the understanding of social reality in the world of social science research. Consequently, qualitative research has gathered and continues to gather momentum from virtually all fields of study in the social and humanitarian sciences. It has given fresh impetus to a new way of doing research by unearthing the ‘truth’ about human existence and experiences of the social world. According to Yates (2004: 138) contemporary qualitative researcher attempts to achieve one or more of the following objectives:

• An in-depth and detailed description of a particular aspect of an individual or group’s experiences;

• An exploration of how individual or members of a particular group give meaning to and express their understanding of themselves and/or their worlds;

• To discover and provide full detail of social events and explore the reason(s) why they unfold;

• An exploration of the complexity, and specific detailed processes taking place in a social context.

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It was on this basis that qualitative research paradigm was adopted as an autonomous method of investigation in this study to understand treatment of malaria from the point of view of the subjects in both rural and urban communities of Nigeria. The subject-matter and the problem of this study make this approach a suitable and the most appealing method of enquiry with a view to understanding local construction of malaria in children under the age of five.

However, contemporary qualitative research is inundated and characterised by internal crisis that includes ontological, epistemological and methodological divides unlike what it used to be few years ago. They include qualitative research methodologists (qualitative researchers who subscribe to rigorous methods of research); the philosophical advocates (consist of those whose concern is to identify and expand “the number of paradigmatic and theoretical lens in qualitative research”); the social justice researchers (who promote the social ends for qualitative research); and those in health sciences whose primary concern is to augment their quantitative studies (Creswell, 2007: 4). The basic challenge was therefore how to locate or situate the current study within the complex epistemological, methodological and ontological stances that characterised modern qualitative research. Fortunately, this complexity seems to have been simplified by Creswell (2007: 4) when he streamlined different possibilities in modern qualitative research into five major approaches: narrative research, phenomenology, grounded theory, ethnography and case study. Related to the present study are ethnography and case study approaches.

Figure 4.1: Approaches to the study: Ethnography and Case Study

Case Study Ethnography

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4.2.1.1 Ethnography Ethnography is a qualitative research method that utilises field observation to study a society’s culture and human actions (Ehigie and Ehigie, 2005: 625). Ethnographers are interested in people’s story as a way of understanding their ways of life. This is usually done by focusing attention on how the local people construct their world over time. Ethnographers usually provide non-interpretative, photographic pictures of a series of activities within a culture. Ethnographic research is however rooted in anthropological studies. Both are therefore intimately and cordially connected. The earliest anthropologists such as Bronislaw Malinowski, Edward Evans-Pritchard, Alfred Reginald Radcliffe-Brown and Boas have used ethnography as a method of investigation in their quest to understanding the non-Western cultures and societies (Umejesi, 2010: 87). One of the foci of a researcher using this method of investigation is to capture the perspective of the subject’s worldview; seeing things from the very “own eyes” of the subject. The job of an ethnographer therefore is to detail the routine daily lives of people by focusing more on predictable patterns of their behaviour (Ehigie and Ehigie, 2005: 625). In some cases, an ethnographer may actually become a permanent member of the group or culture he is investigating. This was the case with Verrier Elwin, an English anthropologist, who worked among ethnic Indians and got married to one of them (see Umejesi, 2010: 87). Thus, in line with ethnographic study, this study focuses attention on how the local people have constructed their own world over time with reference to malaria disease in children younger than five years of age and to capture the local perception and management of malaria.

4.2.1.2 Case Study The case study approach has been selected as an entity of study and as a method of enquiry (Creswell, 2007: 73) in this research because it provides an insightful analysis of a phenomenon under investigation. Creswell (2007: 73) notes that while the primary concern of ethnographers is to determine and describe how a culture works using an entire culture-sharing group as a case, it often falls outside the jurisdiction of ethnography to understand an issue or problem using the case as a specific illustration. This is the job of a case study researcher.

According to the Sage Dictionary of Social Research Methods, a case study is carried out for an in-depth analysis of one (instrumental case study) or more examples (multiple case study) of a current social

106 phenomenon, using a variety of sources of data (Jup, 2006: 20). The case study aspect of this research therefore is inclined towards the exploratory design as the researcher seeks to function within a broad theoretical framework rather than gathering evidence that refutes or supports a particular theoretical orientation (Dyer, 1995: 51). May (2001: 29) argues that “the ability to explain and understand the findings of research within a conceptual framework that makes ‘sense’ of the data, is the mark of a mature discipline whose aim is the systematic study of particular phenomena”. The exploratory aspect of this research provides an in-depth sociological account of the conception and treatment of malaria among, mostly, the economically disadvantaged people in the rural and urban areas of Nigeria using a combination of methods (triangulation) that includes data triangulation, the use of different data sources; investigator triangulation, used to minimise researcher’s bias resulting from the researcher as a human being; theory triangulation, approaching data from different perspectives and hypotheses; and methodological triangulation, researching within and among methods (Denzin and Lincoln, 2003: 289). In this study therefore, triangulation has helped to harness the strengths of different methodological view points with a view to arrive at a more accurate, valid and reliable conclusion.

On the final note, in the most recent time, qualitative research has attracted researchers across disciplines that include health research. According to Wicks and Whiteford (2006: 3) qualitative design has been established as a paradigm of choice that addresses various complex issues in health and human services. McKinlay (1995, quoted from Flick, 2009: 25) is of the opinion that “in public health qualitative methods lead to relevant results at the level of socio-political topics and relations due to their complexity”. Foster and Vilender (2009) have used qualitative data to understand local treatment of malaria in children in Tanga, Tanzania. Finally, according to Wicks and Whiteford (2006: 4) health research epistemologically rooted in qualitative research paradigm assists in understanding the complex web of relationship between human activities, their health and social life. It is on this basis that the qualitative paradigm was adopted as a method of investigation to understand management of malaria from the very “own eyes” of caregivers in this study.

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4.3 Qualitative Instruments of Data Collection Qualitative research is usually multi-method in nature as enumerated above based on the general principles of method triangulation or complementary methods. Therefore, the principal and the most appropriate qualitative instruments used to collect data for this study were the semi-structured interview, in- depth interview, and focus group discussions (FGDs). These techniques were employed to obtain answers to the stated research problems in order to achieve the objectives of the study as mentioned in the first chapter of this thesis. Other reasons for using these techniques are that:

i) The majority of the potential respondents were illiterate and therefore could not read nor write;

ii) It was assumed that the potential respondents were familiar with the interview method as a communicative event considering the fact that discourses about malaria between health practitioners and caregivers usually occurred in interview format using direct verbal questions; and finally;

iii) It is common knowledge that qualitative interviewing is useful in exploring an individual’s attitude and values (Byrne, 2004: 182) and that it is a veritable tool that allows the voices of caregivers to be heard in health studies like this (see Gysels et al 2008).

The data for the study were gathered between October and December 2009 and a follow-up took place between September and October 201013. All interviews and FGDs were conducted in the local language and later transcribed into English for analysis, although in some interviews participants mixed both local and English languages as a medium of communication. All interviews and discussions were tape-recorded. A note book (jotter) was also used to take field notes particularly on non-verbal aspects of the interview that included distractions, respondent’s nervousness or otherwise, key terms and names where important. In rural areas the interviews usually took place in the evening when people had returned from the farm. At the hospital, interviews used to take place in the mornings on Tuesdays and Thursdays for respondents whose

13 Two undergraduate students (hereby known as ‘Femi’ and ‘Kunle’) and one postgraduate student (hereby known as ‘Kola’) of the University of Ilorin, Nigeria, rendered assistance in the process of data collection and collation. They had received training on mechanisms for qualitative research and the best means of handling qualitative data. A young man from the Okanle also volunteered to take us round Okanle and Fajeromi and meet potential respondents even though the researcher was already familiar with the environment.

108 children were not on admission although there were exceptions. Tuesdays and Thursdays were set aside for immunisation programmes for children under the age of five at the Specialist Hospital. Interviews were conducted for those whose children were on admission on an agreed time decided by the participants, which usually took place during visiting hours. Throughout the course of the interviews, the participants were given the freedom to start and end the conversation when they felt like, yet making sure that all elements of the issues were covered.

4.3.1 Semi-structured interview Semi-structured interview is open-ended, flexible and adaptable to various empirical contexts (Corbetta, 2003: 269). However, the degree of openness and flexibility depends largely on the type of interview the researcher intends to do which is further dictated by the research questions, objectives, design and the practical possibilities and limitations. As a result, to examine the local knowledge about the perceived aetiology, threat and symptoms of malaria in children under the ages of five and explore communities’ knowledge and sentiments about preventive measures, 40 semi-structured interviews involving 40 respondents (20 in the rural settings and another 20 in urban) were carried out among caregivers. During the interviews, a pre-set agenda was used to define the flow of the interviews known as the interview guide. The interview guide helped to draw the boundaries within which the interviewer decided not only the order and the wording of the questions but also the themes of investigation in greater depth (see Corbetta, 2003: 270-271). Yet both parties (the interviewer and the interviewees) were not completely tied down by the guide. Both had freedom to touch on relevant issues important for a fuller understanding of the respondent’s opinion and perception about the subject-matter, even where these were not raised in the previous interviews. Where questions were not clearly answered by any of the respondent the interviewer asked for clarity immediately. Each of the interviews lasted between 20 and 60 minutes and was tape recorded.

4.3.2 In-depth interview An in-depth interview is a qualitative field research data-gathering instrument designed to generate narratives that focus on specific research questions under investigation. It is a deeper and lengthier conversation between the interviewer and the interviewees. In in-depth interviews emphasis is often placed

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on “depth, detail, vividness, and nuance” (Rubin and Rubin, 1995: 76). It is commonly used when a researcher intends to gain detailed examples, narratives and understandings of a research under investigation (Yates, 2004: 158) as was the case in this study. One of the basic assumptions in in-depth interviewing is that the meaning people make of their experience often affects the way they conduct themselves (Blumer, 1969: 2, Seidman: 2006: 10). Therefore, to understand the routes to the management of malaria when it occurred in children under the age of five and explore the socio-cultural variables that enhanced or constrained the health care seeking behaviour of caregivers, 20 key informants were selected among the caregivers (10 in rural areas and 10 at the Children Specialist Hospital) and in-depth interviews were carried out. The key informants included opinion leaders and village heads. This category of respondents represented important figures in their respective communities.

In addition, another eleven key informants were selected among modern and traditional practitioners. They included two medical doctors, four nurses and one administrative officer from the Children Specialist Hospital in Ilorin; a health attendant14 and nurse in Okanle/Fajeromi Basic Health Centre and two traditional pharmacists. The selection of medical professionals (both traditional and modern) as key informants was based on the fact that their knowledge, status, expertise and everyday experiences had brought them into contact with caregivers in their respective communities. So, they were assumed to have some knowledge about the subjects and matters important to research themes and objectives. While there is no specific time-line for an in-depth interview of this nature, each of the in-depth interviews lasted between 20 and 60 minutes.

4.3.3 Focus Group Discussions (FGDs) A Focus Group Discussion (FGD) was the third instrument of data collection. FGDs have recently received attention from academics from across disciplines and countless empirical studies have been conducted using FGDs. An FGD is a combination of some elements of both interview and participant observation (Morgan, 1988: 15). It is usually centred on a specific topic of interest like malaria in children under the age

14 During a follow-up in 2010, it was discovered that the health attendant who was previously interviewed had been transferred and replaced with another person. The researcher decided not to interview the new staff member since he was new in the environment.

110 of five where the researcher capitalises on group interaction to generate the required data. FGD data “illustrate the provisional and developmental character of personal opinions, with group members qualifying and extending their views in the course of the discussion” (Bloor et al. 2001: 11). Morgan (2004: 265) observed that FGD has gained momentum in virtually all academic disciplines including many of the specialty areas in sociology like medical sociology. The popularity of FGD cannot be disconnected from the fact that it has the advantage of generating different data a face-to-face interview would not have produced and that it can be beneficial to both the researcher and the respondents (Byrne, 2004: 181).

This method is particularly useful for allowing participants to generate their own questions, frames and concepts and to pursue their own priorities on their own terms, in their own vocabulary. Focus groups also enable researchers to examine people’s different perspectives as they operate within a social network (Byrne, 2004: 181).

It should be noted, however, that researchers are yet to reach consensus about the size or the number of FGDs that can provide saturated viewpoints in any kind of study. This is one critical decision that researchers have to make and control (Morgan, 2004: 265). Hence, to understand the socio-generational changes in the patterns of health care utilisation between young and older caregivers, a total of four FGDs (two in each rural and urban area) were conducted for each group of young and older parents. Each stream of the FGD comprised between six and eight participants. The composed groups were as homogenous as possible based on age, marital status, having children under the ages of five, and geographical location. Participants were brought together in a common place; provided with incentives and refreshments and thus, the group discussion took place in a relaxed social atmosphere. In rural areas, the discussion took place under a tree while that of the urban took place in a quiet, private and comfortable room organised by an informant in Centre Igboro. Each of the group discussions lasted between one and two hours. The FGD took place under the guidance of the researcher known as moderator in this context who performed the following roles adapted from the work of Tonkiss (2004: 204):

• Facilitated interaction and discussion; • Encouraged different group members to make their opinion known;

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• Kept the group discussion focused around the core issues; • Coordinated group discussion to control dominant or inappropriate voices.

The major advantage of FGD in this context is that it allowed the researcher to gain insight into the complex cultural dynamics of the communities under study and brought out aspects of the topic that would not have been anticipated by the researcher and would not have emerged from interviews with individuals (see Babbie, 2005: 317). According to Tonkiss (2004: 194) FGD “can take different forms, and be more or less structured”. In this case, the moderator used an FGD guide containing a fixed schedule of questions to maintain the flow of discussion. The categories of respondents can be summarised using the table below with their details provided in the next chapter:

Table 4.1: Number and Categories of Respondents

Category Frequency of interviews Semi-structured interview 40 caregivers including men and women In-depth interview 31 (20 caregivers of men and women and 11 medical professionals) Focus Group Discussions (FGDs) 28 caregivers (women only) Total 99 interviewees

4.3.4 Visual methods Visual methods have been well established in academic research and literature. However, it has a long history in anthropology and ethnography. Recently, visual methods have taken on new dimensions. When combined with other qualitative research instruments, visual methods could provide an opportunity to reconsider contemporary social problems from a new perspective (Liebenberg, 2009: 444). Generally, data generated using visual methods, particularly photographs and dialogue, can provide a better insight into the social reality of human condition and lead to a richer understanding of the socio-cultural and contextual factors in human behaviour (Keller et al. 2008: 429). Some authors have argued for the incorporation of images in interviews because 1) they could facilitate the interview process; 2) bring greater depth to the

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issue under discussion; and 3) enhance the quality of data generated (cited from Liebenberg, 2009: 444). In sociology, like in other qualitative research, visual method is a distinct but minor sub-discipline concerned with the analysis and interpretation of photographs (Mason, 2005: 328) in understanding social reality of human beings. In this study, visual methods have been adopted to take images and environmental characteristics of the communities studied in order to understand the social reality of the communities studied.

4.4 Population of Study and Sampling Procedures The categorisation of caregivers in the studied communities was complex and problematic. Caregivers went beyond the biological parents to include a whole range of blood relatives commonly referred to as “significant others”. Therefore, the targeted populations were caregivers of children below the ages of five. They included biological parents [male and female] as well as grandparents. The involvement of grandparents in the study became important because they are culturally considered as active players in child rearing and caring in the communities. In the urban centre, participants were drawn from the Children Specialist Hospital. Among them were those who had visited the hospital for malaria related problems and those whose children or wards under the age of five were on admission for malaria-related complications such as convulsions and anaemia. The samples were selected using non-probability sampling techniques known as purposive sampling where participants are drawn on the basis of having a significant relation to the research topic (Tonkiss, 2004: 199). The use of purposive sampling was “to avoid chance fluctuations that might excessively distance the sample from the characteristics of the population” (Corbetta, 2003: 222). Thus, the researcher had established pre-determined characteristics of interviewees to be selected. In rural areas, the list of participants who had previously presented cases of malaria in their children were obtained from the health facilities (though this number was few) while those who had not previously reported cases were selected from their homes until the researcher had enough respondents required for the study. These caregivers were interviewed in their natural settings because according to Denzin and Lincoln (2005: 3) qualitative research like this, studies “things in their natural settings, attempting to make sense of, or interpret phenomena in terms of the meanings people bring to them”. The number of respondents involved in each of the instruments of data collection is provided in the next section. This sampling technique was employed to enable the researcher select the most appropriate respondents that could provide answers to the questions raised in this study.

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4.5 Gaining Entrance into the Study Areas During the first visit to Okanle and Fajeromi, the researcher and research assistants paid homage to the traditional rulers as a mark of respect to the institution where the letter of introduction duly signed by one of the researcher’s supervisors was presented and read out to each of the village heads (see appendix II). This explained our mission to the village heads who readily gave permission for the study to be conducted. In fact, the village heads helped to mobilise participants for the study through some of their chiefs. The respondents received us with open arms. The rapport, understanding and quietness of the environment made data collection in these areas easier and less stressful compared to the hustle and bustle of the hospital environment in the urban area.

At the Children Specialist Hospital on the other hand, the same letter of introduction was presented to a senior administrative officer in the hospital who pledged support for the study and subsequently introduced the researcher and his team to some of the nurses and doctors. Through the assistance rendered by the nurses the researcher was able to speak to as many participants as required by the in-depth and semi- structured interviews. Although there were many health caregivers who came for consultations for malaria related problems at the hospital, only those willing to participate in the study were recruited and interviewed.

4.6 Data Analysis

In this study, data analysis was done both manually and electronically. Both methods were used to corroborate one another. Manually, data were sorted into different themes based on the earlier formulated questions and objectives to reflect potential views and responses of the subjects of concern. As argued by Welman and Kruger (2002: 194) content analysis, like the one adopted in this study, seeks to interpret qualitative data results by seeking ‘recurrent themes’. This approach requires the researcher to examine the content in a systematic manner so that emerging trends, their frequency of occurrence and the manner in which they are portrayed are captured and reflected in the research study.

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Qualitative research is a liberal method of research. Hence, qualitative data reporting or analysis is characterised by lack of specific and distinct rules as known in quantitative approaches (Henn et al., 2006: 197). Neuman (2007: 335) notes that “qualitative data are more diverse, less standardised, and less explicitly outlined”. There exist different approaches to interpreting and analysing data, none of which is widely accepted (Neuman, 2007: 328) and none of which can be said to be most superior. The choice of method of analysis is therefore a matter of interest in qualitative research which is always guided by the research questions and data. Padgett (1998, quoted from Darlington and Scott, 2002: 160) has differentiated between two dimensions relating to voice in qualitative research. They include ‘etic-emic’ approach and ‘reflexive-non-reflexive’ approach. From these two broad approaches Darlington and Scott (2006: 160) delineated four quadrants further, each of which represents different approaches in writing a research report such as this. They are the ‘etic-non-reflexive’, ‘etic-reflexive’, ‘emic-reflexive’, and ‘emic- non-reflexive’ approaches. The approach adopted in the current study is the ‘emic-non-reflexive’ approach where the researcher usually emphasises the lived experiences of the participants with minimal input originating from the researcher’s understanding and interpretation (cited from Darlington and Scott, 2002: 160-161).

Recently, methods of data analysis have taken a new dimension however. This started to unfold in the mid- 1980s with the invention of computer software packages for qualitative data analysis [QDA] (Weitzman, 2003: 311). The incorporation of these changing trends in this study became important against the background that QDA has received much attention and hence extensive literature and essays have been devoted to it in the most recent time. Examples of literature devoted to computer software packages are abound. However, Weitzman (2003: 314) noted that software packages for QDA only provide the tools to help analyse qualitative data, it cannot do the analysis itself, at least “not in the sense in which a statistical package like SPSS or SAS can do, say, multiple regression”. The bulk of the QDA still lies with the researcher.

The NVivo software package (Version 9) was used to aid analysis15. NVivo is a qualitative data analysis software package used to analyse interviews, field notes, textual sources and other types of qualitative-

15 The researcher had sought the assistance of an expert in the qualitative data analysis using computer software packages.

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based data. First of all, collected data were transcribed from the local language to English and typed in MS Word thereby converted into a readable file. Each interview and FGD was entered as a single file. The files were later coded. However, in view of the earlier submission, matrices were manually generated based on the research questions and objectives of the study from where interpretations of substantive themes were developed (see Chapter five).

4.7 Ethical Considerations Ethical issues are of vital concern in social research and have been extensively discussed. They are conceived to safeguard and protect the rights of participants against any harm, and to ensure confidentiality of participants (Bloomberg and Volpe 2008: 76). Thus, in this research these issues were observed according to the best efforts of the researcher.

First of all, emphasis was placed on maintaining high scientific standards in the methods of investigation, analysis and interpretation of data. In addition, the study was conducted responsibly and in accordance with the ethical standards and legal norms of the communities studied. The traditional institutions and the norms guiding the institutions were honoured and respected. Constant homage and visitation was made to the traditional institutions in the rural communities as a mark of respect and honour. The researcher’s relationship with the respondents was clearly defined and balanced. The participants were informed prior to the commencement of the interview and discussions were held about the nature and objectives of the study. The subjects’ participation was voluntary and as fully informed as possible and no group was disadvantaged by routinely being excluded or included for consideration. Each participant signed a consent form to confirm their participation in the study (see Appendix IV for a sample of the consent form). Participants without western education used a thumb print to indicate signature. The respondents were treated with care, dignity and respect. They were assured that their identity would not be revealed in anyway. The respondents were asked not to reveal any information they felt to be embarrassing and uncomfortable to discuss. The respondents were told that although there were no material gains from the study in terms of money or project development, the project was an important avenue to voice their opinions and experiences particularly in the utilisation of modern preventive and curative measures in the prevention and management of malaria in children. They were told not to be afraid of mentioning traditional

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medicine where appropriate, because participants might think that we came to judge the use of traditional medicine in the management of malaria. They were informed that when published the study might be useful in designing policies that would have a direct impact on them in the future. It was clearly stated that their acceptance or refusal to participate in the study would not in any way jeopardise their personal or family life.

4.8 Problems Encountered This study touched on one of the most sensitive issues in the cultural landscape of the communities studied. This has to do with local discourses about witchcraft or the so-called evil doers. Indeed, some young participants found it difficult discussing the witchcraft matter. They believed they were too young to talk about sensitive issue like this because there is a general knowledge that the witches are so powerful that they could hear when you discuss them even in private corner of your room when they are not physically present. This can be linked to a local phrase that says: ogiri leti meaning “the wall has ears”. This apparently limited the ability of the researcher to deeply discuss matters surrounding witchcraft with younger respondents. However, the researcher depended on older respondents more to discuss witchcraft issues as some seemed more comfortable talking about it.

The problem of finance was also encountered. The costs of travelling to and from Nigeria, paying for accommodation in South Africa in order to do the write-up, medical aid whilst staying in South Africa and subsistence are daunting. However, with the financial assistance received from the National Research Foundation through the JM Uys Grant-Holder-Linked (GHL) Assistantships and Bursaries and the UJ Supervisor-linked Bursary, these problems were minimised to a large extent.

Another major problem was the limited time available to conclude the thesis given the pressure from the home University where the researcher teaches. To stay within these time limits the researcher made special efforts to manage his time efficiently and the supervisors advised that a work-plan be drawn for the conduct of the research. Based on the advice, the researcher came up with a tight plan or frame and all energy was directed towards working within the time-frame set. The work plan really helped.

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4.9 Summary This chapter has outlined the steps taken by the researcher in collecting and analysing data for the study. The research design adopted for the study was extensively discussed and the rationale behind the adoption was critically provided. In a qualitative research like this an attempt is made to understand social phenomenon from the perspective of the subjects using qualitative instruments of data collection rather than numbers and figures. The principal instruments used to collect data from the selected participants were semi-structured interview, in-depth interview, focus group discussion and visual methods. The participants were drawn using purposive sampling procedures. The triangulation of methods as employed in this study aimed to enrich the quality, plausibility and reliability of the study. Consequently, data analysis was conducted both manually and electronically. It was explained that the electronic software used to aid manual analysis was Nvivo (Version 9). Also discussed were the ethical issues surrounding qualitative study of this nature. To this end, it was explained that each respondent signed a consent form to indicate their willingness to participate in the study. The limitations of the study are acknowledged in the final analysis (see 6.3 in Chapter six).

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CHAPTER FIVE

DATA ANALYSIS AND DISCUSSION

5.1 Introduction

The purpose of this study was to explore the health care seeking behaviour of caregivers in rural and urban communities of Nigeria. It also sought to investigate the local dynamics that might hinder quick response to malaria in children younger than five years of age. The indigenous representation of malaria and patterns of treatment among the parents of these children were also interrogated and explored. It was believed that a better understanding of a community’s knowledge and response to malaria is indeed imperative to allow policy makers and educators to proceed from a more informed orientation in terms of policy design and implementation. This would allow successful execution of health programmes and initiatives aimed at improving local knowledge and treatment of malaria in children. Samples of caregivers were drawn from rural and urban areas of Kwara State, Nigeria. This chapter presents the analysis of the 40 semi-structured interviews, four focus group discussions (FGDs) and 31 in-depth interviews conducted in Okanle/Fajeromi and Ilorin. The chapter has been divided into three sections. In the first section, the socio-demographic characteristics of the respondents are brought to the fore. This is intended to introduce the reader to the personal information or characteristics of the respondents that participated in the study. In the second section, the results of the study are presented and analysed. In the final part, issues relating to the themes of investigation and findings are discussed. Through this, the research questions are answered and accomplished. For the purpose of clarity the research questions are reformulated below.

5.1.1 The Research Questions Restated: 1. How do caregivers in the communities of study perceive the threat, knowledge, aetiologies and symptoms of malaria in children below the ages of five and how does this corresponds to biological construction and does it matter?

2. To what extent does local knowledge and sentiment about preventive measures affect their utilisation in the communities of study and does it matter?

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3. What are the routes or pathways to health care utilisation in the management of malaria in children in both the rural and urban areas? In other words, does the pattern of health care utilisation differ between the rural and urban dwellers in response to malaria in children? If yes, why, and if no, why?

4. Are there any difference[s] in the pattern(s) of health care utilisation among the young and grandmothers in the management of malaria in children under the ages of five? If yes, what factors could be responsible for the difference[s] and do they actually matter?

5. What socio-cultural variables in the communities of study enhance or constrain the use of modern health care facilities in the management of malaria in children and why?

5.2 Demographic Characteristics of the Respondents

Table 5.1 below summarises the socio-demographic characteristics of the respondents (N= 99) with respect to gender, age, marital status, type of education and occupation as well as household income. A total of 99 respondents participated in the study including the modern and traditional practitioners. They included 27 males (27.3%) and 72 females (72.7%). This shows that by far the majority of the respondents were women. This is largely because women are culturally expected to be more involved in nurturing children than their male counterparts. The majority of the respondents were aged between 40-49 years while the minority were aged 70-89 years. Most of the respondents were married (N=83) living with their respective family members. A total of 14 (14%) were widowed/widowers. Only 2% of the respondents were separated / divorced. This might suggest that the divorce rate in the studied communities is very low with culture playing a significant role. Of the caregivers (N=88), the majority (60%) had a maximum of two children under the age of five. Only 16% of the respondents had formal education including Bachelor Degrees and Diploma qualifications in nursing and education. Most of the respondents had no formal education (84%). The majority of the rural participants were farmers. In both the rural and urban areas 22% were self-employed with the majority engaging in petty trading or buying and selling in the market or on the street. The majority of the educated respondents included the nurses and doctors (N=9), two of whom were student medical doctors (non-permanent members of staff) from the Children Specialist Hospital; five nurses; one administrative officer; and a health attendant.

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The average income was generally low. The majority of the respondents (N=64) earned between 1000 ($7) and 5000 ($33) per month. Even though there was widespread traditional belief particularly about witchcraft, none of the respondents practised traditional religion. An overwhelming majority of the respondents (90%) were Muslims with only 10% Christians. In Ilorin the majority of the respondents came from Ilorin-South local government areas that included Adangba, Fate/Tanke, Balogun Fulani, Centre Igboro, Kankatu and Akerebiata.

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Table 5.1 Socio-Demographic Profile of the Respondents

Study variables Number of cases Percentage Gender Male 27 27.3 Female 72 72.7

Age groups 20-29 13 13.1 30-39 16 16.2 40-49 24 24.2 50-59 19 19.2 60-69 11 11.1 70-79 08 8.1 80-89 08 8.1

Marital status Single 00 0 Married 83 83 Divorced 02 02 Widowed/widower 14 14

Type of education Formal education 16 16 Informal education 83 84

Religion Islam 80 90 Christianity 10 10 Types of occupation Formal 15 15 Informal employment 62 63 Without a job 22 22

Household income per month (in naira) 1000-5000 64 65 5001-10000 10 10 10001-20000 03 3 20001-30000 06 6 30001-40000 2 2 Don’t know/not sure 14 14

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5.3 Local Knowledge, Perceived Threat, Aetiology and Symptoms of Malaria

The first research question posed earlier is loaded with a lot of information and topical issues. The presentation and analysis of results is therefore organised and structured in four different phases that include the local conception and knowledge of malaria, perceived threat of malaria, the perceived aetiology and symptoms of malaria in children. This was to ensure proper organisation of ideas and issues. Recall that the interpretation and analysis of data gathered were done using ‘emic-nonreflexive’ approach (see previous chapter).

5.3.1 Local Conception and Knowledge of Malaria

Malaria is a very common disease in Africa. However, how malaria is perceived varies from one community to the other. For instance, in a study conducted in Ifakara in Tanzania, a clear conceptual designation exists to describe malaria. In this community, malaria is often referred to as homaya malaria (malaria fever) often used interchangeably with homaya mbu (fever due to mosquitoes) (Hausmann-Muela and Ribera, 1998, cited from Okafor and Amzat, 2007: 157). Among the rural women in Uganda, omusujja is the local term used to describe malaria (Kengeya-Kayonda et al., 1994, cited from Okafor and Amzat, 2007: 157). Outside Africa, malaria is locally known as malarya in Morong, Bataan, Philippines, (Espino and Manderson, 2000: 1312). Similarly, in the current study, local discourses about malaria are found to be entrenched in communities’ established indigenous illness representation - an indication that malaria has been an age-long disease in the communities studied. Iba is a popular Yoruba term used to describe malaria among the people studied and used as a general term to accommodate different phases or dimensions of malaria sometimes with some prefixes and suffixes.

The description of iba among the people seems to be consistent with the biomedical construction of uncomplicated malaria. In the communities’ understanding of iba, a distinction is often drawn between abo- iba and ako-iba where abo refers to “female” and ako to “male”. Literally, abo-iba refers to “female-malaria” which connotes ordinary or mild malaria. Ako-iba, on the other hand, literally connotes “male-malaria” which can mean “stubborn” or chronic malaria because of the common belief that a male child is “stubborn”. Normally, the distinction between ako - and abo-iba depends on the perceived symptoms, manifestations

123 and duration of malaria at any point in time. For instance, iba-apanju (symptoms of typhoid fever) was considered by the majority as an example of ako-iba. This episode of malaria is believed to turn the colour of the eyes-balls into yellow according to the respondents. The distinction between ako-iba and abo-iba in children was drawn based on the knowledge of malaria in the adult population. While the people studied were able to distinguish between “abo” and “ako-iba”, unfortunately, such distinction does not accurately correspond to the biological distinction of complicated and uncomplicated malaria.

The health workers interviewed shed light on the distinction between complicated and uncomplicated malaria in this study. According to them, cases of malaria usually start with mild malaria but can become complicated where urgent treatment is denied. The most common cases of complications cited were convulsions and anaemia. Based on the experiences of the health workers (especially those interviewed at the Children Specialist Hospital in Ilorin) they were convinced that children whose parents belong to the lower social class or socio-economic status are prone to experiencing complications more than those from better-off families. For instance, a student medical doctor at the Children Specialist Hospital argued that “complicated cases of malaria are most common among people with lower educational background (s) because they want to avoid coming to the hospital at all costs”. This, they believed could be worsened by a lack of resources and cultural beliefs. One of the nurses gave an example of a woman whom she said burst into tears and almost collapsed when the amount needed for blood transfusion was announced to her because her son was suffering from anaemia. “Unfortunately without the blood transfusion the child might not survive” she said. Among the people where convulsions locally known as giri occurred in children, the majority believed it was a different health problem entirely common among the children during the raining season. An example of the misunderstanding was expressed in the following statement by a 72 year old grandmother at the Children Specialist Hospital in Ilorin whose grandchild was admitted for convulsions:

“My grandchild is on admission for giri (convulsions). That illness that makes children shake spontaneously and uncontrollable. It all started four days ago. When it started I bathed him with cold water and then administered agbo-ibile (local medicine) known as agbo-tutu. I used to give him the concoction every three to four days even when he didn’t manifest the symptoms. In fact, I used to give the herbs to our neighbours at no cost when

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their children manifest similar symptoms. This fateful day it was really a big surprise to me that the same herbs couldn’t contain it. I couldn’t believe it. It was bad. He kept running a temperature after giving him the herbs. It was disappointing. Then I concluded it was malaria. I took him to a nurse who owned a medicine store nearby to examine him. She gave us some drugs. When we got home I administered two out of the drugs she gave us then he collapsed. The whole body started to shake again and again. His eyeballs changed to that of a monster. I was scared. Immediately this happened I called his father on phone to take us to the hospital. It was obvious the sickness was beyond herbs this time around” (a 72 year old grandmother at the Children Specialist Hospital in Ilorin).

The majority of the health workers interviewed claimed that the caregivers used to receive health education about malaria and other childhood diseases at the health centres. However, this claim was refuted by the majority of the caregivers interviewed. A significant number of the respondents denied ever receiving health education from the hospitals or community health centres. What they knew about malaria, according to them, was based on personal experience and reported cases of malaria in and around the neighbourhood, the overall community’s knowledge of malaria as well as the training received from older parents and the community at large which form part of the whole process of socialisation. This confirms the argument raised by sociologists and anthropologists concerning the cultural construction of disease and illness (see 2.3 in Chapter two).

Insufficient knowledge of distinction between complicated and uncomplicated malaria as demonstrated by participants in this study is very common in both the rural and urban communities studied. While such inadequacies may constitute a threat to the broad fight against malaria, similar results have been documented in Nigeria and elsewhere. More than half of the sample studied by Foster and Vilendrer (2009: 4) in Tanga, Tanzania, believed convulsions depicted a separate disease with its origins in the spiritual world. Such negative attitudes and common belief has been attributed to people’s inability to recognise illness as a continuum of symptoms where mild illness can metamorphose to a more severe, chronic or deadly one (Akogun and John 2005: 5). A study of caregivers’ knowledge, attitude and practice towards malaria in children in Enugu, Nigeria found that the majority of the respondents (99% urban; 74% rural) had

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heard of malaria but were not aware of the susceptibility of children and pregnant women to the disease (Oguonu et al. 2005: 411).

From the aforegoing, it is obvious that local discourses about malaria are contained in community’s established indigenous representation of disease and illness. Even though some aspects of community representation of malaria correspond to biomedical constructions, the majority of the caregivers had no clear picture of the distinction between complicated and uncomplicated malaria.

5.3.2 Perceived Threat of Malaria

The magnitude of the threat of malaria to humanity in general was provided in Chapter one of this thesis. It was stated that malaria is ranked as one of the leading causes of morbidity and mortality in children younger than five years of age in Nigeria (Olasehinde et al. 2010: 159; Oshikoya, 2007: 49). Like many states in Nigeria, malaria is one of the major health problems in Kwara State where this study has been conducted and a common childhood disease in the communities studied. Malaria could cause serious damage and pains to children and their parents with multiplier effects on the entire society.

In the current study, the threat of malaria in children younger than five years of age was generally acknowledged by the majority of the caregivers interviewed. Although the communities studied had never experienced a malaria outbreak in children, according to the respondents, a significant number of the caregivers interviewed were of the opinion that malaria is more threatening to children than adult population. It is believed that adults are used to malaria and they usually know when a malaria attack is imminent and what to use to prevent or treat it. The perceived threat of malaria to children in Fajeromi was articulated by one of the participants who recalled that her one year old boy had manifested malaria symptoms and was treated more than four times since he was born less than a year ago. “This malaria thing is my greatest worry”, she said. Another caregiver in Ilorin argued that her presence at the Specialist Hospital where she was interviewed marked the third time she was consulting a doctor at the hospital since she gave birth to her daughter a year ago. “I am tired. I don’t know what to do again to prevent my children from having malaria”, she said. The threat of malaria to children explains why caregivers often take quick action once malaria symptoms are noticed in children. This concurs with the finding made by Nyamongo

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(2002: 378) among the Gusii people in Kenya. Among these people malaria is seen as a very serious health problem and quick action is often taken to avert some of its devastating consequences. However, in the Oguonu et al. (2005: 411) study only 9% believed that children were at the greatest risk of severe malaria.

The following statements describe the state of confusion and worry usually experienced by caregivers when children are struck by malaria. This could also be attributed to the intimate connection between malaria and other childhood diseases like diarrhoea and “worsened by children’s inability to express their feelings verbatim other than crying” said by one of the respondents in Fajeromi.

“As far as I know, malaria is a very common disease in this community. It is a fundamental health problem to children. My children have malaria too often. At least this little boy of mine has had malaria four times since I gave birth to him a year ago. I believe malaria in children should be taken very seriously because it is very dangerous. It can lead to harmful outcomes. In fact, it can kill. That is why I react quickly when I notice the symptoms in him. I think what makes malaria a threat to little children is because they cannot tell exactly how they feel when they are sick. Many of them cannot talk convincingly… That is when parents become confused” (a mother of one year old child in Fajeromi).

“Based on my experience, I do believe that malaria is a very dangerous disease. It is terrible. It causes a lot of distress. It can drain the blood. It causes unnecessary calmness in children. It uses to affect my children. The elder one was brought back from school just yesterday due to malaria”. (a mother from Ilorin).

The health officials interviewed testified to the threat posed by malaria in the studied communities among the children. They provided account of the occurrence, vulnerability and threat of malaria to children in the communities based on the number of casualties and episodes of malaria previously treated at the health facilities. One of the senior nurses at the Children Specialist Hospital in Ilorin recounted that 35 of the 38

127 reported cases of illness in children (which included complicated cases such as aneamia and convulsions) treated at the facility a day before the interview were malaria-related. Even though she was not aware of recorded deaths associated with malaria in children at the hospital, she argued that four out of every five cases of illness in children treated at the Specialist Hospital everyday were malaria-related. A similar notion was shared by the only designated nurse at the Okanle/Fajeromi Health Centre. For her, though there were few cases of complicated malaria, she maintained that two out of every five sick children presented at the basic health centre were malaria-related. This finding concurs with several reports that suggest that malaria constitutes a threat to children in Nigeria and indeed most African communities (WHO, 2003, 2010; WHO/UNICEF, 2003).

Similarly, this study has confirmed the fact that children can die from malaria. Many of the correspondents believed that failure to handle the malaria problem very effectively in children can lead to death. A 28 year old young mother of two cited an example of her sister’s child who died as a result of what she and other relatives believed was caused by malaria. She mentioned that when the case was initially reported at the community health centre, there were no medical personnel to attend to the patient. The parents were forced to report at the health centre in Idofian which was more than 5km away from the community. The boy, according to her, unexpectedly died the following morning. The woman narrated the incident in the following statement:

“There were times when children had died from malaria-related symptoms in this village. This happened to my sister’s child very recently. The child died after a brief illness everybody suspected to be malaria. He did not die at the local clinic because when they took him there, there was no doctor or nurse to attend to him. He was rushed to Idofian. He died the following morning. The boy was about two years old. He was living with his grandmother in the village. The biological mother lives in Lagos”. (a young mother of two children under five years in Okanle).

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According to the Surveillance Report on Malaria Cases and Deaths obtained from the State Ministry of Health, out of a total of 150 127 outpatients recorded in children and pregnant women in 2008 alone, children accounted for more than 140 000; of the 7 920 in-patients, children accounted for more than 7 000; and of the 31 deaths recorded, 24 were children (Kwara State Ministry of Health, 2008). As argued by some of the health officials, apart from the official reported cases, several cases of malaria in children could have escaped the State Ministry health statistics because of non-reporting owing to the widespread home management practice among the people. Therefore, based on environmental, economic, socio-cultural challenges, controlling and eradicating malaria in the communities studied might be a very difficult task. This notwithstanding, the acknowledgement of malaria as a serious health problem to children is a good starting point to minimising the problem of malaria in the communities.

5.3.3 Perceived Aetiology: Where Culture and Biology May Disagree

Cultural beliefs often influence the perceived causes of disease. In indigenous communities, disease causations are viewed from three major angles: natural, supernatural and mystical causes (Adegoke, 2007: 226; Bello, 2006: 325; Teshome-Bahiru, 2004: 30). The natural causes of disease coincide with the biomedical construction where diseases are believed to be connected with germs and other toxins introduced into the blood stream (Adegoke, 2007: 226; Bello, 2006: 325). Hereditary factors also fall under this categorisation. The supernatural and mystical causes fall within the non-scientific realm. They are usually linked to the interference of supernatural forces including witchcraft or evil machination of enemies. For instance, albinism, hunchback paralysis, blindness and dwarfism are usually linked to supernatural forces (Adegoke, 2007: 226). Consequently, the choice of health care system is often driven by the perceived causes of disease (Teshome-Bahiru, 2004: 30). Where it is believed that diseases are caused by supernatural and cosmic forces like witchcraft, traditional healers or faith-based healers (Adegoke, 2007: 225) are likely to be consulted. A study by Owumi (1993, quoted from Adegoke, 2007: 226) among the Okpe people in Delta State, Nigeria, confirmed that Edjele (witchdoctors) are consulted to end witchcraft- related illnesses.

In the same vein, the interviews with caregivers indicated that causes of malaria were believed to be multifaceted and multi-dynamic. Only about a quarter of the caregivers believed that malaria in children is

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caused by mosquitoes. This category of respondents believed that when a mosquito bites a malaria- infected child or person and goes to transfer it to a healthy looking child, he or she can develop malaria symptoms too. This notwithstanding, certain traditional views such as the belief that malaria in children can be caused by dirty water, food intakes, bedbugs, exposure to sun and teething-related problems conflict with biomedical constructions. Haemorrhoids are rarely reported in children. However, for a 70 year old man in Fajeromi “piles” (haemorrhoids) was believed to be the primary cause of malaria. He objected the biomedical knowledge that malaria is caused by mosquitoes outright in the following statement:

“I don’t believe malaria is caused by mosquitoes. Mosquito has not bitten me to the point of having malaria symptoms. Malaria is surely beyond mosquito bite. The major cause of malaria is piles. When one suffers from piles then there is every tendency he or she develops malaria. It is the same in both adults and children”.

An overwhelming majority of the caregivers stated that teething-problems in children are usually connected to many childhood diseases that include malaria. Respondents were divided along the belief that weather conditions have a connection with the occurrence of malaria in children. A significant number of respondents believed that when children sleep in the evening they might wake up weak and subsequently develop malaria symptoms. It is a common belief and as a result mothers used to discourage children from sleeping in the evening time after 4 o’ clock. There was, however, a consensus among the caregivers in both the rural and urban areas that when children played or stayed under the sun for too long or drank dirty water they could come down with malaria. For instance, it was stated by one of the rural participants that malaria in children is usually common during the festive season when children and grandchildren from all over the country gathered in the village to celebrate with their grandparents. She posited that many of the children ended up developing malaria during or after the festive visits “because of the difference between city and village waters”. She contended that the water in big cities such as Lagos and Ilorin is different from what is available in the village. In addition to drinking unsafe water, certain small insects in the rural areas called kotonkan were also believed to cause malaria in children by some of the respondents. The belief that teething-problems, dirty water, exposure to sun and some insects are connected with the aetiology of malaria in children in the rural area is summarised in the following quotations:

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“I do hear from people that mosquito causes malaria. As you can see we live in a village where mosquitoes are easily bred. There are too many of them. So, they could be right. But I also believe that when children play under the sun they usually develop temperature which often results to malaria. Teething-related problem can also result to malaria… There are also these tiny insects known as kotonkan that cause malaria in children”. (a 29 year old mother of two children under five years of age in Okanle).

A similar notion about aetiological factors in malaria was expressed in the urban area. An example is given below:

“Malaria is mostly caused by unclean water. Even the tap water they supply us is not clean enough to guarantee that children will not have malaria… We only take the risk of drinking the water though they do advise us to boil before drinking. Again, when small children play under the sun they could also have malaria”. (a 33 year old caregiver in Ilorin).

This finding is in line with several previous studies. In previous studies (Oguonu et al. 2005; Simsek and Kurcer, 2005) the causes of malaria were also attributed to drinking dirty water, exposure to sun, oily and bad food. Oguonu et al. (2005: 411) discovered that out of 224 respondents in their study, only 24% associated malaria with mosquitoes. Brieger et al. (2001: 14) posited that there are several points of overlap in aetiological attributions in Nigerian communities which include mosquitoes, overwork, sun exposure, dirty water, eating red palm oil and intense heat. Respondents in Ahorlu’s et al. (1997: 497) study claimed that asra (malaria) caused by heat would continue to remain in their community as long as the sun continues to shine.

“Bad” food was also attributed to the cause of malaria. During the interview, a small number of caregivers (usually the elderly parents) in both the rural and urban communities suggested that children could contact malaria through the kinds of food they eat. The argument was that in contemporary society certain food

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items that are consumed are injurious to the body system because they contain some acidic and dangerous components and ingredients. This finding concurs with the finding recorded in Ahorlu’s et al. (1997: 492) study where the majority of the respondents believed that malaria caused by food can only be prevented by eating “good” food. A 46-year old mother from Okanle said:

“Diseases were not common in those days the way they are these days. Malaria disease particularly in children is connected with the kinds of food we give them to eat. Here, I think there is generational gap and this is a very serious problem. The kind of food old people used to eat those days no longer exists or eaten by the young chaps. Yet, the kinds of food we eat are injurious to the body system. We consume and give these dangerous food items to our children. These items include the sugar intake and cooking ingredients like maggi16. Old people didn’t use to take sugar the way we take it these days. They didn’t even cook with maggi and that was why they lived longer”.

A similar belief was expressed by a grandmother of 75 years in the same village. To her:

“Most of the food items we eat these days make us sick. They are injurious to human body. These include sugar intake and cooking ingredients like maggi and soya beans. The old generations didn’t use to take these items and that was why they used to look very healthy and lived very long. My own parents were more than a hundred year before they passed on. Most of our children these days cannot take local pap and tea without sugar. So, people have many diseases and die very young because of these. Even if you decide you won’t give your children these items they eventually suck from the breast. So, they are prone to all kinds of diseases that can include malaria”.

16 Maggi chicken is one of the most popular cooking ingredients in Nigeria. It is made from Iodised salt, flavour enhancers such as glutamate, inosinate, guanylate; starch, sugar, vegetable fat, onion, maltodextrin, spices and spice extracts, condiments etc.

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During the interview, caregivers were asked whether malaria could perhaps be attributed to witchcraft locally known as Aje at any stage in malaria illness continuum in children. The Ajes are female ‘witchcrafts’. Their male counterparts are known as the olobe (literally transcribed to mean the one with a knife). Within the hierarchical structure of this entity, olobe can be described as the “errand boy” or an “executor” of a constituted judgement. According to Ifa17 poems, the Ajes are “entities who suck human blood, eat human flesh, and they can afflict human with various types of diseases” (Abimbola, 2006: 50). However, sometimes they can be benevolent but not without taking “kick-backs” or demanding high prices from their beneficiaries (Abimbola, 2006: 50). For instance, there is a widespread belief among the Yoruba speaking people that the most acceptable “kick-back” is “the child of whomever is seeking their favour” (Abimbola, 2006: 50). This issue became important considering the widespread belief in Yoruba cosmology that certain illnesses can be inflicted by certain people believed to be Aje who might have been offended by a victim’s behaviour or that of his relatives.

In the communities studied, there seemed to be a general belief that the Ajes have tremendous powers and are capable of harming anything and anybody. “If a parent offends these people they might get back at him by inflicting pains on his child which might begin with malaria-related symptoms”, said a father and grandparent. If the offender fails to accept his offence and appease them then, he risks losing his child. This is known as the power of the witchcraft. It is a hidden and mysterious power. A “witch” is believed to possess this power with which she may choose to punish an offender with any kind of ailment. This belief was found to be most common among the grandparents.

One of the village heads in the rural areas argued that the community’s experience has shown that patients have been referred back home from the hospital for traditional treatment having stayed long in the hospital

17 The concept of Ifa has different layers of meanings in Yoruba cosmology. Abimbola (2006: 47-48) identified six of them. i) Ifa is used to represent the name of the god of knowledge and wisdom. ii) It is used as in Ifa divination or Ifa dida. iii) It is also used as a body of knowledge (the Ifa Literary Corpus) connected with Ifa dida. Babalawo or Adifa (Ifa priests) and Iyanifa (Ifa priestesses) are the custodians of this Corpus. iv) Ifa has different poems. In this sense, it can be used to refer to any one specific poem from the Ifa Literary Corpus. v) It symbolises special herbal mixture prepared for medicinal purposes some of which are specifically specified in the Ifa poems. vi) It could also function as ofo (incantations) (see Abimbola, 2006 for the Ifa poems). 133 without any major improvement. Although few participants (usually the educated respondents particularly in the urban centre) disagreed or had mixed-feelings about the connection between metaphysical powers and malaria in children, more than half of the respondents felt that a prolonged and repeated episodes of malaria in children is an abnormal situation. When this happens, an average caregiver becomes suspicious of the unseen forces or powers. This belief usually comes to the fore when all efforts to treat malaria have failed. As found by this study, this kind of belief is often more common in the rural areas in both the young and older people. This may have a serious impact on individual and household resources in an attempt to find a cure. The following statements confirm this:

“As much as I believe that malaria can be caused by mosquitoes, I also believe that disease such as this can be afflicted by evil-doers. In this village in particular, there is a widespread belief that people with metaphysical powers may choose to punish offenders with all kinds of ailments… The good thing is that the witches don’t just unleash punishment on offenders without a tangible reason. It is only when you offend them that they attack you. Sometimes they wait till you have some natural symptoms of ailment before they can strike. It doesn’t mean they cannot cause destruction even when you don’t have symptoms of diseases. They can decide to punish you with all kinds of ailments or misfortunes that may even include malaria symptoms. Though, it might not necessarily be malaria, you might think it was. If parents offend them they might get back at him through his child…” (one of the village heads in the rural areas).

“If your child is repeatedly getting sick, then, that becomes abnormal. You have to be very suspicious because there are bad people outside there who are capable of harming innocent children. You cannot trust anybody because you don’t even know who is a witch or not. You wouldn’t have known a bad person from outside (i.e. physically). During the day they are humans. At night they become something else. There is nothing these evil people cannot do. They might even want to get at you through your child by inflicting pains on him which might begin with malaria-related symptoms”. (an elderly woman from Okanle)

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Similarly, the majority of the older participants in the urban centre expressed similar opinions. A 68 year old mother in Ilorin supplied personal stories and experiences to support the argument that witchcraft was a force to be reckoned with in her community and extended family compound. She believed that the evil- doers and witches were capable of inflicting pains which might include prolonged malaria symptoms. Should that happen, “the wise ones” (usually the traditional healers) are consulted (not the medical doctors) who try to fix the problem. She explained that her brother who was a priest had once told her that once an illness lasts more than five days, then the evil people were at work. She was made to believe that God is a good God and never do anything bad to harm people especially children. Only the bad people do bad things, she said. One of the outstanding stories she narrated was her experience when her three year old boy became critically ill and was desperate for help. At first she thought it was malaria disease but later discovered it was more than that and that the cure was also beyond modern medicine. Her experience is encapsulated in the following statement:

“It’s a long time ago. My child’s illness started with malaria symptoms like headache, body temperature, then dysentery, and then all of a sudden he became deaf and dumb. I became worried. Then, we took him to the hospital but there was no improvement. Later, I was advised by some friends to try the traditional measures. We had to travel both far and near in search of cure. I almost sold all my belongings to enhance my financial status to be able to raise money for treatment. At last, God finally answered my prayers and got the cure from a traditional healer far from this community. Believe me the boy would have died had it been we stayed longer at the hospital. I almost lost hope. He is an adult now”.

The attribution of malaria to witchcraft and evil-machination is in line with other works. In Chapter two it was argued complicated malaria such as convulsions (degedege) is often attributed to witchcraft or evil spirits in rural Tanzania (Foster and Vilendrer, 2009: 4; Makundi et al. 2006: 4). In fact, most of the respondents in Comoro’s et al. (2003: 309) study avoided mentioning it because of the cultural belief that it is a bad omen. More than half of the population studied by Foster and Vilendrer in Tanga, Tanzania, thought that “convulsions signify a separate disease, distinct from malaria, with its origins in the spiritual world” (Foster and Vilendrer, 2009: 4).

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In summary, although few participants supported the biomedical model of aetiological factors in malaria which explains mosquitoes to be the primary cause of malaria, a significant number of caregivers believed that children can contract malaria from different sources that include drinking dirty water, bedbugs and exposure to sun. Some also sensed a connection between severe or prolonged malaria and metaphysical powers. These findings concur with previous findings discussed in previous chapters that disease causation in indigenous African communities is viewed from different angles that include natural, magical and supernatural perspectives. The belief that malaria is caused by dirty water, exposure to sun and witchcraft is not only a misconception as far as biological construction is concerned, but it is also an erroneous understanding of the mode of transmission of malaria. Such misconstruction has also been documented across African and non-African communities. Incorrect knowledge about the causes of malaria as demonstrated in the current and other studies may have constituted an obstacle in the overall malaria control and eradication strategies. Table 5.2 below summarises and differentiates between the actual and perceived aetiological factors in malaria in children as reported by the respondents.

Table 5.2 Actual and Perceived Causes of Malaria in Children as Reported by the Respondents.

Actual Causes Perceived Causes • Malaria is caused by mosquitoes. They are Malaria in children can be caused by: of different species: Plasmodiums vivax, • Mosquitoes; falciparum, malariae, ovale and knowlesi: • Unclean water; The malaria parasite is usually transmitted • Food intakes; by infected female anopheles mosquitoes • Bedbugs; which must have been infected by having • Exposure to sun; drawn blood from malaria infected person. • Teething related problems; • Piles (haemorrhoids); and • Blood transfusion, and • Prolonged malaria can also be attributed • From pregnant mother to unborn child. to witchcraft or evil machinations.

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5.3.4 Perceived Symptoms: Where Culture and Biology Converge

One of the major problems in the fight against malaria in children might be related to the inability of caregivers to recognise the symptoms of malaria in children (Okafor and Amzat, 2007: 157). There is therefore the need to investigate local knowledge of the symptoms of malaria in children as perceived by the caregivers. It has been argued earlier in this chapter that in a medical parlance a distinction is often drawn between complicated and uncomplicated malaria each with different signs and manifestations. On the one hand, some of the clinical manifestations of uncomplicated malaria that have been noted and reported include fever, vomiting, high body temperature, coldness, headache, muscle aches and tiredness. These can be accompanied by shivering, loss of appetite (anorexia), general body weakness and joint pains (see Crawley et al. 2010: 1470; Makundi et al. 2006: 2). The clinical manifestations of complicated malaria on the other hand include anaemia (blood deficiency), convulsions, coma and even death (see Jamison, et al. 2006: 73).

In this study, symptoms and signs of malaria have been investigated as perceived by the caregivers in the communities studied to ascertain the correspondence (if any) between medical and communities’ understandings. According to the majority of the caregivers interviewed malaria in children is characterised by having general symptoms such as high body temperature, uncharacteristic quietness, loss of appetite and weight loss. It is argued that when children manifest these symptoms then malaria is imminent. From this argument it surfaces that there may be a correspondence or a point of convergence between biomedical construction of symptoms of malaria (uncomplicated) and community’s representations of malaria symptoms. In other words, biomedical views of symptoms of uncomplicated malaria particularly in children may be contained in the traditional views of how the malaria disease is manifested in children. Similar findings have been reported in previous studies. In the study by Ahorlu et al. (1997: 491) in Ghana, headache, high body temperature, vomiting, weakness of body and loss of appetite were mentioned as the principal manifestations of malaria (uncomplicated). The perceived symptoms of malaria in children in the current study are illustrated in the following quotations:

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“There are many symptoms of malaria in children. Once my child refuses to play around the way he used to; when he is weak and the body temperature is beyond ordinary; then I know malaria is coming. These symptoms, however, vary from child to child. Some children don’t run temperature when they have malaria but they may have a kind of cold. I have come to know these through my everyday experience and not through health talks with any health official. I use to observe the activities of my children and when something goes wrong I quickly notice and react immediately. A responsible mother should know when her child begins to have malaria problems because it is a common problem here. As you can see him now (pointing to her baby), once he starts crying unnecessarily or stops playing or becomes aggressive, then I know it has something to do with malaria”. (a 33 year old mother from Fajeromi with a child under the age of five).

“When a baby starts developing a temperature, it is a sign of malaria. With the body temperature he won’t be able to eat. So, he becomes weak. Apart from the fact that I have been a father for sometime now, I get to know malaria symptoms through some of the nurses and doctors who have been here years back because we used to socialise together. I can even tell you some of the drugs and prescriptions for certain diseases due to my closeness to these doctors. I am not sure they give health talks from our clinic about these things these days”. (a 52 year old father from Fajeromi)

Based on the submissions by the respondents, it can be argued that communities’ understanding of signs of malaria (uncomplicated) in children is akin to those usually reported in biology. This may be a good starting point in the fight against malaria in children in the communities studied.

5.4 The Use of Herbal Medicines: a Common Phenomenon

In health sociology, the concept of illness behaviour is used to describe the way and manner in which people perceive symptoms and respond or fail to respond to the symptoms (Bhasin, 2001: 81). In the current study, there seems to be a general agreement between the professional group interviewed and the

138 community about the threat posed by malaria to children. However, views expressed concerning treatment differ very significantly. The popular voice in the medical circle advocates for an immediate response to malaria using approved modern health care services. Among the local communities studied, however, response to malaria is clouded by cultural imperatives since every culture has a way of investigating and ascertaining the cause, nature and treatment of diseases (Jegede, 2005: 122). This is usually rooted in historical exigencies of illness representation in the communities.

From time immemorial, local people have maintained a close and unique relationship with the nature. This becomes important against the backdrop that there exists a linkage between the ecosystems and human well-being that is not only limited to the rural but also the urban populace. More importantly, people’s culture has bestowed upon them the right to natural resources embedded in the ecosystems such as the forests and everything in it. The forests provide the locals with sources of livelihood as well as medicines and health diet. Thus, natural resources have become to be seen as both cultural and natural rights different from those “rights” provided by the states. The local people see the natural environments and everything in-between as “theirs” and any attempt to ‘snatch’ natural rights away from the people is often met with some gravity of hostility and protest. In local environments, the forests are held tenaciously by the people given the natural resources a new ‘developmental’ symbolism and characterisation. People are emotionally, spiritually and culturally attached to the forest. Evans et al. (2001: 1) contends that:

If we want to discover the meaning of landscapes for people, it is best to think of them not as collections of material objects placed in geographical space, but as social and cultural constructions of the people who use them… Cultural groups socially construct landscapes as reflections of themselves. In the process, the social, cultural, and natural environments are meshed and become part of the shared symbols and beliefs of members of the groups. Thus, natural environments and changes in them take on different meaning depending on the social and cultural symbols associated with them.

In local communities studied, especially in rural areas, natural resources like forests are socially and culturally constructed. Individuals share spiritual, cultural and social bond with the forests. To local people, forests are cultural assets. They do not just supply means of livelihoods they also form essential and

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intimate part of their social and cultural existence. Most importantly, forests are perceived as sources of health and wellbeing. They are believed to house ingredients for health and wellbeing. As a result, management of malaria begins with the nature where treatment of an episode of malaria in children commences at home with herbal medicines known as oogun-ibile or agbo-ibile. High level of optimism and conviction about the efficacy of herbal medicines at least at the onset of symptoms of malaria in children was demonstrated by the participants. Herbal medicine is usually seen as the first point of treatment and the most convenient. It is a home-grown system of care and culturally compelling. The therapies comprised principally of local plants, bark of a tree or root which are usually boiled together to make malaria herbs locally known as agbo-iba. Once boiled, they are usually sieved and allowed to cool down to create a broth (Ellis et al. 2007: 705). The agbo-iba is used as a normal wash either with or without local soap known as ose-dudu. It is also used as a medicinal drink usually administered at least three times daily as long as the symptoms persisted. As informants argued, this practice has been entrenched in the community’s knowledge of medicine over a period of time. One of the women interviewed in Fajeromi said with some level of confidence that “everybody in this village knows that I don’t go to the clinic when I’m sick and I don’t take my children there either. I prefer herbal medicines… It’s what I inherited from my parents”.

Sometimes, children above three years of age are asked to inhale the vapour from warm herbs for a few minutes while covered with thick shrouds (usually blankets) to allow the generation of sweat which was believed to be a sign of recovery. The use of herbal medicine was despite the fact that there was a community clinic at Okanle/Fajeromi within a distance that can be traversed and a sizable number of private and public hospitals in Ilorin where treatment for malaria can be sought. This indicates that most parents usually ignore the modern health facilities at the onset of malaria symptoms in children causing tactical delays in seeking treatment at government’s approved health centres. Indeed, there are dozens of local plants available in the communities studied especially in rural areas in treating malaria in both the children and adults. The most frequently mentioned plants and leaves during the interviews were dogonyaro, orange, bitter lemon, akintola, cashew, mango, panseke and pawpaw leaves. Where different leaves and plants are mixed together they are called ija-kuja. Although agunmu (ground herbal medicine) is commonly used by the adults, some informants from the rural areas used to administer it on children to treat malaria. The agunmu substance can be used together with a locally made liquid known as pap (eko) or water. It is usually administered 2-3 times daily.

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Surprisingly, there were no specific individual persons regarded or known as traditional healers professionally endowed with indigenous knowledge of medicine in the rural areas studied. Almost everybody in the village was believed to be a “healer”. People learn the medicinal values of leaves, root and bark of trees from each other especially with respect to curing malaria. However, the elderly people in the village were believed to have more experience than the younger ones. A 70 year old grandfather in Fajeromi said “almost everybody in this village is a healer. We all know the kind of leaves, plants or root to assemble to treat malaria either in children or adult because we are used to malaria”. A number of studies have shown that the commonality of malaria in some communities has rendered the services of the traditional healers unattractive to caregivers as people already knew how to prepare herbal remedies to cure malaria (Abyan and Osman, 1993: 17).

To obtain medicinal ingredients for the treatment of malaria is highly convenient in the communities studied. Most of the plants are readily available and are either collected from around the village and town without any fee attached. This makes them conveniently accessible and affordable to families with limited income. One of the participants in the rural areas said traditional medicines “cost no money but time and sweat. All you have to do is go to the backyard and assemble leaves and prepare without any charges”. Figures 5.1 and 5.2 below show the richness of the communities in terms of natural resources (the forest) where the key to wellness lies.

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Figure 5.1 Environmental Characteristics of the Rural Communities

Figure 5.2 The Natural Environment

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However, the position occupied by traditional medicine within the socio-cultural landscape of the communities studied, especially in urban centre, is beginning to be altered. Hence, opinions expressed in the urban areas differ. In a bid to embark on the so-called development projects in the urban centres forests have been destroyed. Access to the forest is thereby increasingly becoming difficult. Consequently, urban participants acknowledged that malaria ingredients are purchased at the market from indigenous pharmacists sometimes at prices higher than what government hospitals charge especially where the malaria is chronic. The high cost of traditional treatment of chronic malaria in the urban centre is attributable to scarcity of plants and roots due to the ongoing deforestation process and expansion of cities. This is worsened by other indirect costs like transportation incurred by sellers who have to travel long distances to get their supplies. Nonetheless, the non-Western medicine remains an important link between disease and behaviour as well as effective treatment among the people studied.

Once symptoms of malaria were observed in children the ultimate goal of the majority of the caregivers interviewed was to restore the body back to equilibrium in order to avoid the devastating consequences of non-response or “delays”. Hence, the symptoms of malaria in children usually attract prompt and quick response from parents although with herbal medicines. The majority of the caregivers attributed the constant and widespread use of herbal medicine in treatment of malaria to the trust they have in it as well as the general belief system rather than poverty. To some of the informants the use of traditional medicine is an avenue to get in touch with the root of their culture. Participants expressed their convictions about traditional medicine in the following statements:

“Over the years we have used herbs to treat all kinds of diseases. I used to have three different pots of herbs for my children. The first one was for bathing, the second for drinking and the third for washing the head only. The herbs were very good and effective. My children grew up healthy as a result of these herbs. Although most young mothers these days do not want to continue with old methods, the few ones that use herbal medicine will confirm their efficacy because of the obvious differences in their children and those without herbs. Children nursed with local herbs look healthier than those without it. When a child was delivered in those days, after washing his body we used to give him some herbs, and then the baby would sleep. He would be breastfed after waking up and

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then slept again. When he finally woke up again we used to give him ordinary water. This was how we used to care for an infant during its first few months in those days. It is a different story today”. (a 50 year old mother in Ilorin).

“I believe and trust traditional medicine more than any other therapy. People who don’t trust traditional medicines are only wasting their time. It is widely known that most of the “oogun-oyinbo” (the white man’s medicine) are extracted from local plants. So, why would somebody condemn traditional medicine when he will eventually use it? There is a particular herb for treating malaria that acts exactly like the Chloroquine tablet... I think this whole thing has to do with belief. In those days when there were no hospitals the people believed in the local plants. They used them to their own advantage. The same thing applies to many people these days”. (a mother and a traditional pharmacist in Ilorin).

However, the introduction of modern medicine and numerous other factors are beginning to alter the communities’ understanding of herbal medicine. Some people in this study, especially the few educated participants, are beginning to believe that herbal medicine is increasingly becoming less potent. One of the elderly men interviewed in Fajeromi however, contested this belief. For him:

“The belief in some quarters that herbal medicine is no longer effective in the treatment of malaria is not true. The problem is that parents are always in a hurry to get well when they or their children are sick. They expect the herbs to start working immediately it is consumed. They normally don’t give the medicine time to work before they start to complain. They forget that malaria did not get into the body one day”. (a 70 year old grandfather in Fajeromi).

However, the use of herbal medicines in local communities in the management of malaria could cause a delay in using modern health care services. This informed the hostility held by health professionals against

144 the traditional medicine. While the use of traditional medicines is well known in the medical parlance, it is not well received. A community health worker interviewed in Okanle said:

“Most parents in this community believe in herbal medicines more than modern medicine. So, they usually start treatment at home using traditional remedies which can include mixing lemon with other ingredients. They consider coming to the clinic only when the situation degenerates. To them, hospital is an alternative solution. This causes complications such as convulsions in children”.

A similar belief was shared by one of the health officials at the Children Specialist Hospital in Ilorin. To him:

“The major challenges we face in this hospital are mostly from the patients. When children have malaria, their mothers don’t make quick consultation at the hospital. They use all sorts of medicines at home such as traditional medicine or drugs bought over from the patent medicine stores. By the time they decide to come to the hospital, the situation may be too critical to handle and in this hospital we have limited facilities. In some cases when chronic malaria cases are presented they are usually difficult treat. Those we cannot handle we refer them to the Teaching Hospital for further treatment or proper health service management”.

Such delays are not limited to the current study. Delays in treatment seeking behaviour have been reported by previous researchers. In their study, Akogun and John (2005: 4) discovered that malaria treatment can be deliberately ignored for at least two days before the decision to seek treatment from qualified medical doctors. Such delays, they argued, are detrimental to the victims of malaria. However, as reported in the next section the trend in the use of traditional medicine is gradually changing. With more caregivers being exposed to Western education a significant number of them are beginning to recognise the efficacy of the modern drugs/medicines in the management of malaria in children.

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5.5 Generational Changes in the Use of Herbal Medicines: a Community Polarised

Prior to the introduction of modern medicine, traditional herbal medicine used to be the dominant medical system accessible not only to the local people studied but across Nigeria. In a typical Nigerian community, traditional healers are important figures who normally occupy a pivotal position in the community’s knowledge of medicine and disease management. The traditional healers are variously addressed as Babalawo or Oniseegun who could act as an intermediary between the visible and invisible worlds; between the living and the dead. According to Adegoke (1990: 2) the healers, in most parts of Nigeria, are held in high esteem. They perform the functions of the priests, physicians and psycho-therapists within the context of their environment. According to Jegede (2005: 122) the faith and trust in the diviners among all other practitioners is stronger among the Yoruba speaking people because they (the diviners) have diagnostic paraphernalia or apparatuses known as ifa or opele. Through these apparatuses they are able to see beyond the physical reality and explore the spiritual world. Others specialise in the production of herbal medicines to ameliorate the threat of disease. They are known as elewe-omo. However, there is a general belief within the domain of biomedical sciences that certain herbal medicines contain some corrosive and toxic elements or particles considered not suitable for human consumption and injurious to the human body. Consequently, some indigenous people are beginning to accept and tolerate orthodox medicine in the treatment of diseases and illnesses. Some generational differences have been observed with respect to predisposition to the treatment of malaria in children in the communities studied (see chapter one for the definitions of young and grandparents).

The multifaceted roles of grandparents in child rearing and caring in African communities have been documented. In these societies, grandparents are integral members of the extended family structure (Jonasi, 2007: 126). Most studies have supported the argument that although grandmothers differ in terms of ideas about child upbringing, they remain powerful forces with whom young mothers have to deal in the whole process of nursing and nurturing. Their role becomes prominent and important where the biological parents are unwilling “or unable to provide adequate care for their children” (Jonasi, 2007: 126). Yet, medical professionals often have judgmental attitudes towards grandparents and their knowledge. As a result health education rarely involves grandmothers and even if they are involved, their ideas are often seen as being obsolete and inconsistent with “modernisation” or Western knowledge of medicine (Kerr et al. 2008: 1100).

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Generational Cohort Theory (GCT) as used in this study suggests that people of the same generation tend to have similar attitudes and thinking based on similar experiences. This often has a serious impact on the formation of personality. The events that occur during the life time of a people make them share similar perspectives about the social reality. Similarly, the current study showcases a polarised community between young and older caregivers with respect to the status and use of indigenous method of healing in the treatment of malaria in children. This came to the fore when focus group discussions (FGDs) were conducted for young and older parents and questions were asked regarding the use of herbal medicine in the treatment of malaria in children. A significant number of respondents recognised the fact that changes are taking place with respect to the treatment of malaria especially among the “new generation” of young parents. It was discovered that while most grandparents are still tied to the cultural pattern of disease management in children (use of traditional medicine), a significant number of young mothers - with or without western education - are beginning to break away from the “old tradition” of malaria management. “In the olden days”, argued by one of the grandparents, “you treat children with malaria with only herbs. Nobody would tell you to go to the hospital or use any white man’s medicine”. In fact, “there was no hospital in those days” said another respondent. According to one of the grandparents:

“In those days we didn’t use to go to the hospital… When a child was sick the parent would go to the bush and gathered leaves and roots and boiled them together. When you suspected that your child was running temperature you rubbed his body with “ori” (local ointment) and within a short period of time he would recover. It is a different story these days because of white man’s medicine. Nowadays people talk about hospital for any little problem. They can even ask you to visit the hospital when dog barks at you (everybody laughed). Children of these days (young parents) believe in white man’s medicine while we believe in traditional medicine. Through our knowledge of local plants we have been able to handle all kinds of situations including malaria. The plants are still there now. They are still very fresh, effective and potent”. (a 70 year old grandmother from Fajeromi).

However, most young mothers expressed different opinions. A significant number of them support modern medicine in the treatment of malaria. This group of mothers see themselves as a new generation of parents

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who are believed to be more exposed than their grandparents. They felt that a total reliance on traditional herbal medicines is not only “precarious” and “dangerous” it is also “uncivilised” and “barbaric”. Many of the young parents believed that herbal medicines are usually prepared under unhygienic conditions which they strongly felt must be corrected. As argued by one of the young mothers: “although, I think there is nothing wrong with herbal medicines but something can be wrong with the way they are prepared”. Others were worried about the measurement, potency and efficacy of traditional drugs. According to a relatively young father at the Children Specialist Hospital in Ilorin:

“When we talk about traditional medicine there is always the problem of dosage, potency and efficacy since their drugs are not clinically tested. There is no proof to show that traditional medicines are efficacious or that when patients use them there won’t be side effects. What we know is that herbal medicines contain some corrosive elements that are injurious to the body system and any drugs taken by any patient goes directly to the liver. Things like that can cause damage to the liver… Although I was raised with herbs I cannot use the same herbs to raise my children now because we have to move with time. Medicine is not static. It is a dynamic thing. In order for us to catch up with what is happening in the world, we have to make sure we move with time”.

A growing concern was observed among the older parents with respect to young parents’ preference for modern medicines. Such attitude towards herbal medicines was condemned by the majority of the grandparents. They suggested it was a derailment from the normative patterns of disease management which the communities have known for years. They attributed the prevalence of chronic diseases in contemporary society to over dependence on modern medicine and non-compliance to cultural instructions regarding traditional medicines. The prevalence of chronic diseases such as HIV/AIDS is believed to be the price to be paid for ignoring indigenous cultural practices and belief systems. How can the observed changes in the pattern of treatment of malaria in children be explained?

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Indeed, the transtheoretical model earlier explained in chapter three of this thesis is very useful in explaining the sweeping changes observed among young parents with regards to perception and use of modern treatment in the management of malaria in children. TTM has specified different stages of change, processes of change, decisional balance, the strong and weak principles and self-efficacy in understanding health switching behaviour. As argued earlier, TTM assigns individuals to one of the six stages of change (explained in chapter four) based on their location in the behaviour change process. A number of important agents of change were also identified among which are the health care providers usually the nurses. Correspondingly, the widespread use of modern medicines by young parents was attributed to a constellation of factors among which are pervasive cultural diffusion, intermarriage, western education, “exposure” as well as nurses’ or doctors’ advice. According to a 46 year old mother in Fajeromi:

One of the grandparents in Ilorin observed that:

“The nurses and doctors are the major reasons for this kind of attitude. They feed mothers with all kinds of dangerous information. They advocate for modern medicine as the most effective way of managing diseases in children as against traditional medicine. They even instruct them to stop giving children herbs completely... So, when we try to convince them at home to use local measures for infants, they simply ignore our advice... More so, exposure is the reason why most young mothers don’t want to use traditional medicine again. This is against what our grandparents taught us. The exposure has also come with corruption. It has induced bad attitude towards our culture. Instead of upholding what past mothers did, modernisation has rubbished it. Also related to the exposure is education. Some people believe that once they have some little education they are exposed and better than us. This is common among the so-called graduates. They even claim there is nothing they don’t teach them at schools”.

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One of the younger parents interviewed in Ilorin summed it up using the following analogy:

“This thing has to do with exposure. You know the world is now a global village and a conglomerate where everybody is trying to catch-up with the train. The train is fast moving and we cannot afford to be left behind. So, whether we like it or not we still look up to countries in America and Europe as the cradle of modern civilisation. We try to catch-up with whatever they do in those countries. They are the custodians of modern civilisation... Formal education has a lot to do with this. If somebody is educated, civilisation definitely sets-in. Therefore, education is the cardinal principle of modern civilisation. Anybody that is not educated we don’t see him as civilised. And how do we come by civilisation? We come by civilisation during our interaction with other people and the only way you can adequately take advantage of this is by attending formal schools. Once somebody has western education he becomes a different person entirely. He becomes critical and tends to challenge everything. He sees things differently. That is when he’s going to tell you this is not right; this is not good. We have been told this and that and so on”. (a 43 year old mother in Ilorin).

On the one hand, the above comments suggest that some older parents are still attached to the cultural patterns of disease management using an exclusively indigenous method of healing for children in their custody. On the other hand, it also suggests that a sizable number of young parents are beginning to break away from what they perceived as the “old tradition” or the “old-fashioned” way of treatment. This is common in both the rural and urban communities studied.

It must be understood however that in spite of the widespread acceptance of modern medicine by young parents, herbal medicines are not completely abandoned when treating malaria in children. A sizable number of young caregivers cautiously combine herbal medicines with selected modern drugs while treating malaria in children at home. This agrees with previous findings where a combination of modern and traditional healing methods has been reported. A study by Amira and Okubadejo (2007: 4) found that a significant proportion of hypertensive patients receiving conventional treatment at the tertiary health facility in Lagos, Nigeria combined modern drugs with traditional therapies. This is often done without the consent

150 of a medical doctor. Some of the respondents in this study expressed the harmonisation of the two methods in proverbs and idioms: “in life one hand washes the other”. For this respondent and many others, the use of traditional and modern drugs was complementary rather than competitive.

Furthermore, one of the young mothers said “it is not that young mothers have stopped using herbs completely. Those of us who appreciate the efficacy of herbal medicines still use them. The difference is that we use them with caution and together with orthodox medicine most times”. Another young parent interviewed in Okanle said “nowadays, you don’t have to be exclusively attached to a single method of treatment. Once you try the traditional one and it doesn’t seem to work then there is nothing wrong in trying the modern ones”. Beyond these, some parents used religion to justify the combination of treatments. A woman in Ilorin said “both the native and modern doctors are ‘angels’ sent by God to heal the people”. In fact, some people were of the opinion that modern medicines particularly injections are stronger and faster acting for children than adults, whereas traditional medicines are considered to be slower acting. Some respondents attributed the slower acting of traditional medicine to modern medicine itself and what they called “differences between children of today and yesterday”. Parents are usually indifferent about the individual effectiveness of each of the therapies that have been combined. This concurs with the finding reported by Ellis et al. (2007) in home management of childhood diarrhoea in Mali.

In summary, it has been argued in this section that a significant number of young and old parents are beginning to see the use of traditional medicines in the treatment of malaria differently. This may explain why the majority of the young parents combine traditional with modern medicines in their efforts to cure malaria in their children. The GCT has helped to shed-light on the socio-generational changes in the patterns of health-care seeking behaviour of young and older parents with particular reference to the issue of malaria treatment in the communities of study. The theory has allowed the researcher to reflect on intergenerational human health care patterns in local communities. This insight is used to recommend a strategic plan that would accommodate age discrepancies with regards to treatment and prevention of malaria in local communities not only in Nigeria but across African indigenous communities.

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5.6 Pathways to Treatment of Malaria

Some studies have found that management of disease in many households usually begins at home usually with traditional medicine as also found in this study, then patent medicine and/or traditional healers and/or faith healers. The services of medical experts are sought only when complications have occurred. In this study, when medicines are combined at home most of the parents expect malaria to be cured therefore never deemed it necessary to make consultation at the modern health care facilities. However, should children continue to manifest symptoms of malaria some days after combined home-treatment, then, caregivers may consider seeking advice from qualified medical experts at the nearest or farthest facilities depending on the availability of health practitioners especially in the rural areas. Normally, many caregivers have a formal consultation at modern health care facilities only when combined home treatment has failed. In other words, seeking treatment at the modern health care facilities is usually the last resort in both the communities despite the growing demand for modern medicine among the young parents. In the process, some of the respondents in the urban centre used the services of private health care facilities before public facilities. Unfortunately, private facilities were not available in the rural areas studied perhaps because of economic reasons but were preponderant in the urban centres. The use of services of faith healers was not common in the communities studied. Only one participant from the urban centre mentioned ever using the services of faith healers in the previous episode of malaria in her child.

Treatment of malaria in children in the communities studied seems to follow similar patterns. Treatment is usually procedural in nature depending on the severity, persistence of malaria symptoms and the age of caregivers without obvious difference(s) between rural and urban areas. It is also depends on preference of the consumer. Ideally, urban respondents supposed to demonstrate a “better” health care seeking behaviour given the advantages in those areas. However, the finding was far from being so. This contradicts the study conducted by Oreagba (2004: 302) in South-western Nigeria where urban participants demonstrated better knowledge about malaria and health care seeking behaviour than their rural counterparts. In Oreagba’s study, caregivers from urban areas were more likely to visit the government’s health care centres than those from rural settings while the opposite was the case with respect to visiting the patent medicine stores. Thus, the patterns of health care service utilisation in the present study can be summarised into the pre-hospitalisation, hospitalisation and post-hospitalisation categorisation (Erinhoso, 2006: 44).

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In the rural areas, on one hand, the first and last treatment options are home treatment with self-prepared herbs. Both are in the pre- and post-hospital categorisations while the second option is home treatment with self-prescribed drugs also in the pre-hospitalisation category. The third treatment choice, the hospitalisation category, is sought outside the home which might include seeking the services of ambulatory vendors or modern health care professionals. In rural area, it may require travelling for miles when such services or care providers are not available in the community health care facility. The use of the final and the last treatment option which was home treatment with herbs is usually adopted to “flush out” the remnants of the malaria parasite believed to be hidden in the body system.

In the urban areas, on the other hand, in addition to traditional and public health consultations, caretakers have the option of using the services of the patent medicine stores as well as those of the private hospitals (though very few participants in this study considered using the services of the private hospitals because of the perceived exorbitant charges). This contradicts the finding reported in Leonard’s (2005: 233) study where participants preferred the services of the private facilities than the public because of the common belief that private facilities provide better services. Therefore, treatment choices in the urban areas follows the following preferences: treatment choice using local herbs which can be sought within or outside homes (pre-hospitalisation); treatment choice using the services of the patent medicine stores (pre-hospitalisation); treatment choice using private health care facilities (though not in all cases) (pre-hospitalisation); and treatment choice using the public health care facilities (hospitalisation); and treatment choice using herbal medicines (the post-hospitalisation category). In the urban area, the use of traditional medicine can either be sought at home or outside homes from the traditional pharmacists. The movement of caregivers from one level of care to the other can be illustrated below:

“When the sickness started I bought some drugs at the chemist. Later I gave him some herbs to drink and bath. But when the situation did not improve I took him to a nearby private hospital for treatment. They gave him injection and some drugs but the situation did not improve. I continued with the herbs at home. At first it seemed as if he was fine but it got worse. That was when we decided to come to government specialist hospital. They just informed us that he is having malaria when the result of the test came out and they have

153 started treatment immediately. The doctor was not happy we reported late. For now he is looking fine. Exactly the same way he was looking when we first treated him at home. But I sincerely hope and pray that he doesn’t relapse this time around because this place is our last hope and final bus-stop.” (a 30 year old mother in Ilorin whose child was admitted at the Children Specialist Hospital).

“When my daughter had malaria four months ago we prepared some herbs for her… but we later decided to take her to the hospital in order to complement the herbal treatment when the symptoms persisted after some days. So, I took her to the clinic and the nurse treated her. After some weeks she relapsed. She was looking pale. I took her back again to the hospital but the nurse was not available this time to attend to us. So, I took her and the mother to the government facility in Basanyin (one of the neighbouring villages about six kilometres away) using my motorcycle. The doctor gave us up to five injections and some drugs. That notwithstanding, I still bought some drugs on my own without the doctors’ prescription from the chemist on our way home… After that she was fine”. (a 52 year old father in the village of Fajeromi).

“I use to combine a number of local plants to cure malaria in my grandchildren. Once I observe symptoms of malaria in them I rush to the bush to pick some plants and roots and prepare for them to make herbal medicine. One of the plants is called “panseke”. I also use “dogonyaro” leaves. All of these are very effective in treating malaria. Should the first set of plants not work you search to assemble another set. This is called “akida”. But if these don’t work then you may not have a choice than to go to the hospital or buy drugs from those vendors that come to the village from the neighbouring communities”. (a grandfather in Fajeromi).

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However, it was discovered that the majority of the parents purchased and dispensed modern drugs without doctors’ prescriptions from private drug shops. In rural areas, on the one hand, modern drugs are purchased from ambulatory vendors or drug peddlers or marketers from neighbouring communities since there were no pharmacists or chemists in the two villages as of the time of study. The drugs could also be accessed through the so-called government’s free malaria treatment programme where drugs are distributed free of charge to mothers especially when they are almost expired. They could also be accessed through the left-over from the previous malaria episodes. Paracetamol and Vitamin C were examples of drugs commonly used in combination with traditional medicines. The free distribution of drugs was confirmed by the community health official in the Okanle:

“Parents often troop in any day free drugs are declared. In fact, some parents come as far as neighbouring communities like Basanyin to collect free drugs. We give out these drugs for free when they are almost expired”. (a community health attendant in Okanle).

In the city, on the other hand, drugs are usually purchased as part of home treatment by caregivers either from pharmaceuticals or retail medicine stores (usually government approved). In addition to paracetamol and Vitamin C, urban respondents claimed they usually included blood tonic because of the common knowledge that the victim of malaria often suffers from weight loss, shortage of blood and body weakness. Indeed, there were obvious indications that many of the drugs used at home particularly in the rural areas may not only be of low quality, there were possibilities that expired drugs were administered on children.

The question is how do people often arrive at preference for a particular treatment choice? To understand this social act, the rational choice theory (RCT) used in this study becomes a very useful construct. Recall that the RCT is based on the premise that an individual consumer is faced with a known set of alternative choices; that for any pair of alternatives (say X and Y), the consumer either prefers X to Y, prefers Y to X, or is indifferent between X and Y; that these preferences are also transitive. That is, if a buyer prefers X to Y and Y to Z, then he/she prefers X to Z. If an individual is indifferent between X and Y and indifferent

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between Y and X, then he/she is indifferent between X and Z; and that an actor is aware of alternative information about how to make the most of their preferences.

Based on the above axioms, the rational choice sees an individual actor as a rational thinker who constantly weighs the prons and cons of his actions which is premised on the belief that individuals have beliefs and desires and thus act to satisfy these desires in accordance with their beliefs (Dietrich and List, 2009: 1). In other words, RCT sees individual actor as a conscious decision maker whose actions are significantly influenced by the costs and benefits of different action alternatives (Hedstrom and Stern, n.d: 1). From this perspective, it is assumed that choices reflect the agent’s preferences in a rational fashion, preferences that could be altruistic as well as self-interested (Hooker, 2011: 2). As observed by Scott (2000: 3):

In rational choice theories, individuals are seen as motivated by the wants or goals that express their 'preferences'. They act within specific, given constraints and on the basis of the information that they have about the conditions under which they are acting. At its simplest, the relationship between preferences and constraints can be seen in the purely technical terms of the relationship of a means to an end. As it is not possible for individuals to achieve all of the various things that they want, they must also make choices in relation to both their goals and the means for attaining these goals. Rational choice theories hold that individuals must anticipate the outcomes of alternative courses of action and calculate that which will be best for them.

In summary, the argument that ensued from the above indicates that caregivers use to follow different routes to cure malaria when noticed in little children. This follows that treatments of malaria, like any other disease, are usually procedural in nature in the communities studied. It involves moving forth and back between the available treatment options. It is the same in both the rural and urban areas. Hence, similar patterns of health care seeking behaviour have been reported. This is finally based on the rational choice theory which sees individual as rational actor who chooses the best among various alternatives.

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5.7 Issues Affecting Treatment of Malaria

The government of Kwara State has introduced “free” malaria treatment for children younger than five years of age. The free treatment can be accessed in more than 60 public health facilities spread across the State. The free malaria treatment programme was launched on the 22nd of September, 2009. The programme intended to encourage early diagnosis, boost access to modern treatment regimens and invariably discourage home treatment. The existence of the programmes was confirmed by the health officials interviewed some of whom saw the programme as “a giant stride and a welcome development”. Surprisingly, it was discovered during the visit to the studied areas that the “free” treatment programme was not actually free. Drugs were not always available, facilities inadequate to accommodate the programme and the majority of the caregivers interviewed were not even aware of the programme. These suggested that there are problems bedevilling or hampering the programmes. From health workers’ perspectives the problems ranged from administrative, logistical and bureaucratic to lack of political will on the part of the government. This is illustrated below:

“It is true that malaria treatment for children younger than five years is supposed to be free. Unfortunately, the Local Government only gave us Vitamin C, Multivitamin syrups and Paracetamol syrups to give patients for free. Unfortunately, these drugs cannot adequately cure malaria. To complement that the local government also gave us some malaria drugs that are not for free which are more expensive but effective. We charge parents for these drugs. This money is remitted into the Local Government account every month. Examples of drugs supplied that are not for free are Analgin, Artesunate, Artemisini, Chloroquine, etc. These drugs could cost up to N400 (approximately $3). Besides, getting the free drugs supplied from the local government to the village is usually problematic... The road network remains a major challenge. Besides, there is no official vehicle. Sometimes I travel with my personal vehicle to collect the medicines from the headquarters” (a nurse in Okanle area).

Consequently, the majority of the caregivers interviewed claimed they were not aware of the free treatment programme. One of the women in Ilorin said “how come I paid that much when treatment was supposedly

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free?” “They are just deceiving us” another caregiver said. A 52 year old father in Fajeromi succinctly argued that:

“Malaria treatment is not for free for children as they claim. I have challenged them at the hospital several times but they keep telling me that the government use to give them limited drugs. They charge between N700.00 and N800.00 (R40) for serious malaria in children. The least you can pay is N300 and that is when the sickness is not serious”. (A 52 year old father in Okanle).

Following the problems facing government’s free treatment, an individual caregiver interested in using the services of the doctors in public health facilities has to pay for treatment from pocket. This has continuously remained one of the biggest challenges facing mothers. Therefore, the majority of the caregivers interviewed identified a lack of money as the most outstanding factor responsible for late or non-utilisation of modern health care services.

The majority of the respondents acknowledged that the amount of money charged during consultation (when there is no free treatment) depends on the severity of cases. However, treatment fees were seen as too high to bear given the socio-economic conditions of the majority of the caregivers. Since most caregivers do consult with the doctor at a later stage of malaria in children there are possibilities of paying more money which might further worsen the financial burden in the household. Many of the caregivers agreed that malaria disease in children usually absorbed a substantial part of the household income. They expressed the fear that malaria occurrence within the family strains the family income since the government has “refused to help us”. For mild malaria, caregivers are usually charged between N150 and N400 ($1 - $3). For complicated cases, charges could run to thousands of Naira which the majority of the caregivers could not afford. This may have had an adverse impact on the incidence and prevalence of complicated malaria observed among the poor participants in the urban centre. According to one of the grandmothers in Ilorin:

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“I can’t specifically say how much money we have spent. But I must tell you it has not been easy. The father gets a meagre salary and I’m too old to work. We all depend on him. His income is not enough to take care of all of us. Can you believe that at my age I joined a political group thinking that things will be better? The politicians only make promises they never fulfil. We go for political meetings day and night yet I have nothing to show for it. We are looking unto God. How do you want to come to this hospital when there is no money”. (a grandmother whose grandson was admitted at the Children Specialist Hospital in Ilorin for an episode of convulsion).

Another mother whose child was also admitted for malaria-related problem at the Children Specialist Hospital in Ilorin also mentioned that:

“We came here two days ago and we have spent up to N2 500.00 ($17) so far. There is every possibility that we are still going to spend more. The more you stay the more you pay. That is their logo here” (a woman whose child was on admission in Ilorin).

To close the financial gap and be able to raise money for consultation and medication fees, parents usually borrow money from neighbours or the cooperative society where they are members. Parents sometime pawn some valuable properties to be able to raise money for treatment. Others appeal to the nurse to allow them to pay for treatment later or in instalments. Unfortunately, those who cannot afford to raise this kind of money continued to rely on herbal medicines until the condition of the child improves. These concerns are illustrated below:

"Once you have tried home treatment and it doesn’t seem to work and you don’t want your child to die then you must have to look for the money. You can borrow or sell any of your property to get money for the treatment. However, people who can’t afford to pay that kind of money and who have nothing to sell to raise money do go back home and continue

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treatment with local measures and wait for God’s miracles. After all, it is our forefathers’ way of curing diseases. This happens all the time because not many people can afford to pay that much at the hospital”. (a 68 year old father in Fajeromi).

“Sometimes when I don’t have money to pay I use to appeal to the nurse to allow me pay in the future, maybe after market days or to pay in instalments. This usually happens only after I have tried the local herbs and the symptoms persisted and my husband and I don’t have money. As I speak to you I still owe the nurse some money for the treatment she rendered to one of my children some time ago”. (a 28 year old mother in Okanle).

While the relationship between the occurrence of malaria and poverty remains highly controversial, several studies have found a connection between poverty and health care service utilisation. A bivariate analysis conducted by Yusuf et al. (2010: 5) between poverty and fever vulnerability in Nigeria shows that the prevalence of fever was highest among children from the poorest households with 17% compared to 15% in the middle income. Other factors believed to influence the use of modern health care services in the case of children with malaria are perceived symptoms and seriousness of malaria, perceived weak health care system, poor service delivery as well as belief and trust in traditional herbal medicines. Many of the respondents in the rural areas thought that there is not much to benefit from an “empty” community clinic. They complained that the only nurse designated to the hospital is not always available to provide services. As shown by Mughisa’s et al. (2004: 578) study in rural Burkina-Faso, different factors can influence both medical treatment initiation and retention. According to them, household income, level of education, urban residency and expected competency of health care provider are important predictors of initiation of treatment in a health facility. However, to retain such treatment would depend on the patient’s perception of the quality of care. In this study, the majority of the participants complained about the typical attitude of the medical officials especially the nurses. One of the respondents argued that “most times those nurses are too moody and arrogant. They talk to you any how as if you are a kid. I feel discouraged to come to the hospital because of them”.

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As argued in the second chapter of this thesis, while patients may have limited capacity to correctly assess the technical competence of a doctor they could make accurate subjective judgments about quality of care based on the recognition of medical training received from the care provider and a facility’s technical capacity (Amaghionyeodiwe 2008: 225). Such an image of the provider may have been built over the years through the societal definition and sub-cultural expectations or the conceptions formed by the patient himself through previous experiences or experiences of others (Amaghionyeodiwe, 2008: 224). Mughisa et al. (2004: 578) therefore suggested that policies directed at enhancing retention should focus on attributes that improve the perceived quality of care at hospitals which is directly connected with the level of trust of health consumers. The participants in this study expressed their frustrations and angers with the public health facilities in the following statements:

“There is no single qualified medical doctor in the community health centre. This has been the case for years. This is why you may have to travel some miles before you get to the neighbouring hospital with better facilities. Some of us travel as far as the city of Ilorin to receive treatment for serious ailments. Four months ago my daughter had what I thought was malaria. I took her to the hospital but the nurse was not around and I didn’t want the community health attendant to attend to her because he doesn’t have the expertise… This is the kind of thing we face here”. (a 52 year old father in Okanle).

At this juncture, the psychological and behavioural models adopted in this study become very useful. The HBM on one hand assumes that health-care seeking behaviour is commonly influenced by belief and attitudes of individuals. The behavioural theory on the other hand, provides a more complex approach that includes elements of psychological and sociological variables in the explanation of health-care seeking behaviour. In the latter approach, it is argued that individual and societal factors or characteristics come together to determine the utilisation of modern health care services. The societal characteristics are broadly divided into type of health service delivery, technological change and social norms regarding the definition and treatment of illness. The individual factors are divided into predisposing, enabling and need factors (see Chapter three for details). Of all the individual factors the need factors (how individual or a family perceives symptoms and professional evaluation) are the most important predictors of health care service

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utilisation. Without positive perception about symptoms and adequate professional evaluation, the behavioural theory argues that health care services may not be used even where the predisposing and enabling factors are ultimately present. In this study, “free” treatment of malaria to children younger than five years of age (enabling factor) and closeness to public health facilities (predisposing factor) did not guarantee adequate and constant utilisation of modern health care services. This contradicts what was documented in the works of De Savigny et al. (2004: 11) and Molyneux’s et al. (2002: 129) where the availability of modern health care services played very important role in utilisation. In Alexandre’s et al. (2005: 84) study longer travel times and greater distances to health centers constituted barriers to repeated visits by pregnant women for prenatal care in rural Haiti (see 2.6.1 in Chapter two).

As argued in the second chapter of this thesis, biological explanations of diseases dominated the understanding of diverse health problems in both medical and public health fields for years. This allowed the development of a comprehensive disease classification, mainly of their diagnosis and treatment (Heller, 1998: 7). One of the shortcomings of this approach however is that the model is more inclined towards curative strategies rather than preventive. A more modern approach and relatively new dimension in the public health horizon and global health discourses has tended to showcase and emphasise the importance of preventive measures rather than curative with serious emphasis on environmental characteristics and health interventions. One of the outcomes of the Global Summits on environment and development is that environmental sustainability is a foundation upon which an enduring developmental synergy can be built. The primary objective was to improve not only the socio-economic status of the people who depend on their immediate environment but the environment itself. For instance, in 1972 at the Stockholm UN Conference on the Human Environment, the interconnectedness of environment and sustainability was emphasised and echoed. At the United Nations’ Conference on Environment and Development (the “Earth Summit”) in 1992, an action plan for a sustainable development was also outlined. The most recent World Summit was held in Durban, South Africa, where world leaders converged to brainstorm about the need for socio-economic and environmental sustainable development. Some discussions at these summits have suggested and encouraged the formulation of research that examines the connection between the environment and health and illness. Consequently, a vast body of knowledge has suggested a correlation between physical environment and the incidence of diseases. However, it appears that the connection between environmental characteristics and the incidence of malaria is still lacking in the broad fight against

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malaria in Nigeria, even though this connection has been established. Jegede and Onoja (1994 cf. Jegede, 1996: 54) attributed the high prevalence of fever in the upland area of Delta State, Nigeria to thick forests and high population density as against the riverine areas with low population density and lesser forests.

Contrary to the general belief among policy makers that malaria could be controlled and eradicated through prompt diagnosis and proper treatment (curative measures), as a result of which free malaria treatment has been formulated, the physical evidence suggests contradictory axioms. The consensus among the health officials interviewed is the fact that there exists a relationship between the incidences of malaria in the communities studied and the environment. This, according to them, constitutes the biggest challenge in the broad fight against malaria in Nigeria. According to the explanations provided by the health professionals, a dirty environment breeds mosquitoes and this often perpetuates the incidences of malaria in the communities. One of them succinctly argued that “the battle against malaria cannot be won” simply because “people here live in a bushy and dirty environment” where stagnant waters are ubiquitous and conspicuously heralded the space as a result of poor drainage systems and nonchalant attitude. Figures 5.3 and 5.4 below illustrate the environmental challenges in controlling and eradicating malaria in the studied communities and Nigeria at large. Also entangled in this analysis are economic and socio-cultural challenges in the fight against malaria. The following statements by health professionals illustrate the challenges posed by environmental, economic and socio-cultural factors in the fight against malaria in the communities:

“There is widespread malaria in children because of poverty and cultural undertones. Most parents complain of not having money and some believe that injection could cause paralysis in children. Some even believe that injection does not work for malaria. This is a cultural belief attached to the use of injection. As a result they prefer using herbal medicines instead. Again, most of these people don’t know the people they are coming to meet at the hospital for treatment but have easy access to traditional herbal medicine and their providers. They speak the same “language” and understand one another. All these pose serious challenge to the fight against malaria”. (a senior nurse at the Children Specialist Hospital).

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“The government cannot win the war against malaria in this environment. I say this because people live in a very dirty environment. How can people wining and dining in dirty environment like this live without malaria? It’s not just possible. People don’t keep their environment clean. Everywhere you go you see stagnant water full of broken bottles because the drainage systems aren’t functional. Unfortunately, stagnant waters usually breed mosquitoes. Even the hospital environments where we work are not clean. It’s just few days ago that the environmental people came to remove the dirt in front of our hospital. It was there for only God knows how long. The drainage was blocked. There was nobody to unblock it. The whole place was stinking. So, I don’t think the government can eradicate malaria in this kind of environment… Although when admitted children are discharged from the hospital health workers usually engage their mothers in health talks on issues of malaria, personal hygiene, environmental sanitation and communicable diseases… However, most of them do not comply because they don’t care”. (a senior nurse at the Children Specialist Hospital).

A similar sentiment was shared and expressed by the only designated nurse in Okanle/Fajeromi Health Centre. To her also:

“There is a relationship between dirty environment and the incidences of malaria. Dirty environment breeds malaria parasites responsible for the transmission of malaria from one person or child to the other. As you can see (pointing around) our environment is very dirty and bushy. So, it is going to be very difficult to eradicate malaria in our communities”.

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Figure 5.3 Environmental Challenges in the Fight against Malaria 1

Figure 5.4 Environmental Challenges in the Fight against Malaria 2

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It can be inferred from the above argument that a number of caregivers acknowledged the potency and reliability of modern medicines. However, their use is always hampered by a number of socio-cultural, institutional, structural, environmental and economic factors. There is also the need to take cognisance of the environmental challenges in the broad fight against malaria. Such understanding could ensure a more permanent and efficacious malaria control and eradication strategy. While this is not peculiar to the communities studied alone it is important that government and policy makers begin to take health care services in the local communities very seriously especially as it affects treatment of malaria in children. For further debate on the social determinants of health and health services see 2.4 in Chapter two.

5.8 Decision Making Process: Who Says What?

An extensive research has been done to ascertain the correlation between economic factors, user fees and health care decision making process in poor communities across Africa and elsewhere. What most of these studies have found is that the introduction of the user fees especially in the 1980s at government’s health care facilities across Africa has resulted in treatment delays, thereby aggravating the levels of morbidity and mortality in women and children in African continent (see Lugalla, 1995; Stratton et al. 2008; Turshen, 1999). However, Kamat (2006: 2946) has noted that an overemphasis on the correlation between user fees and treatment delays has mirrored in previous studies may have prevented or diverted attention away from other significant existing cultural and structural constraints affecting health-care decision making process and outcomes. It was on this note that health-care decision making process was investigated in the communities studied.

In the current study, the role of significant others in health care decision making process cannot be overemphasised. As mentioned earlier, most of the people interviewed lived in extended family structures which comprised biological parents and significant others. At the beginning of the malaria crisis the biological mother and other women within the household, particularly the mothers-in-law and grandparents, have the primary role of ensuring that the child’s health is restored within a reasonable period of time. Hence, the pursuance of health for a sick child commences with traditional medicines as explained above which according to the majority of the respondents is typically under the control of the mother-in-law. The use of an indigenous treatment episode is encouraged and often seen as the first treatment option by the

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mother-in-law because they are easily assembled and prepared often without cost. The influence of the mother-in-law in the decision making process was felt more by the young mothers especially the first time mothers believed to be inexperienced when it comes to childhood illnesses. One of the young mothers in Ilorin said “I stay with my mother-in-law. So, she plays a significant role in decision making process. I always seek for her advice whenever my child is sick because she knows a lot”.

While many respondents recognised the role of community when a child is sick, some of the participants interviewed were scared to involve the community or inform neighbours about the health status of their children because of the widespread belief in witchcraft and evil-machination. This was very common in the rural areas. This finding disagrees with what was recorded in Kaona and Tuba’s (2005: 8) study in some villages in Zambia. In their study Kaona and Tuba found that the treatment of severe malaria usually commences with the family and moves into community especially when the illness progresses. Yet, a very small number young parents mentioned neighbours as important players in decision making process. A young mother with an NCE qualification in Ilorin said:

“I discuss my child’s health with one of my neighbours very often. She is just like my mother. She knows everything about malaria and other childhood illnesses. So, if anything happens to my child she is the first to know and she always proffers solution. She tells me when to use home treatment and when to go to the hospital. I have benefitted from this particular woman a lot”.

Within the household, the husband only intervenes where malaria symptoms have persisted after some days without any improvement and may suggest additional traditional measures or encourage seeking treatment outside home which could include buying drugs from ambulatory quack vendors in the rural areas or over-the-counter drugs or seeking the services of the medical experts. So, when the female participants were asked who was an important figure in the decisions making process for treatment outside the home, particularly the hospital, many of them identified their husbands as the most important. This finding contradicts Kaona and Tuba’s (2005: 6) study in Nakonde District of Zambia where participants mentioned

167 mothers first although father’s role could not be downplayed in terms of providing financial and material support that would facilitate the use of health care services.

As indicated in this study and others (Kaona and Tuba, 2005: 7), as the head of the household, the husband is expected to provide financial and social support before, during and after seeking treatment at the medical facilities. Although the husband could be assisted by his wife in case he does not have sufficient money to pay for medical bills, the wife’s assistance is rendered in a respectful way in order to avoid any suspicion of arrogance or pride. This serves to confirm that the men wield enormous power in a patriarchal structure like the ones studied especially when it comes to children’s health. One of the women interviewed in Ilorin said:

“My husband tells me whether to go the hospital or not. I cannot take any decision regarding his child on my own without his approval or that of his parents. If I do that I disrespect him; I disrespect my culture and my religion. He is the head of the family and the one to pay for the treatment. So, whatever he says is the final”.

However, should the husband be absent from home other members of the family assume the responsibility of the husband by encouraging the mother to seek treatment at the nearest facility. This might include the husband’s siblings. The influence of social networks in decision making process as revealed in the present study is illustrated below:

“When my child was sick and was obvious that the situation was getting out of hand after doing what I was supposed to do I had to call my husband’s elder brother because my husband was not in town. My husband lives at Banni Oko. That is where he farms. The brother on the other hand stays in town in Ita-Merin. I called him on the phone. He was the one that gave me the order to seek treatment in this hospital. I told the brother because I can’t single-handedly manage the situation. What if something terrible happens

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eventually? I need to let at least a family member knows about it. Besides, my husband’s elder brother will be the one to bear me witness when my husband returns. I should have told my mum but she’s not staying where we stay and I don’t have friends around here who could assist. My child is my friend”. (a 30 year old mother in Ilorin).

“The person I have to inform first is of course is my husband. According to our culture he is the one to pay the bill although sometime I make contributions but he would bear the largest share of the bill. But my decision to be here today was informed by my own mother because my husband was not around. I called her to inform her because it was my first experience”. (a 30 year old mother of one year old daughter in Ilorin).

This study has shown that decisions to seek health care on behalf of children with malaria within or outside the family set-up go beyond individual mothers. Grandparents and mother-in-law play a very significant role in the health care seeking decision making process. In fact, young parents who attempt to decline the use of traditional medicines can be forced by their in-laws or grandparents to dispense them to children.

5.9 Preventive Measures

The familiar saying that “prevention is better and cheaper than cure” may have driven the invention, development and subsequent popularity of the ITNs in order to prevent malaria occurrences especially in children younger than five years of age. Unlike the popular untreated traditional mosquito nets, the ITN is made up of certain chemical combinations that can weaken or kill mosquitoes on contact and this has attracted considerable research interest over the last two decades (Muller et al. 2008: 1).

Discourses about malaria prevention have, therefore, brought to the fore the importance of the ITNs as one of the most sustainable devices in the prevention of malaria. In fact, studies have consistently proven that ITN is one of the most effective and sustainable preventive strategies in malaria control in children across malaria endemic regions. It is also one of the cheapest modern malaria control strategies (Frey et al. 2006:

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3). It is estimated that if every child sleeps under the bed nets consistently and correctly about 336 000 malaria deaths could be averted worldwide annually (Lengeler, 2003, quoted from Alaii, 2003: 12). Consequently, the campaign and distribution of the ITNs have attracted the attention of Non-Governmental Organisations (NGOs), private business organisations and celebrities. In Nigeria, there is evidence that private business organisations are participating in the procurement and distribution of bed nets to local people. Unfortunately, the history of malaria control in Nigeria has been plagued by a lot of problems that include insufficient funding and lack of political will on the part of the government (Amzat, 2011: 43). Hence, while questions have been raised about recipients’ knowledge of correct use of the bed nets on one hand, the network of distribution of the nets has also been questioned on the other hand.

In the current study, a number of caregivers interviewed were able to distinguish between the traditional and insecticide treated bed nets. However, more than half of the caregivers had not used the treated bed nets. The majority knew about the bed nets through the electronic media, usually a transistor radio in the rural areas. In the urban areas, awareness is via both the television and the radio. Very few mentioned they knew through the health professionals or any health programmes usually organised at the local clinics. Some of the caregivers in the rural areas pointed out that it is common knowledge in the communities that new born babies are placed under the nets at birth. “It is a tradition that when mothers give birth they should use net to cover the new born baby because of mosquitoes” one of the grandmothers mentioned. The nets she meant were the untreated nets which were readily available in the markets in town. The use of the net (treated or untreated) was not necessarily to prevent malaria infection. The net is commonly used for children to allow them sleep normally since mosquitoes can prevent children from sleeping through their noise and because of the belief that mosquitoes could cause rashes, particularly in children.

In the past years, the government of Nigeria has embarked on free distribution of ITNs to caregivers of children younger than five years of age. In the studied communities the government is able to reach the caregivers through the public hospitals or health centres when caregivers attend government’s immunisation programmes or after a new baby is delivered. However, since the majority of women do not always attend the immunisation programmes and prefer to deliver at home, most women interviewed

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claimed they did not have access to the bed nets. According to the nurse at the Okanle/Fajeromi Health Centre:

“We have distributed bed nets at least twice this year. We gave to those mothers who delivered here in the past two years. We do give to those who come for our immunisation programmes. Those who complained of not having bed nets are those who never participated in our immunisation programmes or delivered their babies here at the health centre”.

Health officials interviewed claimed that ITNs are usually distributed during immunisation programmes or after the delivery of a new baby. Unfortunately, the free ITNs are not often available in health centres. As of the time of the study there was no single bed net available at the Okanle/Fajeromi Health Centre. The same was applicable to the Children Specialists Hospitals. Both caregivers and health workers interviewed attested to this. A problem such as this might have hindered knowledge and access to the ITNs. “When I gave birth to my first child three years ago at our local clinic the nurse gave me the bed net. But when I gave birth to the second born they did not. When I asked them why, they told me it was finished” said by a young mother of two in Okanle. Another mother in Fajeromi said “those nets distributed by the government free of charge (she meant to say the treated bed nets) are not always available in our hospital, so we don’t normally use them”. The scarcity of the ITNs was confirmed by one of the pioneer members of the community association and a community leader in Fajeromi when he recalled that “only nine pieces of the bed nets were allocated to the whole community from the headquarters some time ago”. Hence, health workers are usually forced to distribute bed nets on the basis of “first comes first served” thereby resulting in low access and usage. This scenario sharply contradicts the target set by the malaria control programme that promised to cover 80% of children younger than five years of age with ITN by 2010 (FMoH, 2009: 10).

It was discovered that biomedical views concerning malaria prevention in children appear to be akin to some aspects of tradition in the community. However, it was obvious that certain forces hinder accessibility to bed nets with potentially hazardous consequences. It seemed that the caregivers and health officials interviewed were pointing fingers at each other. For instance, the majority of the caregivers attributed the non-availability or scarcity of the bed nets to certain social vices believed to be common in the way and

171 manner government officials discharged their duties. These include corruption, maladministration, favouritism and nepotism at the government levels. They believed some health officials and administrative officers especially at the Local Government levels were responsible for the scarcity of the ITNs because they believed they use to distribute the bed nets through what they called the “backdoors”. They also believed they hoard the bed nets only to be sold later to business women in the market who buy and sell them at higher prices. According to one of the community leaders who happened to be a retired police officer in Okanle:

“Many people in this village only hear about the treated bed net on the radio and sometime on the television. I have also seen it in the big cities. I am not sure my wife has received any from the community health centre. She would have told me if she did. The people in government have not remembered us here. Where they claim they give to people it does not even go round… These people only make noise over the radio and television. They don’t care about us. They don’t care if we all die here. I suspect people in government hoard and sell them out later because they are corrupt, insincere and unreliable”.

While few health officials interviewed accepted that corruption in the procurement and distribution of the ITNs was a major problem affecting availability, some of them argued that caregivers were also to be blamed. They claimed that some mothers would collect the bed nets at the health facilities for free but resell to marketers at the local market for reasons attributed to poverty and greed. One of the nurses at the Children Specialist Hospital claimed she was aware of buying and selling of the ITNs at one of the most popular markets in the town where baby materials are usually sold. She reported each was sold for at least N400.00 ($3). The question is would anyone buy a bed net if it was consistently available for free at the government hospitals?

With regards to knowledge and the use of the ITNs four different categories of caregivers were observed in this study. In the first category were caregivers who had heard and used the ITNs for their children in the past. These people were just four in rural areas and three in the urban area. Five out of these got the ITN through the “backdoor”; either through a friend who worked at the Local Government Council or the hospitals or bought from the market place and not necessarily through the government free distribution.

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One of the fathers in Fajeromi got the ITN because he was pioneer member of the community association. However, these respondents had mixed feelings about the efficacy of the bed nets. One of the fathers with a positive assessment of the bed net in Fajeromi said his wife informed him prior to the study that mosquitoes had suddenly disappeared from her room. This was attributed to consistent compliance with the use of the ITN. So, they felt it was an effective preventive strategy. However, some felt the opposite. Three of the people who had used the bed nets prior to the study believed it was not effective. They claimed that it was even unappealing to use the bed net when the weather was hot. A similar finding was reported in rural Burkina Faso where compliance with ITN protection was more efficient during the raining seasons but not during hot and dry seasons (Frey et al, 2006: 9). According to a 46 year old mother at the Specialist Hospital in Ilorin:

“I used to have the bed net. But you know in the evening when you go out with children to take fresh air especially when there is no electricity, mosquitoes do bite them and this may cause malaria. I also try to take all sorts of preventive measures like the insecticides but yet they seem not effective because malaria continues to come”.

In the second category were caregivers who had heard of the bed nets but who had not used it for their children. The respondents in this category were the majority. They seemed to be interested in using the ITN but had no access to them even though accessibility to ITN was not a guarantee that it would be correctly used. They alleged irregularities in the distribution of the bed nets. In the third category were caregivers who had not heard of the ITN and as such had not used it before. Finally, in the last category were a few caregivers who did not believe in ITNs at all and as such had no cause to use them even though they were aware of it. According to these respondents, the use of ITNs was considered unnecessary since children are exposed to mosquitoes both day and night and the sun in the afternoon. This finding agrees with previous study. In a study conducted by Ahorlu et al. (1997: 493) a significant number of mothers believed that malaria caused by the sun can be prevented only when the sun stops to shine. According to a 48 year old mother in Fajeromi:

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“Let’s face the reality. There is no way we can prevent children from having malaria if at all malaria is caused by mosquitoes. Malaria caused by the sun cannot be prevented either. We just have to continue to pray to God for his protection. The idea that the bed net (or what do you call it) prevents malaria is not real. In a large family like ours where there are many children, how many of them can you cover with the bed net? Do want to imprison your children because you don’t want them to have malaria when exposed to the sun? So, I don’t think we should deceive ourselves. There is no way we can prevent malaria because children play day and night. They move around the village without any clothes on them sometime. The only effort I make is to use a broom to chase away mosquitoes at night when everybody is going to bed (everybody laughs)”.

Caregivers used to depend on alternative preventive kits and strategies. In urban areas there were numerous malaria preventive devices that include different brands and qualities of insecticides but very few were available in the rural areas. People in the rural areas also depend on some local plants believed to prevent mosquito bites. The use of local plants was perceived as an age-old practice. The low level awareness and non-use of ITNs concurs with other qualitative and quantitative studies. In their studies, Adedotun et al. (2010) and Olasehinde et al. (2010: 162) respectively found that only 16. 7% and 18% of their subjects in Southwest Nigeria had used ITN as a preventive device against mosquitoes for their children. Only 1% was found to have used the ITN in Oyedeji’s (2009: 503) study also in the Southwestern part of Nigeria. In this study the low level of knowledge and awareness is allegedly connected to poor distribution networks, favouritism and nepotism, misappropriation, mismanagement and corruption and lack of political will.

5.10 Discussion

The governments of Nigeria, at all levels, have invested a sizeable amount of resources to control and eradicate the scourge of malaria, particularly in children. In Kwara State, where this study was conducted, government has partnered with a number of local and international non-governmental organisations with the primary objective of providing free bed nets and treatment for children younger than five years of age (Saraki, 2009: 2). These new plans have attracted unprecedented attention from within and outside the

174 government. To some analysts the new plans are giant strategic political strides capable of eradicating the cankerworm. To others, they are mere ambiguous and over-ambitious unachievable plans and goals. To the latter group, given government’s plans to fight against malaria, the trend of malaria ought to have receded very significantly. However, malaria crisis has continued to linger unabated especially among children younger than five years of age with insurmountable psycho-socio and economic challenges.

Generally, most of the literature on health care seeking behaviour has emanated from the field of economics with emphasis on quantitative analyses (Beiersmann et al. 2007: 2). For instance, Alaba and Koch (2008: 7) tried to provide an explicit analysis of the impact of health care decision making process at household level on child health care in South Africa using certain economic analysis and models. Sharma (2008: 2488) used duration analysis for malaria patients in rural Nepal to illustrate people’s reactions to malaria; i.e. what, how and when people seek health care services. Some of these studies have provided rich empirical data analysis in understanding of health care seeking behaviours. Apparently, many of these studies have ostensibly failed to account for the local dynamics in the construction of disease and illness and its impact on health care seeking behaviour despite the fact that its understanding is a prerequisite for effective and sustainable health promotion initiatives and malaria control programmes specifically (Beiersmann et al. 2007: 2). Local dynamics of health and illness have become important against the background that:

i) It usually exhibits coherent structure where causation, prevention and treatment are chronologically connected in a functional way; and

ii) Most literature on treatment seeking behaviour has shown that mere provision of budget for public health facilities and promotion may not necessarily mitigate the casualties associated with malaria where culture tends to dominate or obstructs treatment or plays critical or paramount role in management (Ojikutu, 2010: 24).

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In view of the continuous emphasis on early diagnosis and effective treatment of malaria, therefore, it has become imperative to investigate reasons for avoidance or delay in attending modern health care facilities. This became important against the background that decision on how, where and when malaria is to be treated usually starts with the mother’s interpretation, understanding and diagnosis of children's disease at home. In this study, therefore, the treatment seeking behaviours of caregivers within the context of malaria in children in a typical rural and urban area of Nigeria is examined within the context of sociological enquiry using appropriate qualitative research instruments. While the Nigerian government has officially banned the use of chloroquine in the treatment of malaria and replaced it with the ACT in 2005, there are a lot of questions surrounding affordability, availability and adherence to ACT (Amzat, 2011: 42). There are indications across Nigeria that many households have limited access to ACTs owing to widespread poverty and inadequate access.

An investigation into the perception and knowledge of iba particularly in children indicated that malaria is seen by the majority of the people interviewed as a very serious health problem in both the rural and urban communities unlike the study conducted by Oguonu et al. (2005: 411) in the eastern part of Nigeria where only 9% of the population in rural area studied believed that children were at the greatest risk of chronic malaria. The perception is due to everyday experience and the high number of casualties often recorded among infants and children. Knowledge of malaria was however clouded by cultural undertones which overwhelmingly impacted on how people respond to malaria in the communities. This was demonstrated through the community’s distinction between ako and abo-iba which does not absolutely correspond to the biomedical distinction of complicated and uncomplicated malaria but has some linkages. Such inadequacy is however consistent with the works from other parts of Nigeria (Akogun and John, 2005: 5). It is possible that such inadequate knowledge about the distinction between uncomplicated and complicated malaria have contributed to the surge of malaria cases in Africa and indeed Nigeria (Akogun and John, 2005: 5). Surprisingly, more such cases were observed at the health facilities in the urban area than the rural areas perhaps as a result of poor management at home coupled with the population density in the urban centre (personal observation).

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The usual causes and transmission of malaria have been unambiguously and extensively defined in the biomedical literature (see 5.3.3 in Chapter five). However, sometimes the biomedical construction of disease could contradict community’s taxonomy and perceived causes of disease and illness. As argued in Chapter two, many studies have found that knowledge about disease causation in local communities usually goes beyond the natural or biological explanations. Beyond natural causation, disease causation in local communities is usually and intrinsically believed to be connected with supernatural, magical and spiritual underpinnings thereby providing a multi-causal model of disease causation. Okafor and Amzat (2007: 157) have argued that understanding community’s perceived aetiological factors is an important link towards malaria control and perhaps eradication. Similarly, this study has indicated that causes of malaria in both the rural and urban communities studied related to the presence of multitude of perceived causal factors which contradicts the mono-causal explanation provided in biomedical sciences. Although quite a number of participants believed that children can contact malaria through mosquito bites (which is consistent with biomedical explanation) the majority however felt that children could and often do contact malaria through sources other than mosquitoes. These include unclean water, bad food and exposure to sun.

The main result from this study thus generally supports that the views on witchcraft is perceived by many respondents to be important in the construction of malaria, especially if the disease does not abate within an expected period of time. Belief in witchcraft and sorcery is not restricted to the studied communities though. Such beliefs and notions are common phenomena in African indigenous communities where certain diseases and illnesses are attributed to witchcraft and evil spirits or machination and this usually comes to the fore especially in a bid to find the root cause(s) of an illness. Liddell et al. (2005: 692-692) differentiated between “proximate” and “ultimate” causes of disease in Sub-Saharan African indigenous communities. According to them, a “proximate” cause of disease and illness accounts for “how” a particular disease is contracted while “ultimate” cause accounts for “why”. In this study prolonged malaria was attributed to witchcraft and sorcery but not necessarily considered to be the only possible cause. From a biological standpoint, this could be described as a misconception about the aetiological factors of malaria which may constitute a threat and obstacle to the global partnership against malaria control and eradication. A study by Idowu et al. (2008: 213) in Abeokuta, Nigeria has confirmed this fact. The study

177 shows that early treatment at modern health care services was denied based on caregivers’ ignorance regarding the true causes of malaria.

One of the cornerstones of malaria control and eradication across malaria endemic regions including Africa has been early detection, diagnosis and treatment through primary health care services that offer antimalarial treatment to young children with malaria in line with the WHO’s guidelines of the ACTs. However, much information available, supported by this study, indicates that the majority of malaria cases are treated outside the formal health facilities. Consequently, there is widespread belief that the way and manner in which the treatment is being carried out is often incorrect with potential devastating consequences. Seeking treatment from a community health care centre or hospital may not occur immediately in the communities studied until several days after the onset of malaria symptoms or when the sickness has become complicated and beyond home management. In contrast to Leonard’s (2005: 232-231) study where participants rarely used herbal medicines, the treatment of malaria in children in this particular study usually starts with the use of locally made herbal medicines or modern medicines bought over-the-counter or left over from previous malaria episodes or both. The majority of the local people interviewed saw nothing wrong with the use of traditional medicines or combining treatment without doctor’s prescriptions. A recent study by Bamidele et al. (2009: 287) has proven that a high proportion of people living in the urban areas still believe in and use traditional medicine even where there was adequate access to modern health care facilities and health providers in Osun State, Nigeria.

Meanwhile, it needs to be said that whether responding to malaria using herbal medicines is an appropriate or inappropriate treatment option remains a highly controversial issue. In fact, more than 60% of children with high fever resulting from malaria in countries like Ghana, Nigeria, Mali and Zambia receive herbal medicines from home as the first line of treatment (WHO, 2002 quoted from Abdullahi, 2011: 116). Evidence is bound to show that traditional medicines and the practitioners advocating them have contributed immensely to the overall health care delivery systems, hence the growing demand for traditional medicines across the world. In Gambia, for instance, a drug known as chemoprophylaxis given to pregnant women by the TBAs was found to reduce malaria-related morbidity and poor pregnancy outcomes (Greenwood et al. cf. Mbonye et al. 2008: 93).

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According to the World Health Organisation (WHO), most of the traditional remedies have transcended beyond their original boundaries and cultures thereby becoming known as “complementary and alternative medicines” in foreign countries (WHO, 2000a: 4). There is, therefore, the need to identify research requirements in TM and intensify efforts towards harmonisation of both traditional and modern medicines (WHO, 2000b: 1). This can be strengthened by providing general rules and guidelines for methodological research and evaluation particularly with herbal medicines (WHO, 2000a: 3). What is less controversial, however, is the surge of complicated cases of malaria in children caused by poor handling which may have been induced by incorrect use of herbal and/or modern medicines or lateness to seek care from the appropriate medical service providers. Such delays may have increased the risk of children developing symptoms of complicated malaria such as convulsions and anaemia and which is capable of compromising parents’ faith in modern treatments (Ellis et al. 2007: 708).

A number of studies from Nigeria and the rest of Africa have shown that private drug shops are important health care service providers in the case of childhood illness like malaria (Adome et al. 1996; Amin et al. 2003). Others have shown that many of these shops prescribe drugs of questionable quality (see Oreagba et al. 2004; Sadiq et al. 2009) with potential impact on morbidity and promotion of drug resistance (Ewing et al. 2011: 2). More than 50% of the caregivers who purchased the debilitated chloroquine tablets from private drug shops in Borno State, Nigeria dispensed them wrongly (Sadiq et al. 2009: 118). The use of self-prescribed drugs from private drug shops has been linked to convenience as well as availability and cost effectiveness (Oreagba, 2004: 303) hence the need for appropriate legal frameworks to regularise the activities of the private drug shops.

It was surprising to find that the majority of the caregivers refused to utilise government’s free medical services available at the public health facilities in their respective communities. The widespread non-use of free malaria treatment could be attributed to a lack of awareness and inconsistency in treatment provided under the programme. Health officials confirmed the free treatment programme. However, they acknowledged that the initiative is endangered and riddled with insurmountable challenges that include bureaucratic, institutional, logistic and administrative problems. These problems are largely responsible for

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the non-availability of drugs with a subsequent negative impact on treatment and attitude towards the system. While some drugs were provided for free (usually those that cannot cure malaria effectively) caregivers are nonetheless charged medication fees for others which can cure malaria effectively including the ACT. Therefore, the free malaria treatment might need to be repackaged in order achieve its objective of early diagnosis and treatment. More importantly, there is the need to unblock the socio-cultural, ecological and institutional challenges that impede the utilisation of the modern health care services particularly the free treatment exercise.

Furthermore, this study shows that variation may exist between young and older parents in terms of desire for modern health care services in the treatment of malaria. Younger parents’ thoughts and feelings about modern medicines have been influenced largely by western education and modernisation. Instead of complete reliance on traditional remedies, most young mothers believed that the world is no longer static and that there is nothing wrong with benefiting from each of the healing methods which is also the core issue in contemporary discourses about traditional and modern medicines. The changing patterns of health care utilisation in the treatment of malaria in this study concur with the finding made by Wiseman et al. (2008: 493) in Gambia. While older parents are still attached to the herbal treatment option, younger parents are more likely to seek modern health care services earlier than older parents, having first tried the traditional medicine. The belief that older parents are more experienced in the use of traditional remedies in the management of malaria than younger parents and that younger parents have greater exposure to formal health care services may be another major factor responsible for the variations in the patterns of health care seeking behaviours of these two generations of caregivers. However, the young parents predisposed to modern treatment are usually faced with difficulty in trying to utilise the services of the modern health care services, even though it is one of the key important ways to effectively deal with malaria particularly in children. It is one of the ways identified and highlighted when international health organisations like WHO and UNICEF proposed to bring malaria deaths to an end by 2015 and hasten the progress towards achieving the MDGs (WHO, 2010: vii).

As argued in the second chapter of this thesis, studies have shown that malaria and poverty are intimately connected. Most of these studies suggest that malaria is a cause and consequence of poverty. However,

180 this is most apparent at global more than household levels (Worrall et al. 2002, 2005). Available data linking poverty with malaria at household levels remain highly unclear, ill-articulated and contradictory (Worrall et al. 2002, 2005). This may have to do with the variables used in measuring the socio-economic status (SES) of the respondents (Worrall et al. 2002, 2005) or the fact that cost burdens are the product of complex relationships between social, economic and epidemiological factors (Chuma et al., 2010: 2). In spite of this difficulty, what is certain is that there is some element of connection between poverty, incidence of malaria and health care seeking behaviour at the family level. In the current study, adequate access to treatment in poorer households was hindered by lack of money and resources rather than proximity to health care systems. A substantial part of the limited household income was expended by caregivers on malaria treatment especially where such treatment was sought from modern health care systems. The impact of malaria on poorer households as highlighted in this study and others further justifies the correlation between poverty, malaria and the patterns of health care seeking behaviours. It suggests that being trapped in the lower socio-economic status could exacerbate the depth of malaria crisis when malaria is experienced at the family level.

More often than not, where locations are associated with increased malaria risk for both epidemiological and socio-economic reasons, urban residents can be accompanied by potentially protective socio- economic arsenals or immunity against malaria risk which may include access to western education and relatively high income levels (Worrall et al. cf. Onwujekwe et al. 2010: 19). However, this might also depend on the characteristics of the respondents across geographical categorisation within the urban residents as shown in this study where urban residents found it difficult to pay for treatment. Therefore, in order to address the challenges posed by malaria, poverty eradication ought to be a priority.

Studies on informal social networks and social support have gained momentum in the social sciences recently. A relationship between social interaction and subjective wellbeing (Taylor et al. 2001) as well as prevention of violence (Budde and Schene, 2004; Gervich, 2008) has been documented. There are indications that such interactions might have impacted on the health care decision making process. Studies have found that close social support is a strong independent predictor of good health and that it also enables people to cope better when they are ill (Asher, 1984: 356; Zhang, 2007: 56). Ciambrone’s (2002)

181 study in South Africa shows how women’s social network composition helped to mediate the disruption caused by HIV/AIDS. Similarly, in the cultural domain of the communities studied where preference is attached to an extended family structure and social interaction, household decisions on important issues such as children’s health are influenced by “significant others”, many of which are positively construed. Treatment is usually related to a community rather than for an individual’s responsibility. This is usually based on the principle of “what affects one affects all”. Aside from the child’s mother, the father, as head of the household, the mother-in-law, grandparents and immediate members of the family are important figures that influence the decision making process. They help to decide how, when and where health care is pursued within the household even though the role played by each is determined by whether treatment is sought from within or outside the home.

More importantly, the mother-in-law and grandparents holds a significant position within the family structure and hierarchy when it comes to diagnosing childhood illness and initiating and retaining the treatment process. Many young mothers argued that they relied on the wealth of experience of their mother-in-law and the community at large. Where there was no mother-in-law, young mothers could also depend on their own parents especially where they live very close to one another like in the rural areas. Previous studies have shown that older parents hold powerful positions within the extended family structures and are often able to impose their wills on younger mothers (Kerr et al. 2008: 1095).

It was argued earlier that one of the cornerstones to preventing mortality and reducing morbidity attributable to malaria is through improved access to prompt diagnosis and effective treatment. More importantly, since the emergence of malaria is worsened by the spread of drug resistance (usually chloroquine), prevention and selective vector control have become quite significant control measures (Alaii, 2003: 12). Hence, ITNs have been acknowledged to be an important and effective malaria preventive device. This was part of the resolution made at the World Malaria summit in Abuja, Nigeria where world leaders converged in 2000 to discuss the way forward in the fight against malaria. The summit was tagged the African Roll Back Malaria (RBM). The summit came to be seen as the first well coordinated global effort which marked a significant turning point in the history of the global fight against malaria. The summit made a promise to cover a significant number of the most vulnerable groups especially children under five years of age by 2010

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(Amzat, 2011: 43) because if used persistently and correctly the treated nets could prevent an estimated 336 000 malaria related deaths in children every year (cf. Alaii 2003: 12). However, this remains a very serious challenge to policy makers around the world.

The above notwithstanding, there are indications that public awareness and the health benefits of ITN have increased substantially in African malaria endemic countries (Blackburn et al. 2006: 650; Muller et al. 2008; Osondu and Jerome, 2009). However, with specific reference to Nigeria, research output about household coverage of ITNs has been contradictory. Government reports have indicated that household bed net coverage has increased from 0% in 2003 to more than 6% in 2005 (Lambo, 2006: 285) and to more than 10% in 2009 (FMoH, 2009: 25). However, there is no certainty that the ITNs have, indeed, reached the targeted populations. In the present study, a low level of knowledge about ITN was demonstrated by the majority of the participants in both the rural and urban areas studied. Although some respondents were able to draw a distinction between the traditional and the treated bed nets, the majority still relied on the traditional bed nets (TBN) rather than the ITN. In contrast to ITNs, TBN only provides partial protection against malaria (Osondu and Jerome, 2009: 42). While there was an indication that some mothers in the current study wished to use the ITN to deter mosquitoes and not necessarily prevent malaria, there was apparent limited access to them. Therefore, for equitable distribution of ITNs the alleged allegations of corruption and mismanagement must be taken very seriously by policy makers in Nigeria.

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CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

6.1 Introduction

Research has shown that Knowledge, Attitude and Practice (KAP) surveys are important methods of investigation in quantitative research methodology. They are relatively cheap, convenient, and less hazardous. They are important approaches to assessing distribution of community knowledge in large- scale projects. They also provide a cheap way to gain quick access to knowledge data and relatively easy to carry out (Hausmann-Muela et al., 2003: 3).

Perhaps, based on the advantages of KAP surveys, previously conducted studies on malaria in Nigeria have tended to focus more attention on KAP using a combination of fantastic and robust quantitative research techniques. The rationale is to predict knowledge, attitude and practice towards malaria. For instance, Oguonu et al. (2005) had carried out a KAP survey on childhood malaria and treatment in rural and urban areas of Enugu, Nigeria using a structured questionnaire. Although KAP surveys like this have made stunning discoveries, they are often inundated with challenges. The measurement of knowledge, attitude and practice is usually marred with inadequacies and wrong projections. Knowledge of malaria, for instance, is usually projected in terms of the correspondence between biomedical construction of malaria, particularly signs and symptoms, and local knowledge. Any result that deviates from biomedical constructs is generally considered inappropriate and recommendations are tailored towards knowledge improvement. However, other types of knowledge are often omitted and/or neglected with little information sought on knowledge about the use of health care systems (Hausmann-Muela et al., 2003: 4), the type of health care system used and the reason(s) for choosing the health system used. To close this gap, therefore, this study was conducted using a relatively new and independent paradigm known as qualitative methodology. It is a culturally compelling paradigm rooted in sociological debate and which has spread across other fields of study in social and humanitarian sciences in the recent time. The following research questions have been posed and investigated:

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Question 1. How do caregivers in the communities of study perceive the threat, aetiology and symptoms of malaria in children below the age of five? How does this correspond to biological construction and does it matter?

Question 2. To what extent does local knowledge and attitudes about preventive measures affect their utilisation in the communities of study and does it matter?

Question 3. What are the routes or pathways to health care utilisation in the management of malaria in children in both the rural and urban areas? In other words, does the pattern of health care utilisation differ between the rural and urban dwellers in response to malaria in children? If yes, why, and if no, why not?

Question 4. Is there any difference in the patterns of health care utilisation among young parents and grandparents in the treatment of malaria in children under the ages of five? If yes, what factors could be responsible for the difference and do they actually matter?

Question 5. What socio-cultural factors in the communities of study enhance or constrain the use of modern health care facilities in the management of malaria in children and why?

Using the appropriate research design (qualitative paradigm) and methods of triangulation (structured interview, focus group discussions, in-depth interviews and visual methods), this study has been able to answer these research questions and the implicit tentative hypotheses confirmed and verified. The method has allowed the researcher to dig deep into the cultural construction of malaria in children (in terms of conception, perception, signs, aetiology and symptoms) and also knowledge seeking information about home-grown method of treatment vis-à-vis generational differences in treatment. This chapter presents the summary of findings, conclusion and recommendations in line with the objectives of the study.

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6.2 Summary of Findings

On local knowledge and the perceived threat of malaria in children, the interviews conducted with health officials and caregivers indicated that malaria is a very common and serious health problem in the communities studied. This was based on the experiences of caregivers and health workers and persistent waves of malaria in the communities. Caregivers often took malaria in children “very seriously” and responded “very quickly” although the use of herbal medicine was usually the first treatment option chosen. This, together with other factors, constituted a barrier in seeking treatment at the government health care facilities even though these facilities lie within the reach of the people. More so, complicated cases of malaria such as convulsions and anaemia were believed to be different health problems entirely. This was consistent with the works from other parts of Nigeria (Akogun and John, 2005) and elsewhere (Beiersmann et al. 2007; Foster and Vilendrer, 2009; Makundi et al. 2006). Such inadequacy and non-use of modern health care facilities may constitute a serious threat in the control and eradication of malaria in children in Nigeria.

The local perception of causes of malaria in children was also investigated. On one hand, it was discovered that local knowledge about the causes of malaria was multi-dimensional and multifaceted. Though a number of individuals believed that malaria was caused by mosquitoes, the majority attributed the aetiological factors to unclean water, teething problems, exposure to sun and so on. To some of the respondents prolonged malaria could have spiritual or magical connections or undertones. In this case, where witches were the prime suspects, “the wise ones” were usually consulted. Indeed, the study suggested that this construction contradicts sharply with the biological explanation of malaria and may also constitute a serious threat to the fight against malaria. On the other hand, it was discovered that local construction of symptoms of uncomplicated malaria in children often corresponds to those identified in the biomedical sciences. The majority of the respondents in both rural and urban areas mentioned high body temperature, loss of appetite, loss of weight, weakness of the body and unnatural quietness as some of the symptoms of (uncomplicated) malaria in children. This has been supported by studies from African communities and other malaria endemic regions (Oguonu et al. 2005; Simsek and Kurcer, 2005).

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The local knowledge and attitude towards modern preventive measures were also explored. The majority of the respondents demonstrated a low level of knowledge about the ITNs. Although some respondents were able to draw a distinction between ordinary and the insecticide treated nets, the majority of them had not used the treated bed nets for their children as at the time of the study. With respect to this issue, the study identified four categories of caregivers in rural urban communities of study. In the first category were caregivers who had heard of and used the bed nets for their children or wards in the past and might be willing to use again. In this category, there were mixed feelings about the effectiveness of the bed nets. In the second category were caregivers who had heard but not used the bed nets for their children or wards. These people were the majority. In the third category were those who had not heard of the ITN and as such had not used it. Those in the last category were caregivers who did not believe in ITN at all and as such had no cause to use it. Instead of the bed nets the majority of the people in the areas studied depended on other preventive measures that included in-house spraying and a number of local plants as alternatives to the ITNs. A low level of knowledge and awareness about the ITN has been reported by other studies in and outside Nigeria (see the discussion). Although there were certain misconceptions about the ITNs in the communities studied, non-availability was largely due to alleged poor distribution network, favouritism and nepotism, misappropriation, mismanagement and corruption. Lack of education about the effectiveness of the bed nets was also observed.

The pathways to health care service utilisation in the case of malaria in children were also investigated. It was argued that treatment of malaria in children in rural and urban areas was similar. It is usually procedural in nature. It often depends on the severity, recognition and persistence of symptoms and demographic factors of the health care seekers. It usually starts with home treatment largely with the use of herbal medicines. A number of local plants in the treatment of malaria in children were identified. The use of modern health care facilities in both communities was usually the last resort and then only when home treatments had failed. The study identified interconnected treatment options or pathways in the treatment of malaria among the people. Four different treatment options were found in the rural areas while there were up to five in the urban centre.

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The changing patterns in the use of traditional medicine in the treatment of malaria in children between young and older parents were also explored. The study identified a socio-generational gap in the treatment patterns. The results of this study indicate that while many grandparents are still tied to the cultural patterns of disease management in children using herbal medicines, a significant number of young parents and a very small number of grandparents, with or without western education, are beginning to accept the use of modern treatment strategies. This did not, however, suggest that herbal medicines have been abandoned outright for modern medicines. It is believed that both methods complement one another. The use of modern medicines was attributed to cultural diffusion, western education, exposure and nurses/doctors’ advice. Some grandparents expressed the fear that the widespread use of modern medicine by young mothers may be responsible for reported cases of non-effectiveness of herbal medicine by young mothers.

Finally, it was discovered that caregivers who wished to use or access modern health care facilities often experienced difficulties in spite of close proximity to the facilities and the government’s so-called free treatment exercise. It was discovered that the free treatment exercise for children younger than five years of age was not actually free. Parents are actually charged an exorbitant amount of money which ought not to be so under the programme. The study therefore found that the government’s free treatment exercise is characterised by a myriad of problems and challenges. Hence, poverty or lack of money, lack of trust and inconsistency in government’s programmes, belief in traditional medicine, exorbitant charges in modern facilities and poor service delivery, insufficient medical personnel and nonchalant attitude commonly demonstrated by the health officials especially the nurses were largely alleged as factors hindering the use of the modern health care services in the communities studied. It was also discovered that the network of informal social interaction at household and community levels can sometimes influence the decision of caregivers to seek treatment either from traditional or modern health care providers in the communities studied. These findings call for a design of health interventions nestled within the context of the social and ecological landscape of local communities.

6.3 Theoretical Underpinnings and their Justifications

The change process is a complex and interesting phenomenon that has captured the attention of researchers over the years. Specifically, health educators and health promotion agencies have been

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concerned with changes that can occur at the level of individual, organisation, community and the society at large. Many theoretical and conceptual constructs have therefore been developed to help explain and project health behaviour change. This involved the development of methods that could foster health behaviour change many of which were rooted in quantitative studies however. Others have concentrated on the social factors that can enhance positive health behaviours.

Therefore, identifying theoretical frameworks among countless theories that effectively describe modifiable factors that could result in more successful malaria intervention for the prevention and management of malaria in children younger than five years of age is therefore daunting and challenging. Nevertheless, behavioural, social and cognitive factors associated with management of malaria in the communities studied according to the major constructs of four behavioural science theories have been identified. They are: Health Belief Model (HBM), Transtheoretical model (TTM), the Theory of Health Care Utilisation, the Generational Cohort theory and the Rational Choice Theory (RCT). Each of these theoretical frameworks - except for the GCT and RCT- alludes to the fact that health behaviour is a complex process and as a result influenced by numerous but interrelated factors. The use of several theoretical predictions is informed by the fact that “one size does not fit all” Fishbein (2000: 275) and that “very different types of interventions will be necessary to shift behaviour where people’s intentions to change are governed by attitudes, perceived social norms and/or notions of self-efficacy” (Panter-Brick et al., 2006: 2812).

As narrated in the forth chapter of this thesis, the health belief model assumes that health seeking or treatment behaviour is influenced by attitudes, beliefs and established mechanisms in the society to minimise the occurrence of disease. It is believed that health behaviours are influenced by the perceived threat, perceived susceptibility, perceived seriousness, perceived benefits and barriers, health motivation and cues to action. It is suggested that high perceived threat, low barriers, and high perceived benefits to action are important factors in the individual’s decision to take health related actions. HBM is used in this study to explain health seeking behaviour in the case of malaria. For instance, the model assumes that where an individual does perceive malaria as a serious health problem and sees her or his child prone to it, she or he is likely to take positive health actions. Therefore, to design health intervention programmes aimed at improving knowledge about malaria in children the cognitive variables become important targets in

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HBM. The question is: what happens where an individual feels threatened by malaria but does not have access to prompt treatment, control vector or treated bed nets given socio- structural and organisational factors that stymie access to these kites and treatment?

The theory of health care utilisation provides a more complex approach that includes some elements of psychological and sociological variables in the prediction and understanding of individual health behaviour change. The theory assumes that both individual and societal forces function to influence an individual’s decisions to make use of health care services or not. In other words, health behaviour change is believed to be influenced by a myriad of interacting factors including an individual’s predisposition, and the need factors which are in turn influenced by broad societal attributes and characteristics that include health service delivery, the state of medical technology and societal norms regarding the definition and treatment of illness (Andersen and Newman, 2005: 2). This theory is applied in this context to understand health care seeking behaviour of caregivers in children with malaria within the context of government policies and resources to prevent malaria infections and boost the treatment of malaria (societal characteristics) as well as predisposing, enabling and the need factors (individual characteristics), all of which have been discussed in chapter four of this thesis. An intervention programmes aimed at improving access to modern health care system must therefore take cognisance of the constellation of factors affecting health care utilisation in the first place.

The transtheoretical model identifies specific stages of change, processes of change and decisional balance in health behaviour change which can be used by health educators in Nigeria to design malaria intervention programmes. There has never been a constituted malaria intervention programmes in the communities studied targeting the disadvantaged caregivers. The pieces of advice usually provided by health care providers to change health seeking behaviour are usually conducted haphazardly. They are not based on a predetermined theoretical ideology or foundation. Therefore, transtheoretical theory used in the current study proposes that malaria intervention and education programmes (perhaps in the future) could be tailored or founded on the stages and processes of change. The model includes an understanding of the factors (i.e. the processes of change) necessary for individuals to progress to the next stage, thus providing implicit intervention strategies. The model likewise describes the ideal sequence of these factors. Through these processes health intervention programmes could effectively reach individual caregivers and satisfy

190 the unique behavioural, cognitive and psychosocial needs associated with each particular stage identified in the TTM. For instance, this targeting of stage-specific malaria interventions may identify methods for moving caregivers closer towards quick response to malaria in children using the available modern resources. Successful application of the model with malaria can also furnish a practical segmentation strategy for research and campaign health message design. As found in this study, the nurses and doctors are, therefore, important agents of change in ensuring and fostering behaviour change towards the use of the ‘appropriate’ methods of treatment of malaria disease in Nigeria.

The Generational Cohort Theory (GCT) assumes that there are attitudinal differences in different generations of people. The theory was developed to understand diverse attitudinal differences and behaviours embedded in different generations of people each of which is known as a cohort. It is argued that each generation comprised of a cohort seen as a people born about the same time and who are bound together and profoundly influenced by the events of their formative years. However, belonging to the same age group does not necessarily link people into any meaningful cohort, rather, it is the events that occur at various critical points during the group’s lifetime that create cohorts and define core values. GCT is used in this study to explain the socio-generational changes in the patterns of health-care seeking behaviour of young and older parents especially as it regards the changing issues in the treatment of malaria. Different strategies can be designed for young and older caregivers to achieve a sustainable change in health seeking behaviour with regards to the treatment of malaria in children younger than five years of age.

Finally, rational choice theory (RCT) is a specific theoretical construct with a solid background in the field of economics. It is being used (though in a refined way) among contemporary sociologists (known as rational choice sociologists) to understand the complex nature of human actions. The theory suggests that “an individual has a well-defined manner of ranking alternatives according to their desirability” (Ok, 2007: 2) and that individual actor is a rational being who aims to maximise utility at all cost (Munck, 2002, quoted from Impithuksa, nd: 2). In this study, RCT helps to understand the ‘rational’ calculation often make by individual caregiver in the communities studied with respect to management of malaria given certain institutional, economic and structural challenges beyond their control. As the study shows, caregivers often weigh options available before a final decision to use a particular health care system. They make choices in

191 relation to both the means for attaining their goals as they often anticipate the outcomes of alternative courses of action and calculate that which will be best for them. The movement between available health care systems to cure malaria is an indication of calculations and preferences of caregivers for one particular health care system to the other.

However, the biggest challenge from the above is how to make sense from this canon of psychological and sociological theories to achieve sustainable health intervention strategies especially with regards to malaria prevention and control. A quick look at the Fishbein’s integrative model is therefore highly necessary. Fishbein (2000: 275) has designed an integrative approach from quantum of theories of health behaviour change. The integrative approach to health behaviour change incorporates elements of psychosocial variables (attitudes, norms and self-efficacy) and socio-cultural variables in designing theory-based interventions. Fishbein is convinced that the approach can be adapted to suit any socio-cultural environment and the targeted population depending on the ability of the researcher using it.

I have often heard people argue that theoretical models such as the one presented here are ‘Western’ based models that don’t apply to other cultures or countries or that these types of model are not culturally specific. In marked contrast ... [w]hen properly applied these models are culturally specific..., the variables in the model are expected to vary as a function of both the behaviour and the population under consideration.... [W]hen properly applied, these types of models require one to understand the behaviour from the perspective of the population being considered... Each of the variables in the model can be found in almost any culture or population. Indeed, the theoretical variables contained in the model ... have been tested in over 50 countries in both the developed and the developing world (Fishbein, 2000: 274).

Fishbein integrative approach is based on the premise that different types of intervention strategies are required to switch behaviour where people’s intentions to change are shaped and governed by attitudes, perceived social norms and/or notions of self-efficacy (cf. from Panter-Brick et al., (2006: 2812). For instance, Panter-Brick et al. (2006) have used the model to understand culturally compelling strategies for behaviour change in malaria prevention in rural Gambia. The study focuses attention on the “social and physical settings contextualising behaviour as well as the interplay between human actors and external

192 factors shaping their agency”. Some of the culturally compelling instruments of change used by Panter- Brick et al. (2006) to enhance the repairs of treated bed nets were posters and locally composed songs. The integrative approach known as social ecology approach by Panter-Brick (2006) is illustrated in the diagram below:

Figure 6.1: A Social Ecology Model of Behaviour Change.

SOCIAL ECOLOGY LOCAL AND EXTERNAL INVESTMENTS Constraints on agency Enabling factors Political and financial commitment, community Time, economic, social, physical Skills, ability priorities, organisational supports ¦

Beliefs Psychosocial variables ¦

Behavioural beliefs and Attitudes ¦ their evaluative aspects ¦

¦ Normative beliefs and Social norms INVENTION BEHAVIOUR HEALTH IMPACT motivation to change TO CHANGE ¦ CHANGE

¦ Efficacy beliefs Self-efficacy INTERVENTION STRATEGY Sustainability Triggers/stimuli for change

Culturally Acceptable Intervention Culturally Compelling Intervention Effective Intervention

Source: Panter-Brick et al., (2006: 2813).

Note: Please note that the dashed lines, connecting social ecological context with strategy for behaviour change, are applicable at different points on the continuum.

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6.4 Conclusions and Recommendations

Six major conclusions can be drawn from the current study. Firstly, the research indicated that the perceived aetiology, symptoms and treatment of malaria in children were largely influenced by the socio- cultural patterns of the communities studied such that traditional herbal medicine was the first line of treatment for malaria episodes in children. Secondly, the study found very little or no difference in the patterns of health care service utilisation between the rural and urban respondents. This discovery is striking considering the fact that urban participants have more access to modern health care facilities and are supposedly expected to be more “exposed” and “civilised” than their rural counterparts. Thirdly, the study found that there is low level of knowledge about the use of treated bed nets in the communities. Non- availability was largely due to alleged corruption and mismanagement. Fourthly, the study found that lack of money or poverty, a perceived weak health care system, belief and trust in traditional herbal medicines further constitute hindrances to the utilisation of modern health facilities. Fifthly, there is a generational gap or difference between young and older parents in the perception and use of modern medicines in the treatment of malaria in children. Lastly, the decision making process is often shaped by the network of informal social interaction and support at household and community levels. Apart from the biological mother, other women within the household and community, particularly the mother-in-law and grandparents have the primary role of ensuring that the child’s health is restored within a reasonable period of time. The husband’s role was paramount in seeking treatment outside home.

6.5 Policy Implications

On the basis of the discussion in the preceding chapter and the conclusion drawn, the summary of the key policy recommendations is hereby presented all of which are related to the research questions formulated earlier. It has been demonstrated that communities’ understanding of causes, diagnosis and treatment of disease are interwoven in functional ways and that their understanding and recognition by policy makers and educators is paramount in addressing diseases and illnesses at community levels. For instance, the attribution of witchcraft, bedbugs and haemorrhage as being causes of malaria, and the lack of appropriate knowledge about the distinction between complicated and uncomplicated malaria in children can constitute a threat to malaria control, prevention and management.

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For a workable solution to these problems, the conceptual framework - health field model (HFM) - adopted might have contained important propositions to the lingering crisis of malaria. The HFM has identified a constellation of factors affecting ill-health. On the one hand, the framework demonstrates how the “global factors” such as community and social environment, physical environment, and genetic factors directly affect disease distribution, injury, health and wellbeing in human population (Ratzan et al, 2000: 43). The social and community environment emphasises the social status or class, social networks, government policies on health and wellbeing. The physical environment includes the physical hazards at home, community and work environment, natural health threats (e.g. natural disasters), and chemical agents to which individuals are exposed. The family and individual environment includes human behaviours and lifestyle, family support, access to and use of the medical system. On the other hand, it examines the impact of the risk factors or vulnerability which includes age and exposure to health risks (such as malaria- transmitting mosquitoes), education and income and health care system on health and wellbeing.

As argued in Chapter one, HFM is concerned with what can be done at individual, community and global levels to enhance health conditions. These are further divided into three broad levels: the primary, secondary and tertiary prevention levels. The primary prevention concerns the question of “how do we keep ourselves well or prevent the occurrence of disease?” Secondary prevention relates to questions such as “if we are getting sick, how can we detect these conditions?” The tertiary prevention is concerned with “if we are sick, how do we get the best care?” At global and community levels, these aspects include formulating and enforcing health policies that affect health such as private and social health insurance and full commitment to the implementation of programmes that directly benefit the less privileged. At individual or family level, this can include personal decisions to make the “right” choices such as using the mosquito bed nets to prevent mosquito bites. However, as argued in the chapter the whole of these may not be possible without adequate knowledge and education about prevention and treatment. This underscores the need for health promotion initiatives and coverage.

However, while public health promotion initiatives have tended to focus primarily on changing individual behaviour to reduce the risk of disease, most of them have failed to seek to understand and address the factors that create physical and social health inequalities in the first instance. Therefore, it is important that

195 policy makers take cognisance of the local dynamics of disease and ill-health in designing health promotion strategies and initiatives especially with respect to malaria in children. Health education and promotion should target less disadvantaged mothers and caregivers in disadvantaged areas whether in the rural or urban areas. Local and national health promotion policies should take cognisance of the features of places and people at which they are aimed.

It must however, be reiterated that while health education and promotion is actually a prerequisite for sensitising the uninformed and possibly encouraging them to make the “right” choices, it has been well acknowledged and documented that knowledge on its own is not enough for positive health behaviour. In fact, most studies have indicated that appropriate treatment procedure requires an approach that goes beyond simply raising awareness to a more sustainable behaviour change that people are willing to make every day of their life even when they are less threatened by ill health (Alaii, 2003: 12).

Unfortunately, most health promotion strategies and initiatives in Nigeria have followed similar patterns - portraying an individual as a mechanical device that automatically reacts to a stimulus package without any processing and questioning. It is believed among policy makers in Nigeria that ordinary health education and awareness campaigns or programmes could automatically encourage positive health behaviour. For instance, the so-called comprehensive Behaviour Communication Change Strategy (BCC) was developed in Nigeria in 2004 to achieve consistent, integrated and appropriate malaria interventions (RBM Secretariat, 2008: 11). Sadly, the BCC initiative has recorded a minimum level of achievement so far. One of the major factors responsible for the inability of the government’s initiatives or programmes like the BCC to achieve their mandate in changing behaviour is because they have failed to recognise and incorporate local dynamics into their design and implementation.

Despite the numerous efforts to promote knowledge about malaria treatment and prevention in Nigeria, neither health education nor intervention programmes such as the BCC would be maximally effective unless they include several features. Besides, programmes directors should take cognisance of the many lessons that have been learned from the application of transtheoretical constructs to other health behaviours, such as smoking, lack of exercise, or weight loss, sun protection, dietary fat reduction, condom

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use, adherence to mammography screening, stress management and substance abuse cessation (see Reeding et al. 2000: 187). Facilitating knowledge about malaria risk reduction may be best implemented and understood by systematically applying behaviour change theory in different settings and with different populations (young and grandparents as indicated in this study). TTM has been effectively used in HIV prevention research and interventions (Cabral et al. 2004) as well as the involvement of men in family planning adoption (Abraham et al. 2010: 46). It could as well be particularly useful in explaining the complex processes underlying malaria knowledge improvement and adoption of modern preventive measures especially when the intervention strategies are based on individual’s stages of change. In other words, where programmes that require changes in health behaviour are important, people’s perceptions of disease and illness, their willingness or unwillingness to change, the influence of the subjective traditional ethos on behaviour must be incorporated at the planning and implementation stages. Only then can the intervention initiatives be positively and sustainably channelled towards maximum acceptability by the people (Alaii, 2003: 14). The principal weakness inherently embedded in the stage-based approaches such as the TTM is that messages and priorities are tailored towards individuals at different stages of readiness for change instead of communities as a whole (Panter-Brick et al. 2006: 2811).

Nevertheless, a malaria prevention programme in Nigeria must (i) expand beyond the provision of information alone; (ii) use culturally specific intervention programmes; and (iii) acknowledge and incorporate the socioeconomic and cultural context of the people concerned into the programme’s educational and motivational strategies. Health intervention programmes targeting individual caregiver should be built on existing practices, skills and priorities, recognise the constraints on human behaviour change, and target those most receptive to change (grandparents as indicated in the current study). Furthermore, intervention programme design should strive to be both culturally appropriate and compelling: they must engage local communities and such programmes must be nestled within social and ecological landscapes of the communities concerned (Panter-Brick et al. 2006: 2812).

In the same vein, while integrating ITN distribution with immunisation is a worthwhile approach and measure to provide logical opportunity to reach out to the most vulnerable groups and enhance widespread coverage as shown by Macedo de Oliveira et al. (2010: 9), any attempt to improve awareness, knowledge,

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ownership, use and retention of ITN in local communities must recognise the inherent socio-cultural and ecological cause(s) of i) the low level of knowledge and awareness, and ii) widespread non-use. Only then can the ITNs be seen as a worthwhile public health intervention initiative among the people. To address many of the socio-political and structural or institutional problems associated with the distribution of the ITNs found in the current study, such as poor distribution networks, gross mismanagement, nepotism and favouritism as well as corruption, there is an urgent need for health policy makers to collaborate with the security agencies to put adequate and sustainable measures in place to ensure that the bed nets get to the people they are actually designed and meant for with limited hiccups or obstacles. Furthermore, studies have shown that community based distribution of bed nets is an untapped potential method to enhance and ensure that the bed nets get to the people who need them most in local communities (Onwujekwe et al. 2005: 5). This approach emphasises the importance of recognising social capital in ensuring widespread coverage of the bed nets and positive use of the bed nets. This must go with proper education about the use and effectiveness of the bed nets and the zeal to fight the alleged corruption at all levels.

There is daunting evidence to show that the modern health care system in Nigeria is facing huge challenges. This study shows that apart from finance, the non-utilisation of modern health care services was attributed to perceived weak health care system particularly in the rural areas. A recent survey of the primary health care (PHC) facilities in four states of Nigeria (Kaduna, Bauchi, Cross-river and Lagos States) indicates that facilities at this level of care are hindered by insurmountable challenges with least level of satisfaction reported among the users (World Bank, 2010: xiii-xvi).

Therefore, a refocus on the PHC as a cornerstone to reaching the less privileged in both the rural and urban areas is indeed paramount. A sustainable and comprehensive health care system would require a holistic approach. The health services infrastructure, the human resources and other important machineries of health services that include drugs and community health services call for a general overhauling in order to produce adequate and quality health care services to the people. In addition, constant monitoring and evaluation of the free malaria treatment are also necessary. This can build trust in the free malaria programme and enhance positive health care seeking behaviour of caregivers across society and invariably help to achieve universal coverage. The free distribution of the so-called “almost expired drugs” in the rural

198 areas under the auspices of the free malaria treatment must be looked into by the health policy makers. This may drastically reduce the use of expired drugs for children with malaria in rural areas. In the same vein, the extension of the National Health Insurance Scheme to the rural people needs to be pursued with vigour and determination. It is important that such a programme is built on the prevailing socio-cultural and environmental conditions of the people. There is also the need for proper legal frameworks to regulate the activities of the private drug shops to minimise the administration of fake and wrong drugs.

Community experience has shown that a number of local plants are believed to be effective in the management of malaria. This is common to major communities in Nigeria and across the continent. Indeed, the WHO has acknowledged the contributions of traditional healers and their medicines to the overall health delivery system particularly in developing countries. According to the World Health Organisation the native healers have contributed to a broad spectrum of health care needs that include disease prevention, management and treatment of non-communicable diseases (WHO, 2001). Therefore, some local plants as well as insects and arthropods (Banjo et al. 2003) have been documented as effective in the management of various ailments.

With particular reference to the local communities studied the local plants in the treatment of malaria might include dogonyaro, Akintola, cashew plant, ewe panseke, orange leaves and the bitter lemon plant. The government might need to support pharmaceutical companies to investigate the chemical components and properties of these plants and confirm their efficacy and effectiveness or otherwise in the management of malaria and related ailments. This has become highly important against the background that the majority of the people in Nigeria still trust and believe in this age-old tradition as shown in this study and many others. Besides, recently discovered modern medicines for the treatment of malaria have been extracted from local plants across the world. The cooperation and a systematic relationship between traditional and modern medicines must be guided by adequate legal frameworks. Policy makers in Nigeria may have to learn from the cooperation between traditional and modern doctors in Zambia and Botswana. A series of workshop organised by the Ministry of Health in conjunction with the Zambia Integrated Health Programme (ZIHP) in selected districts of Zambia has helped to improve relationship between the traditional and modern doctors

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very tremendously (Centre Board of Health, Zambia, 2003). Figure 6.1 below could serve as a framework for the integration or cooperation between traditional and modern medicines.

Figure 6.2 A Framework for the Integration/Cooperation between Traditional and Modern Health Care Systems

Traditional Medical Modern Medical Practitioners Practitioners

Government

Educating about Educating about Health policy traditional modern medicine di i

• Extraction Initiating studies on • Standardisation National propagation, acculturation • Safety Pharmacopia method for medicinal plants • Dosage

formulation • Patent right Goals

• Access to health

• Improved human health nationally • Cost of procurement

reduced

Source: Bello (2006: 334).

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However, there are certain problems and challenges to be overcome in order to achieve the objective of integration or cooperation between traditional and modern medicines especially in Yoruba culture. First and foremost, the ethnocentric and medicocentric tendencies of the Western hegemonic mentality that properties of traditional medicine defy scientific procedures need to be addressed. The Yoruba traditional medicine often comprises of the physical and spiritual realms. While the physical aspects can be subjected to scientific analysis using the conventional scientific methods of investigation, the spiritual realm may not (Oyelakin, 2009: 83). The biggest challenge therefore, is how to scientifically analyse the spiritual aspect of Yoruba traditional medicine, for instance, “ofo” known as incantation.

The question again is: if traditional medicine is integrated into the modern health care system, who provides training to medical doctors on the ontology, epistemology and the efficacies of the Yoruba traditional medicine given the ethnocentric tendencies in modern medicine? That is, who determines the efficacy and effectiveness of traditional medicine given the inherent epistemological, methodological and ideological differences of both medicines? It is part of these difficulties that some scholars have suggested that both African traditional medicines be allowed to flourish independent of one another (Oyelakin, 2009). “After all, the western people did not develop their medical aspect in order to integrate it with anyone else. Theirs was to first make themselves and later the rest of the world live a healthy life” (Oyelakin, 2009: 83). Nevertheless, the debate about whether or not to allow traditional medicine to be integrated or co-opted into the mainstream health care system in Nigeria lingers on.

6.6 Future Research Further research in different areas of health care utilisation including the impact of Western education on health care service utilisation might be necessary especially in the communities studied. Again, community- based distribution of bed nets remains an untapped potential to ensure widespread coverage of the bed nets in traditional communities. Therefore, further studies might be necessary to discover how social capital at the community level can ensure that bed nets get to the most vulnerable and thereby enhancing their use in the prevention of malaria infections in children. Furthermore, there is a general consensus among researchers that long-term follow-up of children using ITN can provide a meaningful answer to the question of real impact of ITN in the reduction of casualties caused by malaria especially among the children

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(Lengeler et al. 1998: 287). A complementary method including longitudinal study might therefore be required to ascertain the real impact of insecticide treated bed nets on the incidences of malaria in children. However, the major stumbling-block to the realisation of this noble objective might be related to funding because research and development are yet to receive the desired attention of policy makers in Nigeria.

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LIST OF REFERENCES

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APPENDIXES

Appendix I: Interview Guide (Semi-structured, in-depth and FGD Guide)

a. Semi-structured

SECTION A: Personal Profile of the Respondent

a. How old are you? b. Please status your gender? c. Please state your educational qualification? d. What is your religious affiliation? e. Which community are you from? f. What is your home language? g. What is your occupation? h. How many kids do you have who are less than five years? i. Do you have medical facilities in your community? j. How often do you use them?

SECTION B. Local Knowledge and Perceptions of the Aetiology and Management of Malaria

1. Has your child developed malaria symptoms in the past one year?

2. Would you consider malaria a very serious health problem to you and your child? Kindly expatiate or your community?

3. What do you think are the physical symptoms malaria?

4. How did you know about these?

Probe: Did you know through health counseling about malaria by government health officials or through everyday experience?

5. In your opinion, what would you say are the causes of malaria in children?

6. When malaria symptoms are manifested in your child, what are the available avenues to rectify or fix the problem?

7. When malaria symptoms strike in your children, do you usually start treatment from home by taking certain drugs or herbs believed to be curative measures?

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8. Where self-treatment was used and failed, what option would you consider afterwards?

9. Have you treated malaria in your child using local means such as herbs? If it’s true, what local herbs combinations did you use? Please tell me how you know about them?

10. When herbs were used for malaria in children, did malaria ever disappear? In other words, how effective were they?

11. Did you ever see a medical doctor (or nurse) when your child had malaria?

Probe: Is it when symptoms are first manifested or continued to manifest in your child?

12. Did the doctor (or nurse) ever tell you that you were reporting late? 13. How much does it cost to treat malaria in a clinic?

Probe: Can you afford it?

14. Could money be the reason for consulting native healers, or for reporting late to the modern doctor if you were ever late?

15. Please share with me the method you prefer in the management of malaria in your child (traditional or modern methods) and tell me why?

16. When malaria refuses to disappear after treatment in your child could you attribute this to witchcraft or evil doers?

17. At what stage of malaria can it be said that evil doers are involved?

18. In the case of complications, who would you consult to solve the problem, a medical doctor or native healer

19. Have you ever experienced malaria outbreak in children in this community?

20. In your opinion, what could possibly cause a sudden outbreak of malaria amongst children in this community?

Probe: wrath of gods b. ancestors; c. violation of taboos; d. static water (if any); e. the work of God; f. punishment for sin; g. misfortune

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21. If yes, what was done to stem the crisis?

22. Is there any other issue you will like to share with me on this issue?

SECTION C: Communities’ Knowledge and Sentiments about Preventive and Curative Measures

1. What do you do to prevent malaria infection in your children especially those below the age of five?

Probe: The principal current preventative measures of malaria involve mosquito control and barriers to transmission.

2. Do you know what a treated bed net is? Have you ever seen one? Where did you see it and how did you come to know about it? How would you differentiate ordinary nets from the treated nets?

3. Have you ever used a treated net before especially for your children below the age of five? If yes, how did you get it?

4. What other methods do you usually use to prevent malaria infections in your child? a. Chemicals applied to skin; b. treated bed net; c. ordinary bed net; d. maintaining clean environment; e. prayers; f. Insecticides e.g. Baygon; g. insecticide paper, e.g. Rambo Insecticide paper; h. nothing.

5. Is there any related issue you will like to share with me on this matter?

b. THE KEY INFORMANT INTERVIEW GUIDE (CONDUCTED with biological or foster PARENTS AT THE HOSPITAL or clinic)

Sociological Variables That Enhance or Constrain Health Care Seeking Behaviour of Care Givers and the Routes to Health Recovery.

Start with same personal profile (Section A)

a. By the time your child started to manifest symptoms of malaria, did you do anything in terms of treatment before coming to the hospital? Please explain what you did and why.

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b. Did you consult with any of your relatives (e.g. husband/wife, grandparents etc.) before your decision to visit the hospital? If yes, why would you consult with anybody before your decision to come to the clinic? c. Please share with me people you consider very significant in your decision to come to the hospital and why. d. What was the role of your husband or wife in your decision to visit the clinic? e. Did you ever visit a patent medicine store for consultation before your decision to see a medical doctor? If yes, why did you do that and what drugs were prescribed? Did you find their prescriptions helpful? f. At any time, would you visit a native doctor, for symptoms of malaria in your child?

At any time, would you visit a or ‘aladura’ (priest) g. Did you ever think of not coming to the hospital at any point when you first saw malaria symptoms in your baby? If yes, what would have influenced that thought and why did you debunk or jettison the thought?

Probe: Was your decision influenced by any of the following: i) family size; ii) long distance; iii) income i.e socio-economic status; iv) cultural beliefs. h. What other factors might influence your decision to seek modern health care for your child apart from those mentioned above? i. Having come to the hospital, would you see a native healer or ‘aladura’ if symptoms persist? If yes, why? j. Do you prefer to consult with a native doctor or a priest because of lack of access to adequate modern health facilities? Has lack of access ever debarred you from seeing a medical doctor? c. KEY INFORMANT INTERVIEW GUIDE (HEALTH WORKERS) 1. Are you aware of any family in these communities who have lost a child to malaria complications? Probe: high; moderate; low numbers

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2. Most parents report cases of malaria only when complications have occurred. Do you have similar experience in your hospital?

3. If yes, what factors do you think contribute for the lateness?

Probe; E.g. cultural, ignorance, finances etc.

4. What do you think most parents do first in terms of treatment when malaria occurs?

5. Would do you still consider chloroquine useful when malaria symptoms manifest?

6. At present, the most effective combinations in the treatment of malaria are based on artemisinin–based combination therapies (ACTs) In your experience to what extent can parents in these localities afford that?

7. In most rural communities, it is said that parents prefer to consult with a native doctor because of lack of access to adequate health facilities. In your opinion, do you think this is true in these communities?

8. How much does it cost to treat malaria in children below the age of five? Do you think this is affordable for an average parent in this locality?

9. What are the problems and challenges in treating malaris in this locality?

10. Is there any other issue related to the treatment of malaria in children that you would like to share with me?

d. FOCUS GROUP DISCUSSION GUIDE (grandparents)

Start with personal profiles (As in Section A)

a. In olden days, what were the best ways to manage malaria particularly among young children below the age of five? In other words, what did you use to do to manage malaria when it manifested? Are young mothers doing things differently now? If yes, how and why do you think it is the case?

b. People used to believe that complicated malaria can be inflicted by enemies. Was this the case in your own time?

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c. In your opinion, do you think young mothers believe in this today?

d. Can you remember any incidence that can support your opinion?

e. Is there any matter regarding the treatment of malaria in young children you would like to share with me?

e. FOCUS GROUP DISCUSSION GUIDE (Young mothers)

Personal profiles

1. What procedures and measures would you prefer to be the best methods of preventing and managing malaria in children below the age of five?

2. What do you believe causes malaria?

Probe: Culture etc.

3. When malaria occurs, do you respond to it using traditional methods handed down by your parents or grandparents or you do it in your own way? Please explain what is done and why?

4. Would you share the belief that the way diseases like malaria in children are handled today is different from the way they used to? What is different and why?

5. Any important matter on the treatment of malaria in children you want to share with me?

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Appendix II: Letter of Introduction

TO WHOM IT MAY CONCERN

LETTER OF INTRODUCTION: MR. A. A. ABDULLAHI

This is to introduce to you Mr. Abdullahi Ali A, a Nigerian doctoral student of the Department of Sociology, University of Johannesburg, South Africa. He is currently doing fieldwork in Ilorin-South (Children Specialist Hospital, Centre Igboro) and Okanle-Fajeromi communities. His research is focused on health care utilization of care givers in the management of malaria in children below the age of five. This research is purely for academic purposes and does not represent any other interests such as government, NGO, etc. Your cooperation will be appreciated to ensure the timely completion of his project.

Thank you.

Prof. Anton Senekal

DEPARTMENT OF SOCIOLOGY

UNIVERSITY OF JOHANNESBURG

SOUTH AFRICA

2009/11/03

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Appendix III: THE INTERVIEW IN PROGRESS

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Appendix IV: Sample of the signed consent form

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Figure 2.3: The World Map Showing the World Poverty Estimate

Adapted from European Alliance against Malaria (2007:2).

Figure 2.4: The World Map Showing an Estimate of the World Malaria Burden

Adapted from European Alliance against Malaria (2007:1),

Figure 2.5: The Interplay between Individual, Significant Others and Treatment Seeking Behaviour

Traditional Practitioner

Self-treatment: Home remedies; shop Perception of “Significant Therapy medicines; chemist; Illness others” Choice market herbalism; clandestine sources of injection antibiotics etc.

Biomedical Practitioners; Government or Private

Note: The green arrow on the extreme right indicates movement from one sector to another.

Adapted from Hausmann-Muela et al. (2003: 15):

Figure 2.6 Summary of Pathways to Health Care Utilisation in Nigeria

Pre Indigenous/ Native Christian Faith Islamic Faith Hospitalis- Healers Healers Healers ation

Nurse Patent Medicine Pharmacists Store/vendours

Hospitalis- General practitioners Hospital/Specialists ation

Post hospi- Native Healers Christian Faith Islamic Faith talisation Healers Healers

Source: Erinosho (1998: 48; 2006: 44).

Figure 2.8: Structure of Health Care System in Nigeria

Cabinet

National Advisory Council on Health

Inter-sectoral Federal Ministry of Health Collaboration

Private Sector, NGOs, Teaching Hospital, Traditional and Faith Healers Federal Medical Centre State Ministry of Health

Local Government Department for Health General Hospitals

Primary Health Centre & Health Posts

Adapted from Omoruan et al. (2009: 106).

Figure 3.1: Health Belief Model

Perceived Susceptibility

Belief in a personal health threat Perceived Severity

Health behaviour

Perceived Benefit

Belief in the effectiveness of Health behaviour

Perceived Barriers

Source: Munro et al. (2007: 5)

3.3.3 The Need Factors

Figure 3.2: The First Phase of Behavioural Model

Health Service Use Predisposing Enabling Factors Need Factors Factors

Sources: Hausmann-Muela et al. (2003: 12); Andersen (1995: 2).

In the second phase of this model, the importance of health care system in the utilisation of health care system was explicitly emphasised. According to Andersen (1995: 6):

Thus, the health care utilisation model chart was modified in phase 2 to include type, site purpose of consumption as well consumer’s level of satisfaction.

Figure 3.3: Andersen’s second phase of health services utilisation theory.

Population Characteristics

Predisposing, Enabling, and Need factors Consumer Satisfaction Use of Health Services Convenience, Quality, Type, Site, Purpose and Availability, Financing, and Time interval Provider Characteristics Health Care System

Policy, Resources and Organisation

Source: Andersen, (1995: 6)

Figure 4.1: Approaches to the study: Ethnography and Case Study

Ethnography Case Study

105 factors shaping their agency”. Some of the culturally compelling instruments of change used by Panter- Brick et al. (2006) to enhance the repairs of treated bed nets were posters and locally composed songs. The integrative approach known as social ecology approach by Panter-Brick (2006) is illustrated in the diagram below:

Figure 6.1: A Social Ecology Model of Behaviour Change.

Beliefs Psychosocial variables ¦

Behavioural beliefs and Attitudes ¦ their evaluative aspects ¦

¦ Normative beliefs and Social norms INVENTION BEHAVIOUR HEALTH IMPACT motivation to change TO CHANGE ¦ CHANGE

¦ Efficacy beliefs Self-efficacy INTERVENTION STRATEGY Sustainability

Triggers/stimuli for change

Culturally Acceptable Intervention Culturally Compelling Intervention Effective Intervention

Source: Panter-Brick et al., (2006: 2813).

Note: Please note that the dashed lines, connecting social ecological context with strategy for behaviour change, are applicable at different points on the continuum.

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