bioRxiv preprint doi: https://doi.org/10.1101/486183; this version posted December 3, 2018. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 1 Health seeking behaviour and cost of fever treatment to households in a malaria endemic 2 setting of northern Ghana: A cross sectional study 3 4 Maxwell Ayindenaba Dalaba1*, Patricia Akweongo2, Philip Baba Adongo2, Philip Ayizem 5 Dalinjong1, Samuel Chatio1, and Abraham Oduro1 6 7 8 1 Navrongo Health Research Centre, P.O Box 114, Navrongo, Ghana 9 2 University of Ghana, School of Public Health, Accra, Ghana 10 11 12 13 14 15 16 Corresponding Author 17 Maxwell Ayindenaba Dalaba, Navrongo Health Research Centre, P.O Box 114, Navrongo, 18 Ghana 19 Email: [email protected] 20 21 22 23 1 bioRxiv preprint doi: https://doi.org/10.1101/486183; this version posted December 3, 2018. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 24 Abstract 25 Background: This study examined the health seeking behaviours and cost of treatment of malaria 26 to households in the Kassena-Nankana district of Ghana. 27 Methods: A cross-sectional household survey was conducted between July and September 2015. 28 Individuals who had an episode of fever or malaria in the past two weeks identified during routine 29 Health and Demographic Surveillance System data collection were selected for the study. Socio- 30 demographic characteristics, treatment seeking behaviours and cost of treatment of malaria were 31 obtained from the patient perspective. 32 Results: Out of the 1,845 households visited, 21.3% (393/1,845) reported to have had an episode 33 of fever or malaria in the past two weeks. Of the 393 people with malaria, 66.9% (263/393) 34 reported taking an antimalarial. About 53.6% (141/263) of the antimalarials were obtained from 35 formal healthy facilities. About 36.1% (95/263) reported to have taken Dihydroartemisinin- 36 piperaquine, 35.4 % (93/263) took Artesunate–Amodiaquine and 21.7% (57/263) took 37 Artemether-Lumefantrine. Only 49.6%% (195/393) of the study participants had their blood 38 sample taken for illness (microscopic or Rapid Diagnostic Test). Only 23.6% (62/263) took 39 antimalarial within 24 hours of the onset of illness. The overall average costs (direct and indirect 40 cost) incurred by households per malaria treatment was GH¢27.82/US$7.32 (range: GH¢0.2/ 41 US$0.05 - GH¢200/ US$52.63). The average cost incurred in the treatment of malaria by those 42 who were enrolled into the National Health Insurance Scheme (NHIS) was GH¢24.75/US$6.51 43 and those not enrolled was GH¢43.95/US$11.57. 44 Conclusions: Prompt treatment such as treatment within 24 hours of onset of malaria was low. 45 The average costs to households per malaria treatment was GH¢27.82/US$7.32 and the preferred 2 bioRxiv preprint doi: https://doi.org/10.1101/486183; this version posted December 3, 2018. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 46 antimalarial was Dihydroartemisinin-piperaquine. There was a positive effect of NHIS enrolment 47 on cost of treatment as the insured incurred less cost (US$5 less) in treatment than the uninsured. 48 Keywords: Malaria, fever, treatment-seeking behaviour, cost, Ghana. 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 3 bioRxiv preprint doi: https://doi.org/10.1101/486183; this version posted December 3, 2018. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 69 Introduction 70 According to the WHO report, there are an estimated 198 million malaria cases and 584 000 71 malaria deaths worldwide in 2013. The burden of malaria is more severe in sub-Saharan Africa 72 where about 90% of all malaria deaths occur [1]. It is a major cause of poverty and slows economic 73 growth by up to 1·3% per year in endemic countries[2]. 74 Malaria is a significant public health problem in Ghana where it accounts for about 33% of all 75 outpatient attendances and 49% of under five years admissions[3]. Malaria is a preventable, 76 diagnosable and treatable illness. The main methods for the prevention of malaria include Long- 77 Lasting Insecticidal Nets (LLINs), Indoor Residual Spraying (IRS), Intermittent Preventive 78 Treatment for pregnant women (IPTp) and vector control methods such as larviciding [1,4]. The 79 WHO has recommended that all persons from endemic areas with suspected malaria should be 80 examined for evidence of infections with malaria parasites by Rapid Diagnostic Test (RDT) or 81 microscopy. In addition, WHO recommended that uncomplicated malaria should be treated with 82 antimalarial such as Artemisinin-based combination therapies (ACTs), particularly in areas where 83 malaria is endemic and persons should have access to ACTs within 24 hours of onset of malaria 84 [1].The recommended ACT combinations are artemether-lumefantrine (AL), artesunate- 85 amodiaquine (AS+AQ), artesunate-mefloquine (AS+MQ), dihydroartemisinin-piperaquine (DP), 86 and artesunate-sulfadoxine-pyrimethamine (AS+SP). The choice of ACT in a country or region is 87 based on the level of resistance of the partner medicine in the combination [5,6]. 88 Following WHO recommendation, in 2004 Ghana changed her antimalarial drug policy choosing 89 Artesunate-Amodiaquine combination as the first line drug for the treatment of uncomplicated 90 malaria to replace chloroquine. However, the implementation process was confronted with some 91 challenges which relates to adverse drug reactions, safety concerns and absence of other treatment 4 bioRxiv preprint doi: https://doi.org/10.1101/486183; this version posted December 3, 2018. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 92 options. It therefore became necessary to review the new policy to address all recognized concerns. 93 A task force reviewed the existing policy and selected additional ACT drugs and dosage forms to 94 accommodate for those who could not bear the Artesunate- Amodiaquine combination. Two 95 additional first line ACTs namely; Artemether-Lumefantrine and Dihydroartemisinin-Piperaquine 96 were selected thus making Ghana to have three official concurrent first line antimalarial treatments 97 [7]. 98 To date, however, the reaction of the health system to multiple alternative first line malaria therapy 99 has not been comprehensively studied. Little is known about access to effective and prompt 100 treatment and preferences for antimalarial drugs for treatment of fever/malaria as well as cost of 101 malaria treatment in the face of multiple first line treatment policy. This study therefore examined 102 the health seeking behaviours as well cost of treatment of malaria to households in the Kassena- 103 Nankana district of Ghana in the face of multiple first line antimalarial drugs. 104 105 Methods 106 Study area 107 The study was carried out in the Kassena-Nankana East and West Districts of the Upper East 108 Region of Ghana. The Kassena-Nankana East is home to the Navrongo Health Research Centre 109 (NHRC) and staff of the Centre conducted the study. The NHRC operates Health and Demographic 110 Surveillance System (HDSS) and has a data base of all individuals and households in the Kassena- 111 Nankana East and West Districts. For the purpose of research, the NHRC refers to the two districts 112 by their former name - the Kassena-Nankana District (KND). 5 bioRxiv preprint doi: https://doi.org/10.1101/486183; this version posted December 3, 2018. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 113 The KND covers an area of about 1,674 square kilometres of land [8]. The area is characterized 114 by a short rainy season and a prolonged dry season from October to March. The mean annual 115 rainfall is about 850mm, with the heaviest usually occurring in August. The total population 116 currently under surveillance is about 152 000 residing in about 32,000 households [8]. Malaria 117 transmission in the KND occurs all year round but there is a distinct seasonal pattern with the peak 118 of transmission coinciding with the period of the major rains (August) and the dry season seeing 119 very low rates of malaria infection[9]. 120 The districts have one district referral hospital located in Navrongo town and 8 health centres 121 strategically located across the district which provide secondary curative and preventive health 122 care. There are 28 Community Based Health Planning and Services (CHPS) compounds/clinics 123 located in various communities and providing primary health care treatment for minor ailments 124 and also carrying out childhood immunizations and antenatal services.