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The Impact of Culture and Religion on the Healthcare Seeking Behavior Amongst the Residents of Anambra State, Nigeria with Regards to Malaria Treatment

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Paul C Emeka
Abstract:
The purpose of this study was to examine how the local culture and religion in Anambra State, Nigeria (ASN) contribute to low healthcare utilization regarding malaria treatment. The intent was to investigate ways that residents of ASN seek and obtain adequate healthcare for malaria treatment based on their cultural and religious affiliations. The ethnomedical and health belief models formed the theoretical foundation for this study. The study used quantitative cross sectional design. A structured questionnaire was administered to a random sample of 310 malaria patients drawn from three clinics throughout ASN. Multiple regression and chi-square was used to analyze three main research questions. Results showed that there were strong positive correlations between the local culture and religion and how participants seek malaria treatment. The model was significant for culture and explained 21.7% of the variance (adjusted R2 = .193). The model was also significant for religion, but it only explained 4.5% of the variance (adjusted R2 = .036). The study findings suggest that traditional healers and Western medicine providers should collaborate to alleviate the most severe cases of malaria. Furthermore, the people of ASN should be educated that presenting sick children to health care providers at the soonest possible time can save lives. Traditional healers and biomedical healthcare providers should work together and educate mothers and first responders on the symptoms of malaria and the importance of taking their children to trained healthcare providers for urgent medical attention. The implications for social change include a reduction in morbidity and mortality from malaria among children under age five.

Table of Contents Chapter 1: Introduction to the Study ............................................................................................... 1

History......................................................................................................................................... 2

Discovery of the Malaria Parasite (1880) ........................................................................... 2

Historical Aspects of Malaria ............................................................................................. 3

Human Malaria Parasites ............................................................................................................ 3

Who Is Most Vulnerable ..................................................................................................... 4

Causative Agent .......................................................................................................................... 4

Factors That Determine the Occurrence of Malaria ................................................................... 6

Climate ................................................................................................................................ 7

Statement of the Problem ............................................................................................................ 8

Background of the Problem ...................................................................................................... 10

Population at Risk ..................................................................................................................... 12

Nature of the Study ................................................................................................................... 14

Research Questions and Hypothesis ......................................................................................... 15

Research Question 1 ......................................................................................................... 15

Question 1 Hypothesis ...................................................................................................... 15

Research Question 2 ......................................................................................................... 15

Question 2 Hypothesis ...................................................................................................... 16

Research Question 3 ......................................................................................................... 16

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Question 3 Hypothesis ...................................................................................................... 16

Purpose of Study ............................................................................................................... 17

Theoretical Framework ..................................................................................................... 17

Definition of Terms................................................................................................................... 18

Assumptions, Scope and Limitations ............................................................................................ 20

Assumptions .............................................................................................................................. 20

Scope ................................................................................................................................. 21

Significance of Study ........................................................................................................ 22

Relationship to Social Change .......................................................................................... 23

Summary ................................................................................................................................... 24

Chapter 2: Literature Review ........................................................................................................ 25

Research Strategies ................................................................................................................... 26

Theoretical Framework ............................................................................................................. 26

Health Belief Model .................................................................................................................. 26

Ethnomedical Model ................................................................................................................. 29

Epidemiology of Malaria .......................................................................................................... 31

Religion ..................................................................................................................................... 38

Perception of Western Medicine ............................................................................................... 41

Waiting for Service ................................................................................................................... 44

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Treatment Awareness and Education ........................................................................................ 46

Health Care Systems in Anambra State .................................................................................... 48

Types of Traditional Healers .................................................................................................... 50

Literature Related to Methods .................................................................................................. 53

Summary ................................................................................................................................... 54

Chapter 3: Methodology ............................................................................................................... 56

Introduction ............................................................................................................................... 56

Design and Approach ................................................................................................................ 56

Setting and Sample ................................................................................................................... 57

Participants’ Characteristics.............................................................................................. 58

Inclusion and Exclusion Criteria ............................................................................................... 58

Sampling ........................................................................................................................... 59

Selection Bias.................................................................................................................... 60

Instrumentation ......................................................................................................................... 61

Study Variables ................................................................................................................. 62

Measurement of the Variables .......................................................................................... 62

Validity and Reliability ..................................................................................................... 64

Internal Validity ................................................................................................................ 65

Data Collection and Analysis.................................................................................................... 65

Indexing and Coding ......................................................................................................... 66

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Data Analysis .................................................................................................................... 67

Human Subjects ........................................................................................................................ 68

IRB .................................................................................................................................... 68

Confidentiality .................................................................................................................. 68

Informed Consent.............................................................................................................. 69

Summary ................................................................................................................................... 70

Chapter 4: Results ......................................................................................................................... 71

Introduction ............................................................................................................................... 71

Theoretical Basis of This Study ................................................................................................ 72

Survey Tool ............................................................................................................................... 72

Sample Characteristics .............................................................................................................. 74

Descriptive Statistics ................................................................................................................. 75

Consultation for Malaria Treatment.................................................................................. 77

Knowledge about Malaria ................................................................................................. 78

Causes of Malaria ............................................................................................................. 79

Trust for Religion .............................................................................................................. 80

Influence of religion on malaria treatment ........................................................................ 81

Influence of Cultural Beliefs on Malaria Treatment ......................................................... 82

Availability of Malaria Treatment .................................................................................... 86

Preliminary Analyses ................................................................................................................ 88

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Research Questions and Hypothesis ......................................................................................... 91

Research Question 1 ......................................................................................................... 91

Research Question 2 ......................................................................................................... 96

Research Question 3 ....................................................................................................... 102

Conclusion .................................................................................................................................. 106

Chapter 5: Summary, Conclusion and Recommendations ......................................................... 107

Introduction ............................................................................................................................. 107

The Interpretation of Findings .................................................................................................... 108

Implications for Social Change ............................................................................................... 113

Tangible Improvement to Society ................................................................................... 115

Cultural Awareness ......................................................................................................... 115

Recommendations ....................................................................................................................... 116

Recommendation for Further Studies ..................................................................................... 119

Conclusions ................................................................................................................................. 119

References ................................................................................................................................... 121

Appendix A ................................................................................................................................. 140

Appendix B ................................................................................................................................. 145

Confidentiality Agreement......................................................................................................... 147

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Appendix C ................................................................................................................................. 149

Curriculum Vitae ........................................................................................................................ 150

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List of Tables Table 1 Relationship between cultural belief and seeking treatment .............................. 63

Table 2 Relationship between religious belief and seeking treatment ............................... 63

Table 3 Demographics for the sample of respondents ....................................................... 74

Table 4 Have you been diagnosed with malaria?...............................................................76

Table 5 How many times have you been diagnosed with malaria? ................................. 77

Table 6 If you have malaria, whom do you consult first?.................. ……...…………….78 Table 7 What is your knowledge about malaria?................................................................79 Table 8 What do you think causes malaria?..................................................................... 80 Table 9 Do you trust religion for healing? …………………………………………….. 80 Table 10 Does your religion influence your decision on malaria treatment?......................82 Table 11 How often does your religion determine your healthcare decision?.....................82 Table 12 Which form of cultural belief influences how you treat malaria?..........................84 Table 13 How has your cultural belief influenced how you treat malaria?..........................85 Table 14 How often does your culture determine your healthcare decision?.......................85 Table 15 In your culture do you believe in hospital treatment?............................................85 Table 16 In your religion do you believe in hospital treatment?......................................... 86 Table 17 In the last year, how often would were uou unable to obtain malaria treatment?87

Table 18 What was the reason you were unable to obtain malaria treatment? ………….. 87 Table 19 Pearson’s Correlation Matrix…………………………………………………….90

Table 20 Question 1 Chi Square Test Statistics .................................................................... 92

Table 21

Question 1 Correlation Matrix ............................................................................... 93

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Table 22 Question 1 Model Summary .................................................................................. 94

Table 23 Question 1 Coefficients ........................................................................................ 95

Table 24 Question 1 ANOVA Table ................................................................................... 96

Table 25 Question 2 Chi Square Test Statistics……………………………………………98

Table 26 Question 2

Pearson's …………………………………………………………….99

Table 27 Question 2 Model Summary ............................................................................... 100

Table 28 Question 2 ANOVA Table ................................................................................. 100

Table 29 Question 2 Coefficients ...................................................................................... 101

Table 30 Chi-square test statistics for research question 3 ................................................ 103

Table 31 Chi-square test statistics for research question 3 ................................................ 103

Table 32 Univariate Analysis of Variance; Tests of Between-Subjects Effects ............... 105

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List of Figures Figure 1: Conceptual Mode for the Health Belief Model………………………………………..28

Figure 2. Ethnomedical model for collaboration with traditional healers for health utilization ... 30

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Chapter 1: Introduction to the Study Malaria is an infectious disease with very high morbidity and mortality in Anambra, Nigeria (Okocha, Ibeh, Ele, & Ibeh, 2005). Malaria has been identified as a major public health problem in sub-Saharan African countries such as Nigeria, where the disease’s morbidity and mortality for children under 5 years of age, pregnant women and the very old is very high (Okeke, Okafor & Uzochukwu, 2006). Malaria is one of the major causes of preventable death and the third leading cause of death among infectious diseases (Muty & Arora, 2008). It is a common infectious disease that is widespread in most tropical regions of the world, especially Asia and Sub-Saharan African countries where malaria infects about 515 million persons a year and is responsible for 1.5 to 2 million deaths per annum among children under age 5 (Falade et al., 2004). Malaria has been linked to poverty, since it is known to affect people and regions in poverty that cannot afford malaria treatment (WHO, 2009). Malaria is an infectious disease caused by a single-celled plasmodia protozoan parasite through the bite of Anopheles mosquitoes (CDC, 2007). At the present, there are no known malaria vaccines—hence the importance of preventive drug therapy to reduce the risk of infection (CDC, 2007). Currently, malaria is managed by prophylactic treatments that are very expensive for the poverty stricken people who are usually affected by malaria. Children and the elderly are most vulnerable to malaria, while most adults in the endemic areas possess some form of long-term recurrent infection and some partial resistance that tend to reduce over time. With the reduction of such resistances, these adults become susceptible to severe malaria when they are infected (CDC, 2007).

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The healthcare industry and its delivery systems have continued to struggle with ways to provide preventive measures in many of the poor countries that have no access to malaria treatment. Because of poverty, these populations tend to suffer the most from malaria (Uzochukwu & Onwujekwe, 2004). Because of their poor health, they tend to remain poor as they spend greater amounts of their assets on malaria treatment (WHO, 2009). For example, in 2008, Nigeria spent $12 billion, or 132 billion naira, on malaria treatment (Roll Back Malaria, 2008). Malaria has also been linked to farming which tends to be the major occupation of these poor nations. Links between malaria and farming were found among those that cultivate rice and are engaged in irrigation creating vector abundance from standing water (Jarju, et. al. 2009). Considering these factors, this study intended to identify the impact of poverty, culture, religion and perception of western medicine on the healthcare utilization of the people of Anambra State, Nigeria. History Discovery of the Malaria Parasite (1880) A French army surgeon named Charles Lavern first discovered malaria in 1880 (CDC, 2004; Robert et al., 2003). He first noticed parasites in the blood of a patient suffering from malaria in Constantine, Algeria. He discovered that malaria parasites spread through Human and Anopheles mosquito hosts. Malaria parasites grew and multiply first inside the liver and then in the red blood cells before destroying the cells and releasing daughter parasites (CDC, 2004).

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Historical Aspects of Malaria Symptoms like fever, headaches, chills, sweats, vomiting muscle pain, and nausea that were later discovered to be malaria were inscribed in Chinese medical books in 2700 BCE, including the Nei ching Canon of Medicine. Malaria was identified as the disease responsible for the decline in city populations in ancient Greek by the 4th century. The disease was described extensively in many Roman literatures as a swap disease responsible for rural population decline in places such as Susruta (CDC, 2004). During the second century BCE, the qinghao plant and 52 other plants were described in Chinese medical treatises as remedies for malaria (CDC, 2004). This active ingredient of Qinghao was isolated by Chinese scientists in 1971 and is known today as artemisinin, a very potent and effective antimalarial drug (Nicolas et. al -2007). Human Malaria Parasites In 1890, Italian investigators Giovanni Batista Grassi and Raimondo Filetti introduced the Plasmodium vivax and P. malariae two of the malaria parasites that affect humans. Laveran had believed that there was only one species, Oscillaria malariae. An American, William H. Welch, reviewed the subject and, in 1897, named the malignant tertian malaria parasite P. falciparum. It was not until 1922 that John William Watson Stephens identified the fourth human malaria parasite, P. ovale (WHO, 2008). Today, P. falciparum is still an active and effective human pathogen (Lantos et. al., 2009).

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Who Is Most Vulnerable Young children and the very old with little or no protective immunity against malaria are the most vulnerable (Uzochukwu and Onwujekwe, 2004). Pregnant women in their first and second pregnancies, whose immunity has decreased, along with immigrants to places where malaria has high transmission rate are also highly vulnerable (Okocha, Ibeh, Ele & Ibeh, 2005). Places such as the sub-Saharan African countries are also highly vulnerable as they maintain high transmission rate. In areas with lower transmission (such as Latin America and Asia), residents are less frequently infected. Many persons may reach adult age without having built protective immunity and are thus susceptible to the disease (WHO, 2008). Causative Agent Malaria parasites are transmitted by female Anopheles mosquitoes (WHO, 2008). When the parasites make it into the human blood stream they multiply within red blood cells, causing symptoms that include light-headedness, shortness of breath, tachycardia, as well as other general symptoms such as fever, chills, nausea, flu-like illness, and in severe cases, coma and death (Eliades et al., 2005). Malaria can be prevented by avoiding bites from mosquito by making use of mosquito nets, using insect repellents, or using the many available mosquito control measures which includes spraying insecticides inside houses and draining standing water where mosquitoes lay their eggs (CDC, 2008). There are four different species of these plasmodium parasites that are capable of infecting humans (Lantos et al., 2009; WHO, 2008). The Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium malariae are introduced into humans during a

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blood meal, the most lethal being Plasmodium falciparum (Uzoegwu & Onwurah, 2003). While in the blood stream, they spend some parts of their life cycles inside a mosquito, and the remaining cycle is spent in humans. Parts of the life cycle that is spent in human body allows the parasites to infect and multiply in the liver and in red blood cells. The red blood cells eventually burst from the increasing numbers of the multiplying parasites infecting more blood cells while the ones in the liver are broken down and excreted. Plasmodium falciparum is responsible for causing the fatal types of malaria in humans (CDC, 2008). Humans infected with malaria parasites can develop a wide range of symptoms that varies from asymptomatic infections, to the classic symptoms of malaria such as fever, chills, sweating, headaches, muscle pains, to severe complications such as cerebral malaria, anemia, and kidney failure that can result in death (Eliades et al., 2005). The severity of the symptoms depends on factors such as the type of species infecting parasite and the human's acquired immunity and genetic background (WHO, 2008). The blood stage parasites are those that cause the symptoms of malaria. When certain forms of blood stage parasites (gametocytes) are picked up by a female anopheles mosquito during a blood meal, they start another, different cycle of growth and multiplication in the mosquito (CDC, 2008). The parasites are found in mosquitoes’ salivary glands in about 10 to 18 days. If and when an anopheles mosquito bites a human taking a blood meal, the sporozites are injected with the mosquito's saliva and start another human infection when they parasitize the liver cells. This is how a mosquito carries the disease from one human to another (CDC, 2008). In parts of Mexico, Central

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and South America, Africa, Haiti, India, Pakistan, Turkey, Afghanistan, Sri Lanka, Bangladesh, Nepal, Maldives, China, South Asia, Papua New Guinea, Malay Archipelago, and several South Pacific Islands, malaria is carried by mosquitoes (WHO, 2008). Residents of counties that have high infection rates have been exposed to malaria parasites on many occasions. In general, after the initial infection, a person’s immune system creates a protection so that consequent infections are not as severe as the initial one, assuming that one is infected within the next 2 years. If one does not experience any further infection within 2 years, the immunity usually dissipates (WHO, 2008). Other than by mosquito bites, malaria can also be spread in high transmission areas by receiving contaminated blood transfusions, sharing drug needles, and by transportation of contaminated organs. Pregnant mothers can pass malaria to their unborn children through the umbilical cord, leading to low birth weights and sometimes fatality (CDC, 2008). Factors That Determine the Occurrence of Malaria For malaria to occur in any environment, three components must be present: humans, anopheles mosquitoes, and parasites. Anopheles mosquitoes must be in contact with humans, and the parasites must be in contact with humans to complete the "invertebrate host" half of their life cycle. However, in rare occasions, malaria parasites can be transmitted from one person to another without requiring passage through a mosquito, as in malaria transmission from mother to child (congenital malaria), shared needles, blood transfusion, and organ transplantation (CDC, 2004).

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Climate All three components can be influence by a number of things, the most important of which is the climate. Changing climate conditions give rise to increased infectious disease such as malaria (Manning, 2008). Water from rainfall can accumulate in places that become breeding sites for anopheles mosquitoes to lay and deposit their eggs, and larvae and pupae develop into adulthood. This process takes approximately 9-12 days in most tropical countries. These breeding sites can be eradicated if sites dry up prematurely due to lack of rainfall, or they can be flushed away by erosion and destroyed by excessive rains. Areas with standing water, such as those created by dams built by farmers to irrigate their crops, become breading grounds for the mosquitoes that carry malaria (DeWeerdt, 2007). The surrounding temperature, rainfall, and humidity determine the survival chances of these adult mosquitoes. For malaria transmission to be successful, female anopheles must survive long after they infect the human blood to enable the parasites to complete their growth cycle. These cycles range anywhere between 9 to 21 days with an ambient temperature that ranges between 25°C or 77°F. The warmer the temperature, the shorter the cycle, a condition that elevates the chances of transmission (Nicolas et al., 2007. Climate also determines human behaviors that may increase contact with Anopheles mosquitoes between dusk and dawn, when the anopheles are most active (CDC, 2008). Hot climate conditions increase the chances of people contracting food poisoning, malaria, and a host of other infectious diseases (DeWeerdt, 2007). Hot

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weather may encourage people to sleep outdoors or discourage them from using bed nets exposing themselves mosquito bites. During harvest seasons, agricultural workers might sleep in fields or nearby locales, without protection against mosquito bites. It has been speculated that current trends of global warming may increase the geographic range of malaria and may be responsible for malaria epidemics (Nicolas et al., 2007). Global environmental degradation that includes soil erosion from heavy rains, deforestation, no clean drinking water and clean environments all contribute to increased risks of infectious disease including malaria (Manning, 2008). Statement of the Problem Malaria is a deadly infectious disease that is transmitted by protozoan parasites and poses huge public health crises in poor countries (CDC, 2007). The disease is the most common cause of outpatient visits in Nigeria (Anumudu et al., 2006). Most rural Nigerian towns experience high malaria transmission, with an estimated 990,000 people dying from malaria in 1995; that is more than 2,700 deaths per day, or 2 deaths per minute. Among children under 5, malaria is responsible for the deaths of 1.5 to 2 million people every year (WHO, 2008). An initial literature review revealed that the relationship between culture and healthcare seeking behavior is unclear. Furthermore, the nature of the relationship between the local religions practiced in Anambra and malaria treatment seeking behavior needs to be clarified. The problem is that, while scientists know that malaria is one of the most complex diseases facing mankind, and is responsible for 25% infant mortality and 30% childhood mortality in Nigeria (Okwa, Akinmolayan, Cartter &

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Hurd, 2009), researchers do not know how local cultures and religions influence how people seek malaria treatment. Researchers have noted that the socioeconomic impact of malaria in Anambra State, Nigeria, and the burden on mankind around the globe is immense (Okocha et al., 2005). Roll Back Malaria (2008) reported that among the 149,107,133 people living in Nigeria, 144,633,916 of them, or 97% of the Nigerian population, are at risk for malaria, and that there are 70 to 100 million clinical cases of malaria in 2008. The most vulnerable populations are those under 5 (29,821,429 in 2008) and pregnant women (7,940,134). Malaria is responsible for 66% of outpatient visits, resulting in an under-5 mortality rate of 30% and a maternal mortality rate of 11%. Anambra State and Nigeria as a country have experienced a continuous lack of access and healthcare underutilization of biomedical health services for malaria treatment and has suffered immensely due to poverty (Ahmed, 2007). Malaria more heavily affects people who are in poverty, as they have no means of paying for healthcare (Obikeze, Onwukekwe, Uzochukwu & Eze, 2006). Families, communities, and countries that were not already in poverty have been driven to poverty from spending their assets on the care of malaria (WHO, 2008). Malaria is the main reason why children miss school in Anambra State, the reason why most adults miss work, affecting the economic conditions of familes and the country’s Gross Domestic Products. In 2008, the World Health Organization estimated that 58% of malaria deaths occur amongst the poorest 20% of the global population.

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Background of the Problem Anambra State is in a highly malaria endemic area in southeastern Nigeria (Obikeze, Onwukekwe, Uzochukwu, & Eze, 2006). Like the residents of Badagry Lagos state Niger, the people of Anambra state live in a costal environment surrounded by Anambra and Niger rivers. The annual seasonal rainfall is about 199mm (Okwa, Akinmolayan, Carter & Hurd, 2009). Seasonal flooding of the Niger and the Anambra rivers coupled with the long rainy season are most favorable for malaria transmission (Berg & Knols, 2006). During farming season, some farm communities such as Anam will usually have many families migrate to the fertile river floodplain to cultivate yam, cassava, corns, peanuts and many other farm produce. These farm families may live for several months in these temporary shelters, far from home, the city and away from any form of health services. The climatic and ecological conditions in Anambra State foster an elevated case of perennial malaria transmission (Berg & Knols, 2006). During the rainy season, many farmers will take advantage of the wet land to cultivate their agricultural products and harvest them in time before the two major rivers, the Niger and Anambra River overflows its banks from excess rain and floods their farm lands. Based on current knowledge of water and mosquito ecology, this provides a fertile breeding ground for mosquitoes and malaria transmission (Jarju, 2009). In Nigeria with Anambra State, most of the health infrastructures, such as healthcare centers, drug stores, and healthcare providers, are situated in the urban centers and very few are within reach from the rural areas, except for a few patent medicine

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providers that may put shops in some villages (Ademiluyi & Aluko-Arowolo, 2009). To access reliable health services, residents have to go to urban centers often located at a considerable distance from the remote villages and farm settlements. Due to the standing water, those that live in farm settlements can often only access any health services by walking long distances and wading through water in the rainy seasons and through rough and dusty roads in the dry season. The remoteness of these rural areas tends to create a health service barrier that has resulted in poor access to preventive and curative malaria treatment. Inadequate sanitation, lack of disease awareness, distance, and poor access to clean drinkable water complicates the situation. Malaria transmission in Anambra State and the mortality rate for children under the age of five is 30%, while the maternal mortality stands at 11% (Roll Back Malaria, 2009). Nigeria as a country has experienced an elevated infant mortality rate of 100 per 1000 from malaria disease in 2003 compared to the rate of 87 per 1000 in 1993 (WHO- Nigeria, 2009). This is attributed to lack of healthcare utilization that leads mothers to give birth in places other than in healthcare facilities and without the supervision of trained healthcare practitioners (Ibeh, 2008). The WHO-Nigeria office reported that two thirds of births in the year 2003 took place at home with just about one-third of the births having a licensed physicians present. These elevated mortality rates are indeed fueled by low healthcare utilization that came as a result of poverty, distance to healthcare centers, and lack of transportation (WHO-Nigeria, 2008).

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Addressing the treatment seeking behavior of the people of Anambra State may be a complicated task, but it is important to underscore the role that poverty plays in the underutilization of malaria care (Uzochukwu & Onwujekwe, 2004). Most studies have highlighted the fact that poverty, culture and religious beliefs, perception of Western medicine, and the time of waiting for service has forced most families to self medicate and/or seek treatment from local traditional healers (Falade et al., 2004). This may be dangerous as most of these traditional healers believe that some cases of malaria are caused by evil spirits and may choose to treat them as such, thereby increasing the mortality rate by not collaborating with orthodox medicine practitioners (Okeke, Okafor & Uzochukwu, 2006). Population at Risk The populations at risk are citizens of Anambra State and, like most parts of Nigeria, the impact of malaria has posed a huge public health concern (Falade et. al, 2004). Ethnically, the people of Anambra State are Igbo and are mainly Christians with a few traditional worshipers (Uzochukwu & Onwujekwe, 2004). Their enterprising business acumen has earned them the reputation as skilled business people. Their native language is Igbo, while English is widely spoken and used in schools for education. Because of limited dry land due to undulations and narrow ridges above the flood plains, the state has small land area for settlement. The settlement pattern is further dispersed, especially on deep slopes; however, due to the urbanization of places such as Nnewi, Onitsha, Nkpor, Awka, Obosi, and Akpoko, large cities have come have become

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part of the landscape. The northern part of the State that is surrounded more by the rivers Anambra and Niger are settled more closely due to the deep slopes. Anambra State was created in 1976 but was broken into Anambra and Imo States when East Central State was divided. Since that time, the state has been comprised of the present Anambra State and Enugu State, which covers parts of Ebonyi State and Abakaliki. In 1991, the state was further divided into Enugu State and Anambra State as presently constituted, with Awka as its capital. The state derives its name from the Anambra River, the largest, most southerly, left bank tributary of the River Niger. The river derived its name from the town Anam that it surrounds – the river is the source of livelihood for the Anam people as they rely on it for fishing and the irrigation of the farmlands. Anambra State is located on very low elevation on the eastern side the River Niger with a total land area of 4,416 sq. km. The state shares boundaries with Enugu, Kogi, Imo, Delta, Abia, Edo, and Rivers states. Anambra state is made up of 21 local government areas with the state capital at Awka, known for its craft industries, especially wood carving and blacksmithing. The state is divided in to three main senatorial districts, (a) Anambra North, comprising Awka North and South, Njikoka, Dunukofia, Anaocha, and Idemili North and South Local Government Areas (LGAs); (b) Anambra Central, made up of Onitsha North and South, Ogbaru, Oyi, Ayamelum, and Anambra East and West LGAs; and (c) Anambra South consisting of Orumba North and South, Aguata, lhiala, Ekwusigo, and Nnewi North and South LGAs. The 1991 National census estimates the population of the state to be 2,796,475 within its 4,416 sq. km, meaning that the average population density is 633

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persons per 1 square kilometer making it one of the most densely populated states in Nigeria. The urban centers appear to be more populated than the rural areas with averages exceeding that of the state where Nnewi is sporting 738 persons per square kilometer, Nijikoka at 1,379, Aguata at 1,420, Idemili at 14,448 and Onitsha at 3,771 (Encyclopedia Britannica, 2009). Nature of the Study This study was a quantitative, cross-sectional design to determine the influence of religion and culture on treatment seeking behavior for malaria in Anambra, Nigeria. A confidential survey was administered to residents of Anambra State at three clinics situated in major population centers of the region. Twenty-two questions were laid out in four basic categories: general questions, cultural related questions, religious related questions, and perception. All the questions were analyzed using nonparametric chi- square, multiple regression, bivariate comparisons and descriptive statistics. Two theories, health belief model and ethnomedicine, were used to ground the findings of the study. Paradigms about the healthcare seeking behavior of a people have focused on cultural concepts such as the health belief model (Strecher & Rosentock, 1977). Ethnomedicine explores how cultural beliefs and attitudes are another area of concern in Sub-Saharan African countries, and in Anambra State it is considered central to healthcare utilization and possible malaria eradication (Igoli, Ogaji, Tor-Anyiin & Igoli, 2005). These methods and theories allowed for analysis that could consider perception of medicine as well as treatment seeking behavior regarding malaria. The following research questions were specifically examined.

Full document contains 169 pages
Abstract: The purpose of this study was to examine how the local culture and religion in Anambra State, Nigeria (ASN) contribute to low healthcare utilization regarding malaria treatment. The intent was to investigate ways that residents of ASN seek and obtain adequate healthcare for malaria treatment based on their cultural and religious affiliations. The ethnomedical and health belief models formed the theoretical foundation for this study. The study used quantitative cross sectional design. A structured questionnaire was administered to a random sample of 310 malaria patients drawn from three clinics throughout ASN. Multiple regression and chi-square was used to analyze three main research questions. Results showed that there were strong positive correlations between the local culture and religion and how participants seek malaria treatment. The model was significant for culture and explained 21.7% of the variance (adjusted R2 = .193). The model was also significant for religion, but it only explained 4.5% of the variance (adjusted R2 = .036). The study findings suggest that traditional healers and Western medicine providers should collaborate to alleviate the most severe cases of malaria. Furthermore, the people of ASN should be educated that presenting sick children to health care providers at the soonest possible time can save lives. Traditional healers and biomedical healthcare providers should work together and educate mothers and first responders on the symptoms of malaria and the importance of taking their children to trained healthcare providers for urgent medical attention. The implications for social change include a reduction in morbidity and mortality from malaria among children under age five.