Even though symptoms and laboratory parameters of P. falciparum malaria do not differ by sex in adults, this study revealed different malaria exposure behaviors and preventive measures between males and females. In addition, the mixed method approach showed the existence of economic, cultural and social triggers which influence malaria exposure behaviors and preventive measures.
More women than men presented to hospital with malaria infection during the study period, but neither parasite density nor clinical manifestations suggested gender differences.
This study demonstrated that women with malaria have less formal education than men because only 4% of men didn’t receive formal education compared to 18% of women (p < 0.05). This feature is in line with the Multiple Indicator Cluster Survey Six (MICS 6), conducted in 2017-18 by Ghana Statistical Service (GSS), revealing that 19% of women didn’t attend school or pre-primary education compared with 10% of males. In addition, a higher proportion of our respondents only completed primary school (women 49%, men 29%, p > 0.05) with less having attended secondary school (women 38%, men 53%, p > 0.05) or reached higher education levels (women 13%, men 18%, p > 0.05). More females (49%) than males (21%) couldn’t read, confirming the unbalanced education distribution between genders (p < 0.05).
Infectious diseases responses require multifactorial components, including not only the availability of adequate clinical care but also improvements in the living conditions of citizens and access to education. The most vulnerable groups are likely to be affected by the dual burden of low literacy and high prevalence of infections (37).
The other important gender difference in malaria incidence is related to occupation. Indeed, significantly more female malaria patients were principally traders, while males were mostly students from the surrounding boarding schools. This is in agreement with data reporting that, in Ashanti, 51% of the female population are engaged in service and sales occupations in comparison to only 19% of their male counterparts (38). The main female service and activities were trading in the market (37%) or queueing for water (31%), which were generally accomplished either before the sunrise (73%) or after the sunset (63%). This is probably the reason why more women (61%) than men (37%) with malaria step-out into open spaces earlier than 6 am, when there is a higher risk of mosquito bites.
Although we have no specific data regarding the economic conditions of the respondents, education, literacy and occupation are suggestive of different socio-economic status between women and men.
The uneven distribution of wealth in Ghana and in Kumasi might be explained by two major phenomena: urbanization (39) and migration (40). Regions in the southern half of the country have received more migrants from other regions in the country, particularly the northern regions (40, 41). Ashanti Region has 61% of the population living in localities classified as urban (2010). The 2010 Census showed a higher proportion of females in urban than rural localities. This may be due to the recent phenomenon of relatively more female than male children migrating from rural communities into urban areas (42). The young migrants, especially those from the north, mainly work in the informal sector and are largely self-employed. Many young migrant women from the north are involved in head-load carrying or kayayei as an adaptive response to poverty, and this could increase their vulnerability to poverty and poor health (40, 43).
Ghana has a long history of using mass media and other communication channels to educate the population about malaria (6). The Ashanti Region has the highest rate of household ownership of information and communication technology (ICT) equipment according to the MICS 6. These ICT features could explain the high rate of malaria awareness found among our study population, mainly attributable to radio and television advertisements.
Differently from that reported in the MICS 6 57% of household in Ghana own at least one ITN (38), but in line with other studies conducted in sub-Saharan African countries showing a similar trend in ITN use (44, 45), our survey revealed that only 39.6% and 33.3%, of cases and controls respectively own an ITN. However, the use of ITNs is higher among healthy controls (64%) than subjects with malaria (43%, p < 0.05) suggesting that controls could have a better use of ITNs. Similarly, this study shows a very low use of ITN among highly educated healthcare professionals. The low ITN use especially in a highly urbanized setting could be explained by the adoption of different malaria prevention measures; for example, wealthier households tended to have better access to housing improvements like window screens and closed eaves that reduce exposure to indoor mosquito bites (15). Having a decreased perception of vulnerability to malaria also resulted into decreased net use (46). Another recent study also found that net ownership and use vary widely across sociodemographic groups within and across countries (44). Among 261 subjects, including both controls and cases, window screens were the most common preventive measure applied (60%), followed by mosquito coil (47%), indoor spraying (43%), and only 36% of interviewees mentioned ITN.
Qualitative research can be more suitable for investigating socio-culture aspects of health. Both IDIs and FGDs, used to investigate socio-culture aspects of health perception, indicated that the interviewees find ITNs uncomfortable, referring to heat and claustrophobic feelings. Both male and female interviewees in Fankyenebra complained because of the four-square-net, the type of ITN generally available in pharmacies and shops or provided free of charge during Government Malaria Prevention Campaigns, cannot be easily installed in their small houses. Poor housing is common in these regions, where most people live in uncompleted buildings with no indoor toilets, potable water, electricity or waste disposal facilities, the most common toilet facility is the public toilet used by 41% of the population, and also used by two of five urban households in the country (39). In urban areas, 30% of households are disposing liquid waste into the gutter. Therefore, often the words “hygiene”, “cleanliness”, “waste” and “environment” were mentioned as the most favorable habitats for mosquito breeding during all FGDs.
Indeed, the FGDs interviewees mentioned precarious conditions of dwellings as a source of malaria infection, while Darko male respondents proposed that women get more malaria because they more frequently use public toilets, which are potential areas of mosquito activity due to septic tanks within communities acting as potential vector breeding sites (47).
The misconceptions about being more susceptible to malaria if eating oily foods or not having good personal hygiene reported by the community members in our study are very similar to those reported in southern Ghana about twenty years ago (48).
Notably, socio-cultural practices of interviewees appear to be the main reasons to mosquito exposures, among both males and females, and cases and controls. with 70% of them spend time in open spaces after the sunset. A similar finding was described in a study conducted in Tanzania, where the men’s habit of spending time outdoors drinking alcohol and watching television was linked to malaria risk (33).
Prescribing anti-malarial drugs for patients without parasitemia is a common practice both for severe as well as uncomplicated malaria, as documented in Kenya and Uganda (49, 50).
The quantitative measure of PD did not reveal gender differences in our cohort, which is consistent with other investigations conducted in Ghana (51, 52) and may be due to the widespread use of personal antimalarial measures, greater awareness of malaria as a deadly disease and adequate knowledge about its prevention among the more urbanized and better educated population (51).
Urban environments are less favorable for vectors which have a strong preference for unpolluted waters (18, 53). Mosquito dispersal is also limited in urban areas due to the higher housing density (54) and vector breeding sites are common in areas with slum-like conditions (55). Therefore, the low parasite density found in our patients may be attributable to the urban setting where they live. It could be hypothesized that in urban settings people being less exposed to malaria could develop a weaker immunity response and a symptomatic malaria clinical status besides the low parasitemia
Preference for home treatment and self-initiated medication mostly by men (43%) and more among cases than controls is highlighted by the quantitative approaches as much as by the FGDs. Herbal remedies were also identified as a preferred method of malaria treatment in other research conducted in Kintampo in 2016 (56). In contrast, a different attitude towards sickness in children is reported, mostly relying on formal health facilities instead of self-initiated medication. The same feature was described for another study conducted in the Upper west Region (57) where about 3% of children with malaria was treated at home using herbs and leftover drugs. The employment of mixed methods we have used for this study gave multiple insights concerning malaria traditional beliefs and herbal preparations, which are also used elsewhere in Africa (58, 59).