Knowledge, attitude and practices of people living in Awka Metropolis, on malaria treatment, prevention and control

doi:10.21203/rs.3.rs-5019915/v1

Background: The World Health Organization (WHO), malaria report has consistently shown the poor performances of malaria-endemic countries such as Nigeria in controlling the malaria parasite.

Methods: The study is a cross-sectional mixed quantitative and qualitative analysis. Regarding existing literature on the Knowledge, Attitude and Practices (KAP) on malaria treatment, prevention and control within the study area, a structured questionnaire suiting for the study was drafted with reliability analysis done following the review of the study instrument by three field experts.

Results: The study involved a total of 350 respondents who filled out the questionnaires independently. Sixty percent (60.3%) had good knowledge of malaria prevention methods. Using a Likert scale mean of 3.97, the sample population was shown to have a positive attitude towards the prevention of malaria, also a mean of 3.7 indicated that the population showed a positive attitude to treatment. Insecticide Treated Nets (ITNs) were poorly used while other methods of prevention were preferred. Above 90% of the participants agreed that malaria is preventable and cited several preventive methods.

Conclusion: In conclusion, the study respondents had good knowledge of malaria infection, treatment and control, although the majority knowing this, do not follow the accurate prevention practices. The study exposed the need to train and retrain the communities on the benefits of adequate prevention and treatment practices as a tool for effective malaria control and eradication.

Malaria

Knowledge

Attitude

Practice

Prevention and Control

Treatment.

Despite interventions towards the control and elimination of malaria infection, malaria remains a major concern, especially in developing nations such as Africa. It currently is one of the leading public health concerns in Sub-Saharan Africa¹. The disease malaria is caused by parasites of the genus Plasmodium and transmitted by the female anopheles mosquito in the cause of a blood meal. Currently, five species of Plasmodium; P. knowlesi, P. falciparum, P. malariae, P. Ovale, and P. vivax are known to cause an infection in humans², with fever being the most common symptoms after about one to three weeks of an infection. In 2022, the World Health Organization report on malaria, put Africa at the lead of malaria infection, with Nigeria accounting for nearly 27% of the global malaria burden, and a 31% mortality rate¹.

Of the 91 countries with reported cases of malaria transmission, 80% are within Sub-Saharan Africa and India, with 14 countries located in the former. Increased incidence of malaria infection in Nigeria and some parts of Africa, has been linked to factors such as increased cases of drug misuse and abuse, climate changes, and effects that encourage the growth, survival, and reproducibility of the mosquito vectors ^3,4.

Effective control and elimination of malaria infection are centered on early detection, proper treatment, and accurate vector control as the major tools. Hence a need to study the Knowledge, Attitude, and Practices (KAP) of people living within the Awka metropolis about malaria treatment, prevention, and control. With reports of Artemisinin antimalarial efficacy decline in various parts of the world^18,19,20,21, there is a need to also understand the roles individuals play in contributing to these reported failures.

Study design, site and population

The study was a cross-sectional and descriptive study. Data was collected between January and June 2021 from individuals willing to participate in the survey. The study was conducted in Awka metropolis, the capital city of Anambra State, Nigeria. The study population comprised adults, at least 18 years of age, living within the study site who gave oral or written informed consent to participate in the survey. The sample size was determined using the single population proportion formula by taking the proportion in population based on past literature studies at 35%, with a confidence interval of 5%, using the formula by Nang et al., (2006).

Data collection instrument

A structured questionnaire prepared from existing KAP literature targeted at malaria prevention and control was used for the study. The questionnaire was reviewed by three researchers knowledgeable in the field. In addition, a reliability analysis was done to ascertain how reliable the instrument is for measuring the main idea of this study it was designed for. This was done using the Cronbach alpha (CA) value which should not exceed 0.50. However, it did not affect the knowledge assessment since that will be based on grading, but it was applied to the attitude and practice of the study population regarding malaria treatment.

Data collection

Data for the study was collected via a face-to-face interview using a semi-structured questionnaire prepared in English and translated into the local language (Igbo) for participants who are not fluent in English.

Data management and analysis

The analysis was done on different variables using frequency and percentages and the results were presented in tables, graphics and figures. The data collected were analyzed using the Computer-Aided Statistical Package for Social Sciences (SPSS version 20).

We determined the knowledge by assessing the responses of the respondents using variables concerned with transmission, mortality, breeding sites and symptoms of the disease.

Ethical considerations and consent approval

Ethical approval for the study was granted by the Ethics Committee of the Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), Awka. Information and purpose of the study were clearly described to all prospective participants and those who consented to be part of the study indicated by giving oral or written consent. All information obtained during the study from the participants was handled confidentially and data were restricted for this study only.

Reliability analysis

A reliability analysis helps to check how reliable a study instrument is in measuring an idea that it was designed for. This was done using the Cronbach Alpha (CA) value which should not exceed 0.50 at least. This, however, did not apply to our knowledge assessment since it was based on a grading system. Tables 1A and 1B, show the reliability analysis result for participants' attitudes to prevention and treatment.

Table 1A: Reliability test for attitude on prevention
Item	Scale Mean if Item Deleted	Scale Variance if Item Deleted	Corrected Item-Total Correlation	Cronbach's Alpha if Item Deleted
You are bothered by the presence of mosquitoes	11.87	.981	.592	.626
Do you think malaria is preventable	12.00	1.143	.776	.613
I think malaria is a serious and life-threatening disease	11.93	1.210	.394	.732
I believe in sleeping under a mosquito net to prevent mosquito bites	12.40	.686	.559	.708

Table 1B: Reliability analysis on attitude on treatment
Item	Scale Mean if Item Deleted	Scale Variance if Item Deleted	Corrected Item-Total Correlation	Cronbach's Alpha if Item Deleted
Blood smear necessary for malaria diagnosis	11.13	2.124	.442	.323
I believe in visiting health centers when I feel sick	11.33	1.667	.546	.180
I think it’s risky when malaria medicine is not taken properly and completely	10.53	2.552	.414	.369
Your most deciding factor(s) when deciding to treat malaria are: perceived cost and time	10.60	4.400	-.317	.672

For reliability analysis on attitude on prevention, the removal of any item had little to no effect on the CA value, hence all items were retained. In the case of attitude on treatment, the removal of the first three questions as shown in Table 1B, showed a slight adjustment in the CA value, if we further removed the highlighted item (in yellow), the CA improved even better, thus the items were removed, giving a CA value for attitude on treatment of 0.672.

The same analysis was carried out for treatment and prevention practices, to see if we can improve the CA values. Following adjustments, the CA for both was at 0.583 and 0.751 respectively. Item coding was reviewed following the negative CA value due to a negative average covariance among items.

Demographic characteristics of study participants

The study analyzed 350 well-filled participant questionnaires, with the demographic data of respondents shown in Table 2. The demographic data showed a male-to-female ratio of 147:203. Most (42.6%) of the respondents fell into the age bracket of 21-30 years, while 26.3%, 15.71%, and 12% were between ages 31-40 years, 41-50 years, and < 20 years respectively. With regards to educational qualification, 178(50.9%), 128(36.6%), and 33(9.2%) of respondents had up to tertiary, secondary and primary school education respectively, while 8(2.3%) and 3(0.9%) respectively had higher degree certificates or no certificate at all.

Showing on Table 3 shows the frequently used antimalarial medicines by respondents. The result in Table 4 also brought to light a possible poor face-to-face education of the population by health workers in educating the public on the treatment, prevention and control of malaria infection. The majority of respondents (23.9% and 24.3%), got information on malaria infection via television (talk shows and medical adverts) and through friends and neighbours respectively.

Table 2: Demographic analysis of study participants

		MALE (%)	FEMALE (%)
AGE	<20 years	8 (5.4)	34 (16.7)
	21-30 years	50 (34.0)	99 (48.8)
	31-40 years	51 (34.7)	41 (20.2)
	41-50 years	31 (21.1)	24 (11.8)
	51-60 years	7 (4.8)	5 (2.5)
ETHNICITY	Igbo	139 (94.6)	182 (89.7)
	Hausa	0 (0)	2 (1.0)
	Yoruba	1 (0.7)	7 (3.4)
	Others	7 (4.8)	12 (5.9)
RELIGION	Christianity	136 (92.5)	201 (99.0)
	Muslim	0 (0)	1 (0.5)
	Traditionalist	11 (7.5)	1 (0.5)
MARITAL STATUS	Married	63 (42.9)	75 (36.9)
	Single	80 (54.4)	122 (60.1)
	Divorced	4 (2.7)	6 (3.0)
EDUCATIONAL STATUS	Primary	22 (15.0)	11 (5.4)
	Secondary	58 (39.5)	70 (34.5)
	Tertiary	63 (42.9)	115 (56.7)
	Post-graduate	2 (1.4)	6 (3.0)
	No formal education	2 (1.4)	1 (0.5)
TOTAL		147 (42)	203 (58)

Table 3: Antimalarial used frequently by respondents
		Responses		Percent of Cases
		N	Percent	Percent of Cases
Antimalarials used by respondents^a	Arthemether/Lumefantrine	206	27.6%	94.9%
	Artesunate/Amodiaquine	115	15.4%	53.0%
	Dihydroartemisinin/Piperaquine	92	12.3%	42.4%
	Sulfadoxine/Pyrimethamine	76	10.2%	35.0%
	Artesunate	88	11.8%	40.6%
	Chloroquine/Primaquine	117	15.7%	53.9%
	Arterolane/Piperaquine	25	3.4%	11.5%
	Halofantrine	27	3.6%	12.4%
Total		746	100.0%	343.8%

Table 4: Source of malaria information
		Responses		Percent of Cases
		N	Percent	Percent of Cases
Source of information	TV as a source of information about malaria	217	23.9%	63.1%
	Friends/Neighbors as a source of information about malaria	221	24.3%	64.2%
	Newspaper as a source of information about malaria	120	13.2%	34.9%
	Hospital as a source of information about malaria	171	18.8%	49.7%
	Health workers as a source of information about malaria	180	19.8%	52.3%
Total		909	100.0%	264.2%

Knowledge of participants

We determined the malaria knowledge level of participants by assessing the respondents’ responses using variables bothering on transmission, mortality, breeding sites and symptoms of the disease. The average knowledge of participants was placed at 60.3%. we moved further to check if the knowledge was gender-based but there was no significant difference between the knowledge of men and women on malaria treatment, prevention and control as seen in Table 5. The knowledge of men on malaria treatment, prevention and control stood at 60.3% while that of women stood at 60.2%. This is supported by our T-test which shows a p-value of 0.968.

Table 5: Knowledge of participants based on gender
Gender				Statistic	Std. Error
Male	Knowledge of Respondents on Malaria	Mean		60.2969	1.24753
		95% Confidence Interval for Mean	Lower Bound	57.8313
		95% Confidence Interval for Mean	Upper Bound	62.7624
		5% Trimmed Mean		61.1180
		Median		63.6364
Female	Knowledge of Respondents on Malaria	Mean		60.2329	.99937
		95% Confidence Interval for Mean	Lower Bound	58.2624
		95% Confidence Interval for Mean	Upper Bound	62.2034
		5% Trimmed Mean		61.0066
		Median		63.6364

Knowledge of malaria from the age perspective, showed that two age groups, 31-40 years and 51-60 years were lower than those < 20 years. Regression analysis suggests that respondents between 31-40 years were 6.8 times less knowledgeable than respondents aged < 20 years while those aged between 51-60 years were 12.5 times less knowledgeable than those aged < 20 years. Other independent variables such as education had no impact on the knowledge base of respondents.

Attitudes to Treatment, Prevention, and Control

Respondents answered a combination of 8 statements that are related to attitudes toward treatment, prevention, and control of malaria. The larger proportion agreed to sleeping under mosquito nets are the best method of malaria prevention. Using two separate groups of variables that measure for prevention and treatment, we calculated the mean Likert value as shown in Table 6. Likert value of above 3.5, shows that a study population is in agreement, with a Likert value of 3.07 and 3.7 for attitude to prevention and treatment respectively, the study showed that the respondents had a positive attitude towards both treatment and prevention. For attitude on prevention, regression analysis as shown in Table 7, shows that employment status, education of at least tertiary level and religion had the three highest impacts on the attitude towards prevention of malaria. This regression model also accounts for 32.3% (adjusted R²) of the variation in the attitude of respondents towards malaria prevention. Regression for attitude towards treatment showed very similar values.

Table 6: Mean Likert value for attitudes
		Statistic	Std. Error
Mean		3.9663	.03475
95% Confidence Interval for Mean	Lower Bound	3.8980
95% Confidence Interval for Mean	Upper Bound	4.0347
5% Trimmed Mean		3.9873
Median		4.0000
Mean		3.7994	.03672
95% Confidence Interval for Mean	Lower Bound	3.7272
95% Confidence Interval for Mean	Upper Bound	3.8717
5% Trimmed Mean		3.8132
Median		3.6667

Table 7: Regression analysis for Attitude to prevention

Model		Unstandardized Coefficients		Standardized Coefficients	t	Sig.
Model		B	Std. Error	Beta	t	Sig.
1	(Constant)	3.337	.164		20.407	.000
	Age=31-40 years	-.093	.080	-.063	-1.157	.248
	Age=51-60 years	-.047	.173	-.013	-.274	.785
	Age=21-30 years	-.046	.078	-.035	-.586	.558
	religion=Christianity	.347	.160	.101	2.174	.030
	marital_status=Single	.004	.080	.003	.055	.956
	education=Tertiary	.248	.079	.191	3.158	.002
	education=Post graduate	.533	.198	.123	2.697	.007
	employment=Student	.534	.088	.399	6.046	.000
a. Dependent Variable: attitutude_Prevention

Practice

A total of 127 respondents (36.3%), frequently use insecticides within or outside their homes as a preventive measure, while 213(60.9%) rarely practice this and only 2.6% had never used an insecticide. Also worrisome is the fact that majority of the respondents, over 40% across the board of the participants do not use insecticide-treated nets, change or repair or treat worn out ITNs. The vast majority of respondents stated that cost (344, %) was the reason for not using or adhering to preventive and treatment guidelines. On the attitude towards the search for medical attention, and treatment-seeking behaviour, 64(18.3%) pay regular visits to a health centre when sick, while 273 (78.0) visit the clinics occasionally, leaving 12 (3.4%) of the 350 respondents that had never visited the clinic for a suspected malaria case, Table 8. The practice of self-medication was on the extreme amongst respondents with over 95% practicing self-medication with suspected cases of malaria infection.

Table 8: Respondents practices when sick
		Frequency	Percent	Valid Percent	Cumulative Percent
Valid	Never	12	3.4	3.4	3.4
	Sometimes	273	78.0	78.2	81.7
	Always	64	18.3	18.3	100.0
	Total	349	99.7	100.0
Missing	System	1	.3
Total		350	100.0

The survey evaluated the knowledge, attitudes and practices of participants of this study within the study area members of the Awka metropolis communities on issues surrounding malaria transmission, symptoms, prevention measures and treatment. The study showed a high knowledge of malaria infection amongst respondents (%), and majority believed that malaria is a public health care concern, as previously reported by ^5,6,7,8. Similarly, previous studies reported, ^7,9,10,11, also showed that above 90% of respondents are knowledgeable in the prevention and control of malaria with use of ITNs, drainage of stagnant water, IRS as the main stay in the prevention and control of the parasite.

Respondents exhibited poor treatment-seeking behavior and this is a necessary step for early diagnosis and treatment of malaria infection which in turn reduces the transmission of the parasite. Majority of participants mentioned Artemether-lumefantrine as their drug choice for malaria treatment. The study in addition, revealed the most common source of information on malaria treatment, prevention and control as mass media as shown in Table 4, indicating the importance of these in dissemination of important health information and also the need to improve the involvement of health care professionals in health education of the general populace. This agrees with the findings by results from Belay, 2021⁸ as well as other research works that have shown that 90% of individuals living in malaria-endemic areas have access to at least a means of mass media communication and get basic malaria information that is malaria-related from there as well. A vast majority of participants indulge in self-medication, while a few visits the health clinic in the case of a suspected malaria infection. This is in contradiction with previous studies where respondents had good treatment-seeking behavior with 91.4% of participants visiting the health facilities when ill ^9,12–15. This suggests the need to properly educate the populace on the advantages of visiting health clinic when sick and the possible adverse effects of self-medication which is a common practice in Nigeria and Africa at large. It is also important to point out how early treatment-seeking behaviour contributes significantly in the diagnosis, treatment, transmission and control of malaria infection.

This study also revealed that over 80% of participants are aware of the need to use ITNs as a protective measure, but also showed that only about a half of the participants make use of them, which is consistent with works by Animut, 2014; Alelign, 2018; and Yimer, 2015^16,11,17. There is therefore the need to strongly educate the populace on the advantages of owning owing and actually using ITNs and how they offer protection from malaria infection. Some participants also noted their inability to access the ITNs, discomfort especially during the hot seasons, and fear of a burning sensation as reasons for non-compliance with the use of ITNs. This calls for proper community education and awareness through public health education schemes targeted at educating the masses on how ITNs have been proven effective in the prevention of malaria infection.

From our study, over 70% of participants engaged in self-medication as against their counterparts in other regions like Europe where studies have shown 91.4% of participants seeking treatment at health facilities within 24 hours of clinical symptoms. The majority of the study participants possess ITNs as well as IRS but only a few make use of them regularly as and when due as a control measure despite knowing the role they play in preventing mosquito bite, the rate-limiting step to malaria infection. This also buttresses the need for adequate health education to awaken people’s consciousness and raise awareness of the need for the right treatment-seeking behaviour and its practice. This has been proven to be effective in mitigating the misbelief on malaria disease, its transmission, control and prevention strategies

The study demonstrates that participants are knowledgeable about malaria transmission, prevention and control strategies, but the practice and attitude and practice towards malaria infection prevention and control are generally poor. The comprehensive knowledge and attitudes of participants towards malaria were comparable with previous studies. However, there is a need for training and retraining of individuals living in malaria endemic areas on the right approach for effective control and elimination of malaria infection. The training would also enlighten the public on varied misconceptions regarding the cause, mode of transmission and treatment plan for malaria.

Ethics approval and consent to participate

Ethical approval for the study was granted by the Ethics Committee of the Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), Awka. With reference number, COOUTH/CMAC/ETH.C/VOL.1/FN:04/0104. Information and purpose of the study were clearly described to all prospective participants and those who consented to be part of the study indicated by giving oral or written consent. All information obtained during the study from the participants was handled confidentially and data were restricted for this study only.

Consent for publication: NOT APPLICABLE

Availability of data and materials

Datasets generated and analyzed during the current study are not readily available to the public but are available upon reasonable request to the corresponding author.

Competing interest

The authors declare that they have no competing interests.

Funding: NOT APPLICABLE

Clinical Trial Number: Not Applicable

Authors contributions

CKE participated in the design, data collection, analysis and interpretation of the results as well as the drafting of the manuscript. OS and AB participated in data collection, while OC and OUC coordinated data entry, analysis and interpretation. All authors read and approved the final manuscript.

Acknowledgement

The authors wish to thank the study participants and all who in one or the other contributed to the success of this study.

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No competing interests reported.

Knowledge, attitude and practices of people living in Awka Metropolis, on malaria treatment, prevention and control

Status:

Version 1

Abstract

Background

Method

RESULT

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1