Community knowledge, attitude and practice about malaria in a low endemic setting of Shewa Robit Town, northeastern Ethiopia

Malaria remains a major global public health and development challenge. It caused 216 million cases and 655,000 deaths worldwide in 2010, of which 81% of the cases and 91% of the deaths were from sub-Saharan Africa [1]. In Ethiopia, malaria also remains one of the most public health problems despite considerable effort made to control it [2–4]. Approximately 75% of the land mass where 68% of the total population lives is malarious [2]. The Federal democratic Republic of Ethiopia Ministry of Health estimated that there are more than 5 million clinical cases and thousands of deaths due to malaria each year [2]. However, the epidemiological pattern of the disease varies from place to place and even from time to time [5–7]. About 1 million confirmed clinical cases and 1,581 deaths were officially reported due to malaria in 2010 [1].

Due to availability of favorable conditions for the vector to develop and multiply, malaria tends to predominantly occur in rural areas [5, 8, 9]. However, studies documented increased malaria transmission in urban areas [10–13]. This could be associated with the rapid growth of cities coinciding with lack of proper sanitation, poor housing and poor drainage of surface water that facilitate human-mosquito interaction and subsequent malaria transmission [10–13].

Additionally, weak health services, increased migration of people from malarious rural areas to urban areas, limited tradition of indoor residual insecticide spraying (IRS) and bed net use, increased number of man-made mosquito breeding sites, and unplanned irrigation schemes and water collection reservoirs my hasten the spread of the disease in Ethiopian urban settings [5, 13]. In view of the increasing urbanization in the country, there is a need to assess the risk of plasmodial infection. This provides baseline information to integrate malaria control activities with urban planning. This study assessed malaria prevalence and community KAP about the disease in Shewa Robit Town, northeastern Ethiopia.

Community-based cross-sectional study on malaria prevalence and communities’ knowledge, attitude and practice towards the cause, transmission, prevention and control measures of the disease was undertaken in Shewa Robit Town, northeastern Ethiopia. The study revealed lower malaria prevalence (2.8%) compared to reports from Jimma Town, southwestern Ethiopia (5.2%) [13] and Kenya (18.0%) [17]. Environmental variation, type of study population and level of endemicity may explain this difference [7, 18, 19]. Our study participants were all age groups, but those of Kenya were pregnant women who are more susceptible to malaria attacks [17].

The predominant Plasmodium species detected among the current study participants was P. vivax. Only one individual was positive for P. falciparum. This is in agreement with the previous report from Jimma Town [13] possibly due to the dominance of P. vivax over P. falciparum in recent years [20].

IRS with DDT, use of mosquito nets, lack of holes in living houses and good knowledge and practice of participants in preventing malaria were significantly associated with a lower prevalence of malaria which agrees with reports from other parts Ethiopia [21], Eritrea [22] and Kenya [17]. Similarly, decreased malaria prevalence was observed among community members living far from breeding sites which agrees with previous report from Ethiopia [21] and western Kenya [23]. Woyesa et al. [10] also observed an inverse relationship between mosquito density in village and the distance of settlement from the river suggesting that mosquitoes tended not to fly far from breeding sites for blood meals.

The questionnaire survey results showed that all respondents had ever heard of malaria and more than 90% of them believed that malaria was one of the most important health problems of the community affecting both sex and all age groups, which is consistent with previous reports [24, 25]. Most of the respondents were also familiar with at least one of the classical symptoms of malaria which is expected for a population in endemic areas where people are aware of the clinical manifestations of the disease [26, 27]. However, the lower prevalence of malaria (2.8%) observed among the study participants could be due to different malaria preventive and control measures being implemented in the area. Currently, the government is undertaking control measures, including distribution of ITN and residual spraying of houses with insecticides in malarious regions of Ethiopia. This may contribute to the reduced malaria prevalence observed among communities in the current study area.

The majority of the respondents mentioned that mosquito bite was a possible cause of malaria, and transmission occurs from person-to-person through mosquito bite. This awareness is higher than the level reported in other parts of Ethiopia [24, 26, 28]. The difference might be due to the presence of accessible house-to-house health extension services, which focuses on information, education and communication (IEC)/behavioral change communication in the current study area. In Ethiopia, regular practice of creating awareness in communities about health issues through health extension workers has started in recent years.

Although majority of the respondents associated the cause of malaria with mosquito bite, more than 20% of respondents mentioned lack of personal hygiene, exposure to cold weather, hunger, chewing maize stalk, body contact with malaria patient, flies and respiratory route as the causes of malaria. Such misunderstandings have also been reported by other studies [24, 28–31]. Although the belief of the community that exposure to cold weather, hunger and chewing maize stalk as direct causes of malaria seem incorrect, the idea may stem from the occurrence of other related factors with stated condition which could be risk factors for malaria. For example, cold and cloudy weather could be related to the presence of mosquito breeding sites. In addition, maize pollen is released following rainy season which can be used as food source for larval stage enhancing their development and survival. Thus, malaria transmission could be accelerated in cold weather during winter seasons where maize is common [32]. Hunger could also lead to poor nutritional status which could make individuals more susceptible to malaria [33, 34]. Despite these facts, perception of these by the study participants as direct causes of malaria may influence the actual prevention mechanism they may choose. Thus, this should be corrected with appropriate health education which could change their behavioral. Studies have reported better understanding of the causes of malaria in communities who had better awareness about the issue through health education [30, 35].

More than half of our study participants mentioned mosquitoes’ habit of biting during sleeping time, breeding in stagnant water as well as resting at edges of streams. However, in rural parts of central Ethiopia, night biting habit of mosquitoes and breeding in stagnant water were reported by 42.6% and 36.2% of the respondents, respectively [24]. This correct perception among respondents of the present study is encouraging to take appropriate preventive measures and proper use of mosquito nets.

The most common sources of treatment mentioned by respondents in this study were health facilities. This is consistent with other observations in other African countries and India where health facility services were preferred most frequently when malaria is suspected [19, 25, 36]. Nevertheless, some of the respondents claimed to have used traditional medicines which is similar with previous reports from Sudan [19] and Bangladesh [37].

In this study, all respondents believed that malaria is preventable disease which is in contrast to the finding of a study in other areas of Ethiopia (85.7%) [26]. Use of mosquito nets, filling and draining mosquito breeding sites (stagnant and surface water) and house spray with insecticide were the three main types of malaria preventive measures frequently reported by the current study participants. This agrees with previous observations from other parts of Ethiopia, Tanzania and Bangladish [28, 31, 37]. A great number of respondents (94.7%) knew that ITNs prevent malaria, and hence made use of them to prevent the disease. More than half of respondents also mentioned IRS as a preventive measure and that they get their houses sprayed during spraying campaign. These could be some of the reasons for the low malaria prevalence detected among the present study participants However, about 45% the respondents usually re-plaster their houses after spraying with insecticide. This suggests the necessity of health education to raise community awareness about proper uses of preventive measures. The present study participants also practiced environmental management (filling and drainage of mosquito breeding sites) activities as preventive measures for malaria.

The limitations of this study include failure to use qualitative method and direct observation of ITNs usage. Immunological, genetic, nutritional and health status (e.g. occurrence of co-infections) of the study participants, which could affect status of Plasmodium infections were not considered. In addition, the number of malaria cases was too small for making firm conclusion regarding predictors of malaria prevalence.

In conclusion, it is evident that the community’s overall awareness about the cause, symptoms and preventive measures of malaria was found to be high, and prevalence of malaria was found to be low in Shewa Robit Town. However, knowledge gaps about the cause and transmission of malaria were also observed among the residents in the area. Thus, appropriate health education should be implemented to correct misconceptions about the cause and transmission of malaria, and attention should be focused on the residents near to breeding sites.