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 Table of Contents  
Year : 2017  |  Volume : 16  |  Issue : 1  |  Page : 43-51

Knowledge of malaria and adherence to its preventive measures among adults attending out-patient clinics of a Nigerian tertiary hospital: Has anything changed?

1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication5-Jul-2017

Correspondence Address:
Godpower C Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Zaria Road, P.M.B. 3452, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajmhs.ajmhs_81_16

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Background: Despite global control efforts, malaria still accounts for preventable morbidity and mortality in Africa. Reported knowledge of its preventive measures appears high, but disparity exists between knowledge and uptake of preventive practices in Nigeria. It becomes necessary to evaluate adherence to use of insecticide-treated nets (ITN) and other malaria preventive measures at peak periods of malaria transmission as the Millennium Development Goal era terminates. Materials and Methods: A cross-sectional study was conducted at the general and pediatric out-patient clinics of Aminu Kano Teaching Hospital, among 413 adult patients and caregivers of children selected by systematic sampling technique and using a validated interviewer-administered questionnaire. Their knowledge of malaria and utilization of and adherence to preventive measure utilization were assessed. Results: The respondents’ mean age was 33.6 ± 8.9 years. Majority (90.6%) had adequate knowledge of malaria. Their mean malaria knowledge score was 78.7%. Among those who used ITNs, only 54.1% adhered to daily use. For other preventive measures, 65.3, 52.3, 46.5, and 25.2% adhered to environmental sanitation, insecticide spraying, wearing protective clothing, and mosquito repellent use, respectively. Hot weather was the main barrier to ITNs and wearing protective clothing adherence, whereas cost, lack of time, fear of side effects was the barrier to adherence to insecticide spraying, environmental sanitation, and mosquito repellent, respectively. Tertiary education was associated with adequate knowledge of malaria (χ2 = 8.36, P = 0.004). There was also association between adequate knowledge of malaria and monthly environmental sanitation participation (χ2 = 9.06, P = 0.003). Conclusion: Knowledge of malaria was high but adherence to practice was low. Nonadherence with preventive measures is an obstacle to achieving malaria control and could be overcome by effective mass education and addressing adherence barriers.

Keywords: Adherence, knowledge of malaria, nigeria, preventive measures, tertiary hospital

How to cite this article:
Michael GC, Aliyu I, Grema BA. Knowledge of malaria and adherence to its preventive measures among adults attending out-patient clinics of a Nigerian tertiary hospital: Has anything changed?. Afr J Med Health Sci 2017;16:43-51

How to cite this URL:
Michael GC, Aliyu I, Grema BA. Knowledge of malaria and adherence to its preventive measures among adults attending out-patient clinics of a Nigerian tertiary hospital: Has anything changed?. Afr J Med Health Sci [serial online] 2017 [cited 2021 Apr 18];16:43-51. Available from: http://www.ajmhs.org/text.asp?2017/16/1/43/209491

  Introduction Top

Malaria is a preventable and curable disease of public health importance. However, despite global gains in malaria control evidenced by a 60% plunge in malaria death rates between 2000 and 2015, malaria still accounts for about 438,000 deaths annually with 90% occurring in Africa (predominantly in under-five children and pregnant woman).[1] Nearly everybody (97% of the population) in Nigeria is at risk of malaria infection.[2] Malaria accounts for 50 to 60% of out-patient visits, whereas about 132 billion naira is lost to the disease as cost of treatment and loss of man-hours.[3],[4]

Malaria is caused by plasmodium species. The bite from infected female anopheline mosquito is responsible for the transmission of the Plasmodium falciparum species, responsible for the most severe symptoms and death. Following its discovery over 4000 years ago,[5] the world has been preoccupied with efforts aimed at preventing and eradicating malaria from various parts of the world. The World Health Organization (WHO) advocates a multiprong approach to its control; this involves vector control, preventive therapies, diagnostic testing, treatment with artemisinin-based combination therapies, and malarial surveillance.[6] Malaria candidate vaccines (currently at various stages of trials) are expected to join the armamentarium of control measures in the future.[7]

The use of preventive measures, such as the long acting insecticide-treated bed nets or insecticide-treated bed nets and indoor residual spraying, have reduced malaria burden and child mortality in parts of Africa.[8],[9],[10] However, in relative terms, malaria burden has not significantly changed in many highly endemic African countries (Nigeria inclusive) despite increased coverage of insecticide-treated nets (ITN).[11],[12],[13],[14],[15],[16],[17],[18] This suggests that the implementation of preventive strategies have yielded mixed results in various countries and in various regions within the same country.[2]

Furthermore, although most studies have been done on caregivers of children or pregnant women,[19],[20],[21] other populations are also at risk of the disease. This makes studies involving other population groups relevant in malaria control efforts. This study was, therefore, to assess the knowledge of malaria and adherence to its preventive measures among adult patients and caregivers of children attending the general out-patient clinic (GOPC) and pediatric out-patient clinic (POPC) of Aminu Kano Teaching Hospital (AKTH), respectively, to highlight the adherence issues in malarial prevention and for clinicians and policy-makers to improve malaria prevention strategies as the Millennium Development Goals (MDGs) era terminates.

  Materials and Methods Top

This was a descriptive cross-sectional study conducted at the GOPC and POPC of AKTH Kano. Kano is a commercial city and capital of Kano state in northwest Nigeria. It lies in the Sahel savanna, with a hot, semiarid climate. It has an average rainfall of about 690 mm (27.2 in) annually, most of which occurs from June to September. Kano is typically hot but is cooler from December to February.[22] Nigeria is endemic for malaria with moderate-to-high transmission in all states.[4]

The study population was adults accessing healthcare services for themselves or their dependents at the GOPC and POPC from the August 1 to the September 11, 2015, a period of high malarial transmission.[4] All parents or caregivers of children (≥18 years) attending the POPC and patients (≥18 years) attending the GOPC were included in the study. However, parents/caregivers with severely ill children, patients with emergency conditions, and those who declined consent were excluded from the study. From clinic records, an average of 1250 and 750 adult patients are seen weekly at the GOPC and POPC, respectively. Thus, the estimated sample frame was 12,000 (2000 × 6) participants over the 6-week study period.

Using out-patient malaria prevalence of 50%,[3] and the Leslie Fisher’s formula for estimating sample size for study populations >10,000, a sample size of 385 was obtained. Ten percent was added for possible incomplete data or nonresponses. Therefore, the study sample size was 428. Systematic random sampling technique was used to proportionately select every 28 (12,000/428) eligible caregiver or patient attending the POPC and GOPC after the first had been selected by balloting until the sample size was obtained.

Ethical approval was obtained from the AKTH Research Ethics Committee. An interviewer-administered, validated questionnaire (with closed- and few open-ended questions) was administered after written informed consent had been obtained. The questionnaire assessed the respondents’ sociodemographic characteristics (in the “Introduction” section), knowledge of malaria (the “Materials and Methods” section), and utilization of and level of adherence with malarial preventive measures (the “Results” section). Adherence was defined as sleeping under ITN, spraying insecticide indoor, or wearing of protective clothing at night on every day of the preceding week. This was adopted to determine pattern of utilization of the preventive measures by the respondents. Adherence with environmental sanitation (ES) was defined as having reported involvement in ES (i.e., clearing bushes, gutters, clearing water containers, automobile tyres, etc.) around the home in the preceding two ES days. The last Saturday of every month is a mandatory Kano state ES day, when all citizens in Kano except those on essential services are to participate in the cleaning of their environment. Adherence with the use of mosquito repellents was assessed by the reported frequency of use when outdoor or when the use of ITN and insecticide spraying was impracticable in the preceding week. A response of “always” was defined as adherence, whereas “most times” or “occasionally” was defined as nonadherence. The adherence to use of window nets was not assessed as it was thought to be a one-off activity.

Data were entered and analyzed using Epi Info Version (2012) (CDC, Atlanta, GA, USA). It was summarized using frequency tables, means, and standard deviations. Knowledge of malaria was obtained by dividing the total number of correct answers by the total number of options (15) stated in the “Materials and Methods” and “Results” sections and multiplied by 100 to obtain the percentage knowledge score. Excellent, good, average, fair, and poor knowledge were assigned to scores of ≥70, 60 to 69, 50 to 59, 40 to 49, and ≤39%, respectively.[19] Adequate knowledge was defined as a knowledge score of ≥60%.[19] The relationship between the sociodemographic characteristics of the respondents, adherence to preventive measures, and knowledge of malaria was assessed using Chi-square test of statistical significance. A P value of <0.05 was considered significant.

  Results Top

Respondents’ Sociodemographic Characteristics

Of the 428 participants selected for the study, 15 provided minimal data; therefore data for the remaining 413 (representing a 96.5% respondent rate) was used for analysis. There were 212 (51.3%) females and 201 (48.7%) males. Their ages ranged from 18 to 70 years with a mean age of 33.6 ± 8.9. A majority of respondents 304 (73.6%) were married [Table 1] and had tertiary education (64.7%). Civil service 200 (48.9%) was the predominant occupation; the gainfully employed (civil servants, traders/businessmen and women, artisans, and farmers) constituted 263 (63.7%), whereas the unemployed (housewives and students) were 150 (36.3%). They had predominantly monogamous families (72.4%) with a mean family size of 7.1 ± 3.6.
Table 1: Sociodemographic characteristics of respondents (N = 413)

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Respondents’ Knowledge of Malaria Transmission, Symptoms, and Preventive Measures

All respondents had heard of malaria before. A majority 321 (77.7%) knew mosquito bite was commonest mode for malaria transmission [Table 2], whereas dirty, stagnant water in gutters around the home was the most reported factor that promotes breeding of mosquitoes 225 (54.5%). Ten respondents (2.4%) were ignorant of what aids mosquito breeding.
Table 2: Respondents’ knowledge of malaria transmission (N = 413)

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All respondents reported at least one malaria symptom; fever and body weakness were reported by most 334 (80.9%) of them. Similarly, a majority 382 (92.5%) knew malaria can kill, whereas 346 (84%) reported that malaria affects everybody; 370 (91.6%) reported that malaria was preventable.

The commonest preventive measure known to the respondents was ES 398 (96.4%), whereas the least was mosquito repellents 171 (41.6%) [Table 3]. However, a majority 358 (86.7%) were aware that sleeping under ITN would prevent malaria. Topical application/ingestion of herbs or burning of dried orange pills was reported by 31 (70.4%) of 44 respondents as other ways of preventing malaria.
Table 3: Respondents’ awareness of malaria preventive measures (N = 413)

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The mean knowledge score of the respondents was 78.7 ± 14%; 324 (78.5), 50 (12.1), 23 (5.5), 12 (2.9), and 4 (1.0) had excellent (≥70%), good (60–69%), average (50–59%), fair (40–49%), and poor (≤39%) scores, respectively. A majority 374 (90.6%) of respondents had adequate knowledge of malaria [Figure 1].
Figure 1: Knowledge of malaria

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A higher proportion of respondents (66.84%) who had tertiary education had adequate knowledge of malaria when compared with those who had other levels of education (33.16%) and the difference in proportions was found to be statistically significant (χ2 = 8.36, P = 0.0038). However, there was no statistical association among age, sex, marital status, religion, occupation, tribe, family type, family size, and knowledge of malaria [Table 4].
Table 4: Relationship between sociodemographic characteristics and knowledge of malaria (N = 413)

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Respondents’ Utilization of Preventive Measures

All respondents had used at least one malaria preventive measure before. ES was the most common preventive measure ever used by the respondents 369 (89.3%), whereas the least was mosquito repellents 143 (34.6%) [Table 5]. Similarly, most respondents 316 (76.5%) had slept under net before.
Table 5: Respondents’ utilization of malaria preventive measures

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Respondents’ Adherence with Preventive Measures

Remarkably, there was disparity between reported use of the preventive measures and adherence to their use. Only 241 (65.31%) of those who reported participation in ES activities before did so in the preceding two mandatory state environmental sanitation days [Table 6]. Similarly, only 180 (52.33%) respondents who had used insecticide spray before used it daily in the preceding week, 171 (54.11%) slept under the net at night daily in the preceding week, 91 (48.92%) wore protective clothing at night in preceding week and 37 (25.87%) reported always using mosquito repellent whenever it was impracticable to use ITN or insecticide spray in the preceding week. A higher proportion of respondents who participated in the preceding two monthly environmental sanitation days were found among those who had adequate knowledge (67.45%) than in those with inadequate knowledge (39.29%) and the difference was statistically significant (χ2 = 9.06, P = 0.003). However, adherence with ITN, insecticide spray, wearing protective clothing at night, and use of mosquito repellents were not associated with knowledge of malaria [Table 6].
Table 6: Respondents’ knowledge of malaria and adherence with preventive measures

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Barriers to Adherence with Malaria Preventive Measures

The most common reasons reported for nonadherence with preventive measures were; lack of time for environmental sanitation 48 (43.6%), insecticide spray being expensive to purchase 117 (71.3%), being uncomfortable sleeping under net 102 (70.3%), or wearing protective clothing 76 (76.0%) because of hot weather and fear of side effects for mosquito repellent 52 (49.0%) [Table 7].
Table 7: Reason for nonadherence with preventive measures

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  Discussion Top

With the winding down of the MDG era, it became imperative to assess the knowledge of malaria and adherence with malaria preventive measures in our practice setting. Consequently, we found that 90.6% of the respondents had adequate knowledge of malaria, which is consistent with previous studies in Nigeria.[21],[23] The high proportion of respondents with tertiary education could be responsible for this finding. This is corroborated by the association observed between tertiary education and adequate knowledge in this study. Malaria is endemic in Nigeria and hardly any family that has not been affected by it. However, this proportion with adequate knowledge is at variance with 56% obtained in a study among antenatal women in Abuja, Nigeria[19] with similar urban populations and high literacy levels. The difference may be due to the different study populations and their exposure to public health information.[24]

Though a majority knew that mosquito bite was responsible for malaria transmission, 22.3% of the respondents either had erroneous beliefs (such as transmission being from germs and drinking dirty water) or were ignorant. This finding is also consistent with previous studies in rural low educational settings of Nigeria and Tanzania.[23],[25],[26] In contrast, our study population was urban and 87.7% had at least secondary school education. Ignorance or erroneous beliefs about the mode of malaria transmission has public health implications. For instance, it could be an indictment on the effectiveness of existing disease control programs in the area; in addition, clinicians may not have been adequately educating their patients about the disease. It is also likely that some of the respondents with erroneous beliefs may be unwilling to embrace appropriate preventive practices.[19] Furthermore, the knowledge of mosquito breeding habitats was also high amongst respondents; this also is consistent with previous studies in Nigeria.[23],[27],[28] This implies that a majority of them will be able to choose appropriate vector control measure as knowledge of the vector habitat is essential in making this decision.

All the respondents knew of at least one symptom of malaria; 80.9% of respondents reported fever and body weakness as symptoms. These findings are also consistent with previous studies in Nigeria and Tanzania.[21],[23],[26] The knowledge of fever as a symptom has the potential of improving healthcare seeking behavior among affected people.[23] The high proportion (92.5%) of respondents that knew that malaria could be fatal was similar to previous studies in Africa[21],[29] but varied with earlier studies in Ghana and Tanzania where most respondents perceived malaria as either merely a disease with headache and weakness or a mild disease with less potential to kill.[30],[31] The perception that malaria can kill could also increase healthcare-seeking behavior among respondents with this belief.[32] Similarly, the high proportion (84%) of respondents that knew that malaria affects everybody was consistent with findings of a previous study.[29] This knowledge has the potential of encouraging respondents to embrace preventive measures. Again, there were also a high proportion of respondents that knew that malaria was preventable; this is consistent with previous studies in Nigeria and Tanzania.[19],[21],[23],[26] Such knowledge has the potential of improving their willingness to engage in preventive practices as was observed in our study.

Similarly, the high proportion of respondents’ that knew that environmental sanitation, indoor insecticide (aerosol) spraying, and sleeping under ITN were preventive measures was consistent with previous studies in Nigeria.[19],[23] This knowledge has the potential of also improving their willingness to engage in appropriate preventive practices. ITN and indoor residual spraying are considered the most cost effective methods of mosquito control, but they are largely for indoor control.[10] In endemic countries (Nigeria inclusive), mosquito bites also occur in the early evenings (when people are still outdoor).[33],[34] This necessitates the use of complementary measures like mosquito repellents (creams, lotions, and coils) and wearing of protective clothing. Mosquito repellents are also recommended for travelers going to malaria endemic areas.[35] Unfortunately, fewer respondents in our study knew that mosquito repellents and wearing protective clothing (bright-colored, long-sleeved shirts and trousers) could be used to prevent malaria. This underscores the need for education on appropriate preventive measures for different situations and environments.

Two-thirds of the respondents knew that malaria could be prevented in pregnancy with drugs. This finding, though consistent with that of a previous study,[19] could be due to the information obtained by those female respondents who had previously received antenatal care. This could also suggest that the male respondents among this group took interest in issues concerning their wives during pregnancy and are likely to encourage adherence to antenatal malarial preventive measures for their spouses. We also found that 10.7% of respondents reported burning of herbs or dried orange pills, electric light, malaria vaccination, daraprim (pyrimethamine), and closing doors always as other ways of preventing malaria. These are largely unproven, ineffective, or unavailable methods of malaria prevention, and such respondents are unlikely to utilize or adherence to ITN and other proven preventive measures.

To get the full benefits of ITN, families must obtain appropriately treated nets, hang the net properly on the wall or roof, sleep under the net every night all year around even if mosquitoes are not seen or heard, everybody in the household must sleep under the net, and if not using the long-lasting ITN, the net should be retreated after three washes or at least once a year.[36] Most respondents (76.5%) in our study owned and have used ITN at least once. This finding is consistent with previous studies in Nigeria and Ethiopia[20],[37] but varied with earlier studies in Nigeria with lower ownership and utilization because of increased publicity and access to ITN in recent times.[38],[39]

Furthermore, only five of those who owned and had used ITN were using it daily in preceding week at a period of high malaria transmission when this study was conducted. It implied that many receive the free ITN distributed by health agencies, but many of those do not use them daily as found in a previous study.[40] This finding falls short of the recommendation by the national malarial control program that at least 80% of the at-risk population must own ITN and sleep under it daily.[41] Nonadherence to its use could be responsible for the unchanged statistics in many parts of the country. ITN ownership alone has the potential of misleading policy makers into assuming that distribution of the nets will equal using them and reducing malaria burden.[40] In addition, the nonadherence with ITN usage may result in frequent malaria episodes despite owning the nets and may discourage continued use of the nets. Unfortunately, we found no association between knowledge of malaria and it preventive measures and adherence with ITN use. Hence, the need for more than just reinforcement of adherence information at the grassroots but to evolve other strategies to improve behavior change. Respondents who were nonadherent ascribed the hot weather in Kano as reason for irregular use. This barrier to ITN use is consistent with findings from previous studies.[19],[23],[38],[42] Provision of adequate and regular electricity supply (to power fans) in the country must go together with the free distribution of ITNs. The covering of the body with protective clothing at night may also improve with regular electricity supplies in the country. Similarly, difficulty in hanging the ITN was cited by some respondents for infrequent use (as in other studies),[38] suggesting that free distribution of the nets had not been followed by adequate information on how to use them.

Only 52.3% of the respondents adhered with indoor insecticide spray. This is in variance with studies where utilization was as low as 32% in Lagos, Nigeria.[39] This difference could result from the differing sociodemographic characteristics of the two study populations. Understandably, the low adherence could also be because two-thirds of respondents had used both ITN and insecticide sprays at least once, resulting in nonadherence to one preventive measure. In addition, high cost of insecticide spray was cited as reason for infrequent use.

The high proportion of respondents that participated in environment sanitation was similar to finding from another study in Nigeria.[23] However, only 67.5% of respondents adhered to regular ES. The nonadherent respondents cited lack of time, laziness, waiting for authorities to do so (those living in government houses), and nonchalance of neighbors as reasons for this behavior. This implies that authorities may need to start holding families accountable for their dirty environments by strengthening the oversight functions of local health authorities and punishing offenders after adequate public enlightenment.

Among the limitations of this study was that as a hospital-based study, generalization of study findings would be limited to out-patient practice settings.

  Conclusion Top

The knowledge of malaria and its preventive measures was high but adherence to use of ITN and other preventive measures was still below expected targets. As the MDG programs continues as the Sustainable Development Goals, there is a need to scale-up efforts toward increasing adherence with malaria preventive practices. Multisectoral approach involving adequate and appropriate public enlightenment on preventive measures for different environments and addressing barriers to adherence may need to be considered.


The authors are grateful to the research assistants Saminu Shehu, Zubaida Kalleel, and staff of the family medicine and pediatric departments of Aminu Kano Teaching Hospital.

Financial support and sponsorship

The authors have no support or funding to report.

Conflicts of interest

Authors’contribution: G.C.M. was involved in the conception, design, data collection, analysis, interpretation, manuscript drafting, and revision. I.A. was involved in the data analysis, interpretation, manuscript drafting, and revision. B.A.G. involved in the design, interpretation, manuscript drafting, and revision. There are no conflicts of interest.

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Ankomah A, Adebayo SB, Arogundade ED, Anyanti J, Nwokolo E, Ladipo O et al. Determinants of insecticide-treated net ownership and utilization among pregnant women in Nigeria. BMC Public Health 2012;12:105. Available at: http://www.biomedcentral.com/1471-2458/12/105. [Accessed 2016 May 26].  Back to cited text no. 40
Federal Ministry of Health. National Malaria Control Programme, Abuja, Nigeria. Strategic Plan 2009-2013; A Road Map for malaria control in Nigeria; 2008. p. 23-4.  Back to cited text no. 41
Atieli HE, Zhou G, Afrane Y, Lee MC, Mwanzo I, Githeko AK et al. Insecticide-treated net (ITN) ownership, usage, and malaria transmission in the highlands of western Kenya. Parasit Vectors 2011;4:113. Available at http://www.ncbi.nlm.gov/pmc/articles/PMC3135563. [Accessed 2017 Jun 6].  Back to cited text no. 42


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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