Knowledge, attitude and practice towards malaria among symptomatic patients attending Tumbi Referral Hospital: A cross-sectional study

Background Despite significant improvement in prevention and control over the past decades malaria remains a significant public health concern in Tanzania with 93% of the population being at risk. To prevent malaria infection and promote malaria free zones, understanding the community’s knowledge, attitudes, and practices toward malaria control are essential. This study therefore aimed at determining the levels of understanding, and attitudes, as well as socio-cultural aspects of malaria prevention and treatment-seeking behaviours among suspected malaria patients. Methods This study was a hospital based cross-sectional study, in which patients attending Tumbi Referral Hospital with symptoms and signs that warrant inclusion of suspicion of malaria, were recruited. We used a pre-tested semi-structured questionnaire to collect participants’ demographic characteristics, as well as information on their knowledge, attitudes, and practices towards malaria infection. Data were analysed using Stata Version 12.1. Results We enrolled a total of 295 respondents of which 179 (60.68%) were females. Participants’ ages ranged from 1–91 years, with a mean of 31.4 years. Seventy-nine (26.8%) patients reported having malaria in the previous 28 days, with 57 (72.2%) being laboratory confirmed. Only 52 (65.8%) individuals reported taking prescribed medications for malaria. A total of 277 (93.90%) were aware of malaria, and 264 (95.31%) knew that it is transmitted by mosquito. Nearly all participants (263, 94.95%), identified sleeping under bed nets to be protective against malaria. About half of the respondents either agreed 63 (22.74%) or strongly agreed 62 (22.38%) that malaria can be transmitted like the common cold. Self-reported mosquito net use was 88.09% (244). Conclusion Despite the endemicity of malaria in our study site, patients had adequate knowledge, encouraging attitudes, and good practices related to malaria prevention and control.


Introduction
Malaria is an infectious vector-borne disease caused by four common species of protozoan parasites of the genus Plasmodium: Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium malaria [1]. A global reduction in investment in malaria research and control in 2016 conversely led to an increase from 2015 of 211 million malaria cases to 216 million in 2016 [2]. Of all global malaria cases, 90% occur in the World Health Organization's Africa Region with 15 sub-Saharan countries carrying 80% of the global burden of malaria [2]. Plasmodium falciparum accounts for about 99% of all the malaria cases [2]. Apart from being the major cause of morbidity and mortality, malaria programs account for over US$12 billion annually in African nations [3].
Despite significant improvement in prevention and control for the past decades, malaria remains a significant public health concern in Tanzania with 93% of the population at risk for malaria infection [4]. It remains among the leading national causes of morbidity and mortality especially in children under five years and pregnant women whereby malaria dominates outpatients, inpatients and admissions of under five year children at health facilities [4].
Malaria is a treatable and preventable disease requiring well-organized and delivered intervention programs. Tanzania, along other sub-Saharan African countries, adopted the "President's Malaria Initiative", which was launched in 2005 to reduce malaria-related mortality by 50% [5]. Malaria reduction is targeted through a rapid scale-up of four proven and highly effective malaria prevention and treatment measures: insecticide-treated mosquito nets (ITNs); indoor residual spraying (IRS); accurate diagnosis and prompt treatment with artemisinin-based combination therapies (ACTs); and intermittent preventive treatment of pregnant women (IPTp) [5]. The Tanzanian National Malaria Control Program Strategic plan for 2015-2020 calls for the reduction of malaria morbidity and mortality by 80% by 2020, reduction of malaria prevalence from 5% in 2016 to 1% by 2020, and increased proportion of women receiving two or more doses of SP during their pregnancy from 32% in 2012 to 80% by 2016 [5]. To attain the expected results and sustain the expected gains, strengthening of the health system and capacity building is crucial [5].
To achieve the above national goals, community knowledge, attitudes and practices towards malaria are essential in preventing malaria infection and promoting malaria free zones [1]. The success of malaria control efforts is highly dependent on the level of understanding, attitudes, and socio-cultural aspects of malaria prevention and treatment-seeking behaviours in the community [6].
Previous African-based studies regarding knowledge, attitude and practices about malaria and its control concluded that unsatisfactory practices and misconceptions towards malaria persist [7]. Therefore, we must improve our knowledge of community beliefs and practices respecting malaria in order to engage and embed them in surveillance and control activities [8]. Failure to consider the communities' knowledge, attitudes, and practices towards malaria will impact the achievement of successful sustainable control programs [9], as studies on malaria control programs have demonstrated direct interaction with community plays a crucial role in dealing with malaria problems [10]. Addressing community knowledge, attitudes, and perceptions can be of critical importance towards developing malaria control strategies [8], understanding who knows what about malaria and malaria prevention, who adopted malaria prevention and mosquito avoidance, who is at risk for malaria infection are all precursors to successful implementation and sustainability of malaria control efforts [11]. There remains scarcity of studies regarding knowledge, attitudes, and practices in Tanzania. As there is a scarcity of studies on this important topic, our study aimed to determine knowledge, attitude and practices towards malaria among symptomatic patients attending Tumbi Referral Hospital in the Coastal Region of Tanzania.

Study setting
The study was conducted at Tumbi Referral hospital located in the Coastal Region, which is about 45 kilometers from Dar-es-Salaam, which was previously the central administrative and most populous city in the country. Tanzania's Coastal Region has one of high endemic rates for malaria throughout the year, with highest transmission intensity during the rainy seasons. The study was conducted during and just after the rain season from December, 2017 to May, 2018.

Study design
This study was a hospital based cross sectional study.
Study population. The study involved all patients attending at the hospital with symptoms and signs that warrant inclusion of malaria (suspected malaria cases of all ages).
Sample size. The minimum number of study subjects was estimated by using a sample size formula by Kish and Leslie for cross-sectional studies [12]: Where Zα = Standard normal deviate at 95% confidence interval corresponding to 1.96; P = Assumed true population prevalence of Plasmodium falciparum malaria, assumed to be 30%, from a previous study done in Kibaha District, Coastal Region [13]; δ = Absolute error between the estimated and true population prevalence of Plasmodium falciparum malaria of 5% or 0.05; and n = estimated sample size. yields a minimum sample size of 323 study participants for this study. Sampling procedure. Systematic sampling procedure was used to recruit study participants. A sampling interval of five (5) patients was used to select participants from patients with signs and symptoms consistent with malaria and who were referred to the outpatient laboratory for blood smears. Questionnaires were collected between December 2017 to May 2018.

Data collection
Assessment of socio-demographic information and risk factors. A pre-tested Kiswahili translated semi-structured questionnaire was used to capture demographic characteristics (age, sex, socio-economic status) of the study participants as well as gather information on their knowledge, attitudes, and practices towards malaria infection. The questionnaire probed for the participants' knowledge of malaria including its transmission and symptoms; prevention and control measures/practices and use of ITNs. The questionnaire was initially developed in English and then translated to Kiswahili and back-translated by a different person who was blinded to the original questionnaire. For children who could not express themselves and comprehend the questions, the parent/caregiver was interviewed instead.
Data analysis. The collected data were entered into a database using EpiData Version 3.1. Data analysis was done using STATA Version 12.1 (Stata Corp, Texas, USA). Descriptive statistics, including percentages and mean values, were used to visualize the data, augmented with graphs drawn using Microsoft Excel program.
Ethical statement. The study was approved by the University of Dodoma, Institutional Research Review Committee. Before enrolment into the study, the objectives of the study and the study procedures to be followed were explained to the patients. Written informed consent was sought from all study participants who were informed of their right to refuse to participate and/orto withdraw from the study at any time. Assent was sought from children, who were also informed of their right to refuse to participate and to withdraw at any time during the study, and their parents or guardians provided a signed informed consent form.

Socio-demographic characteristics of study participants
We enrolled a total of 295 respondents, with the majority being females [179 (60.68%)]. The age of the respondents ranged from 1-91 years, with a mean age of 31. 4

Clinical characteristics of study participants
Out of the 295 study participants, 79 (26.8%) reported having malaria within the previous 28 days of whom 57 (72.2%) was laboratory confirmed. All 79 participants reported using antimalarial drugs but only 52 (65.8%) reported taking prescribed medications.

Respondents' knowledge of malaria transmission and symptoms
Respondents were asked if they have ever heard of malaria to which 277(93.90%) responded positively. The most common sources of malaria related information were television 186 (67.15%), radio 155 (55.96%), family members 154 (55.60%) and health facilities 142 (51.26%

Need for more information about malaria
We asked participants whether they felt that they had enough information about malaria, yield a majority response of no by 41%, and with 37% responding yes. In most responses, malaria prevention (51.75%) and control (35.09%) were areas indicated as needing more information.

Participants' attitudes towards malaria
In this study we assessed participants' attitudes towards malaria. Most respondents agreed 105 (37.91%) or strongly agreed 146 (52.71%) that malaria is a serious and life-threatening disease. Close to a half of the respondents, either agreed 63 (22.74%) or strongly agreed 62 (22.38%) that malaria can be transmitted from one person to another like the common cold. More than three-quarters of the subjects either agreed 124 (44.77%) or strongly agreed 90 (32.49%) that the best self-prevention was to avoid getting mosquito bites. About 90% (247/277) of respondents said they were sure that anyone could get malaria. More than 85% (237/277) of the respondents agreed or strongly agreed that sleeping under an ITN prevents contracting malaria. Around 27% (75/277) of the respondents said they could treat themselves when they get malaria, whilst 19% (52/277) said one can recover spontaneously from malaria. Most respondents [79.06% (219/277)] agreed or strongly agreed that it is dangerous when malaria medicine is not taken completely. Of the respondents 48.73% (135/277) either agreed or strongly agreed that they can buy anti-malaria drugs from the medicine shop/pharmacy to treat themselves when they get malaria. The majority [88.08% (244/277)] of respondents thought they should go to the health centre/clinic to confirm malaria via a blood test (Table 3).

Discussion
This study aimed at assessing the level of knowledge, attitudes, and practices towards malaria among symptomatic patients attending Tumbi Referral Hospital.Overall, we found adequate knowledge, encouraging attitudes and good practice on malaria prevention and control.
In this study, we found that amongs the 79 participants who reported having malaria and using anti-malarial medications in the past 1-month, approximately 28% did not confirm the diagnosis through laboratory examination, a practice which is discouraged by the World Health Organization. It recommends that all individuals with symptoms and signs suggestive of malaria should have a confirmatory parasitological test, either via microscopy or Rapid Diagnostic Test (RDT) [14]. Symptomatic management of malaria has been a common practice in Tanzania [15], as in other endemic settings [16]. This study revealed that about 34% of individuals who used anti-malarials in the past month were using drugs not prescribed to them. The use of self-administered, over-the-counter medications has been reported elsewhere in East Africa East Africa [17] and has a documented history [18]. This study has found participants' awareness on malaria is high, which was similarly reported in another study in Tanzania [19]. However, awareness alone is insufficient as one must understand the causes and modes of transmission in order to achieve disease control [20]. Individuals mentioned that the most common source of information about malaria was television followed by radio and family member signifying these as strategic channels through which to deliver malaria-related information to the community. These findings are in line with other studies done in malaria endemic settings which report that over 90% of individuals in such settings are aware of malaria ad that television, radio and family members are the most frequently mentioned source of malaria information sources [21,22]. One caution in terms of generalizability is that this study occurred in a peri-urban area with high television penetration which is not necessarily representative of the country's more rural demography. Similar to other studies in malaria endemic settings, we found that about 95% of participants knew that malaria is transmitted by a mosquito bite [21,22]. However, our findings differed with a study done in Zanzibar in which the majority of participants could not associate malaria and mosquito bites. This variance may be attributed to the low endemicity of malaria in Zanzibar compared to mainland Tanzania. In terms of symptoms, over 90% of participants correctly identified fever while over 75% of the individuals mentioned headache as a symptom. Similar findings were obtained in studies done in other malaria endemic settings respecting mosquite bite as vector and the same presenting symptoms [7,21,23,24].
In our study, about 95% of individuals mentioned sleeping under ITNs as a means for malaria prevention and control, which is similarly reflected in previous studies [25,26]. As the participants reported sharing the ITNs with family members, this was evidence of their knowledge of the protective use of ITNs. Tanzania through the Global Fund has been conducting ITN distribution campaigns with the aim of universal coverage. In our study, the majority of the participants (> 80%) reported hearing about ITN and/or owning an ITN, which is comparable to other studies done in East Africa [26,27]. More than half of the participants reported radio, television and family member as the source for ITN knowledge. Despite the net distribution campaign, less than 40% of participants reported to have obtained the nets from the distribution campaign making this an area for improvement and optimization which has been reported previously [28,29]. Free distribution, despite improving coverage, has been shown to reduce inequity in ownership and use as well [29]. Despite knowledge on ITNs as protective, a significant number of participants did not know that wearing long sleeved clothes, clearing of the bushes close to the houses, and mosquito sprays can prevent transmission of malaria. Knowledge translated into practice was seen in their self-reported clearing of bushes and clearing stagnant water, while very few reported using mosquito repellents/sprays. Similar findings were reported in a study done in Nigeria where the use of repellents and spraying was low; however wearing of long sleeved shirts was high in the Nigerian study than our study [21]. This knowledge to practice aspect must be addressed in future campaigns to further reduce malaria transmission in the country.

Limitations
We acknowledge that not having recruited the required sample size might have compromised the power of our study. Furthermore, we acknowledge that the study was done in a peri-urban area which may have impacted the level of knowledge that is reported by this study (due to higher education levels, sources of income, and access to health information). Finally, we acknowledge that the hospital-based study population may not be representative of the general population, and limits our inference to febrile patients attending Tumbi Referral Hospital.

Conclusion and recommendations
In our malaria endemic study site, participants had adequate knowledge, encouraging attitudes, and good practices on malaria prevention and control. However, a few misconceptions on malaria disease, its transmission, and prevention persist as reported in this study, which ideally should be addressed and clarified before launching a comprehensive malaria control program in the area. Using findings from this study, messaging to clarify and engage people in future malaria programs in this area should be done through television, radio or engaging family members.