Perception and practices of Lagos state residents on the prevention and control of malaria in Lagos, Nigeria

Background: Malaria remains one of the major public health problems worldwide. It is an important cause of death and illness in children and adults in sub-Saharan Africa accounting for over a million deaths per year. The purpose of this study was to determine the perception and practices of the Lagos state residents on malaria. Materials and Methods: A descriptive cross-sectional study was conducted in five of the 20 local government areas (LGAs) in Lagos Nigeria. Using a multistaged sampling method, 5 LGAs and 12, 500 study participants were selected. The survey instrument was a structured, pretested, interviewer-administered questionnaire which sought for information on knowledge, attitude, and practices of the respondents on malaria. Data analysis was done using Epi-info V6.04d software. Results: The mean age was 35.5 ± 10.5 years. There were 8697 females (69.7%) and 3786 (30.3%) males. About 84% of the respondents correctly knew that malaria is transmitted by mosquitoes. Headache was the most recognized symptom (56.6%), while vomiting was the least (17.9%). About half of the participants recognized cleaning the environment as a primary preventive measure and the same number claimed to do so. Approximately, half of respondents claimed usage of insecticide-treated bed nets. Sulphadoxime-pyrimethamine (Fansidar) was the most frequently used (32.7%) antimalarial agent and the use of artemisinin combination therapy was low. Conclusion: Knowledge of malaria symptoms was average and the use of preventive measures was suboptimal. Increasing awareness of all stakeholders on traditional and contemporary preventive measures may enhance the control of this health condition.

Keywords: Attitude, knowledge, malaria, practices, prevention

Malaria remains a global public health problem. It is estimated that 3.2 billion people are at continuous risk of malaria. ^[1] Africa accounts for over two-thirds of these cases and over 90% of deaths. According to the National Malaria Control Program, in Nigeria, the disease is responsible for 60% of outpatient visits to health facilities, 30% of childhood deaths, 25% of deaths in children under 1 year of age, and 11% of maternal deaths. ^[2] Anumudu et al., ^[3] in a study done at Ibadan, reported a malaria prevalence of about 17% among the youths.

The hardest hit countries spend up to 40% of their public health expenditure on malaria. ^[4] The economic loss due to malaria in Africa is in excess of 2 billion US dollars per year. ^[5] The aim of this survey was to determine the perception and practices of Lagos state residents on the prevention and control of malaria.

Lagos state is located in South-West Nigeria. It encompasses an area of 3,577 sq m and is bound on the north and east by Ogun State, the west by Benin republic and the south by the Atlantic Ocean. Its cosmopolitan population is estimated at 17 million people. The state is made up of rural and urban areas with various welfare facilities. It is the economic base of Nigeria and has a resultant high rural-urban migration rate. Environmental conditions make it an area of stable endemic transmission.

Study design

This is a descriptive cross-sectional study conducted on adult male and female heads of households between April and May 2009. The survey instrument was an interviewer-administered questionnaire constructed to consist of the following sections: (a) sociodemographic details of respondents; (b) knowledge about malaria, its mode of transmission, signs and symptoms, and methods of prevention and control; and (c) attitudes and practices as regards the prevention and control of malaria, methods used, attitudes toward bed nets, indoor residual spraying, and side effects.

The study instrument was pretested among a selected community to exclude ambiguities and administered by research assistants who were trained for 2 days to ensure lexical coherence as well as efficient and effective discharge of duties.

Using a multistage sampling approach, the following steps were undertaken to recruit participants from five of the local government areas (LGAs).

1. Lagos state has 20 LGAs which comprises of 4 rural and 16 urban LGAs. The proportional distribution of rural to urban local government (LGs) is 1:4 (4:16) Therefore, one rural and four urban LGs were randomly selected by balloting.
2. Each LG comprises of approximately 20 wards out of which 10 wards were chosen using the simple random sampling method by balloting.
3. At the selected wards, four communities were selected by the simple random sampling method from each ward and participants were selected by the systematic random sampling method employing a sampling interval of one in four (based on the fact that five LGAs were sampled from a total sample frame of 20 LGAs) such that every fourth house was picked for the study.

The minimum sample size for this study was 2016; however, to cater for poor filling and nonresponse rate of 10%, the sample size was rounded up to 2,500 and a total of 12,500 participants were recruited from the 5 selected of the 20 LGAs.

Ethical approval for the study was sought from the state ethical committee and informed consent obtained from the authorities at the community level as well as the participants.

Data entry and analysis were conducted with the aid of Epi-info v.6.04d statistical software. Findings were presented in tabular form and chi-square test was used to assess possible relationships between variables. The level of statistical significance for comparing association between variables was set at P < 0.05.

The majority (8533; 68.3%) of the respondents in this study are of female gender with the age bracket 30-39 years being the most prevalent group (4612; 36.9%). The mean age of the study participants was 35.5 + 10.5 years [Table 1]. Almost all (12469; 99.8%) of those interviewed had heard of malaria and the commonest known mode of transmission of malaria parasite selected was by mosquito bite (10440; 83.7%). Approximately, half of the respondents reported fever, body aches and headache as symptoms of malaria, while less popular symptoms known include vomiting (2227; 17.9%) and loss of appetite [4690; 37.6%; [Table 2]].

It was observed that children under 5 years of age and all adults were perceived as those most at risk of malaria [Table 3]. Concerning preventive practices of respondents against malaria, use of insecticide treated bed nets (6117; 49.1%), cleaning of the environment (5921; 47.5%), and use of medications (4789; 38.4%) were the most popular preventive practices [Table 4].

With regards to choice of antimalarial during the last episode of malaria, the drug Fansidar (sulphadoxinepyrimethamine) was used by the majority (4073; 32.7%) of respondents, while less than 10% had used artemisinin combination therapy (ACT). There was a strong statistically significant association between educational level and use of bed nets (P = 0.000). The use of bed nets was higher amongst the more educated [Table 5].

Participants of this study demonstrated considerable knowledge about malaria. Almost all (99.8%) had heard about malaria and over 80% of them correctly identified the mode of transmission as being from the bite of a mosquito. Furthermore, almost half of them knew the signs and symptoms of malaria. This knowledge is not surprising as Lagos state falls within a region of malaria endemicity and most of the respondents would have suffered at least one episode of malaria within the last 1 year. Furthermore, the high level of knowledge observed in this study may be related to the high educational status of the respondents as over 70% of the study participants had a minimum of secondary school education. This finding is comparable to a study done in Haiti on malaria-related knowledge, perception, and practices in which socioeconomic status was found to have a statistically significant association with knowledge of malaria. ^[4]

Malaria in pregnancy is known to have serious adverse effects on maternal health and fetal well-being. ^[6],[7],[8] It is interesting that only 7.2% of respondents in the present study felt that pregnant women were at risk of malaria. It is all the more fascinating because the majority (68.3%) of the study participants were female and in addition, over three quarters of all the respondents (86.9%) are likely to fit into the reproductive age group of 25-49 years. The implication of this finding is that preventive interventions such as intermittent presumptive treatment of malaria in pregnant women or the use of bed nets may not be practiced by those at risk.

The most common preventive practices among the study participants include the use of insecticide treated nets (49.1%), cleaning of the environment (47.5%), and use of medications (38.4%). A study which sought to investigate the knowledge and use of preventive measures of malaria in rural parts of Northern Thailand showed that those with a greater knowledge about malaria were more likely to use a preventive measure with over 90% of them wearing protective clothing and 80% of them using nontreated bed nets and 45% of them using insecticide treated bed nets. ^[4] Conversely, in the present study, respondents’ level of knowledge about malaria was not commensurate with preventive practices given that less than half of the participants engage in preventive practices such as use of insecticide-treated bed nets, cleaning of the environment, and use of medications.

The current guideline for the treatment of malaria indicates ACT-based as the first line of treatment. ^[9] Adherence to this policy was limited as evidenced by the fact that only 7% of respondents reported use of ACT during their last episode of malaria. The most commonly used antimalarial was sulphadoxine-pyrimethamine. A possible reason for this is the high cost of ACTs relative to other less effective antimalarials, making it financially inaccessible. Another interesting finding is the use of chloroquine by the study participants, despite reports of widespread resistance to this medication. ^[10],[11]

Further analysis of the data showed a statistically significant association between educational level and the use of bed nets (P < 0.05). This association may be due to a number of factors such as a greater awareness about malaria as well as increasing access to preventive measures such as bed nets which have been provided at government health facilities in the fulfilment of the political mandate of free health services of the Lagos State Government. Moreover, advanced education among other factors is a key determinant for the adoption of innovations and concepts which could have accounted for more use of bed nets with increasing educational level. ^[12] Similarly, a related study done in South-West Nigeria on malaria prevention revealed that over 80% of people using bed nets had above secondary school education. ^[13]

This study had two main strengths namely; the large sample size used for the study and the spread of the study across the three senatorial districts in Lagos. These two characteristics of the study improve its validity.

Maintaining a clean environment is a simple intervention which could reduce the breeding places of the vector; in addition to a synergistic effect in controlling other diseases. While efforts leading to the utilization of insecticide treated nets are consolidated, further efforts are also required to promote environmental sanitation as a simple and cost-effective control measure. Moreover, in view of the knowledge gap observed as regards the risk of pregnant women to contracting malaria, community health education by means of recurrent sensitization programs are essential to reinforce these messages using multipronged approaches. Intermittent presumptive treatment of malaria in pregnancy should also be scaled up where necessary.

We thankfully acknowledge the Lagos State Government, Dr. Olajide Idris (Lagos State Commissioner for Health LMOH), Dr. Femi Taiwo (Director for Disease Control LMOH) and other officials of the ministry for the Funding and Facilitation of this research project.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.133698

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