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Human malaria infection in nigeria: critical review of prevention and control techniques.

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Abstract

Human malaria infection is among the leading global parasitic diseases which have substantial effects on all facets of human life. A series of measures have been devised to prevent and control malaria infection, including vaccines and prophylaxis. Nigeria, the most populous country in Sub Saharan Africa, is burdened by the effect of malaria infection. This review critical analysis various preventive and control measures employed in malaria infection with a focus on Nigeria.

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Uzochukwu Benjamin SC, Chiegboka Lausdeus O, Enwereuzo Chibuike, Nwosu Usonwanne, Okorafor David, Onwujekwe Obinna E, Uguru Nkoli P, Sibeudu Florence T, Ezeoke Ogochukwu P. Examining appropriate diagnosis and treatment of malaria: availability and use of rapid diagnostic tests and artemisinin-based combination therapy in public and private health facilities in south east Nigeria. BMC Public Health . Vol. 10(1)2010. Springer Science and Business Media LLC. [ Cross Ref ]

Arora Navneet, Anbalagan Lokhesh C, Pannu Ashok K. Towards Eradication of Malaria: Is the WHO’s RTS,S/AS01 Vaccination Effective Enough? Risk Management and Healthcare Policy . Vol. Volume 14:1033–1039. 2021. Informa UK Limited. [ Cross Ref ]

Islam Md. Saiful, Sujan Md. Safaet Hossain, Tasnim Rafia, Sikder Md. Tajuddin, Potenza Marc N., van Os Jim. Psychological responses during the COVID-19 outbreak among university students in Bangladesh. PLOS ONE . Vol. 15(12)2020. Public Library of Science (PLoS). [ Cross Ref ]

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Towards improvement in malaria policy implementation in Nigeria: a qualitative study on factors influencing the translation of malaria policies to practice

Affiliations.

• 1 Department of Health Policy and Management, College of Medicine, University of Ibadan, Ibadan Nigeria.
• 2 Department of Biological Sciences, Faculty of Pure and Applied Sciences, Lead City University, Ibadan, Oyo State, Nigeria.
• 3 Public Health and Epidemiology Department, Nigerian Institute of Medical Research, Yaba Lagos, Nigeria.
• 4 Department of Pure and Applied Zoology, Federal University of Agriculture, Abeokuta, Nigeria.
• 5 National Malaria Elimination Program, Abuja, Nigeria.
• PMID: 35134242
• DOI: 10.1093/trstmh/trac005

Background: Malaria is a severe health issue in Nigeria, particularly for pregnant women and children <5 y of age, despite all malaria control programs. From the standpoint of major stakeholders in Nigeria, this study explored both promoting and limiting factors affecting the implementation of malaria policy.

Methods: From March to June 2019, in-depth interviews were conducted with 16 key respondents. Key informants such as malaria researchers, policy advisers and program managers were identified using purposive and snowballing sampling strategies. Interviews were performed in English, recorded, transcribed and analysed using QSR NVivo 11.

Results: Some of the variables increasing the implementation of malaria policies in Nigeria, according to respondents, were political will, access to funds from donors, and staff commitment. Insufficient planning, lack of commitment, poor finance, manpower shortages, and a lack of synergy between academics and policymakers, on the other hand, were recognized as important barriers to the malaria policy implementation process by respondents.

Conclusions: Implementation gaps may result from a lack of capability for the policy implementation process and a lack of support for policy objectives. The difficulties in implementing malaria policy in Nigeria were highlighted in this study, and relevant recommendations were made.

Keywords: implementation research; in-depth interview; malaria; policy analysis; policy translation.

© The Author(s) 2022. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.

• Health Policy
• Malaria* / epidemiology
• Malaria* / prevention & control
• Nigeria / epidemiology
• Policy Making
• Qualitative Research

• Research article
• Open access
• Published: 13 May 2021

Malaria intermittent preventive treatment in Nigeria: a qualitative study to explore barriers

• Fatima Mahmud Muhammad 1 ,
• Saharnaz Nedjat 1 ,
• Haniye Sadat Sajadi 2 ,
• Mahboubeh Parsaeian 1 ,
• Abraham Assan 3 &
• Reza Majdzadeh   ORCID: orcid.org/0000-0001-8429-5261 4  

BMC Infectious Diseases volume  21 , Article number:  438 ( 2021 ) Cite this article

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While the use of sulphadoxine pyrimethamine (SP) is effective in preventing malaria infection during pregnancy, there are challenges limiting its uptake in Nigeria. This study aimed at exploring the barriers to IPTp usage among pregnant women in Kano state - Nigeria.

This is a qualitative study. The purposive sampling strategy was used for identification and selection of 14 key informants for interviews. In addition, six focus group discussions (FGDs) were conducted with pregnant women (3 FGDs) and married men (3 FGDs). The conventional content analysis method was used to interpret meaning from the content of the data. MAXQDA 10 software was used for data management and analysis.

Poor policy implementation, poor antenatal care attendance, inadequate access to intermittent preventive treatment at the community levels, lack of sustainable funding, and poor community engagement emerged as major barriers to IPTp use in Nigeria.

While the political will to allocate sufficient financial resources could help improve service delivery and IPTp usage among pregnant women, community participation is critical to sustain the gains.

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Malaria is a major public health challenge in several low-middle income countries (LMICs). Pregnant women are among the most vulnerable groups affected by the disease. In the year 2018, an estimated 11 million pregnant women residing in the sub-Saharan Africa were infected with malaria [ 1 ]. Besides, 29% of all pregnancies are at risk of malaria [ 1 ]. This is life-threatening as it poses substantial health risk to pregnant mothers, the fetuses and the neonates [ 2 ].

However, the good news is that malaria is preventable and curable. Intermittent preventive treatment in pregnancy (IPTp) is given at routine antenatal care regardless of whether the pregnant woman is infected with malaria or not [ 3 ] to prevent maternal malaria infection episodes, maternal and fetal anemia, placental parasitaemia, low birth weight and neonatal mortality [ 4 , 5 ]. As a result, the World Health Organization (WHO) guidelines on antenatal care highlight the need of countries to improve utilization of malaria prevention initiatives [ 6 ], including opportunities to expand use of IPTp with sulphadoxine pyrimethamine (SP).

Although great strides have been made over the past two decades to increase IPTp-SP uptake globally, a recent report by the WHO indicates a decline in progress in many African countries, including Nigeria [ 3 ]. Moving forward, several efforts have been made by the Government of Nigeria to address the burden of malaria. They include: scale-up activities of intermittent preventive treatment for pregnant women (IPTp); mass media campaign on long-lasting insecticidal nets (LLINs) use, and scale up of malaria case management [ 7 ]. Yet, the prevalence of malaria in Nigeria remains high – ranging from 19.7 to 72.0% across states [ 8 , 9 ]. Pregnant women that have received at least two doses of IPTp is still low [ 10 ]. Furthermore, pooled data showed a moderate coverage (of about 18.7%) of IPTp with a wide variation of IPTp usage across Nigeria [ 10 ]. According to the recent demographic health survey, about 40.4% pregnant women do use IPTp [ 11 ]. This is still low to realize the vision of a malaria free world by 2030.

Quantitative studies have been used to determine the burden of malaria and risk factors influencing use, coverage and access to IPTp in Nigeria [ 12 , 13 , 14 ]. Major limitations of these studies include the inability of study design to capture the comprehensiveness of barriers and facilitators of intermittent preventive treatment (IPT) usage among pregnant women. In addition, there are limited evidences in the use of qualitative approach in exploring the phenomenon in Nigeria.

The study aimed at exploring the stakeholders’ perspectives regarding barriers to IPTp usage among pregnant women in Nigeria, through the equity lens. It is anticipated findings could be used to improve IPTp usage among pregnant women in malaria control program.

Study setting

This study was conducted in Kano state, located in North Western Nigeria. It is the second most populous state in the country with an estimated 13.4 million people. The state was selected for the study due its high level of malaria burden compared to other regions [ 12 ]. For example, malaria prevalence in the state is approximately 32.4% [ 11 ]. In addition, maternal mortality ratio in the region is high, i.e., about 1025 per 100,000 births [ 15 ].

Participants and sampling

We employed snow ball and purposive sampling strategy to select participants for face-to face in-depth interview and Focus Group Discussions (FGDs). Interviews were conducted with 14 malaria stake holders at the national and state level. The maximum variation sampling approach was used to capture responses from varied participants, thereby enhancing the comprehensiveness of our findings [ 16 ]. Participants, mainly, policy makers in malaria prevention, health workers, malaria experts and community heads were recruited from three local governments in the states. This includes Nassarawa, Fagge and Kano municipal respectively. Six FGDs were conducted – 3 FGDs were held with pregnant women and 3 FGDs with married men. Each focus group consisted of about 8–10 participants. Data for health workers and pregnant women was gathered across three hospitals – all stationed at different communities. This enabled us to capture wide range of perspective from participants irrespective of their socioeconomic status and geographical location. The selected hospitals were: 1) Aminu Kano Teaching Hospital, 2) Abdullahi Wase Specialist hospital, and 3) Murtala Mohammed Specialist Hospital. Interviews were conducted by FM. The three FGDS for married men and the in-depth interviews for the community heads were conducted in the communities within the three local governments unlike the other interviews conducted in the hospital. Community contact persons assisted in recruiting the eligible participants for the FGDs. The FGDs were conducted in a venue arranged by the community heads (Table  1 ).

Data collection tool and procedures

All interviews were audio recorded. Field notes were also taken where necessary. Separate pre-tested semi- structured interview guides were used for data collection during both the key informant interviews and FGDs. Interview questions covered: challenges of IPTp policy implementation, attendance of women for ANC, IPTp distribution in ANC units, accessibility of IPTp in the communities, knowledge about adverse effects of malaria during pregnancy, facilitators and barriers of IPTp usage. Interviews lasted between 20 and 45 min – when saturation was reached [ 17 ].

Data processing and analysis

Data was transcribed verbatim. The conventional content analysis approach was used to interpret meaning from the content of data due to the inductive nature of this qualitative design [ 18 ]. Some of the transcripts were translated from local language to English and verified by experts to enhance accuracy. Transcripts were analyzed by FM and SN using a coding scheme developed from the topics. Data were thoroughly examined by researchers, and relevant perceptions were coded as concepts. Codes related were then summarized to form categories. Next, RM and MP developed the categories, sub-category and the themes. AA, HS and the whole research team ensured that the themes were linked to research questions and study objectives. The themes were compared and discussed to enhance understanding of data. MAXQDA 10 software was used for data management and analysis.

Quality control and assurance

To enhance the rigor of the study, several researchers independently assigned pre-specified codes to the data [ 19 ]. First, five interviews were double-coded by FM. The remaining interviews were double-checked by SN. Next, the entire research team thoroughly discussed the findings for completeness and accuracy. Following that, some data were returned to the interviewees to check the correctness of interpretations. Interviews and data analysis were done at the same time. This enabled us to explore alien responses that emerged during interviews [ 16 ].

A total of 14 face-to face interviews and 6 FGDs were conducted. Stakeholders considered for the interviews included national malaria director, state malaria coordinator, other malaria experts, community members and health care providers. The age of pregnant women ranged from 17 to 40 years. Again, majority of them had attained primary education (50%), secondary education (35%), and about 15% had no formal education. Further, approximately 40% of them were rural dwellers while 60% were from urban areas. The following themes emerged from the analysis: policy implementation; attendance of women for ANC; distribution of IPTp in hospitals; accessibility of IPTp in the communities; and strengthening of IPTp service delivery. Refer Table  2 below.

Implementation of malaria policies

Financial obstacle.

Most key informants revealed financial barrier as the major limitation to effective policy implementation targeting IPTp usage. Based on our findings, there is lack of sustainable funding for malaria programs. Governments mainly rely on foreign aids to fight malaria which is not enough, considering the high population growth of the country.

“ We have about 1,200 pregnant women attending the antenatal care monthly in this hospital. In a year, we have nearly up to 16,000. How much does a pack of IPTp cost? Providing three packs for each of these women costs 4.8 million Naira (13,445 Dollars). Hence, providing IPTp for all pregnant women is a huge burden on the government”. – Malaria Expert from Murtala Mohammed Teaching hospital, Kano.

Political obstacle

According to stakeholders, reaching the entire population of Nigeria with malaria interventions require stronger political commitment. However, participants asserted that there is poor political willingness to this cause. Interviewees believed this has contributed to insufficient investments in the provision of IPT in public hospitals. Based on their opinion, political commitment was required to advance progress in the fight against malaria in the country - FGD, a married man.

A malaria program focal person complained that “ … . after we finished training the health workers about malaria issues in pregnancy and how to administer IPT, a local government chairman would just come to give another task changing them from the ANC units” - Policy maker at national level.

Attendance of women for ANC

Poor educational status.

Almost all the focal persons interviewed complained of poor attendance of pregnant women during ANC in Kano state compared to other regions of the country. According to stakeholders, turnout was unsatisfactory and fascinated by the poor educational status of women in the locality.

“ About 58% of pregnant women had at least an ANC visit in Kano state. Some pregnant women delayed the visits till their third trimester, so as to have one of the IPTp doses. Besides, it is during such visits that nurses and midwives talked on malaria. Their educational status contributed to their understanding in attending the antenatal care”- Malaria expert at Abdullahi Wase specialist hospital.

Poor male engagements and support for maternal care

Policymakers, experts and pregnant women also lamented the inadequate male engagements and support for maternal care, including: provision of needed financial assistance to support progress of the initiative; ensuring that their wives acquire basic health education and more importantly accompanying them during the ANC so as to be well-informed of their health condition. Views from experts include: ‘The men should help the society by making sure that their wives are educated and financially empowered. Women who are resourceful will always have the financial means to attend ANC.”- Malaria expert at Aminu Kano teaching hospital.

Distribution of IPTp in hospitals

Inadequate availability of iptp in healthcare facilities.

The findings from almost all the FGDs conducted with pregnant women revealed availability of free IPTp. Informants confirmed that IPTp prescribed for the pregnant women were to be paid for thereby limiting its access and use, especially among the poor who could not afford to pay. “ we were given hematinic as part of the free drugs, but IPTp was not included in the package – Pregnant woman during FGD. Further, the health professionals also confirmed that “it has been many years free IPTp and mosquito nets were distributed to pregnant women. - Health care provider.

Accessibility of IPTp

High out of pocket payments for ipt.

Most of the married men interviewed confirmed that they did not buy IPTp for their wives when they were pregnant due to financial constraints. Majority of the married men also stated that their wives only visited the hospitals when it was time for delivery. The informants complained about the cost of health care especially at the primary health care (PHC) units because majority of users at that level still could not pay for the drugs. A community head mentioned that “ we needed the government to provide us with free drugs in the PHC units, especially the IPT, since some couldn’t afford to pay the fees.”- Community opinion leader.

Strengthening delivery of IPTp service

Poor supervision of treatment.

While experts mentioned supervision of treatment as an important step to facilitate the uptake and coverage in the health facility, they lament on the poor supervision on the part of health workers to enhance use of IPTp by their clients. “ The training of nurses and midwives about IPTp should be given much attention because they are the best people to corporate with, and in this situation, directly observed therapy should be done in all health facilities as a routine.”-Policy maker at state level.

Poor community participation

Most participants emphasized on the importance of community involvement. Opinions of experts were that improved community participation is key to a successful delivery of primary health care (PHC). That is, according to interviewees, active engagements of community members can foster effective delivery of malaria programs including usage of IPTp. However, based on our findings, only small group of dedicated community members do promote malaria control. Participants therefore proposed that, “just as people use the monthly sanitation day to spray insecticide in the community, the same should be done to promote usage of IPTp” - Community head. This, they believed “can make the pregnant women, husbands and community members know more about the malaria prevention during pregnancy”.

The findings of this study provided insight on barriers to IPTp usage.

Four overarching themes emerged explaining the phenomenon. They are: poor policy implementation, absenteeism during ANC visits, inadequate availability (due to increased population size) and financial accessibility (due to limited budget allocation) to enhance the use of IPTp. On the other hand, improved supervision of treatment and community participation emerged as the major facilitators to strengthen service delivery of IPTp. Studies conducted in Uganda and Malawi have revealed similar findings [ 20 , 21 ]. The study revealed poor ANC attendance by pregnant women as one of the major barriers to IPTp use. Similar studies reported from Ghana and Malawi indicated that irregular and late ANC visits were the key factors for low uptake of IPTp [ 22 , 23 ] and the reason majority of pregnant women received just a single dose during their period of pregnancy.

Unavailability of SP in ANC units was identified a major challenge to IPTp usage. Quantitative studies conducted in the Southern and Western parts of Nigeria also identified lack of free IPTp thereby limiting its usage [ 24 , 25 ]. While IPTp is to be provided for free, most of the respondents in the community mentioned that the SP at the PHC units was allegedly sold to patients including the poor who could not afford to pay. This finding was similar to the study reported from Uganda where women were asked to pay for SP whenever it was out of stock [ 18 ]. Further, most pregnant women did not s receive the needed financial support from their husbands to enhance usage of IPTp use. Again, several studies have revealed instances where pregnant women were afraid to take SP due to sociocultural barriers [ 14 ] All these have renewed the importance of awareness creation of IPTp usage in PHC [ 26 ] through active community participation mechanism due to its effectiveness [ 27 ].

Strengths and limitations

The study captured responses from experts with wide range of experiences and background, thereby enhancing the comprehensiveness of our findings. Again, we used various data collection strategies including in-depth interviews, focused group discussions and review of secondary data, which help enhance methodological rigor. Our research team comprises of different researchers with varied backgrounds including epidemiologists, health economist and policy makers. This enabled us to address reflexivity, i.e., individual beliefs, judgements and practices that might have influenced the interpretation of our findings. Still, the study was not without limitation as participants might have had underlining rationale to the responses due to their political and social affiliations. Hence, our findings should be interpreted with caution.

Malaria infection during pregnancy remains a major public health concern. A call for action to enhance the use of IPTp-SP is relevant and timely. While political commitment is required to make further progress in the uptake of IPTp-SP, improved community participation and sustainable funding mechanism are critical to ensure sustainability of malaria prevention initiatives.

Availability of data and materials

The data can be made available upon reasonable request from the corresponding author.

Abbreviations

Antenatal care

Community head

Focused group discussion

Health care provider

Intermittent preventive treatment in pregnancy

Malaria experts

National malaria director

• Pregnant women

State Malaria coordinator

Sulphadoxine pyrimethamine

World health organization

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Acknowledgments

The authors would like to acknowledge Tehran University of Medical Sciences-International Campus (TUMS-IC), the National malaria control program, malaria control unit under the Kano state ministry of health in Nigeria. We are grateful to Professor Hadiza Galadanci, Dr. Audu Bala, Dr. Bashir Lawal, Dr. Imam Wada and Dr. Yusuf Belga for supporting the study.

The research was funded by Tehran University of Medical Sciences, Tehran - Iran. The funding body have no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Fatima Mahmud Muhammad, Saharnaz Nedjat & Mahboubeh Parsaeian

Knowledge Utilization Research Center, University Research and Development Center, Tehran University of Medical Sciences, Tehran, Iran

Haniye Sadat Sajadi

Global Policy & Advocacy Network (GLOOPLAN), Accra, Ghana

Abraham Assan

Department of Epidemiology & Biostatistics, School of Public Health, Knowledge Utilization Research Center and Community-Based Participatory-Research-Center, Tehran University of Medical Sciences, Tehran, Iran

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Contributions

FM organized the data, RM provided the idea of the research, developed the research methodology and contributed to the interpretation of the data., FM and SN performed data coding, analysis, interpretation and writing the manuscript. MP and HSS participated in study design, data collection and transcription. AA contributed to technical development of the manuscripts. All authors read and approved the final version of the Manuscript.

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Correspondence to Reza Majdzadeh .

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Ethics approval and consent to participate.

Verbal consent was obtained from the participants before the interviews were conducted so that they can make a voluntary choice to or nor to participate in the study. Participants’ anonymity and confidentiality were also guaranteed. The Ethics committee accepted it and grant an approval number, by the ethics review boards of Tehran University of Medical Sciences (Project No. IR.TUMS.SPH.REC.1398.070), Kano State Ministry of Health in Nigeria (MOH/0ff/797/T. I/1417).

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Muhammad, F.M., Nedjat, S., Sajadi, H.S. et al. Malaria intermittent preventive treatment in Nigeria: a qualitative study to explore barriers. BMC Infect Dis 21 , 438 (2021). https://doi.org/10.1186/s12879-021-06135-2

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DOI : https://doi.org/10.1186/s12879-021-06135-2

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Malaria infection among children under-five: the use of large-scale interventions in Ghana

• Clifford Afoakwah 1 ,
• Xin Deng 1 &
• Ilke Onur 1  

BMC Public Health volume  18 , Article number:  536 ( 2018 ) Cite this article

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Despite the significant investments to control malaria infection rates over the past years, infection rates remain significant in sub-Saharan Africa. This study investigates the association with use of large-scale malaria interventions such as: Indoor Residual Spraying (IRS), Insecticide Treated bed-Nets (ITN), and Behaviour Change Communication (BCC) strategies, and the prevalence of malaria among children under-five in Ghana.

Cross-sectional data on 2, 449 children aged 6 to 59 months who were tested for malaria, through Rapid Diagnostic Test (RDT), are drawn from the recent wave of the Ghana Demographic and Health Surveys (GDHS 2014). We use a logit model to analyse the heterogeneous association between control measures and malaria infection among under five children of different age cohorts and household poverty statuses.

Our estimates suggest that IRS offers much more protection than ITN use. The odds of malaria infection among children who sleep in IRS is significantly lower (odds ratio [OR] = 0.312; 95% CI -1.47 -0.81; p  = 0.00) compared to those who are not protected. This association is even high (odds ratio [OR] = 0.372; 95% CI -1.76 -1.02; p  = 0.00) among children in poor households protected by IRS compared to those who have no IRS protection. ITN use did not have a significant association with malaria infection among children, except among children whose mothers have at least secondary education. For such children, the odds of malaria infection are significantly lower ([OR] =0.545; 95% CI = − 0.84 -0.11; p  = 0.011) compared to those who are not protected. Regarding BCC strategies, we found that malaria education through television is the best strategy to covey malaria education as it significantly reduces the odds of malaria infection ([OR] =0.715; 95% CI = − 0.55 -0.10; p  = 0.005) compared to those who do not received malaria education via television. BCC strategy via print media has a significant but limited protection for children of educated mothers.

Policy makers should direct more resources to IRS, especially in communities where the use of ITN is less likely to be effective, such as poor and rural households. The distribution of ITNs needs to be accompanied with education programs to ensure its best protection.

Peer Review reports

Malaria is a life-threatening disease caused by infection through the bite of a female anopheles mosquito and poses the biggest health threat to children under five and pregnant women in malaria-prone areas such as sub-Saharan Africa. It is considered an endemic disease and a public health problem in Ghana due to the significant death toll associated with it [ 1 ]. It is also leads to poverty and low productivity due to human development, as well as due to its financial burden on households and the economy [ 2 , 3 ]. In Ghana it is estimated that every malaria episode recorded corresponds to an average of 5 workdays lost; 3 days to the patient and 2 days to the caretaker [ 4 ]. Figures from the World Health Organisation (WHO) [ 5 ] also suggest that malaria alone accounts for about 4 sick days in a month, and 6.4% of income loss in Ghana. Concerted efforts by governments, international organisations and charities to combat the disease have resulted in a sharp decline in global malaria morbidity and mortality by 37 and 60% respectively between 2003 and 2015 [ 6 ]. However, nearly half of the world’s population, or 3.2 billion people, are still vulnerable to this disease. Sub-Saharan African regions, in particular, carry a disproportionately high share of the global malaria burden. In 2015, the region experienced approximately 88% of global malaria infections and 90% of malaria deaths [ 6 ].

Over the past decades, there has been a significant increase in investment towards the fight against malaria. WHO reports an increase in resources for malaria control from US$ 960 million in 2005 to US$ 2.5 billion in 2014 globally [ 6 ]. In Ghana, as part of an eight-year malaria strategic plan to bring down the incidence of malaria by 2015, the government pledged to contribute US$ 231 million in 2008. Donors, including The United States Agency for International Development (USAID), Presidents Malaria Initiative (PMI), The World Bank, United Nations Children’s Fund (UNICEF) and the private sector, all financially support malaria control programmes in Ghana [ 7 ]. PMI is an inter-agency initiative led by USAID. Launched in 2005, PMI has a task of reducing malaria-related mortality by 50% across 15 high-burden countries in sub-Saharan Africa including Ghana.

Unfortunately, the rising investment to control the disease does not lead to a significant fall in infection among young children. Contrary to the global trend, malaria infection rates among children under-five in Ghana have been rising despite the efforts and investments. As shown in Table  1 , the number of reported cases of malaria among children under-five has been rising since 2000. Indeed, malaria accounts for more than half of Out Patient Department (OPD) cases of children under-five between 2010 and 2012, a sharp rise from 36.57% in 2000.

Although in 2016 there was a significant reduction in the number of deaths attributable to malaria (1037 in 2015 to 590 in 2016) as well as the decline in Case Fatality Rate (CFR) (0.51 in 2015 to 0.32 in 2016) among children under-five, the proportion of cases attributable to malaria for under-five children remains high at 46.7% [ 8 ].

According to the Ghana National Malaria Control Programme (NMCP), malaria kills at least 3 children every day and also tops OPD cases in Ghana. While it is encouraging to observe a decline in in-patient deaths emanating from malaria infection among children under-five, the statistics on morbidity and in-patient cases remain alarming. This, therefore, raises questions about the role of malaria interventions and the type of effective strategies among children under-five in Ghana. In particular, the challenge is identifying the factors which play an important role in improving the protection offered by the malaria control tools. Utilising a sample of 2449 children in Ghana, we explore the impact of most popular intervention tools on malaria infection among children under-five.

We use an objective malaria infection measure that was not previously available in Ghana. In 2014, for the first time, children under-five were tested for malaria using a RDT in the GDHS. This objective measure makes it possible to test the association between IRS, ITN use and malaria infection in a large scale.

The rest of the paper is organized as follows. Section 2 gives an overview of malaria control tools in Ghana alongside with the literature review. The methodology and data are described in Section 3. Our main results are presented and discussed in Section 4, followed by robustness analysis in Section 5. The last section concludes with policy recommendations.

Malaria control tools and the Ghanaian context

IRS and ITNs are the two main interventions recommended by the Global Malaria Programme in the WHO for malaria control. IRS is regarded as one of the most efficient vector control measures for tackling malaria transmission. It involves the spraying of walls and roofs of houses with long-acting chemical insecticides. This helps to kill the adult mosquitoes that dwell on such surfaces [ 9 ]. The role of IRS in reducing malaria infection is well-established with ample scientific evidence [ 10 , 11 ]. Similarly, an empirical study on Ghana by Fuseini et al. [ 12 ] provide evidence on the efficacy of IRS.

In Ghana, IRS is carried out by the government, private individuals, and non-governmental organisations such as Anglogold Malaria (AGAMal), Global Fund and PMI. The use of IRS has been shown to have economic benefits in Ghana. For example, work absenteeism due to malaria infection has dropped from 6983 man-days in 2005 to 163 in 2010 due to the use of IRS [ 7 ]. However, due to the high cost of new insecticides for spraying, IRS exercise has reduced overtime. The PMI on IRS, for example, has scaled down its exercise from 9 to 4 districts in 2013 [ 7 ].

Similar to IRS, ITNs work as a vector control intervention to reduce malaria and other infections transmitted by insects [ 13 , 14 , 15 ]. Use of ITNs refers to hanging treated nets over one’s sleeping area to prevent mosquito bites [ 16 ]. Ghanaian government started to distribute ITNs to targeted groups through a multi prolonged distribution system in 1998. Beginning 2009, the Universal Coverage strategy was adopted and it aimed at providing one net to every two persons in a household through door-to-door distribution [ 7 ]. Distribution of bed-nets is also targeted at school pupils in order to increase its coverage. Pregnant women are also given ITNs on antenatal visits and all other individuals have the option of buying ITNs from shops/markets, pharmacy stores, and street vendors, among others [ 1 ]. Afoakwah et al. [ 17 ] have also shown that the use of ITNs can reduce under-five mortality by about 18.8% in Northern Ghana. Information on the direct impact of ITN use on malaria infection of the young children is however rare.

In addition to IRS and ITN use, BCC is also shown to be an important strategy through which malaria education is conveyed to communities, especially in malaria prone areas. In Ghana, malaria education in the form of prevention and treatments are conveyed through media sources including the television, radio, newspaper and magazines, posters, leaflets and brochures, and health workers and community volunteers [ 1 ]. The Ministry of Health (MoH) and the NMCP have adopted this approach to disseminate malaria information to Ghanaians in order to increase their knowledge and awareness, and to promote positive behavioural changes towards malaria prevention. Rhee et al. [ 18 ], for example, found that better knowledge levels about malaria significantly increased ITN use among households in Mali. Their controlled trial revealed that ITN use was greater among participants who had received malaria education compared to participants who did not receive any education. Ayi et al. [ 19 ] also found that malaria education improved school children’s perception about malaria in Ghana, and led to an increase in the proportion of adults using treated bed-nets. However, the effect of such efforts on malaria infection among children under-five in Ghana is still unclear. To this end, we include BCC strategies such as television, radio and print media (newspaper) in addition to IRS and ITN to evaluate their association with malaria infection rates among children under-five.

Building on the current literature, this study uses a logit model to estimate the likelihood that a child gets infected with malaria. The model considers child’s attributes and household effects as well as observed malaria control measures including ITN, IRS and BCC. The aim is to control for covariates that theoretically and intuitively impact the child’s propensity to being infected. The corresponding logit model is specified as:

where M ∗ is a latent variable that is unobserved. M is a dummy variable that takes the value of 1 if the test outcome is positive and 0 if negative; I is a vector of variables for individual child attributes such as age, weight and gender. E captures environmental factors such as parental education, rural dwelling, household size and household wealth. MP captures malaria preventive measures, ITN use, IRS, and BCC. u is the error term.

IRS is a dummy variable with the value 1 if the child slept in a room that has been sprayed in the last 6 months. ITN, as captured by the GDHS report, includes factory-treated net that does not need further treatment, or a pre-treated net obtained within the past twelve months, or a soaked net with insecticides within the past twelve months. There are two indicators of ITN use in the data set: mother’s use of ITN and child’s use of ITN. It is common practice in Africa that mothers sleep with their young children [ 20 ]. Therefore the mother and child’s use of ITN is a better measure of the use of ITN as a preventive tool for young children. The data indicated that malaria infection is higher among children who slept under ITN alone than those who did not (49.77% vs 36.89%). A possible explanation is that children are more likely to be put under ITN after they show symptoms of fever or tested positive for malaria. In other words, ITN is used as a treatment method instead of a preventive tool. This could also be due to social desirability on the part of the parents in reporting use of ITNs by their children. Given the fact that it is popular in Ghana for mothers to sleep with their young children, we consider ITN use only when both mother and child use it. Footnote 1

Regarding behavioural change communication, we include media source of malaria education such as audio (radio), audio-visual (television), and print media (newspaper), mainly due to their high utilisation rate among the population. Other sources were not included because this was not a mutually exclusive response, possibly causing multicollinearity. In estimating Eq. ( 1 ), the Maximum Likelihood Estimation (MLE) technique (specifically a logit model that has a flatter tail compared to a probit model) is employed. The logit model is appropriate as the study seeks to provide information on the odds of being infected with malaria.

The study uses secondary data sourced from the current round of the Ghana Demography and Health Survey [ 1 ]. This survey is conducted every five years since 1988, with 2014 being the most recent wave, and it is collected from rural and urban areas in all ten regions in Ghana. These data sets are collected by the Ghana Statistical Service (GSS) and the Ghana Health Service (GHS) with support from the National Public Health Reference Laboratory (NPHRL) of the GHS. During the 2014 survey, field health assistants collected capillary blood samples from children aged 6 to 59 months in half of the households surveyed. The health assistants then tested for malaria on the field using a RDT with consent from the parent or the guardian. The outcome of the test was then recorded as either positive or negative. Children with positive results are considered as having malaria infection. About 2698 children had their blood samples tested, which represents 97% of all eligible children [ 1 ]. Demographic information is also collected via parental self-reports.

The sample used for this study comprises 2449 children aged between 6 and 59 months in Ghana. This represents 90.77% of the total children who were involved in the malaria test exercise. The remaining 9.23% were excluded due to missing information on some of the covariates used for the regression analysis. Descriptive statistics are presented in Table  2 . 40.50% of children have tested positive. The average age is 32 months and 52% are boys, with an average weight around 12 kg. With regards to household attributes, average family size was 6 persons and 60.20% lived in rural areas. A significant proportion (73.20%) lived in poor households. Household wealth index used in this study was constructed by the GSS using Principal Components Analysis (PCA). Items such as television, bicycle or car, as well as dwelling characteristics, such as a source of drinking water, sanitation facilities and type of flooring material are used to compute this index (see [ 1 ] for further details). It is noteworthy that 57.10% of mothers have no secondary education and 32.40% of mothers have no formal education at all. Fathers have significantly higher levels of education compared to mothers.

38.2% of children in our sample were not protected by either ITN or IRS, and 40.20% of children and their mothers slept under ITN the night before the survey and only 13.20% of children slept in a room that has been sprayed. The remaining 8.40% were covered by both ITN and IRS. In terms of malaria education, it was found that most of these households (78.4%) receive malaria education via radio, followed by television (52%) and newspaper (9.10%).

Table  3 presents the prevalence of malaria among children under-five for the entire sample, and for various sub-groups. There is not much difference between boys and girls in terms of infection rate, but the prevalence of malaria among rural children (56.08%) is more than twice of that among urban children (21.71%). Maternal education level is found to be highly correlated with malaria infection among children. Children whose mother has at least secondary education are the least vulnerable groups while children whose mother has no education record the highest prevalence of malaria infection. Relative to ITN use, children who sleep in rooms with IRS are less vulnerable to malaria infection. Children whose carers receive malaria education through television have lower rates of malaria infection than those reporting to have received education through radio or print media (newspaper).

In order to observe how individual attributes, environmental factors and malaria preventive measures interact with risk of malaria infection, a step-wise regression is employed. The results are reported in Table  4 . The Chi-square statistics (a goodness-of-fit test) suggest that all four specifications present regression lines that are a good fit at 1 % significance level. In the first specification, the impact of individual characteristics of the children is tested. Age and weight are the only significant variables, and gender does not play any significant role in malaria infection. We then add the environmental factors and present our results in specification 2. We observe a decrease in the coefficient and the odds ratio for age, but an increase for weight. Moreover, most of the environmental variables are also statistically significant, except for the poorer households when compared the poorest ones, and mother’s primary education when compared to no education. Specification 3 then adds malaria preventive measures to specification 2, followed by addition of interaction variables in the last specification. In specifications 2 to 4, the coefficients and the odds of malaria infection are very similar for the age and weight variables. Weight also has a non-linear effect on the odds of malaria infection. Results for the weight and weight-squared variables suggest an increase in the odds of malaria infection among children weighing up to 11.5 kg but a reduction in the odds for those above this weight limit. The reflection point is computed using the coefficients for the weight and weight-squared variables in Table  4 . Similar to the child attributes, we observe little variation in the coefficient and the odds ratios for the environmental factors when specification 2 results are compared to the ones in specifications 3 and 4. As a result, we focus our discussion on the results for the individual, environmental, and malaria control variables from specifications 3 and 4.

Individual attributes

A child’s odds of being infected by malaria are positively associated with his/her age. This relationship may not be linear and the non-linearity may be explained by weight and weight-squared. Given that the turning point for weight (11.5 kg) corresponds to the mean weight, it suggests that children become more resistant to diseases after reaching a certain weight. This could be an indicator of an improved immune system after 37 months of age as shown in Table  5 of the sensitivity analysis. Also at the age the child weights 11.5 kg, he/she may sleep with his/her mother under one ITN and would receive a better protection from the net. The gender dummy variable is not significant in all four regressions. This finding seems to be different from the experimental observation by Cernetich et al. [ 21 ] where they noticed that females had faster recovery from anaemia, induced weight loss and had reduced mortality.

Environmental factors

Due to the endemic nature of malaria in Ghana, we investigate the influence of the environment surrounding the children. We control for rural dwelling, household size, household wealth and parental education. Each of these contextual factors significantly influences the odds of malaria infection among children under-five. The prevalence of malaria in rural areas is reported to be about 38% compared to 15% for people who live in urban environments [ 1 ]. Consistent with the GDHS [ 1 ] our study shows that living in a rural area increases a child’s odds of being infected. The dichotomous rural dwelling variable is statistically significant in both specifications at 1 % level. Children in rural areas are about 75 to 80% more likely to be infected with malaria than their counterparts in urban settings. This could potentially be due to the low use of intervention tools among rural folks. For example, the GDHS [ 1 ] reports that while 64% of rural dwellers have access to ITN, only 47% use the net. Another reason is that most in rural areas are wetlands used for farming activities [ 22 ] which present breeding places for mosquitoes. This finding emphasizes the need for critical attention to children in rural areas.

With regards to parental education, we show that higher parental education is associated with lower odds of malaria infection among their children. Secondary education of parents has the highest significant effect on malaria prevention. Maternal education is also argued to play a significant role in child health outcomes through increased labour market earnings [ 23 ] and changes in individual behaviour through increased autonomy [ 24 ].

Similarly, children who live in large households are more likely to have malaria infection. Having one additional member in the household increases the likelihood of infection by about 6.5%. With a mean household size of 5.89 (Standard deviation 2.73), a plausible explanation is that the presence of congestion in homes may produce better breeding grounds for mosquitoes and less time and resources for preventive measures. In addition, a larger household means less space for sleeping and this makes it difficult to mount ITNs to protect all household members. It is common in rural Ghana that an area is used for living room in the day time and a bedroom at night. In such cases, the ITN needs to be mounted on the wall every night. This is a burden for the household and may discourage the use of an ITN. Justeson and Kunst [ 25 ] suggest that the risk of disease spread among groups of persons living together is significantly correlated with the level of nucleation that exists among them. Large households might also tend to be busy and early disease symptoms, especially in young children, can remain unnoticed, resulting in delays in treatment and therefore lead to more adverse effects [ 26 ].

We also show that malaria infection is highly correlated with household wealth. The odds of malaria infection among children aged below five years decreases as household wealth rises. Compared to the poorest households, children from richer households are about 77.8% less likely to be infected with malaria, and the odds are 86% lower for children in the richest households, all else being equal. This may be attributed to the fact that wealthier families can afford better goods and services leading to more positive health outcomes. Arthur [ 27 ] found a similar correlation between wealth and antenatal care in Ghana. It is therefore important to note that poorer households should be prioritized in any mass distribution of ITNs as well as IRS campaigns. This form of prioritisation is critical especially since the summary statistics suggest that 54.3% of these children live in poorer households.

Malaria control measures

As mentioned earlier, in Ghana ITNs have been freely distributed to households by public and private organisations since 1998 [ 7 ]. The GDHS report shows that about 85% of ITNs were obtained in this way. IRS is only implemented by government and non-governmental organisations in selected districts of Ghana depending on financial costs and technical feasibility [ 1 ]. Therefore, a significant proportion of households not covered by IRS had to rely on ITN as the main preventive measure.

Of the two main preventive measures, we find no significant association between ITN use and malaria infection among young children. Previous studies identified two main reasons that may undermine the protection offered by ITN use. First, the ITNs used may have lost their insecticidal protection, making the nets less efficient [ 28 ]. Second, some users may not lay out the net correctly due to the perceived heat increase and fear of suffocation that come with the use of ITNs [ 29 , 30 ].

IRS, on the other hand, is associated with reduced incidence of malaria infection. Children who sleep in rooms that have been sprayed in the last 6 months are about 68% less likely to be infected with malaria than children who do not, all else being equal. This finding supports similar evidence presented by Loha et al. [ 10 ] that IRS significantly reduces the incidence of falciparum malaria. The dual use of both ITN and IRS, however, does not provide an added protection.

Although ITN use alone is not significantly linked with a reduction of malaria infection, specification 4 suggests that ITNs used by educated mothers are associated with a lower incidence of malaria. We interact only mother’s education because they are the primary care giver of the child. For children whose mother has at least secondary education, use of ITN reduces their odds of malaria infection by 45.50%. Inasmuch as this finding gives credence to Gary Becker’s human capital theory, the implication here is that educated mothers are more likely to be aware of the benefits of using ITN and are capable of the appropriate use of the net to protect their children. Our finding is consistent with findings that in Botswana and Zimbabwe educated mothers were more successful in reducing the prevalence of diarrhoeal diseases among the children [ 31 ].

With regards to behavioural communication change measures, our study analyses how three forms of media – television, radio and newspaper impacts malaria infection among children. Although a significant percentage of households receive malaria education through the radio (78.4%), no significant association has been identified with radio exposure and malaria infection reduction. Malaria education via television is the only variable with an independent significant link with child’s malaria infection. On average, malaria education through television reduces the odds of infection by 26.9%, keeping all else constant.

While malaria education through print media did not show a significant independent effect, it was significant for children whose mother had at least secondary education. This is not surprising because it is more likely that educated parents can read, understand and communicate information conveyed through print media. These findings suggest that television and print media play a critical role in disseminating information on malaria but providers need to be aware of the audience. Given that nearly 60% of carers were educated at primary level or below, audio-visual (television) forms of malaria education appear to be the most effective method.

Our study has shown that the effect of the IRS is far more than of that for ITN use. We have also demonstrated the important role of mother’s education in facilitating the protection provided by malaria intervention tools, especially ITN use. Thus, our results echo the crucial need to educate the users before implementing an intervention that requires correct use. We also find that an association between mother’s exposure to print media and children’s infection rate, but only if the mother has completed at least secondary education. However, a more effective way of communicating behaviour change towards malaria control is the television.

Sensitivity analysis

It is probable for the effectiveness of the malaria preventive measures as well as some of the explanatory variables to differ depending on the age of the child or the wealth of the household. Thus, as a sensitivity analysis, we run the regressions for various age cohorts and household wealth groups. We run the regressions for both specifications 3 and 4, and report only the odds ratios. For comparison reasons, the main results for specification 3 are presented at the top panel, and the bottom section includes all the variables from specification 4.

For the age-cohort regressions, presented in Table  5 , we divide the sample into three; 6 to 24 months, 25 to 36 months, and 37 to 59 months. Focusing on the results for specification 3, we show that ITN does not have a significant effect on malaria infection in none of the age cohorts. Although the coefficient for the ITN variable is not significant, it has a negative effect on malaria among children up to two years old, which supports the assertion that younger children sleep with their mothers and are protected through proper use. However, IRS has a sizable effect on the odds ratios for all age cohorts. The results for using both ITN and IRS does not differ much compared to the only IRS odds ratios. Although the dual use of both ITN and IRS does not provide an added advantage to the youngest cohort, our results show that for children above 2 years of age, a combination of the two offers better protection.

Child weight has a notable effect on incidence of malaria infection depending on the age cohort. For young children and babies child weight increases the incidence of malaria infection, while we observe the opposite effect for older children aged 37 to 59 months. Weight gain among children aged 37 months and above corresponds to a decline in the odds of malaria infection. Living in a rural area and living in a more crowded household cause an increase in malaria infection rates. The only exception is for the effect of household size on older children; we find no statistical significance. Household wealth has the expected effect on malaria infection and the results are consistent among age cohorts. Richer and the richest households significantly lower the malaria infection incidence irrespective of the child’s age. An interesting finding is the effect of the education variables. More educated parents significantly lower the malaria infection incidence for only the oldest cohort.

Regarding the malaria prevention measures, the IRS variable has a significant effect in lowering malaria incidence, and this effect is slightly lower in specification 4 compared to specification 3 for all age cohorts. ITN and the mother’s education interaction terms are all insignificant except for the 2–3 year old children. Having a more educated mother significantly lowers the malaria incidence for these households. Finally, among the BCC strategies, we observe that television has a significant effect except for the oldest cohort, and the effectiveness of the newspaper depends on the mother’s education level.

To analyse our findings by varying household wealth, in Table  6 , we present the results after dividing the sample into three categories; poor, middle-class, and rich. An interesting observation from specification 3 results is that there is a statistically significant link between IRS and malaria infection of young children among poor and middle-class households, but such a link is absent among the rich households. Moreover, the effect of using both ITN and IRS is significant only for the poor households.

Similar to our previous findings, child weight has a positive effect on malaria incidence while the weight square has a negative effect. Both of these variables, however, are not significant for the rich households. Living in a rural area and in a crowded household again increases the odds of malaria infection except for the effect of household size on children in richer families. Parent’s education matters for the poor households and lowers the malaria incidence rates for children. However, a similar effect of parent’s education on malaria is missing for the middle-class and rich households.

Comparable to our finding in specification 3, the IRS is significant only for the poor and the middle-class households. However, the ITN variable interacted with mother’s education is only significant for the rich households. Similar to IRS, Television as a BCC strategy is only significant for the poor and the middle-class households. Another BCC strategy, newspaper, has a significant effect in lowering malaria incidence when interacted with mother’s education and this holds only for the poor households.

Overall, we find that our explanatory variables and malaria preventive measures have more of a significant effect on the poor households. The significance of our findings diminishes as the household wealth increases, with the least significant effects for the richer households. This is of great importance for the government while identifying the households to target their policies towards. Our findings also have crucial implications in terms of policy recommendations which we discuss extensively in the next section.

This paper explores factors influencing malaria infection among children under-five from three dimensions: individual attributes, living environment and intervention measures. Three conclusions can be drawn. First, we identify vulnerable groups among children under-five. Our results show that children living in a large family with low income in rural areas are most prone to malaria infection. In addition, our results suggest that children under age three are more prone to malaria infection. Therefore, children must be given critical attention during their early formative years until their immune systems have significantly improved. Second, this study has shown that the most effective tool to prevent malaria infection among children under-five is IRS and its protection far exceeds that noted for ITN use. Given that the number of young children protected by IRS is half that of those protected by ITN, policy makers should consider increasing the use of IRS. Such a policy change promises more significant positive results than trying to increase ITN use. This is because, unlike ITN, the effect of IRS is not moderated by any human capital attribute. In a developing country like Ghana, where educational levels are very low especially among women, intensifying IRS is the most efficient way of preventing malaria among children in poor and rural households. Third, mother’s education moderates the protection of ITN use and BCC strategy through print media. Mother’s education was found to be an important ingredient in the campaign to reduce malaria infections. Education enhances the role of ITN use and also strengthens BCC campaigns aiming at improving the efficacy of malaria preventive and curative measures.

Drawing on the findings of this study, we recommend that policy makers implement an intervention program tailored for various social and economic groups. First, prioritise the use of IRS to poorer and rural households where primary carers have low levels of education. Due to the significant cost associated with IRS, resources should be directed to assist the poorest households and communities where the use of ITN is less likely to be effective. Second, distribution of ITNs should be accompanied with a multi-media education program to enhance its protection. Television education offers the best protection compared to other forms. However, given its limitation in providing detailed information, other types of media should also be utilised. Care needs to be taken to ensure that families and carers who are less literate can be assisted to understand the information provided. Thirdly, more attention must be paid to educate mothers and mothers-to-be. The significant impact of an educated mother on the health outcomes of children suggests educating women not only benefits them by enhancing their human capital, but also benefits the family and community with improved child health. More effort and resources should be diverted to lift the education level of women in Ghana to benefit the nation as a whole. Inasmuch as this study does not observe a significant independent effect of ITN use on malaria infection, we recommend that future surveys consider continuous use of the ITN tool in order to ascertain its independent effect on malaria among this vulnerable group.

Although our study has outlined some policy implications, it is limited by the cross sectional nature of our data. Thus, our data makes it difficult to evaluate the efficacy of the intervention tools. Our findings demonstrate the associations rather than confirm effectiveness. Another limitation is associated with the measurement for ITN use. Since the surveyed households were only asked whether the child slept under ITN the night before, our ITN measure does not necessarily mean that the child had been protected by ITN on continuous basis. We would suggest future surveys to include a question on the frequency of the use of ITN in a longer period of time. Finally, the analysis is limited by our inability to control for some cofounders such as areas in Ghana that could have high malaria endemic. However, we believe that any bias coming from such exclusion is mitigated by the inclusion of rural dummy variable since such areas are more likely to be in rural areas.

Preliminary regressions suggested that mother and child use of ITN better explained malaria infection rate compared to when the child alone uses the net. This is due to malaria incidence for children sleeping under ITN alone, as mentioned earlier. The results on ITN use by child alone is available upon request.

Abbreviations

Anglogold Malaria

Behaviour change communication

Ghana demographic and health surveys

Ghana health service

Ghana statistical service

Indoor residual spraying

Insecticide treated bed-nets

Ministry of health

National Malaria control programme

National public health reference laboratory

Out Patient Department

Principal components analysis

Presidents Malaria initiative

Rapid diagnostic test

United Nations children’s fund

United States Agency for International Development

World Health Organization

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Acknowledgements

The authors wish to thank Rachel Milte for her comments and two referees for their suggestions to improve the manuscript. All errors are the sole responsibility of the authors.

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Afoakwah, C., Deng, X. & Onur, I. Malaria infection among children under-five: the use of large-scale interventions in Ghana. BMC Public Health 18 , 536 (2018). https://doi.org/10.1186/s12889-018-5428-3

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A systematic review of factors influencing participation in two types of malaria prevention intervention in Southeast Asia

• Breagh Cheng 1 ,
• Saw Nay Htoo 2 ,
• Naw Pue Pue Mhote 3 &
• Colleen M. Davison   ORCID: orcid.org/0000-0002-0410-3352 1  

Malaria Journal volume  20 , Article number:  195 ( 2021 ) Cite this article

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Multi-pronged malaria elimination strategies are increasingly being considered for accelerating efforts against malaria transmission in Southeast Asia. Two malaria prevention interventions used in in the region are insecticide-treated bed-nets (ITNs) and mass drug administration (MDA). Universal access to ITNs is recommended and high population coverage (e.g. above 80%) is needed during MDA initiatives to maximize the impact of these interventions. However, variability in ITN use and individual MDA participation exists. This systematic review aims to provide a summary and overview of literature discussing factors influencing uptake of these two malaria control strategies in Southeast Asian countries.

A search of OVID Embase, OVID MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, OpenGrey, ProQuest, and Google Scholar was undertaken in February 2020. English-language publications with any study design using data from any of the ten member countries of the Association of Southeast Asian Nations were eligible for inclusion. In addition, reference lists of identified articles were manually searched. Websites for relevant international agencies were also searched to identify related grey literature.

The review identified thirty publications that met the inclusion and exclusion criteria. Most discussed ITN use (n = 18) and were relevant to populations in Myanmar (n = 14). All MDA studies were published after 2016, whereas included ITN studies spanned from 1998 to 2020. Seven main themes emerged across the studies. Knowledge of malaria and attitudes towards ITNs were emphasized as key factors associated with ITN use. For MDA participation, key factors included the importance of positive attitudes towards the program, the influence of indirect costs and incentives, and the tendency for group decision-making.

Conclusions

As countries in Southeast Asia continue to work towards becoming malaria-free by 2030, the knowledge and attitudes of local population sub-groups should be assessed and incorporated into the planning and implementation of malaria prevention activities. The role of incentives and group decision making should also be considered particularly as they relate to MDA. There is need for ongoing involvement of health educators, the continuation of implementation research and the prioritization of community engagement efforts alongside malaria interventions in the region.

Marked reductions in malaria incidence have been made in Southeast Asia over the past two decades. Southeast Asian countries, such as Singapore and Brunei, have maintained malaria-free status, the remaining countries have committed to the goal of eliminating malaria by the year 2030 [ 1 ]. Despite achieving notable decreases in morbidity and mortality, malaria remains an important disease burden in the region. Nearly 8 million combined cases of malaria were reported across Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand and Vietnam, with over 200 million people in this region at risk of contracting malaria in 2018 [ 2 , 3 ]. Aside from direct health consequences, malaria diverts time away from income-generating activities leading to reduced household income, which can be especially severe for poor households, highlighting additional economic and social implications for the region [ 4 , 5 ]. Malaria has also been reported to adversely impact the educational attainment of school children, with decreased school performance as the number of malaria infections increase [ 6 ].

Insecticide-treated bed nets (ITNs) or long-lasting insecticidal nets (LLIN) have been a cornerstone of malaria control for decades [ 7 ]. These interventions have been shown to be generally effective for malaria prevention, although their impact on malaria transmission in Southeast Asia is lower compared to in sub-Saharan Africa due in part to differences in the outdoor biting and outdoor resting behaviour of relevant vectors of mosquitoes [ 8 , 9 ]. To accelerate malaria elimination efforts in Southeast Asia, mass drug administration (MDA) has increasingly been considered as part of multi-pronged strategies [ 10 ]. These interventions have been co-implemented in several Southeast Asian countries including as Cambodia, Vietnam, and Laos, and have been shown to help decrease malaria incidence [ 11 ]. The impact of MDA relies on high individual uptake of MDA in the target population; given that malaria transmission intensity partly depends on vectorial capacity, the MDA coverage required is likely higher than 80% of uptake to interrupt malaria transmission [ 12 , 13 , 14 ]. Modelling studies predict that coupling of ITNs and MDA drastically improves the likelihood of elimination in countries in the Greater Mekong Sub-Region. There is a possibility that malaria will be eliminated by the year 2025 in Cambodia, Indonesia, Laos, and Myanmar with the adoption of these combined approaches or scale up of these interventions for countries such as Bhutan and Thailand [ 15 , 16 ]. Understanding factors affecting intervention uptake in previous and current intervention programmes is necessary to understand and address potential barriers to effective and equitable implementation and scale-up [ 17 ]. The purpose of this systematic review was to provide an overview of factors that contribute to the use of ITNs and to individual participation in MDA programmes in Southeast Asia. Specifically, this review aimed to quantify the current state of research aimed at understanding uptake of these malaria interventions, describe any patterns in uptake and identify key gaps in knowledge needed to develop effective elimination strategies for malaria in Southeast Asia [ 18 ].

The methodology for this systematic review followed the procedure proposed by Arskey and O’Malley [ 19 ]. These steps include developing the research question, searching for relevant literature, selecting publications, charting data, and collating, summarizing and reporting results. Reporting of this review followed the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was guided by the research question: What has been described about the determinants affecting the use of ITNs and/or individual participation in MDA in Southeast Asian countries?

Search strategy

To search for and identify relevant studies, a search strategy was developed in consultation with an experienced health sciences research librarian. A systematic search was conducted on February 21, 2020 in seven academic and grey literature databases: OVID Embase; OVID MEDLINE; Cochrane Central Register of Controlled Trials (CENTRAL); Web of Science; OpenGrey; ProQuest; and Google Scholar. Additionally, a manual search was also conducted of reference lists of included publications and websites belonging to the Shoklo Malaria Research Unit and international organizations including: the World Health Organization (WHO) Index Medicus for the South-East Asia Region, Roll Back Malaria Partnership, International Organization for Migration, United Nations High Commission for Refugees, United Nations Children’s Fund, The United States Agency for International Development, President’s Malaria Initiative, Partners for Development, Asia Pacific Leaders Malaria Alliance, Malaria No More, and Population Services International [ 20 ].

Key search terms included: “malaria, “bed net,” “mass drug administration,” and “Southeast Asia” as well as the names of the ten ASEAN member countries [ 21 ]. Given that Web of Science does not have Subject Headings, only keywords in the search strategy were searched, including mass drug administration or antimalaria* or anti-malaria*. A complete list of search terms used can be found in the Additional file 1 .

Eligibility criteria

Relevant publications were selected based on the inclusion and exclusion criteria that were defined a priori (Box 1 ). Given this study’s aim to provide an overview of available literature on factors affecting ITN use and/or individual MDA participation, no restrictions were placed on published year or study design. Publications were included if they explicitly had as part of their objectives to assess one or more determinants of delivery affecting either the use of ITNs and/or individual-level MDA participation for malaria prevention in a Southeast Asian country belonging to the Association of Southeast Asian Nations (ASEAN). Given that English is the primary working language of the lead author, eligible publications were restricted to the English language. Publications were excluded if they were not focused on malaria, did not discuss ITNs, LLINs or MDA or collected data from any countries not belonging to the ASEAN group.

Study selection

The final search results were imported into the online review manager Covidence (version 2020) and duplicate articles were removed. Abstract and full-text screening were independently reviewed by two investigators (BC and a graduate student) and excluded publications that did not meet the inclusion criteria. Any discordances were resolved through discussion and reaching consensus between the lead author and the graduate student volunteer.

Synthesis of results

The fourth step was charting selected articles. Publications meeting inclusion criteria were grouped based on the intervention of focus and then summarized by key characteristics, including first author and year of publication, setting of data collection, sample characteristics, and study design. An inductive approach was used to assess the extracted data for common themes related to the barriers and facilitators for ITN use and/or MDA participation.

A total of 6364 titles and abstracts were screened. After assessing abstracts and full-text articles based on inclusion and exclusion criteria, thirty eligible publications consisting of academic and grey literature were included. The process of article selection followed PRISMA guidelines [ 22 ] (see Fig.  1 for PRISMA flow chart). Summaries of the main characteristics of the included papers are presented in Additional files 2 and 3 .

PRISMA flow diagram outlining the search and study selection process

Of the included publications, eighteen (60%) discussed ITN use, eleven discussed MDA, and one study discussed both ITN and MDA. All MDA studies were published within the last 5 years (2016–2020) whereas only a third of included ITN studies were published in the same period and the rest spanned between 1998–2015. Of the eight quantitative cross-sectional studies, most (n = 5) focused on ITN use. Half of the sixteen (53%) publications that followed qualitative or mixed methodology research designs focused on ITN use. One systematic review fulfilled the inclusion criteria and five publications were grey literature documents (17%), of which four discussed ITN use. Of the twenty-five studies with a single country focus, publications discussed intervention uptake in Myanmar (n = 14, of which 10 focused on ITN use), Cambodia (n = 5), Laos (n = 3), Vietnam (n = 1), Thailand (n = 1), and Malaysia (n = 1). Five publications had a multi-country focus. Publications examined factors influencing ITN use and/or MDA participation among the general population, as well as mobile and migrant groups. One study focused on factors specific to ITN use among the Laos military [ 1 ] and one study had a focus on factors affecting MDA participation as perceived by policymakers [ 23 ].

While factors describing intervention uptake fell broadly into a total of seven themes, it is recognized that ITNs and MDA are different types of interventions. ITNs have been in routine use for extended periods in Southeast Asia whereas MDA projects are typically conducted by academic institutions as research projects and have been more recently implemented. Thus, the factors found to affect uptake of these interventions have been summarized in separate additional files. Additional file 4 presents themes describing factors related to ITN use and Additional file 5 is specific to MDA participation.

Themes describing factors related to ITN use

Access and delivery.

Insufficient access to bed nets was a key factor associated with delayed possession and use of bed nets, with the most common reason being absence during net distribution [ 24 , 25 , 26 ]. Other reasons associated with non-ITN use include insufficient household net supply and selective distribution practices by staff involved in net distribution among general and specific populations [ 25 , 26 , 27 , 28 ].

Costs and benefits

ITNs costs and benefits were both related to their use. The cost of ITNs was a common reason reported for not owning or using nets, or not replacing older or damaged nets [ 25 , 28 , 29 , 30 , 31 , 32 , 33 ]. Individuals were motivated to use ITNs by perceptions of bed nets as beneficial [ 32 ] due to reasons such as, preventing malaria infection [ 34 ] and sense of privacy [ 28 , 33 ].

Malaria knowledge

Greater knowledge about malaria transmission was significantly associated with increased likelihood of ITN use in most analytical studies [ 32 , 34 , 35 , 36 ] except for in one quantitative study that found a non-significant association between net use and knowledge of malaria aetiology in Thailand [ 32 ]. Poor awareness of malaria transmission was related to some families using nets for reasons other than malaria prevention, such as for fishing and for warmth [ 29 , 37 , 38 ].

Intervention knowledge

Awareness of ITNs and their role in malaria prevention was related to their increased use. Individuals who reported receiving information about impregnated bed nets from malaria workers had a higher likelihood of ITN use and conversely, not knowing about ITNs was a primary reason for their non-use [ 32 ].

Attitudes and perceptions

Using ITNs was related to a belief in their malaria risk and recognition of malaria as a serious health hazard [ 25 , 38 , 39 ]. Some subgroups, such as male youth in Cambodia and Vietnam, refrained from using nets due to self-perceived low vulnerability to malaria [ 28 , 40 ], and instead prioritized nets for use by mothers and children under five [ 28 ]. ITNs were also not prioritized for use following participation in leisure activities, such as late-night TV-watching [ 28 , 30 , 33 ]. Low ITN use was reported among Laos soldiers, migrant workers and mobile male youth due to the inconvenience of carrying nets while on the move [ 26 ].

Attitudes regarding the comfort and perceived effectiveness of ITNs also seemed to be associated with the characteristics of the interventions themselves [ 25 , 26 , 28 , 37 , 38 , 39 , 41 , 42 ]. For instance, ITN use was discontinued after experiencing excessive heat [ 25 , 39 , 41 ], unpleasant insecticide smells [ 26 ] or texture [ 37 ], as well as health concerns (e.g. burning sensations) while sleeping underneath the net [ 37 ]. Larger households preferred bigger nets with finely woven meshing, the larger size to accommodate more people and the fine meshing because of the perception that other meshing might allowed insects inside the net [ 28 , 31 , 37 , 39 , 43 ]. Perceived poor durability due to rapid deterioration after net washing also contributed to low net use [ 28 ].

Personal characteristics

ITN use was associated with several demographic characteristics. Wealthier households living in urban locations near health facilities were positively associated with ITN ownership [ 35 , 44 , 45 ]. The likelihood of living in a household with at least one ITN decreases as age of a household member increased [ 45 ]. A significantly higher likelihood of sleeping under an ITN was also associated with higher altitude regions, smaller household sizes, and if a household was headed by farmers and fisherman compared to household heads who were skilled workers [ 36 ]. Ethnic male youth in Cambodia and adult males were less likely to use ITNs compared to women and children due to behavioural risk patterns and the tendency for males to have temporary sleeping arrangements [ 28 , 31 , 33 ].

Themes describing factors related to individual MDA participation

Accessing remote communities targeted for MDA implementation was a time and resource-intensive endeavour that is linked to frequent programme staff turnover [ 41 ]. Further challenges in obtaining policymaker support and government approval prior to MDA study initiation has contributed to implementation delays [ 23 ]. Absence during the MDA campaign due to work responsibilities was commonly cited as a reason for non-participation [ 24 , 34 ].

Costs and incentives

Direct and indirect costs were related to participation in MDA. Non-participation stemmed from unwillingness to divert time away from work, concerns for the economic implications associated with contracting malaria and management of perceived side effects of taking anti-malarial drugs [ 25 , 46 ]. While financial compensation was associated with a greater likelihood of participation, participation rates did not change significantly in its absence [ 41 , 47 ]. Community members also strongly valued additional incentives associated with the intervention such as the provision of free essential medical services and responses to other community needs, such as installing water pumps, as well as attention to their health concerns at the same time as door-to-door MDA delivery [ 48 , 49 , 50 , 51 ]. These services were seen as a demonstration of genuine care for the community’s health and social concerns, which was associated with increased confidence in the intervention and ultimately played a motivating reason for participation [ 48 ].

Knowledge of malaria was a key factor associated with individual MDA participation [ 24 , 34 , 47 , 48 , 49 , 50 ]. Respondents were more likely to participate in MDA campaigns if they had knowledge of the cause of malaria and that asymptomatic cases exist [ 47 ]. This indicates similar results to another mixed-methods study that found that the desire to volunteer in MDA was positively associated with higher likelihood of accepting the idea of asymptomatic malaria [ 50 ].

Awareness and knowledge of the intervention itself was positively associated with MDA participation [ 47 ]. MDA participation was more likely to occur if villagers were familiar with the risks and benefits of MDA [ 49 , 51 ], and the rationale for MDA [ 47 , 48 , 49 , 50 ]. More participants completed an entire MDA course if they received education on MDA from local health teams [ 34 ]. Conversely, villagers were less likely to participate if they had a poor understanding of or reported not being informed about MDA [ 24 ].

MDA participation was associated with a concern about malaria [ 51 , 52 ], a desire to improve one’s health [ 50 ], and a general confidence in the intervention [ 41 , 48 ]. On the other hand, fear of certain MDA programme elements, such as blood tests, was strongly emphasized as reasons for non-participation [ 23 , 24 , 25 , 47 ]. Additional concerns around real and perceived adverse side effects at times led to rumours that were linked to decreased participation [ 23 , 25 , 41 ].

Social dynamics

Social dynamics and interdependence within communities were related to individual MDA participation [ 41 , 47 , 50 , 53 ]. Individuals often made decisions to participate in MDA on a household or group basis [ 41 , 51 , 53 ], where household heads had a strong influence on the participation of other household members [ 41 ]. MDA participation and refusals were also impacted by the degree of community cohesiveness and a tendency for social conformity [ 24 , 28 , 41 ]. Poor participation in one community was attributed to perceived affiliations of a MDA project with an opposing political group [ 50 ]. Wealthier community members and recent immigrants to a village did not consider themselves to be part of the wider community. These factors were related to a diminished sense of responsibility to participate in MDA campaigns [ 41 , 46 ] and a low proportion of participation [ 46 ].

MDA participation was positively associated with older age, seeking malaria treatment at a government health centre for fever, literacy, and religion, as well as residency in certain villages [ 24 , 34 ]. Mixed associations were found between certain ethnic backgrounds and willingness to participate [ 34 , 47 ]. Occupation type and whether respondents had children were not significant factors associated with MDA participation [ 34 ].

This systematic review identified thirty publications from academic and grey literature sources focusing on factors influencing the uptake of two key malaria interventions, ITNs and MDA, in countries belonging to the ASEAN [ 23 ]. Several broad observations were noted among all included studies. First, no research was identified in Singapore, Brunei, Indonesia, or the Philippines. While the search was performed for all ASEAN countries, not all countries had evidence pertaining to them in the final publications that were identified in the search. This lack of research evidence may reflect the success of Brunei and Singapore, as well as several regions in Indonesia and the Philippines, where malaria-free status was already achieved in the 1980s [ 54 , 55 ]. Programme managers in these countries should assess the findings of this review to determine its relevance to their current malaria monitoring efforts. Secondly, most (60%) publications identified in this review examined factors contributing to use of ITNs, with relatively limited evidence on the reasons for variation in individual MDA participation in Southeast Asian countries. This finding may be explained by the more recent implementation of MDA for malaria elimination in the region and highlights the need for continued implementation research in this area.

In addition to the included qualitative studies (n = 16), quantitative studies (n = 8) highlighted several predictors of intervention uptake, such as area of geographic residence. Reasons for ITN use and MDA participation across different geographic and sociodemographic groups were not widely explored in qualitative studies. Future studies may consider the use of mixed methodology to identify sub-groups, who may be more or less likely to uptake interventions for malaria prevention and their underlying reasons for non-intervention use.

Two out of the six themes influencing ITN use were emphasized above the others in the included publications. These were knowledge related to malaria and ITNs, as well as attitudes and perceptions towards ITNs. Attitudes generally towards malaria intervention were also strongly associated with likelihood of uptake [ 26 , 40 ]. These findings align with evidence from countries outside Southeast Asia that indicates that knowledge and attitudes are key factors elsewhere as well [ 56 ]. Non-ITN use was related to inadequate programme focus on user attitudes regarding convenience for example, particularly among those belonging to mobile populations, including military personnel, migrant workers, and forest goers [ 26 , 40 ]. These results emphasize the need for a clearer understanding of net design preferences among different population subgroups, for instance, to inform optimal net distribution campaigns. To help ensure inclusive protection of all sub-groups vulnerable to malaria infection, implementation campaigns must also align timing of ITN distribution campaigns with regional migratory patterns and implementation at work sites, including agriculture fields, fishing areas, or other places where large numbers of people congregate for work [ 37 , 57 ].

In terms of MDA, the degree of knowledge about malaria and the intervention, as well as perceptions towards MDA were key factors influencing participation. These findings underscore the need for education and communication initiatives to complement delivery of integrated malaria programmes that include MDA, especially in endemic communities where knowledge about malaria and newer interventions are often lacking [ 37 ]. Alongside direct cost considerations, studies also emphasized indirect costs and benefits (i.e. free medical care). Future research, modelling of cost-effectiveness, and the design of MDA activities should include the role and nature of appropriate incentives as additional considerations. Finally, factors related to the theme social dynamics also uniquely described individual MDA participation. It is possible that trust plays a stronger role in shaping decisions to participate in MDA given its limited deployment in ASEAN countries compared to ITNs which have been in the context for a longer period of time [ 50 , 58 ]. There is a need for continued formative research and strong collaboration between the scientific community and other stakeholders to coordinate malaria elimination strategies that are adapted to the local social context. These findings highlight the critical role of community engagement and engaging with local leaders to ensure interventions are not perceived negatively, to guide the implementation of MDA programmes especially [ 48 , 53 , 59 ].

Strengths and limitations

This systematic review of two types of malaria intervention provides a timely overview of evidence from research and grey literature sources to assist in policymaking for Southeast Asian countries approaching malaria elimination. It provides the basis for developing strategies for maximizing adherence to drug regimens that the WHO identified as a key question in its 2019 Evidence Review Group Meeting report [ 60 ]. This review highlights potential research gaps about user preferences related to net design for further qualitative investigation. There are a number of limitations to this study that should be noted. First, it is possible that there may be some data duplication since some of the publications, particularly about MDA, may be from the same original malaria intervention project. Other potentially relevant publications may have also been excluded because they were not available in full text in the English language. Additionally, there was a lack of evidence about intervention uptake in a number of the ASEAN countries that ideally would have been included in this review. Given the types of study designs used in many of the included studies, it is likely that the results do contain some level of bias and thus appropriate caution should be taken when interpreting the results. Also, while there are summarized factors associated with intervention uptake across these various studies and contents, it is possible that differences in uptake may be related to variations in the receiving populations or implementing agencies that were not measured, compared or reported and thus could not be considered here.

This systematic review described factors for ITN use and MDA participation among populations in the ASEAN region. Results of this study can support decision-making for policy-makers and programme managers involved in malaria control in Southeast Asia. Malarial disease and intervention knowledge and positive attitude towards interventions remain key factors associated with higher rates of uptake and participation in both of these forms of malaria intervention. There is a continued role for health educators in malaria prevention in Southeast Asia. There is also a need to maintain a focus on sociocultural and gender norms as well as details of local contexts of intervention, such as seasonal movement of subpopulations, to ensure successful implementation of malaria prevention strategies. Ongoing operational or formative research could lead to improvements in rates of ITN use and increasing levels of acceptability of MDA in remote and hard-to-reach mobile communities especially. In addition to ITNs and MDA, future reviews could examine the effectiveness and uptake of other kinds of malaria interventions such as larval source management and housing improvements. This review identified 30 unique studies looking at factors affecting ITN use or MDA participation in ASEAN nations. As countries move forward with plans to eliminate malaria by 2030, it is essential that intervention studies remain part of, and are drawn on to inform, these efforts.

Availability of data and materials

The datasets supporting the conclusions of this article are included within the article and its additional files.

Abbreviations

Association of Southeast Asian Nations

Insecticide-treated bed net

Long-lasting insecticidal net

Mass Drug Administration

Preferred Reporting of Items for Systematic Reviews and Meta-Analyses

World Health Organization

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Acknowledgements

We thank Brianna Cheng for assisting with abstract and full-text screening. We also acknowledge the Queen’s University faculty who provided comments that provided valuable input to improve the quality of manuscript.

Funding for this study was supported by a Frederick Banting and Charles Best Canada Graduate Scholarship and a Michael Smith Foreign Study Supplement provided through the Canadian Institutes of Health Research (CIHR). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Additional file 1..

Search Strategy. Detailed search string used for scientific database searching.

Additional file 2.

Summary of publications discussing insecticide-treated bed net (ITN) use (n = 18). Summary of publications included in this review discussing insecticide-treated bed net (ITN) use.

Additional file 3.

Summary of publications discussing mass drug administration (MDA) (n = 12). Summary of publications included in this review discussing mass drug administration (MDA).

Additional file 4.

Themes describing factors related to ITN use. Themes describing factors related to ITN use.

Additional file 5.

Themes describing factors related to MDA participation. Themes describing factors related to MDA participation.

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Cheng, B., Htoo, S.N., Mhote, N.P.P. et al. A systematic review of factors influencing participation in two types of malaria prevention intervention in Southeast Asia. Malar J 20 , 195 (2021). https://doi.org/10.1186/s12936-021-03733-y

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Prevalence and associated factors of malaria in children under the age of five years in Wogera district, northwest Ethiopia: A cross-sectional study

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Supervision, Writing – original draft

Affiliation Department of Epidemiology and Biostatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Writing – original draft

Affiliation Wogera District Health Office, North Gondar Zone, Gondar, Ethiopia

Roles Data curation, Formal analysis, Methodology, Software, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia

• Adino Tesfahun Tsegaye, 
• Andualem Ayele, 
• Simon Birhanu

• Published: October 11, 2021
• https://doi.org/10.1371/journal.pone.0257944
• Reader Comments

Malaria is a major public health problem in sub-Saharan Africa, and children are especially vulnerable. In 2019, an estimated 409,000 people died of malaria, most (274,000) were young children and 94% of the cases and deaths were in Africa. Prior studies in Ethiopia focused on the adult population and high transmission areas. Hence, this study aimed to determine the prevalence and associated factors of malaria in children under five years in low transmission areas.

A facility-based cross-sectional study was conducted among 585 under-five children who attended public health facilities in the Wogera district from September to October, 2017. Health facilities were selected by stratified cluster sampling, and systematic random sampling was held to select study participants from the selected facilities. Multivariable logistic regression was used to identify correlates of malaria.

Of 585 children who provided blood samples, 51 (8.7%) had malaria. The predominant Plasmodium species were P . falciparum 33 (65%) and P . vivax 18 (35%). Regularly sleeping under long-lasting insecticide treated nets (LLIN) was associated with decreased odds of malaria (AOR = 0.08, 95% CI: 0.01–0.09), and an increased odds of malaria was observed among children who live in households with stagnant water in the compound (AOR = 6.7, 95% CI: 3.6–12.6) and children who stay outdoors during the night (AOR = 5.5, 95% CI: 2.7–11.1).

The prevalence of malaria in the study population was high. Environmental and behavioral factors related to LLIN use remain potential determinants of malaria. Continued public health interventions targeting proper utilization of bed nets, drainage of stagnant water, and improved public awareness about reducing the risk of insect bites have the potential to minimize the prevalence of malaria and improve the health of children.

Citation: Tsegaye AT, Ayele A, Birhanu S (2021) Prevalence and associated factors of malaria in children under the age of five years in Wogera district, northwest Ethiopia: A cross-sectional study. PLoS ONE 16(10): e0257944. https://doi.org/10.1371/journal.pone.0257944

Editor: Benedikt Ley, Menzies School of Health Research: Charles Darwin University, AUSTRALIA

Received: December 10, 2020; Accepted: September 14, 2021; Published: October 11, 2021

Copyright: © 2021 Tsegaye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data generated or analyzed during this study is included in this published article.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: AIDS, Acquired Immune Deficiency Syndrome; AOR, Adjusted Odds Ratio; API, Annual Parasite Incidence; CI, Confidence interval; DRC, Democratic Republic of Congo; EMIS, Ethiopia Malaria Indicator Survey; HIV, Human Immune Virus; IRS, Indoor Residual Spraying; LLITN, Long Lasting Insecticide Treated Nets; OPD, Outpatient Department; RDT, Rapid Diagnostic Test; SNNPR, Southern Nation Nationalities and People Region

In sub-Saharan Africa, infectious diseases remain the primary public health threat [ 1 ]. Malaria is one of the commonest infections, disproportionately affecting children and pregnant women. In 2019, an estimated 409,000 people died of malaria. Most (274,000) were young children, and 94% of the infections and deaths occurred in Africa [ 2 , 3 ]. Although several Plasmodium species are responsible for malaria, only a few of them cause most infections.

In 2018, Plasmodium falciparum accounted for 99.7% of estimated malaria cases in the World Health Organization (WHO) African Region, 50% in the WHO South-East Asia Region, 71% in the Eastern Mediterranean, and 65% in the Western Pacific. P . vivax is the predominant parasite in the WHO Region of the Americas, representing 75% of malaria cases [ 3 ]. In Ethiopia, peak malaria transmission occurs between September and December in most parts, following the rainy season from June to August, mainly affecting young children, and P . falciparum and P . vivax are the major malaria parasites [ 4 , 5 ].

Children under five years are one of the most vulnerable groups affected by malaria. Severe anemia, hypoglycemia and cerebral malaria are features of severe malaria more commonly seen in children than in adults [ 6 ]. Children’s susceptibility to diarrhea, respiratory infections, and other illnesses increases when they develop repeated malaria infections [ 7 ]. An estimated 2% of children who recover from cerebral malaria develop learning impairments and disabilities, including epilepsy and spasticity, resulting from the brain damage caused by the infection [ 8 ]. In general, malaria could cause severe outcomes in children in three major ways: First, since children do not usually have acquired immunity, they are more likely to develop severe malaria manifested by seizures or coma (cerebral malaria), which can cause emergency death. Second, through complications related to repeated infections such as anemia. Finally, it causes low birth weight when it happens during pregnancy and increases the risk of death in the first month of life [ 4 ].

According to the WHO 2016 report, the global prevalence of malaria among under-five children was 16% [ 9 ]. In the same year, the prevalence in Ethiopia was 0.6% [ 5 ].

The Ethiopian government developed a National Malaria Control Strategy (NMSP) for the years 2017–2020 that was envisioned to be aligned with the country’s four-year health sector transformation plan (HSTP) 2015/16–2019/20. The proposed goals for the 2017–2020 NMSP include: maintaining near-zero malaria deaths (< = 1 death per 100,000) by 2020, reducing malaria cases by 40% by 2020, and eliminating malaria from Ethiopia by 2030 [ 2 , 5 ].

Even though malaria is one of the leading causes of under-five morbidity and mortality in Ethiopia, prior studies focused only on the adult population and were done in malaria-endemic transmission areas. Nevertheless, it is a potential threat in non-endemic regions [ 5 ]. There has been limited information on the epidemiology of malaria among under-five children living in low malaria transmission areas [ 10 ]. This study aimed to close a critical knowledge gap by assessing the prevalence and determinants of malaria among under-five years old children living in low malaria transmission areas. The findings from this study will inform public health and clinical decision-making and will initiate further investigations.

Methods and materials

Study setting and design.

A health facility-based cross-sectional study was conducted from September to October, 2017 in the Wogera district. Wogera is one of the districts in the North Gondar zone. It has an average altitude of greater than 2050 meters above sea level, with an estimated total population of 274,384, of which 37,152 (13.5%) are children under five years old. The district has 42 rural and one city kebeles (the smallest administrative unit ), of which 15 kebeles (35.7%) are malaria-endemic. In the Wogera district, there was 1 hospital, 10 health centers, 42 health posts, and 4 private health institutions. It shares borders with Dabat and Tach-Armacho in the North, Misrak-Belesa and Janamora in the West, Merab Belesa in the South and Lay-Armacho in the East [ 11 ]. According to the new stratification of malaria risk in the country, the district is under the classification of low transmission areas with expected sporadic epidemics every five years [ 5 ]. Despite that, the report of the district health office indicates that malaria is one of the leading causes of morbidity both in adults and under-five children.

Study participants

All children whose age was five years or below visiting the selected health facilities during the study period were the source population.

Sample size estimation

The calculated sample size was 266 using a single population proportion formula as well as a power approach using a double proportion formula based on previous studies [ 12 ]. Adding a 10% non-response rate and a design effect of two, the final sample size was 585.

Sampling procedure

First, we stratified the health facilities as malaria-endemic and non-endemic based on their altitude. Then, we randomly selected five health centers (Ambagiorgis HC, Gedebgie HC, Selarie HC, Tirgosgia HC, and Chichiki HC) and one hospital (Wogera hospital) from the non-endemic clusters by using a lottery method. The calculated 585 sample size was proportionally allocated to the selected health facilities. Finally, a systematic random sampling technique was used to reach under-five clients who attended the selected health facilities.

Data collection tools and procedures

A structured questionnaire was used for data collection. The tool contained socio-demographic, environmental, and malaria prevention related questions. The questionnaire was initially developed in English and translated into Amharic for data collection. A face-to-face interview of the parents/guardians of the under-five children was conducted to collect the data.

After the interview was completed, following the Federal Democratic Republic of Ethiopia Ministry of Health National Malaria Guidelines, blood was taken from a finger prick to prepare thick and thin blood film smears [ 13 ]. Using a sterile lancet, a finger prick was performed, and 5 micro liters of whole blood was drawn from each child included in the sampling regardless of signs and symptoms of malaria using a capillary tube. The blood smears were prepared on microscope slides and stained using 10% Giemsa to be examined under 100x microscopes for the presence of malaria parasites. The thick smear was used to determine whether the malaria parasites were present or absent and the thin smear was used to identify the type of Plasmodium species. A positive result was defined as the presence of one or more asexual stages (trophozoite, ring stage, merozoite, or gametocyte) of plasmodium [ 14 ].

Data quality assurance

Six laboratory technicians (1 from each health facility) and two supervisors from the district health office were trained for two days by the investigators. Each filled questionnaire was checked thoroughly for completeness and consistency, and the necessary feedback was given to data collectors. Recruitment was preceded by obtaining informed written consent from parents or caregivers of the children. To assure the quality of the microscopic examinations, all positive and randomly selected five percent of the negative slides were checked blindly by another experienced medical laboratory technologist.

Operational definitions

Bed net utilization: was self-reported ownership and regular use of bed nets. A 15-day recall period was used to measure whether each child regularly slept under long lasting insecticide treated nets (LLIN) or not.

Malaria : was defined as a positive thin or thick blood film for the Plasmodium parasite.

Data processing and analysis

After data collection, data were entered using Epi info version 7 and then exported to SPSS version 20 for analysis. The correlates of malaria were identified using bivariate and multivariate logistic regression models. Variables which had a P-value of <0.2 in the bivariable regression were included in the multivariable logistic regression analysis. A P-value <0.05 was considered to determine statistical significance. Finally, adjusted odds ratios (AOR) with a 95% confidence interval (CI) were used to determine the strength of association of variables.

Ethical approval and consent to participate

Ethical approval was obtained from the ethical review committee of the Institute of Public Health, College of Medicine and Health Science, University of Gondar, Ethiopia. Permission was gained from the Amhara Regional Health Bureau, North Gondar health department, and Wogera health office. The caregivers were given detailed explanations about the study’s objectives, procedures, and potential risks and benefits, and written consent was obtained following that. The interview of each study participant took place in a separate room after the children gave blood samples. Appropriate treatment was given to children who tested positive.

Socio-demographic characteristics of study participants

In this study, 585 children from five health centers and one district hospital participated: Gedebgie health center (HC) 178 (30.4%), Ambagiorgis HC 114 (19.5%), Tirgosgia HC 111 (19%), Selarie HC 98 (16.8%), Ambagiorgis hospital 37 (6.3%) and Chichiki HC 47 (8%). Three hundred twenty-three (55.2%) were males and 218 (37.3%) were below 12 months. About 370 (63%) of the respondents live in rural areas, and 305 (54%) of the caregivers can not read and write ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0257944.t001

Indoor Residual Spraying (IRS), Long Lasting Insecticide Treated Nets (LLIN), and environmental characteristics of study participants

Only 131 (22.4%) of the respondents had LLIN. Of the respondents who possessed LLIN, 90% of respondents reported that their children had regularly slept under LLIN in the last 15 days ( Table 2 ).

https://doi.org/10.1371/journal.pone.0257944.t002

Magnitude of Malaria

In this study, the prevalence of malaria by microscopy among under-five children was 8.7% (51). There was a considerable variation in the prevalence rate between the health facilities, ranging from 0% at Wogera hospital to 21% at Selarie health center ( Table 3 ).

https://doi.org/10.1371/journal.pone.0257944.t003

Factors associated with malaria infection

Both bivariable and multivariable binary logistic regression analyses were done to identify the determinants of malaria infection. In bivariate analysis, factors with a P-value of <0.2 were: place of residence, stagnant water around the home, staying outside during the night, possession of an LLIN and regularly sleeping under an LLIN for the last 2 weeks. However, place of residence, sex of the child, age of the child, age of the mother/guardian, educational status of the mother/guardian, presence of radio/television, child having a regular sleeping area, construction material of the house and incidence of IRS within six months had a P-value of >0.2 in the bivariate analysis and were not included in the final model.

In the final adjusted model, children who stayed outside at night had 5.5 times higher odds of malaria infection than children who did not stay outside at night (AOR = 5.5, 95% CI: 2.7–11.1). Children who regularly slept under a LLIN had 92% lower odds of infection than those who did not sleep regularly (AOR = 0.08, 95% CI: 0.08, 0.09). Children who lived in households with close to stagnant water had—4 times higher odds of malaria infection than children who did not live in those homes with nearby stagnant water (AOR = 4, 95% CI: 1.9, 8.1) ( Table 4 ).

https://doi.org/10.1371/journal.pone.0257944.t004

In this study, we estimated the prevalence of malaria among under-five children in the low-risk area and its determinant factors, and the results showed that the malaria prevalence in under-five children was 8.7%, which is in line with the study conducted in Dilla, Southern Ethiopia, where the prevalence of malaria in under-five children was identified to be 7.1% [ 15 ] and a study of analysis of the five-year trend of malaria at Bichena primary hospital, Amhara Region, Ethiopia, where the overall prevalence of malaria was 9.28% [ 16 ].

This finding is much higher when compared to the national malaria indicator survey in 2015 that identified a prevalence of 0.6% among under-five children [ 5 ] and another study conducted in four regional states in Ethiopia, where the prevalence was 4.6% [ 17 ]. This could be due to the difference in methodology used, and also, it might be due to the season when the studies were conducted. Malaria increases from September to December (major transmission season). However, this finding is lower when compared to the global magnitude of malaria among under-five children, which is about 16% [ 9 ] and studies conducted in East Shewa 18.9% [ 18 ], Tanzania 26.3% [ 19 ], Sudan 22% [ 20 ], Uganda 19.5% [ 21 ], and Mozambique 33% [ 22 ]. Those studies were conducted in low land areas, and the difference could be due to a study population difference in the case of a study conducted in Mozambique in which the study population was people with comorbidity.

In Ethiopia, there is spatial and temporal variability in the occurrence of malaria. The current findings also demonstrated similar spatial variations in the proportion of Plasmodium species, with the predominant occurrence of P . falciparum infections at 65% over P . vivax at 35%. This estimate is approximately similar to the study conducted by the Carter Center in Amhara, Oromia, and Southern Ethiopia, where P . falciparum accounted for 56.5% and P . vivax for 43.5% [ 17 ], and a 7-year trend of malaria study done at primary health facilities in Northwest Ethiopia P . falciparum accounted for 15.6% of the participants, which was threefold higher than P . vivax in the seven-year trend [ 23 ]. However, other studies reported a different proportion, such as those conducted in East Shewa ( P . falciparum = 41.2%, P . vivax = 57.1 and Mixed = 1.8%) [ 19 ]; Hadiya ( P . falciparum = 25.5%, P . vivax = 71.7% and Mixed = 2.8%) [ 24 ] and Dilla town ( P . falciparum = 26.8%, P . vivax = 62.5%, and Mixed = 10.7%) [ 15 ]. The variability could be related to the wide climatic diversity between the areas.

Sleeping under LLIN for the last two weeks was found to be protective against malaria. This evidence is supported by other similar studies conducted in East Shewa [ 18 ], Amhara, Oromia, and SNNRP [ 17 ], Dilla [ 15 ], Ethiopia [ 25 ], Ghana [ 26 ], and Uganda [ 21 ]. It was evident that using ITN properly decreased mosquito bites, and thereby decreased malaria infection.

In this study, malaria was highly prevalent among children living in households with stagnant water in the compound compared to their counterparts. This is consistent with a facility-based cross-sectional study conducted in a low transmission area of the Hadiya zone, south Ethiopia [ 24 ]. This is because water collection is one of the favorable conditions for mosquito breeding, which in turn increases malaria transmission. Staying outside during the night showed a statistically significant association with malaria. Staying outside during the night increases the probability of mosquito bites due to the nocturnal nature of the mosquito.

Limitations of the study

As a limitation of this study, since it is a cross-sectional study, it only captures the point prevalence and can not account for seasonal trends in transmission. All surveys are self-report with no confirmation of bed net ownership or use. RDTs with PCR confirmed were not conducted, nor are there details on the life stages of detected parasites observed–gametocytemia, parasitemia.

The prevalence of malaria in under-five children attending health care facilities in Wogera district was high. Regularly sleeping under a bed net, staying outside during the night, and stagnant water around the household were the main correlates of malaria. Focusing on LLIN distribution, environmental management, and changing attitudes towards malaria prevention and control through health education would help minimize the burden of malaria.

Acknowledgments

We would like to thank the Wogera health bureau, the study participants, data collectors, and supervisors who participated in this study for their commitment and cooperation.

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