Community knowledge, perceptions, and practices regarding malaria and its control in Jabi Tehnan district, Amhara Region, Northwest Ethiopia

Malaria is a major threat in Ethiopia with high health and economic burden, especially among poor households. It also imposes a fiscal burden on the national government due to public health expenditure related to treatment and prevention of the disease. In 2017 alone, 71 million Ethiopians were at risk, 2.7 million people were infected, and 5300 died due to malaria [1]. Thus, malaria profiling provides insights that can help design targeted strategies to reduce the impact of the disease.

Currently, Ethiopia relies on multiple interventions namely community empowerment and mobilization, vector control using LLINs and IRS, prompt diagnosis and treatment and disease surveillance to curb the burden of the disease [1]. However, insecticide resistance [2], drug resistance [3], the plastic nature of malaria vectors feeding and biting behaviour [4], and household factors hindering the proper use of LLINs [5] constitute series challenges which undermine the efficacy of various interventions. Therefore, it is imperative to explore new approaches and tools to augment the existing malaria control interventions.

One of the emerging approaches being evaluated by researchers, and malaria programmes in Africa is house screening (HS), involving the screening of open eaves, windows, and doors of houses [6‐11]. HS reduces malaria among house occupants by serving as a physical barrier to mosquito entry into house. HS is not a new innovation, but it has never got enough attention as a practical intervention for malaria prevention at household level [11‐14].

There are limited research reports that focus on malaria profiling in Jabi Tehnan district and their aims, delimitations and contexts also varied. For instance, Animut et al. conducted a study focused on hospital-based data to determine the causative agent of acute febrile illness in the area and reported malaria as a primary source of morbidity in the area [15]. Ayalew et al. conducted a malaria cross-sectional survey in Jiga area, which was limited to three kebeles and reported a 2.8% prevalence rate [16]. Further two studies were conducted by Animut et al. [17, 18]. These studies do not comprehensively reflect the malaria profile in the area as the former mainly focuses on peoples’ perception of basic malaria information. The latter mainly describes the dry season vector information in the area. This paper aims at documenting peoples’ perception towards malaria, the prevalence of the disease, and the constraints related to the ongoing interventions such as access and utilization in Northwest Ethiopia.

Malaria control programme managers mainly depend on case reports from health facilities to make major intervention decisions [30]. The fact that decisions are made mainly based on case reports puts the entire programme on passive posture, i.e. if other outbreak alert and response methods such as entomological information, weather forecast, regular cross sectional malaria indicator surveys are not in place, the programme office will always left with to play catch-up to contain the disease outbreak [38]. While case reports from health facilities always remain a critical component in deriving both policy and strategic decisions, they may not sufficiently provide the necessary information regarding malaria transmission intensity, hot spots, and endemicity problem. In this study, key malaria disease control indicators were assessed in Jabi Tehnan district using household level KAP and cross-sectional malaria parasitological surveys. In addition, recent trend of malaria cases and its implication for malaria elimination was evaluated.

The socio-demographic features of community members in the study area were similar to those reported from other parts of Ethiopia including a pre-dominance of male-led households, high level of illiteracy and engagement in agriculture as the main community occupation [39]. The average family size of 5.6 reported here is slightly higher than the country average of 4.6 [19]. It might be economically difficult for large households to buy enough insecticide-treated bed nets and this is documented in studies conducted in Gambella and Jimma, Southwestern Ethiopia [40, 41]. LLINs are freely available by the government in Ethiopia, however, a household cannot receive more than four LLINs regardless of any extended family size. This means households with extended family size are forced to buy the extra bed nets needed. Most members of the community have separate cattle sheds or houses, and this is an important behavioural difference documented compared to the reluctance of families in most parts of Ethiopia to separate cattle from human residences. Keeping livestock away from human residences is acknowledged as a practical strategy for diverting certain malaria vector species from human hosts to other vertebrate hosts, thereby, decreasing the contact between humans and infectious mosquitoes [42, 43]. Houses in this study were made of walls with wooden frames, plastered mud walls and roofs made of corrugated iron sheets. The absence of traditional huts with grass thatched roofs could be partly explained by improved economic status of the community [44]. The coverage of households in the area with LLINs was found to be moderate, with every household having at least 0.5 LLINs and with total coverage being 70%. This was below the country and regional average of 72% and 76% respectively [24].

Both long-lasting insecticidal nets (LLINs) and indoor residual spraying (Propoxur, 1–2 g m²) were being used in the district with IRS given priority to 4 villages (Ergib, Awunt, Hodansh and Jiga Yelimdar) which had higher ongoing transmission. LLINs was the only intervention available throughout all the health clusters of the district. Universal coverage (100% access) was ensured in the district as confirmed through FGD, personal observation and information obtained from the district health department. Supplementary interventions such as filling and draining of standing water were reported by FGD participants even though they were not regularly implemented. Major emphasis was given to case treatment and bed net distribution from malaria control programme office of the district.

Universal coverage or access to at least one vector control intervention/per household is the direction adopted by national malaria control programme since 2006 in Ethiopia [45]. Low utilization of the already available interventions and using nets for unintended purposes however remains major challenges in the area as close to half (50%) of the households who had access to bed nets did not use it in the previous nights in the area. Lack of persistency in using bed nets is a cross-cutting problem throughout the country as it is assessed in country wide malaria indicator surveys [24]. Continued community education and communication effort should be done in order to bring the desired behavioural changes.

As it is confirmed in this study repurposing of bed nets was reported as commonly available. Thus, there is serious gap in behavioural change to be addressed from all stakeholders involved in malaria control programmes. Studies documenting misuse of bed nets in Ethiopia are not many, but a study conducted in Adame-Tullu district of East Shewa zone, central Ethiopia showed that misuse and repurposing of bed nets for other purposes such as wrapping maize kernels, wrapping teff and transporting it from field to home using animal carts are the common acts of misuse [5]. The observed repurposing of LLINs can be improved through continued teaching of communities about the adverse effects of accidental contamination of cereals covered with insecticidal nets and facilitating access of target communities to cheaper and suitable materials for making ropes, transportation, or coverage of grain stores.

In this study, different traditional practices were assessed, including vector control and diseases treatment approaches used by the communities in the study area. Despite the reliance on modern medicine predominantly as the participants described, some community members believed that extracts from leaf and succulent parts of different plants such as Ocimun lamiifolium (loc. “damakese”), Phytolacca dodecandra (“Indod”), Clausena anisate (“limmich”), Croton macrostachyus (“Bisanna”) and mashed garlic could be used for treating malaria. Provision of traditional medicine for malaria remedy is a long-established trend in Ethiopia [46, 47]. While the essence of indigenous knowledge is undoubtedly important in the quest of new antibiotic options, the anti-malarial potential for the plants has not scientifically established yet.

The delayed treatment-seeking behaviour observed in this survey is also a common problem documented throughout the country with reports from Central [48], South East [49], Western [50] and Southwestern Ethiopia [51]. While the cessation of death due to malaria in Jabi Tehnan district is an achievement, the disease continues to cost considerable working days (2.53 per person-per episode) due to morbidity and money spent on treatment (18.18 USD/person/episode) and loss of income especially for people working on daily wager. The economic impact of malaria is analysed from different perspectives including the death of workers, school absenteeism, loss of family members’ time due to caring, loss of savings, loss of household and farm assets [52]. The reported working days lost due to malaria is relatively low as compared to recent studies conducted on malaria economic impact in Ethiopia which estimates loss of 6.3 working days, but money spent per episode per person was relatively high as compared to the 17.8 USD expense/episode/person [53] in Ethiopia and Kenya with loss of 5 USD [54].

Health posts and government hospitals were reported to be the main source of treatment in the area. Malaria treatment is freely accessible in Ethiopia through government health institutions (Health Posts, Health centres, and hospitals) [1]. Despite free access to malaria treatment at every village level in the district and in other parts of the country, some people either did not seek treatment at all (7.66%) or used other unreliable treatment sources such as traditional healers (1.6%). This showed that there are still significant gaps in the awareness level of the community in treatment-seeking behaviour. However, the fact that some community members use traditional treatment options consciously for different reasons cannot be ruled out. Avoiding travelling longer distance, seek of cheaper cost, having bad experience from medical centres in the past, influence of local traditional healers are some of the justifications reported elsewhere [55].

Malaria disease prevalence in Jabi Tehnan district was low (0.89%). In this survey, Plasmodium vivax was the main parasite documented in the area followed by Plasmodium falciparum. Besides, all positive samples were documented in areas well below 2000 m above sea level, between 1300 and 18,000 m. As Jabi Tehnan is one of the 239 districts selected for all human to human malaria elimination in the country [56], the current low prevalence rate gives hope for the envisaged elimination programme. However, the recent resurgence of P. vivax in some of the villages (Ergib, Goref, Abasem, Jiga Yelimdar, and Guay) may jeopardize the plan.

Malaria case reports from health facilities in the area were collected concomitantly to make comparisons and cross-validations with prevalence data. Accordingly, those villages where positive cases were found in the cross-sectional survey had also the highest share of cases as reflected in clinic-based data in the district. Jiga and Awunt had reported considerably higher cases with the former being the second and the latter being fourth most affected in the district. However, no positive case was found in the cross-sectional parasite survey. Moreover, malaria disproportionately affected the adult segment of the population as 50% of the total case was reported from people whose age was 15 and above followed by the age between 5 and 14. In Ethiopia, malaria transmission is unstable and highly seasonal with few exceptions of areas bordering Sudan and South Sudan. This has resulted in low host immunity and risk of the adult population being more affected unlike the trends observed in other parts of Africa [1, 57].

In this study, malaria parasite testing was done using microscopy only. This might have contributed to the observed low level of parasite prevalence. Conventional diagnostics such as microscopy and RDT have led to missing nearly half of the asymptomatic Plasmodium reservoir, which were detected by more sensitive molecular diagnostic tools such as nPCR and qPCR [58, 59]. Thus, future parasite screening surveys should consider utilization of combination of both microscopy and molecular screening techniques.

Overall malaria cases have been substantially declined in the last 5 years in Jabi Tehnan district. Thus, the highest malaria case was documented in 2016 and the least case was documented in 2019. There was 80% reduction of cases in the last 5 years, however, comparison of the last 2 years data (2018 and 2019) showed that case reduction had almost flattened. Outdoor transmission in Jabi could be driving substantial portion of transmission as the area is known for harbouring large mechanized farms, such as Bir Sheleko mechanized farm and Bir Sheleko military training campus. These sites become a point of attraction for migrant workers which mostly originate from less immune highland areas [60, 61]. The temporary workers in these areas are usually stay in poorly constructed temporary shelters, which are called “satera”, tent like structures which are made of wooden framework and partially covered with plastic cover. These structures are porous and easily allow the influx of vector mosquitoes. Moreover, the structures are constructed to accommodate multiple workers and, therefore, it is difficult to put on bed nets. This was confirmed from FGD conducted by the community members and the members agreed that temporary workers, guards, people who work until late evening are the main victims of mosquito bite. The government of Ethiopia mainly focuses on aggressive deployment of indoor based vector intervention tools (IRS and LLINs), however, the loophole created by the above conditions continued to reverse hard earned gains through indoor vector control interventions and need immediate action from policy makers. This is also a common problem across Africa as a certain portion of malaria vectors defy the existing vector control efforts [45]. It becomes clear that even with universal coverage of mainstay vector control interventions, there will be still sustained transmission due to outdoor transmission [62]. Mosquito net utilization is affected by a number of factors. These include the absence of sufficient mosquito nets, the size of the net (single, double, family) [63], education level of the user, housing setting [64], sleeping and mobility patterns of the specific community [65, 66]. Thus, mosquito net distributions should be followed by appropriate operational researches in order to determine mosquito net utilization and the constraints against the achievement of the desired behaviour.

In conclusion, this study assessed the status of key malaria control interventions namely access and utilization rate of LLINs, and treatment-seeking behaviour. In both regards, there was a serious gap that must be addressed through social mobilization and education. Both cross-sectional and hospital-based positivity rate studies showed that malaria prevalence in the area was low. However, the fact that the rate of reduction did not change for the last 2 consecutive years showed that there should be a concerted effort to further drive case reports to zero. The situation, therefore, calls for the implementation of supplementary interventions such as house screening as recommended in several recent studies in both Ethiopia and other countries [67‐71].

Despite the achievement of universal coverage in terms of LLINs access, utilization of vector control interventions in the area remained low. Moreover, using bed nets for unintended purposes was a major challenge. Consequently, continued community education and communication would be necessary in the study area in order to bring about the desired changes in community behaviour and practices. Community education could be more effective if delivered in more targeted approaches such as malaria education for women groups, intensified education in hotspot neighborhoods and cascading malaria education through primary schools [72, 73]. Moreover, behavioural changes may take long time (years) to achieve. Hence, positive communication approaches should be implemented to slowdown community fatigue development. These include integrating passive and active mass education [74, 75], using local approaches such as coffee ceremony [53] and artistic interventions such as songs, drams and poets [76].

In this study, it was confirmed that botanical extracts from leaf and succulent parts of different plants such as Ocimun lamiifolium (loc. “damakese”), Phytolacca dodecandra (“Indod”), Clausena anisate (“limmich”), Croton macrostachyus (“Bisanna”) were being used for treatment of malaria. In addition, there were other plants being used for malaria treatment, but their names were concealed from disclosure by the healers. Therefore, the potential of these plants should be further investigated in order to identify and evaluate their active ingredients and their effectiveness for preventing or clearing malaria.