Knowledge of malaria prevention among pregnant women and non-pregnant mothers of children aged under 5 years in Ibadan, South West Nigeria

Malaria is a major public health problem in ninety-one countries world-wide with sub-Sahara Africa bearing 80% of the disease burden [1]. Malaria remains endemic in Nigeria where the parasitic disease disproportionately affects children aged under 5 years and pregnant women compared to the rest of the population groups [2‐6]. In pregnancy, malaria increases the risk of maternal anaemia, spontaneous abortions, stillbirths, premature deliveries, intra-uterine growth retardation and low birth weight babies, and these are all important causes of infant mortality [7]. Also, more than 70% of all malaria deaths occur in children aged under 5 years [4, 8]. The scope of malaria control is changing worldwide with more emphasis on community and individual participation. Health education can improve participation in malaria control, when such education is designed to address gaps in the knowledge, attitudes and practice of individuals in the communities [4, 9]. Nigeria has implemented three national malaria strategic plans (NMSP) till date, and is presently implementing a fourth NMSP (2014–2020). This fourth NMSP aims to achieve pre-elimination status and reduce malaria-related deaths to zero by 2020 [10].

Evidence from malaria knowledge, attitudes, and practices (KAP) studies reported that misconceptions on malaria transmission and risk factors still exist with adverse impact on malaria control programmes [11, 12]. Findings from a study conducted by Singh et al. in rural areas of Northern Nigeria revealed that although knowledge about malaria prevention measures was high (90%), it was poorly reflected in their practices (16%) [13]. Another study by Adebayo et al. [14] assessed the knowledge of malaria prevention among mothers of children aged under 5 years and pregnant women in a rural community in Southwest Nigeria. This latter study also found poor knowledge and utilization of malaria prevention measures among majority of the caregivers in the rural study area [14]. Considering the vulnerability of both children aged under 5 years and pregnant women to malaria [10, 15], this study aimed to determine the knowledge of malaria prevention and management among pregnant women and non-pregnant mothers of children aged under 5 years seeking health care at one of the main secondary maternity hospitals in Ibadan, Nigeria. Only few studies have assessed knowledge on malaria prevention among mothers in hospital-based setting. This study sought to fill this gap and provide new insights on the depth of knowledge gaps. The findings will help to improve implementation of integrated malaria control strategies. It will also be essential in establishing epidemiological and behavioural baseline indicators to evaluate and improve progress by malaria control programmes.

Table 1 presents results on the socio-demographic and clinical characteristics of the study respondents. Of the 1373 women in the study, 59.6% (818) were pregnant women whereas 40.4% (555) were non-pregnant mothers of children aged under 5 years. Mean age of respondents in the study was 29 years ± 5.2 years old. Mean age of the pregnant women in the study was 28.9 ± 5.21 while mean age of non-pregnant mothers of children aged under 5 years was 30.0 ± 5.14. The most predominant age group was 25–34 years of age (pregnant women: 71.3% vs non-pregnant mothers of children aged under 5 years: 66.8%). The most predominant socio economic class among both maternal groups were the lower upper class (60.4% for the pregnant women and 61.4% among non-pregnant mothers of children aged under 5 years). Married respondents were the majority in the study across both maternal groups (pregnant women: 89.4% vs non-pregnant mothers of children aged under 5 years: 95.5%). A larger proportion of the mothers had attained secondary education more than the less educated mothers, and this distribution was similar in both maternal groups (Table 1).

With regards to the clinical characteristics of respondents, about a third of the pregnant women were primegravida (33.6%) while the rest were multigravidae (66.4%). There were about 1.5% of pregnant women and 1.4% among the non-pregnant mothers of children aged under 5 years who self-reported that they HIV positive. Also, 24.8% and 18.9% of the pregnant women and non-pregnant mothers of children aged under 5 years did not know their HIV sero-status, respectively. With regards to the blood group of the respondents blood group ‘AB’ was less common (6.2% vs 12%, in pregnant and non-pregnant mothers of children aged under 5 years, respectively). Conversely, the predominant genotype was ‘AA’ (pregnant women: 70.4% vs non-pregnant mothers of children aged under 5 years: 65.9%) followed by ‘AS’ (pregnant women: 23.3% vs non-pregnant mothers of children aged under 5 years: 22%), ‘AC’ (pregnant women: 5% vs non-pregnant mothers of children aged under 5 years: 8.8%) and ‘SS’ (pregnant women: 1.2% vs non-pregnant mothers of children aged under 5 years: 3.2%).

Nigeria contributes the highest morbidity and mortality rates to the global burden of malaria, accounting for 25% of the global malaria cases and about 24% of global malaria-related deaths [1]. Thus, the initiative to study maternal knowledge on malaria prevention was essential in understanding the extent and impact of malaria programmatic efforts in malaria control. Women serve as role models for their families in raising awareness and participating in malaria prevention and control [18]. They are also responsible for home-based management of malaria for themselves when pregnant and among children aged under 5 years in the home [19]. In this study, findings revealed obstacles to effective malaria control despite high awareness of malaria as an illness which has been previously reported in studies conducted in South Western Nigeria [20], Northern Central Nigerian [21] and as confirmed in this study (93% among pregnant women and 97% among mothers of young children). There were knowledge gaps on; breeding sites for the vectors that transmit malaria, symptoms of malaria and malaria prevention measures. According to Killeen [22], level of knowledge on mosquito behavioural pattern (biting and resting times) and breeding sites has been associated with the severity of malaria. Killeen further explains that elimination of malaria from most endemic regions of the tropics requires vector control strategies that address residual transmission by deliberately targeting the mosquito behaviours which enable it [22].

In relation to the knowledge on malaria symptoms and preventive measures by respondents in this study, about 60% of pregnant women and 46% of non-pregnant mothers of young children did not have correct knowledge on malaria prevention. Further, there were 26% of pregnant mothers and 31% of the non-pregnant mothers of young children who correctly reported more than 3 clinical symptoms of malaria. Similar studies conducted in rural South West Nigeria [14], North Central Nigeria [9] and Burkina Faso [18] also showed low knowledge on malaria prevention measures. Conversely, the study by Singh et al. showed that high knowledge about malaria symptoms and prevention measures (90%) however; this knowledge was poorly reflected in practice (16%) [13]. Misconceptions about causes of malaria in this study although reported by few respondents include living in dirty environment, eating contaminated food, stress, and exposure to sunlight. Some studies in Nigeria and parts of Africa have also reported spurious causes of malaria such as staying for long in the sun and drinking bad water among other misconceptions on malaria [11, 21, 23, 24]. Overlapping knowledge on malaria causes, key symptoms, and prevention was observed between pregnant women and the non-pregnant mothers of children aged under 5 years in this study. In some aspects of malaria prevention, higher proportion of pregnant women was less knowledgeable about malaria, compared with the mothers of young children and vice versa. However, the differences in malaria knowledge on preventive measures between the maternal groups were not significant from the analysis of variance performed.

Level of knowledge on malaria was associated with; socio-demographic factors such as marital status, education and clinical factors like gravidity and HIV status of the mothers. Good malaria knowledge was associated with higher level of educational status of the women. In previous studies, educational status has been linked with good health awareness and health-seeking behaviour for the child [23, 25], and also improved knowledge on malaria and prevention among mothers [9, 18, 26]. Such association according to Fana et al. stresses the role education could have on the overall success in malaria control programmers in a region [26]. Another important finding was that respondents who knew their HIV status had a good knowledge of malaria compared with those who did not know their HIV status. Further, those who were HIV positive had better malaria knowledge when compared with both those were HIV negative and those who did not know their HIV status. The high knowledge of malaria among HIV positive respondents in the study might be due to the awareness of the high risk of acquiring opportunistic infections. For instance, knowledge of HIV status as reported by the study respondents reflects a higher awareness of their health status. This agrees with finding from study in Uganda by Katrak et al. where a > sixfold lower risk of infection with malaria parasites among HIV-infected participants with an undetectable viral load was seen when compared to HIV-uninfected participants [27]. Possible explanation could be because individuals who knew their HIV status tend to have good health-seeking behaviour and knowledge on malaria compared with those who do not know their HIV status.

Although the study investigated the knowledge of malaria prevention and control, and sought to find the socio-demographic and some clinical factors associated with malaria knowledge this study did not investigate the programmatic factors that may influence the knowledge of the respondents on malaria and would like to recommend this for future studies. Limitations of this study include recall bias on account of information provided by the respondents. Since the study population was hospital-based, another bias related to the limitation of this study is selection bias because this hospital based study population could have been more knowledgeable than similar population if recruited from the community. Though these limitations, this study has implications for control programmes given the findings, which highlights the knowledge gaps requiring urgent interventions targeted at mothers.

This study has demonstrated that pregnant women and mothers of children under 5 years are aware of malaria, but still lack comprehensive knowledge about the disease. Many mothers know some important symptoms of malaria such as fever, cold and headache. There was also some level of misconception about malaria, which needs to be totally debunked by intensifying education about malaria among mothers who are either pregnant and or caring for young ones who are more vulnerable to malaria disease. Education as a socio-demographic factor was an important predictor knowledge of malaria among mothers and so government policies should be geared towards improving citizens ‘educational statuses in order to reduce the burden of the disease in the country, especially among the most vulnerable population. Mothers need to be educated about the importance of a better health-seeking behaviour and awareness about their health status. Nigeria’s malaria strategic plan should to ensure that the knowledge cleft on malaria prevention and treatment needs to be addressed. This insight will help the policy makers to implement continuous strategic intervention including health awareness and educational programs to attain 2030 malaria goals.