Background
Malaria is one of the major public health problem across the world. The World Health Organization (WHO) has reported 214 million new cases of malaria and 438,000 deaths in 2015 [
1]. Historically, China was a malaria-endemic country. The large-scale outbreaks of malaria which occurred in the 1960s and 1970s severely influenced public health and socioeconomic development [
2], especially in central China [
3]. The combination of human behaviours and livestock reduction was explored as an important factor contributing to some of these outbreaks [
4,
5]. The number of malaria cases decreased significantly [
6], and the incidence of malaria has declined from a peak of 2961/100,000 in 1970 to 0.1/100,000 in 2014 [
2,
7]. The last decade has witnessed a decline of malaria prevalence in China and the government has set the target to eliminate malaria by 2020 [
7].
The roadmap for elimination was developed alongside the initiation of the national malaria elimination programme (NMEP) [
8]. All malaria endemic counties in China were divided into three types according to annual incidences [
9]. The endemic counties, ones where autochthonous infections had been detected continuously from 2006 to 2008 and the annual incidence had been no less than 1/10,000, were categorized as type I. The ones where autochthonous infections had been detected continuously and the annual incidence had been lower than 1/10,000 at least in 1 year were classified as type II [
10,
11]. Other counties with no autochthonous malaria cases during these 3 years were defined as type III. Since the initiation of the NMEP in 2010, China has achieved a remarkable autochthonous malaria-eliminating progress, and malaria map had shrunk dramatically [
12]. However, given that imported cases have increased rapidly in recent years [
13], risks of recrudescence and transmission need to be taken into account urgently by counties that had already passed the sub-national elimination assessment [
14]. The malaria transmission in infection hotspot is important predictor infection of malaria in the future [
15]. Therefore, the high at-risk populations were defined as returnees from the malaria epidemic area, such as Africa and Southeast Asia, and residents living in malaria foci, who require greater consideration.
Health education and health promotion was the indispensable part that contributed to the elimination of malaria [
16,
17]. As in previous studies, malaria awareness campaigns played an important role in health promotion by increasing the level of knowledge regarding malaria and improving health-related behaviours, as well as promoting inter-sectoral collaboration and social support [
10]. In China’s plan for malaria elimination, public awareness of malaria has been set as an essential index to evaluate elimination progress [
9], and it aims to cover various populations and increase the level of awareness of malaria among residents in type I and type II counties to 80 % by 2015. In a recent review of research activities on malaria in China, most malaria studies have been undertaken by Chinese Center for Disease Control and Prevention (CDC) or its affiliated units [
18], and independent third parties have been involved in investigations related malaria issues. In order to achieve the final goal of malaria elimination by 2020, this study was carried out in the middle stage of NMEP to investigate the current status of public awareness of malaria, contribute to an adjustment of the strategies to improve public awareness of malaria in the next elimination phase.
Discussion
This study has shown the pubic awareness of malaria in the middle stage of the NMEP, which is unsatisfactory to the demand of elimination in the perspective of health education and promotion. It is a major concern that the level of knowledge regarding malaria still needs to improve in the sample counties. A similar study conducted in 2014 reported that 43.7 % of the Indians had poor knowledge of malaria [
23], however, the percentage of respondents with poor knowledge reached 48 % in this study. Compared to the situation at the beginning of the NMEP [
10], the percentage of respondents with an over-60 % correct rate has declined from 58.86 to 52.00 %. This could be explained by that subtle differences occurred in measured questions, and residents from type II counties in previous studies were responsible for 82.56 % of the sample population, which contributed a great impact on the high level of knowledge regarding malaria (see Fig.
1). In addition, elimination has allegedly been achieved in the majority of the sample counties. The focus of health staff in daily work may be shifted to the control of other diseases. Lack of staff or passive publicity activities may be the substantial reasons leading to these unsatisfactory results.
Higher public awareness of malaria contributes to malaria prevention and elimination, and it could improve self-protection [
24], early treatment-seeking [
25], and disease detection [
26]. Although some studies from Africa have argued that the practice of protection measures was independent of personal knowledge [
27,
28], others have confirmed the impact of sufficient knowledge on behaviours and the effectiveness of the control measures [
29], and reduced the probability of malaria infections [
23]. The current status of public awareness of malaria in type I and II counties still has much to catch up in order to achieve the objective of 80 % of residents having good malaria knowledge, which was set at the initiate of the NMEP. Poor public awareness may be unresponsive to the potential malaria resurgence [
14], the results indicate that more attention should be paid particularly to type III counties, where approximately 61.9 % of the respondents have a poor level of knowledge, which is consistent with the experience from Indonesia [
30].
In terms of the basic understanding and knowledge of malaria, a present study also reported that compared to other subgroups, students and the youth aged below 29 had the poorest level of knowledge regarding malaria and even lower than that at the beginning of the NMEP [
11]. The main reason for this might be the selection bias that some of them still left their houses for hanging out, travelling or working. Additionally, the level of knowledge is similar to that found in a study of a survey regarding the knowledge of malaria among high school students in Thailand [
31], but it is lower than that in Tanzania a decade ago [
32]. In addition, the average level of knowledge regarding malaria seemed to rise along with the distance to township hospitals. In line with a similar study conducted in Iran, township hospitals were the most important source to disseminate information related to malaria [
33], and people who live close to township hospitals might acquire more knowledge due to more interaction with the health staff. Simultaneously, a longer distance to township hospitals might result in less frequent visits given the cost and loss of work time [
23]. However, no difference was found in the distance to village clinics. It suggests that as the scattered village clinics are close to inhabited regions, village doctors in those clinics should be involved into the malaria health promotion system.
Interestingly, the knowledge of malaria of the at-risk population as aforementioned in the text is similar to that of the general population. In accordance with previous studies [
34], it is far from satisfactory. Therefore, it is vital to improve the knowledge regarding malaria of the at-risk population to enhance their self-protective awareness and reduce any potential recrudescence risk. Nevertheless, the health education campaign covering migrant population involves various departments, such as Public Security, Commerce, Health and Family Commission, Quarantine Bureau, and Social Media. (unclear meaning) [
10]. This may often be practically intractable, which requires an improvement in multi-sectoral cooperation. Simultaneously, in the context of China’s “Belt and Road Initiative” and its aid programmes in African countries [
35], malaria cases, most of which were imported from Africa and Asia [
36], have increased rapidly, which becomes as a critical potential challenge to the elimination programmes [
13,
37]. Meanwhile, further communication on malaria education could be developed between China and countries in Africa and Asia. However, even if this may be intuitively appealing, this is often practically intractable for the populations at risk, because cooperation in health education between different sectors is usually complicated.
Findings of this study also show that the public awareness of basic malaria knowledge is poor, especially regarding symptoms of malaria, and vectors involved in the transmission of malaria. Only one-third of the rural respondents considered malaria as an infectious disease, and the proportion is lower than that in Vanuatu [
38]. This indicates that more than half of the residents just hold a simple understanding that may lead to residents’ low level of alertness of malaria infection and a lack of self-protection. This study also showed the negative results of the public awareness of malaria, and it needed to improve continuously. Although more than two-third of the respondents knew at least one main symptoms of malaria: fever and chill were widely termed as common symptoms of malaria, however, the public awareness was still lower than that in other Asia–Pacific counties [
39,
40] and Iran [
41]. Moreover, only one-third of them know that the mosquito is the vector of malaria transmission and the proportion tend to be much less than that in Myanmar [
39], Iran [
41], Cambodia [
42] and Peninsular Malaysia [
43].
Nevertheless, this study also showed that the majority of the respondents knew about malaria prevention. Compared to other studies, public awareness of medication to prevent malaria was higher than that of Ethiopia [
44], a country heading towards the pre-elimination phase. The awareness of seeking treatment when suffering from malaria was considerably higher than that reported from Cameroon [
45]; this may be due to the large-scale self-medication in that country. Interestingly, people do not know that anti-mosquito measures are an effective method to prevent malaria, but they still use those measures. This may be explained by the fact that mosquitoes have always been considered as one of the most harmful pests by the Chinese government, for carrying pathogens and biting people, and it is rooted in the social environment. It shows that raising the public awareness of malaria among populations is possible, with sustained effective health education and promotional activities over a long time.
Limitations
There are several limitations in this study. First, the sample size is small. In China, the population of one county may reach approximately 500,000, only 180 residents in rural areas from one counties were enrolled, it may result in a selection bias. The strict sample procedure across four stages was controlled, and the indoor interview was conducted, it can represent the population of sample counties and the awareness of the population. Secondly, the distance to village clinics or township hospitals and the household income are hard to estimate. The data were collected by respondents’ self-reporting, which certainly is subject to individual variances. Hence, the assessment criteria were assumed as the same for every respondent in this study.
Authors’ contributions
SFT, TH and ZCF conceived and planed the study. SFT and LJ conducted the analysis and wrote the paper. RXW, TS, CYL, PPS and ZH collected the data. SFT, TS and GL analysed the data. RXW, and HF participated in editing of the paper. All authors have read and approved the final manuscript.