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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 27
| Issue : 1 | Page : 81-91 |
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Knowledge and preventive practices against malaria among pregnant women in urban and rural public healthcare facilities in nigeria’s federal capital territory
Sabastine N Esomonu1, Edmund N Ossai2, Apagu D Gadzama1, Matthew A Ashikeni3, Benjamin S Uzochukwu4
1 Federal Capital Territory Primary Health Care Board, 9, Abuja, Nigeria
2 Department of Community Medicine, College of Health Sciences, Ebonyi State University, Abakaliki, Nigeria
3 Office of the Honourable Secretary, Health and Human Services Secretariat, Federal Capital Territory (FCT) Administration, Abuja, Nigeria
4 Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
| Date of Submission | 06-Oct-2020 |
| Date of Decision | 27-Apr-2021 |
| Date of Acceptance | 17-May-2021 |
| Date of Web Publication | 3-Dec-2021 |
Correspondence Address:
Sabastine N Esomonu
Federal Capital Territory Primary Health Care Board, 9, Orlu Street, Area 3, Garki, Abuja.
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijmh.IJMH_66_20
Background: Malaria is a life-threatening parasitic disease, and pregnant women are at risk of its adverse consequences. Objectives: The study aimed to determine knowledge and preventive practices against malaria among pregnant women at urban and rural public health facilities in Abuja, Nigeria. Materials and Methods: A cross-sectional study design was used. The two-stage sampling method was used to select 520 pregnant women in 16 health facilities. A structured questionnaire was used for data collection. Data analysis was done using SPSS statistical software version 22.0, and the level of statistical significance was determined at P-value of less than 0.05. Results: The mean age of respondents was 29.6±4.6 and 27.9±4.9 years in urban and rural areas, respectively (P≤0.001). A significantly higher proportion of women in the urban area (44.2%) had good knowledge of malaria than those in the rural area (26.2%) (P < 0.001). Comparable proportions of respondents in urban (13.1%) and rural (23.1%) areas had good preventive practices against malaria (P = 0.218). The predictor of good knowledge of malaria in the urban area was using secondary health facilities for antenatal care [95% confidence interval (CI): 1.3–4.4], whereas tertiary education (95% CI=1.1–2.3) and utilizing secondary health facilities (95% CI=1.2–2.8) were predictors in the rural area. Predictors of good preventive practice included being self-employed (95% CI=1.5–11.6) and having good knowledge of malaria (95% CI=1.3–6.4) in the urban area. Conclusion: Minor proportions of respondents in the study area had good knowledge of, and good preventive practices against, malaria. There is a need for relevant authorities to enlighten women on malaria and its preventive practices and to motivate them to practice malaria prevention throughout pregnancies. Keywords: Health facilities, knowledge, malaria, Nigeria, pregnant women, preventive practice, rural, urban
How to cite this article:
Esomonu SN, Ossai EN, Gadzama AD, Ashikeni MA, Uzochukwu BS. Knowledge and preventive practices against malaria among pregnant women in urban and rural public healthcare facilities in nigeria’s federal capital territory. Int J Med Health Dev 2022;27:81-91 |
How to cite this URL:
Esomonu SN, Ossai EN, Gadzama AD, Ashikeni MA, Uzochukwu BS. Knowledge and preventive practices against malaria among pregnant women in urban and rural public healthcare facilities in nigeria’s federal capital territory. Int J Med Health Dev [serial online] 2022 [cited 2023 Mar 30];27:81-91. Available from: https://www.ijmhdev.com/text.asp?2022/27/1/81/331733 |
| Introduction | |  |
The World Malaria Report (WMR) of 2018 indicated that 90% of deaths due to malaria occur in the African region, with pregnant women and their unborn children being particularly vulnerable to the deleterious effects of the disease.[1] Malaria infections in pregnancy remain a major public health problem in tropical and subtropical regions of the world, with substantial risks for the pregnant woman, her fetus, and the newborn child. The symptoms and complications of malaria during pregnancy depend on the intensity of malaria transmission and the level of immunity the pregnant woman had acquired.[2]
In Nigeria, malaria contributes to an estimated 11% of maternal deaths and 25% infant mortalities chiefly caused by Plasmodium falciparum through its impacts on maternal anemia, low birth weight, still births, abortions, and prematurity.[3],[4] In the African continent, about 30 million women living in malaria-endemic areas become pregnant each year. For these women, malaria is a threat both to themselves and to their babies; P. falciparum infection during pregnancy is estimated to cause about 10,000 maternal deaths, 200,000 new born deaths, and 11% of deaths from low birth weights.[5],[6]
The Roll Back Malaria (RBM) partnership recommends the use of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and insecticide-treated nets (ITNs) for effective prevention of malaria in pregnancy in areas of stable malaria transmission.[7],[8] The IPTp-SP involves providing all pregnant women with at least three presumptive treatment doses of sulfadoxine-pyrimethamine (SP) drug during routine antenatal clinic visits, starting early in the second trimester and at least 1 month apart. This approach has been shown to be safe, inexpensive, and effective. In addition, most pregnant women in areas of stable malaria transmission in Africa attend antenatal care (ANC) at least once during their pregnancy, making clinic-based prevention feasible.[8],[9]
The ITNs are low cost and highly effective way of reducing the incidence of malaria in people who sleep under them. By preventing malaria, ITNs reduce the need for treatment and the pressure on health services.[7],[10],[11] They decrease both the number of malaria cases and malaria death rates in pregnant women and their children, and their use further benefits the infant who sleeps under the net with the mother by decreasing exposure to malarial infection.[11],[12],[13],[14] The RBM partnership further recommends that management of cases of malaria illness during pregnancy should be done as stipulated in the national and WHO malaria treatment guidelines.[15],[16]
However, available studies have shown variations in the implementation of malaria prevention programmes both within and across the countries of Africa, with level of knowledge and practice significantly different among pregnant women in urban and rural areas.[17],[18],[19],[20],[21] This study aimed to determine and compare the knowledge and preventive practices against malaria among pregnant women who attend ANC at urban and rural public health facilities in the Municipal Council of Nigeria’s Federal Capital Territory (FCT).
| Subjects and Methods | | |
Description of study area
The study was carried out at public primary and secondary health facilities in Abuja Municipal Area Council (AMAC) of Nigeria’s FCT, Abuja. The Municipal Council is one of the six councils in the FCT with a land area of 156 km2 and a projected population of 2,473,764 based on the growth rate of 9.3% and a population density of 1,377 people per square kilometer.[22] The council harbors most federal government agencies and therefore home to the major and minor ethnic groups of Nigeria, as well as foreign nationals who constitute substantial part of the population. The indigenous people of the area include Gbagyi, Gwandara, and Hausa/Fulani, whose main occupation is farming and fishing at the subsistence level and mostly domiciled in rural areas. A total of 31 public primary and 6 public secondary healthcare facilities, as well as one public tertiary hospital and 315 private hospitals, are located within the Municipal Council.[23] All the health facilities conduct routine ANC services during the working days of the weeks.
Study design and population
This was a health facility-based comparative cross-sectional study. The population comprised pregnant women who registered for ANC services at the selected health facilities. Pregnant women who came for second visits and above were included, whereas those who declined consent were excluded.
Sample size determination
The minimum sample size for the study was determined by the formula for comparing two independent proportions.[24] A sample size of 520 respondents (260 each for urban and rural areas) was included in the study based on type 1 error (α) of 0.05, power of 80%, and proportions of 17.3% and28%, respectively, that used IPTp in urban and rural areas of south-east Nigeria.[18],[25]
Sampling technique
The two-stage sampling technique was used to select the study participants. In the first stage, health facilities were stratified into urban and rural areas. Out of the 37 public health facilities, the urban area has 6 public primary healthcare facilities (PHCs) and 5 general hospitals, whereas the rural area has 25 PHCs and 1 general hospital. Simple random sampling technique of balloting was used to select 3 PHCs and 3 general hospitals in the urban area and 9 PHCs and one general hospital in the rural area. This gave a total of 16 health facilities used for the study.
In the second stage, a systematic random sampling technique using facility registers was used to select pregnant women as they present for ANC services at the selected facilities on each day of data collection. The last 6 months attendance at the ANC clinics was used to determine the sampling frame. An average of 200 pregnant women present for ANC on a monthly basis at the PHCs, whereas an average of 750 clients present monthly at the general hospitals and these served as sample frames. Therefore, 60 women were allocated to the PHCs and 200 to the secondary facilities at the ratio of 1:3 proportionately. Sampling interval was determined by dividing the sampling frames by the sample sizes; hence, a sampling interval of 3 for the PHCs and 4 for the secondary facilities was obtained. So, every third client at the PHCs was included in the study, whereas every fourth client was included at the secondary facilities. The index clients in each day were selected using simple random sampling technique of balloting. Data were collected over a period of 1 month.
Study instrument
A pre-tested, semi-structured questionnaire which was developed by the researchers was used for data collection. The questionnaire contained information on respondents’ biodata and the outcome measures. Research assistants were recruited and trained to administer the questionnaire.
Data management
Data entry and analysis were done using IBM Statistical Package for Social Sciences (SPSS), version 22. Frequency tables and cross-tabulations were generated. The χ2 test and multivariate analysis using binary logistic regression were used in the analysis, and the level of statistical significance was determined by a P-value of less than 0.05. The outcome measures of the study were good knowledge of malaria and good preventive practices against malaria. Similar principles adapted from past studies were used to generate multiple choice questions to measure knowledge and preventive practices.[19],[26]
Knowledge of malaria was measured using 10 variables: a correct answer was assigned a score of 1, whereas an incorrect answer attracted a score of 0. Good knowledge of malaria was determined by the proportion of respondents who correctly answered 6 of 10 questions used to assess knowledge. Preventive practices against malaria was assessed using three variables and a correct response attracted a score of 1, whereas incorrect responses attracted a score of 0. Good preventive practices against malaria was determined by the proportion of respondents who answered “Yes” to all three questions used to assess preventive practices.
In determining the factors that affect good knowledge and good preventive practices against malaria, variables that had P-values of ≤0.2 on bivariate analysis were entered into logistic regression model to determine the predictors of good knowledge and good preventive practices. This was done separately for urban and rural areas based on the study objective. The result of the logistic regression analysis was reported using adjusted odds ratios (AORs) and 95% confidence interval (CI), and the level of statistical significance was determined by a P-value of less than 0.05.
Ethical consideration
Ethical approval was obtained from the Health Research and Ethics Committee of FCT Health Authority. The respondents were required to sign or thumb print to a written informed consent before the interviews, and the nature of the study, its relevance, and the level of their participation were made known to them. Respondents were assured that participation in the study was voluntary, and all the information provided through the questionnaire will be kept confidential.
| Results | | |
[Table 1] shows the sociodemographic characteristics of the respondents. The mean age of respondents in the urban area was 29.6±4.6 years, whereas the mean age of those in the rural area was 27.9±4.9 years (P < 0.001). Higher proportion of women in the urban area (61.2%) had post-secondary education (P < 0.001). The majority of unemployed women were in the urban area (36.9%), whereas the majority of self-employed women were in the rural area (40.0%) (P = 0.003).
[Table 2] shows the knowledge of malaria among the respondents. A significantly higher proportion of respondents in the urban area had good knowledge of malaria (44.2%) when compared with those in the rural area (26.2%) (P < 0.001). A significantly higher proportion of respondents in the urban area (80%) knew that infected mosquito can transmit malaria when compared with those in the rural area (67.7%) (P = 0.001). Comparable proportions of women in the rural area (76.5%) had the idea of IPTp when compared with those in the urban area (73.1%). Similarly, comparable proportions of women in the rural area (61.2%) knew the correct dose for IPTp when compared with those in the urban area (58.5%).
[Table 3] shows the preventive practices against malaria among the respondents. A significantly higher proportion of respondents in the rural area took drugs for IPTp (91.9%) than those in the urban area (60.8%) (P < 0.001). There was no significant difference in the ownership and use of ITNs among women in the two study groups. Respondents in the two study groups gave varying reasons for non-use of ITNs such as hot weather and the feeling of being encaged under the nets, and the difference was statistically significant (P = 0.007). Comparable proportions of women in the rural area (13.1%) had preventive practices against malaria than those in the urban area (13.1%).
[Table 4] shows the factors affecting good knowledge of malaria among respondents in the urban area. Knowledge of malaria was associated with the type of health facility where women registered for ANC. Those women who registered for ANC at secondary health facilities were twice more likely to have good knowledge of malaria when compared with those who registered at PHC facilities (95% CI = 1.3–4.4). | Table 4: Factors affecting good knowledge of malaria among respondents in urban area
Click here to view |
[Table 5] shows the factors affecting good knowledge of malaria among respondents in the rural area. Those women who had tertiary education were 1.5 times more likely to have good knowledge of malaria when compared with those who had secondary education and below (95% CI = 1.0–2.3). Also, women who registered for ANC at secondary health facilities were twice more likely to have good knowledge of malaria when compared with those who registered at PHC facilities (95% CI = 1.2–2.8). | Table 5: Factors affecting good knowledge of malaria among the respondents in rural area
Click here to view |
[Table 6] shows the factors affecting good preventive practices against malaria in the urban area. Those women who were self-employed were four times more likely to have good preventive practices against malaria when compared with those who were unemployed (95% CI = 1.5–11.6). Also, women who had good knowledge of malaria were three times more likely to have good preventive practices against malaria when compared with those who had poor knowledge of malaria (95% CI = 1.3–6.4). | Table 6: Factors affecting good preventive practices against malaria in urban area
Click here to view |
[Table 7] shows the factors affecting good preventive practices against malaria in the rural area. Those women who registered for ANC at secondary health facilities were 1.3 times more likely to have good preventive practices against malaria when compared with those registered at PHCs, but the difference was not statistically significant (5% CI = 0.7–2.6). | Table 7: Factors affecting good preventive practices against malaria in rural area
Click here to view |
| Discussion | | |
The majority of the respondents in the two study groups (80% and 67.7%, respectively) knew that infected mosquitos could transmit malaria. This is a plus for the fight against malaria as they are likely to make conscious efforts to prevent mosquito bites. Findings from studies in Ethiopia and Lagos, Nigeria showed that 90.2% and 78% of the pregnant women, respectively, were aware that infected mosquitoes could transmit malaria.[20],[27] The proportion of respondents who had good knowledge of malaria was low (44.2% urban and 26.2% rural) and significantly different in the two study groups. Two Nigerian studies recorded good knowledge of malaria scores of 71.5% and 1% in the urban and rural areas, respectively.[19],[26] A study in Burkina Faso recorded 68.2% and 53% good knowledge of malaria for women in the urban and rural areas, respectively, with women in the rural area having lower odds for good knowledge of malaria.[28] The higher proportion of good knowledge of malaria recorded in the urban area in this study could be attributed to the higher educational attainment of women in the urban area, as recorded in the previous studies.[19],[28],[29] The implication is that the poor educational attainment of women in the rural area will continue to pose significant challenge to the fight against malaria. However, a study in south-eastern Nigeria found that awareness of mosquitoes being associated with malaria was high among mothers of under five children in rural settings.[30]
From the result of this study, there was no significant difference in the preventive practices against malaria among respondents in the two study groups. A Nigerian study reported 69% practice of malaria prevention strategies in a secondary health facility.[31] However, significantly higher proportion of women in the rural area took SP for IPTp, resulting in better preventive practices among them. The possible reason may be the higher knowledge and awareness of IPTp recorded among women in the rural area. This corroborates the finding from the Nigerian study that individual women’s beliefs and lack of understanding of IPTp contribute to low uptake and adherence to IPTp.[32] Related studies in Africa have shown IPTp to be very effective in preventing maternal and placental anemia, as well as in improving pregnancy outcomes.[33],[34],[35] Therefore, the good preventive practice using IPTp recorded among women in the rural area in this study is commendable as malaria endemicity and resultant effects are known to be more severe in rural communities.[36] However, a number of African studies reported that coverage for IPTp was higher in urban than in rural areas.[16],[17]
There was no significant difference in ownership and utilization of ITNs among respondents in the two study groups. The data further show comparatively lower ITNs utilization than ownership among women in the two study groups. A similar pattern was observed in a study in Abuja, Nigeria where 42.6% of the pregnant women own ITNs but only 24.6% of them used the nets.[26] Another Nigerian study found that a high proportion of pregnant women in the rural area who own ITNs slept under them in the night preceding the survey. This was because the women received lectures on ITN use and got free ITNs.[30] The figures on utilization of ITNs by respondents in this study (23.5% urban vs. 25.8% rural) are, however, much below the revised Abuja target of 80%,[37] but compare well with the figures from Ethiopia.[21] The major reasons advanced by respondents for non-use of ITNs included hot weather (62.7% urban vs. 48.3% rural) and the feeling of being caged (7.8% urban vs. 10.0% rural). These are comparable to findings from studies in Nigeria and Kenya, as well as those from a review of available evidence across sub-Saharan Africa.[38],[39],[40]
It has been reported that improvement in knowledge and education of women of child-bearing age has an influential impact on malaria control.[27] This was demonstrated at the rural area in this study as those who had tertiary education were one and half times more likely to have good knowledge of malaria when compared with those who had secondary education and below. This further agrees with the findings from Nigeria and Tanzania that higher knowledge of malaria was significantly associated with increasing educational status of pregnant women.[19],[26],[41] Therefore, improving the educational status of women in the study groups will likely improve their knowledge of malaria.
Preventive practices against malaria was generally poor among respondents in the two study groups. However, those women who were self-employed in the urban area were four times more likely to have good preventive practices against malaria when compared with the unemployed. A similar pattern was observed in Ugandan households where those who were not employed were less likely to use mosquito nets.[42] It has been documented that knowledge of malaria is positively associated with practice of malaria prevention among pregnant women.[18],[19],[31] This was corroborated by the results of this study, which showed that those women in the urban area who had good knowledge of malaria were three times more likely to have good preventive practices against malaria when compared with those who had poor knowledge of malaria. A different scenario was also observed in Yaoundé, Cameroon, where over 50% of the respondents had good knowledge of malaria and prevention measures but less than 50% applied good practices concerning malaria treatment and prevention.[29]
Study limitations: In assessing preventive practices against malaria among the respondents, the variable, “Slept under an insecticide treated net the previous night,” was assessed based on the responses of the respondents and not by observation. This may be subject to social desirability bias on the part of the respondents. However, the respondents were duly informed that information as obtained during the study was for research purposes and not an audit process by the government or any its agencies or organization.
In conclusion, this study revealed that minor proportion of respondents had good knowledge of malaria (44.2% and 26.2%) and good preventive practices against malaria (13.1% and 23.1%) in urban and rural areas, respectively. Knowledge of malaria was associated with preventive practices against malaria in the urban area. Health education and enlightenment of pregnant women on malaria prevention should be intensified in the study area. The FCT health authorities should motivate pregnant women to embrace the use of malaria preventive measures such IPTp-SP and ITNs throughout pregnancy through provision of affordable malaria commodities at public health facilities.
Acknowledgements
The authors appreciate the cooperation from the respondents and management of the health facilities during the study period.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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