Zerihun Zerdo Zeleke

PhD summary

Introduction

Malaria remains a public health problem in economically disadvantaged, low and middle-income countries (LMICs), particularly in the Africa region of the World Health Organization (WHO). Globally, an estimated number of malaria cases were reduced from 238 million in 2000 to 229 million in 2019. Of the total 241 million malaria cases and 627 thousand deaths due to malaria in 2020, 95% of the cases and 96% of the deaths occurred in the WHO African region. The high burden of malaria in 2020 was due to the malaria prevention service disruption by the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The WHO and the world malaria community envisioned to see the world free of malaria by 2050. To realize this vision, malaria prevention strategies such as artemisinin-based combination therapies and vector control strategies are widely implemented. Because of the widespread use of these interventions, malaria substantially decreased in the last two decades.

In malaria endemic settings, age is a predictor of disease as antimalarial immunity develops due to frequent exposure to malaria parasites. The decline in the malaria burden led to an age-shift in the susceptibility pattern of malaria. Due to less exposure of under-five years old children to Plasmodium species, school-aged children (SAC) have not acquired functional antimalarial immunity as compared to the same age groups before the decline of malaria and become more vulnerable to malaria. In the recent malaria indicator survey in Ethiopia, the highest prevalence of malaria was seen among SAC. Furthermore, many infections were asymptomatic and persist for a longer duration among SAC as compared to children under the age of five years and pregnant mothers. They also carry a large number of gametocytes and thus, play a major role in the transmission dynamics of malaria. Ultimately, asymptomatic infections progress to clinical malaria and associated problems such as low school achievements, low cognitive performance and cognitive sequelae after severe malaria.

Despite the increased prevalence of malaria, malaria associated morbidities and their major contribution in malaria transmission dynamics, SAC were not given the emphasis that they deserve from the national malaria programs. Their adherence to malaria prevention measures like bed net utilization and prompt diagnosis and treatment from a health facility was the lowest as compared to other age groups. Consequently, several research groups recommend well-tailored malaria prevention education (MPE). However, little is known about how and where MPE should be given.

Objectives

The general objective of this thesis was to assess perceptions and additional impact of MPE on the use of malaria prevention measures and incidence of malaria among schoolchildren in Southern Ethiopia.

Specific objectives

1. To explore parents perception of cause of malaria and their malaria prevention experiences among SAC
2. To estimate long‑lasting insecticide‑treated bed net ownership, utilization and associated factors among SAC
3. To estimate the prevalence and associated risk factors of asymptomatic malaria and anemia among SAC
4. To assess the effect of MPE on bed net utilization, incidence of malaria and treatment seeking among SAC in Southern Ethiopia
5. To evaluate the implementation of malaria prevention education in southern Ethiopia via qualitative methods  

Methods

The thesis employed a cluster randomized controlled trial with an embedded qualitative evaluation. To develop MPE, parent’s perception of cause of malaria and their malaria prevention experiences among SAC were explored in Kutcha district. Semi-structured interviews and focus group discussions with parents of SAC and key informants were made. The collected data were analyzed thematically with a focus on the three major areas of concern: perceived cause of malaria, experience of malaria prevention and challenges of bed net use for malaria prevention.

After MPE was developed following the findings of the above qualitative study, a cross-sectional survey as baseline part of the cluster randomized controlled trial was conducted (PACTR202001837195738). The baseline survey assessed the bed net ownership by households, bed net utilization by SAC, the prevalence of malaria and anemia and their associated risk factors in Dara Mallo and Uba Debretsehay districts. Data were collected from SAC and households through face-to-face interviews; malaria was diagnosed by using a rapid diagnostic test (RDT); hemoglobin concentration was determined using hemoCue hb 301 and adjusted for altitude to determine anemic status; helminth infections were determined by using stool kato-katz thick smear technique and anthropometric measurements were made to determine nutritional status of children.

After the baseline data was collected between October and December 2019, MPE was delivered to selected SAC and one of their parents in cluster randomly assigned intervention schools by trained science teachers from each of the intervention schools. The teachers were trained on the cause of malaria, consequences of malaria, symptoms of malaria and malaria prevention measures among SAC. The training for science teachers was delivered by the research team members from Arba Minch university. The delivery of MPE was monitored by independent monitors, who were not part of the research team to minimize bias.

Within two weeks after MPE was delivered to children and their parents in the school-compound, we assessed how the participants experienced the MPE; the challenges for the success of the training, anticipated challenges to practice as per the protocol of the trial interventions. One year after MPE was given, the bed net ownership, bed net utilization, reported cumulative incidence of malaria and treatment seeking behavior from a health facility as the 1^st choice was assessed by a survey. The data collected by using android version ODK data application tool were converted to CSV data by ODK briefcase and transported to R statistical software for data cleaning and analysis. Mixed effects logistic regression using school as a random variable was used to assess the association between predictor variables and the outcome variables: bed net ownership, bed net utilization, infection status of malaria, anemia, reported cumulative incidence of malaria, treatment seeking from a health facility as a first choice of malaria treatment. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were used to determine the strength and statistical significance of association. After data collected for quantitative evaluation of the trial, the barriers and facilitators for bed net utilization and prompt diagnosis and treatment (PDAT) of malaria were explored through a qualitative study with intervention implementers, recipients and key informants. The interviews were transcribed verbatim and analyzed thematically and the analysis was supported by Nvivo- a software package.

Results

Analysis of the data collected to address the parents perception of cause of malaria and their malaria prevention experiences among SAC identified five themes as suggested cause of malaria, namely hunger, mosquito bite, exposure to hot sunshine, poor sanitation and hygiene and eating some sweet foods and unripe maize. Participants perceived that eating sweet foods and unripe maize lead to enlargement of the spleen that ends in malaria while poor hygiene and sanitation leads to either development of the ova of mosquito and the landing of a housefly to contaminate food for consumption. The experiences of malaria prevention were largely influenced by their perceived cause of malaria. The malaria prevention measures undertaken by parents were vector control measures, homemade herbal remedies and restricting children from eating the above food. The challenges of malaria prevention by using bed nets were related to a negative attitude, sleeping behaviors of children, use of bed nets for unintended purposes, shortage of bed nets and delays in the distribution of bed nets.

At baseline, the ownership of at least one LLINs by households of SAC was about 19.3% (95% CI: 17.7-21.0%) but only 10.3% (95% CI: 7.7-13.7%) of these households had adequate access for the household members. About 7.8% (95% CI: 6.7-10.0%) of all SAC participated in the study and 40.4% (95% CI: 57.4-66.7%) of children conditional to owning at least one LLINs in the households slept under LLIN the night before the survey. LLIN utilization by SAC conditional to the presence of at least one in the household was significantly associated  with education level of the mother above grade 6 (adjusted OR= 3.4; 95% CI: 1.3-9.3) and the household size to bed net ratio less than or equal to 2 (adjusted OR= 20.7; 95% CI: 4.7-132.5). 

The baseline survey also revealed that the overall prevalence of malaria was 1.6% (95% CI 1.2 -2.3%) (35/2,167). Of the 35 children positive for malaria, 20 (57.1%), 3 (8.6%) and 12 (34.3%) were due to Plasmodium falciparum, Plasmodium vivax or mixed infections respectively. The odds of malaria was significantly lower among children from literate household head (Adjusted OR=0.38; 95% CI: 0.15-0.95) and residence house located at an altitude range above 1,100 MASL (AOR=0.40; 95% CI: 0.17-0.94).

The ownership of bed net in the households of the control and intervention schools was similar respectively, with 84.6% and 88.6% (Crude Odds Ratio (COR): 1.5; 95%CI: 0.5-4.8). The percentage of SAC slept under the bed net  the night before the survey was also similar (55.1% versus 54.0%); COR=1.04; 95%CI: 0.5-2.4). Bed net utilization was affected by household size to the bed net ratio ≤2 (AOR=1.6; 95% CI:1.3-2.1), bed net utilization at baseline of the study (AOR =2.3; 95%CI:1.5-3.6), and history of malaria attack in the last twelve months (AOR=1.3; 95%CI:1.01-1.8). Reported cumulative incidence of malaria and treatment seeking from a health facility by SAC was similar between intervention and control arms: -2.1% (COR=0.8; 95%CI: 0.5-1.5) and 9.6% (COR =1.4; 95%CI: 0.4-4.3) respectively. The reported incidence of malaria was affected by altitude (AOR=0.5; 95%CI: 0.3-0.8), low and medium wealth index (AOR=0.7; 95%CI: 0.5-0.96 and AOR=0.7; 95%CI: 0.5-0.98), adequate number of bed nets for household members (AOR=0.7; 95%CI:0.5-0.9) and bed net utilization (AOR=1.3; 95%CI:1.1-1.8).

In the qualitative evaluation of MPE, four themes were identified. These were the setup of the training, challenges for the success of the training, anticipated challenges for practice as per the protocol and experienced immediate influences of the training. Participants appreciated the training:  content covered, way of delivery and the mix of the participants. The context specific facilitators to bed net utilization were the collateral benefits of ITN use and perceived at high risk of malaria while its barriers were quality and quantity of the bed nets, bed net associated discomforts, malaria health literacy and housing condition. The severeness of malaria symptoms and malaria health literacy were reported as both barriers and facilitators of the PDAT of malaria. The identified facilitators of PDAT of malaria were health professionals’ attitude and exposure to MPE; and its barriers were poverty, use of traditional medicine, health facility problems and SARS-CoV-2 pandemic.

Conclusion and recommendation

The prevalence of malaria in Dara Mallo and Uba Debretsehay districts was very low and all the infections were asymptomatic. The bed net utilization by SAC was also far from the universal coverage target. The prevalence of malaria and use of malaria prevention measures were associated with formal education. In addition, parents of SAC associated malaria with multiple causes and their perception of the cause of malaria highly influenced their malaria prevention measures among SAC. In our study, the MPE had no effect on the use of malaria prevention measures considered and reported cumulative incidence of malaria but we observed a massive increase in bed net use after bed net distribution by the national malaria elimination program.

The study area may be targeted for malaria elimination. Strategies targeting asymptomatic infections are highly imperative to assist the elimination efforts of the national malaria elimination program. Thus, complex implementation studies targeting from awareness creation campaigns to behavioral changes in the practice should be conducted after ensuring access to the malaria prevention measures and considering the identified barriers to the successful implementation of MPE. The functional literacy adult education program in Ethiopia may be one of the platforms to be strengthened by giving due emphasis to malaria in the health theme section of the program.