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A Study on Knowledge, Attitude and Practice about Malaria Awareness and Bed Net Use Zangpo, Kado; Zangpo, Nado; Poulsen, Kjeld between 2008-06 and 2008-08

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 A Study on Knowledge, Attitude and Practice about Malaria
Awareness and Bed Net Use
Kado Zangpo*, Dr. Nado Zangpo", and Dr. Kjeld Poulsen***
Abstracts
The purpose ofthe KAP Study was to determine the community
perceptions in terms of malaria cause, prevention and
treatment, and also to find out the extent of bed net use and
the factors associated with the net use.
The study was carried out in two malaria hyper-endemic
districts of Sarpang and Samdrup Jongkhar covering four rural
areas and two urban areas with 250 households and 1415
members.
92%> of the household members sleep under a mosquito net.
87% ofthe nets are treated with insecticides. And 35.6% ofthe
respondent had encountered some problem in using the treated
nets, primarily as skin irritation. A total of 81 persons (5.7%)
were diagnosed and treated for malaria in 2001. On an
average 19.6% ofthe households had at least one member who
had malaria in the past 12 months. The gewogs of Chuzagang
and Bangtar had one third of their households with at least
one member contracting malaria. Farmers and household with
more than 6 members had more than two times the risk of
having a household with malaria compared with other
variables. Also households where they know malaria can be
dangerous, if they are sure neighbour had malaria and using
preventive measure other than nets then the risk of getting
malaria is comparatively high. Probably this indicates that
people must be living in high incidence areas except from usage
'Principal   Researcher,   Health   Research   and   Epidemiology   Unit,
Ministry of Health. Any correspondence with regard to this study
should be addressed to the Principal Researcher.
**   Dr.    Nado   Zangpo   was   then   Program   Manager   for   Malaria
Programme.
*** Research Adviser to Health Ministry.
 Journal of Bhutan Studies
other than nets. The results are also significant when tested in
a multivariate statistical model.
35.6% of the respondents had encountered some problem in
using the treated nets, primarily as skin irritation. This survey
points that it should be possible to reduce side effects
substantially in Bhutan too. This may be very critical to the
program if it means that people will stop using nets because of
the side effects.
It is suggested that awareness and prevention should be more
differentiated on how to protect, and when to protect at all
places.
It should be considered whether delay plays an important role
for malaria morbidity and mortality in Bhutan, and if more
efficient measures could be implemented to prevent mortality
and severe morbidity especially in localities where falciparium
incidences are increasing.
Background
Malaria is an age-old problem for the Bhutanese community
and the cause many felt was because of intensive heat. Even
today, many of our people do not know that the malaria is
caused by the infected mosquito bites. To mitigate the
malarial deaths a survey was conducted which resulted in the
establishment of the National Malaria Eradication Program
(NMEP) in 1964. NMEP was later renamed as National
Malaria Control Program (NMCP) on realization that malaria
cannot be eradicated.
Malaria is a public health problem with the Annual Parasitic
Incidence (API) ranging between 66.2 to 19.9 per thousand
over the five-year period from 1995 to 1999. What is more
alarming is the rising trend of Plasmodium falciparum from
1998 onwards. This parasite falciparium is the most fatal
malarial parasite known so far. Also the latest genetic
analysis of the largest survey carried so far on Plasmodium
falciparium lends weight to the argument that the parasite is
136
 Malaria Awareness and Bed Net Use
worryrngly adaptable to anti-malarial efforts. This is of a
major concern, as malarial treatment in the coming years
might increasingly become more complex. And the fact that
more than half of the country's population is at varying risk
of malaria also justifies the National Malaria Program (NMCP)
to develop preventive strategy. The preventive strategy is how
to inform, educate and communicate (IEC) on the disease
awareness. Little is known if this strategy had worked in the
past. But there has been substantial reduction of malaria
morbidity and mortality since 1995. With the inception of 9th
Five Year Plan where Health Department is gearing towards
quality assurance and standardization of health services, it is
time to reassess, evaluate and also to consolidate the
achievements made thus far. This wiU also help to
understand the problems and seek for appropriate and cost
effective solutions. This calls for an assessment to be carried
out. Therefore this study is not only timely but a necessity in
the wake of scarce resources.
Methods
The study was carried out in two malaria hyper-endemic
districts of Sarpang and Samdrup Jongkhar covering four
rural areas and two urban areas. The district and the blocks
were chosen randomly. The rural areas covered 200
households whtie urban covered 50 households. This is a
cross sectional study and the unit of enumeration is
household.
The households were selected using the systematic skip
interval with replacement. The first household was chosen
using the simple random number table. For urban centers
where complete household listing was not available, blocks
(5-10 households) were formed. Using the same procedure as
above blocks and households were then selected for
enumeration respectively.
Concurrent to this survey (1st May 2002-20th May 2002),
anemia survey was also taking place. Both the survey needed
malaria   technician.   Therefore   the   need   to   have   malaria
137
 Journal of Bhutan Studies
technician as survey enumerators could not be realised. So
the lab data (blood sample for malaria test) proposed in the
study protocol could not be carried out.
The quantitative data were coUected through structured
questionnaire interview by the enumerators who were mostly
health personnel trained for two days (29th & 30th Aprti 2002).
The qualitative data was coUected using Focus Group
Discussion. In total four FGDs were conducted; two each in
urban and rural. The discussion was conducted in local
dialect by the team coordinator.
Data entry, data cleaning and data analysis was done using
Epi Info 6, SPSS, Statistix and SAS.
Results
The survey covered a total of 250 households with 1415
members. The respondents preferably were the head of the
households and the most appropriate substitutes were made
where the head of the households were not available. 67% of
the respondents were male with significantly higher male
prevalence in the two urban centers (82% versus 62%
p=0.01).
The mean age of the respondents were 42.9 years. The head
of the households were older in Orong and Bangtar compared
to the rest of the gewogs. The average size of the households
was 5.7 persons. Almost three quarters of the respondents
were farmers. People working in government and business
were mainly located in the two urban centers.
92% of the household members sleep under a mosquito net.
87% of the nets are treated with insecticides. And 35.6% of
the respondents had encountered some problem in using the
treated nets, primarily as skin irritation.
A total of 81 persons (5.7%) were diagnosed and treated for
malaria in 2001. On an average 19.6% of the households had
at least one member who had malaria in the past 12 months
138
 Malaria Awareness and Bed Net Use
from the date of survey. The gewogs of Chuzagang and
Bangtar had the highest prevalence of malaria (see figure 1).
About one third of the households in these two gewogs had at
least one member contracting malaria during the same year
(see figure 2).
Figure 1: Annual prevalence of household members with
malaria in 2001.
40
30
20
10
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Figure 2: Prevalence of households with at least one member
who had malaria in 2001
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139
 Journal of Bhutan Studies
a) Relation between background variables and malaria
The relation between a household where there had been at
least one case of malaria in the preceding twelve months and
a set of explanatory variables are shown in table 1. The
farmers have 1.8 times higher risk of getting malaria
compared to other occupation. Odds ratio is equivalent to risk
ratio. (OR 2=double risk, l=equal risk, 0.5=half risk and so
on)
Table 1. Variables having significant co-relation with household
experiencing at least one malaria case in preceding 12months
Variable
Odds Ratio
(OR)
U-CL
L-CL
p-value
Farmer vs. other jobs
2.8
1.2
6.6
0.018
Household > 6 persons
2.2
1.1
4.3
0.015
There are no bi-variate relation between age and gender of the
respondents and the prevalence of malaria.
b) Relation between knowledge and causes of malaria
Three quarters of the respondents correctly believed that
malaria was caused by mosquito bites. But there was no
difference in malaria prevalence compared with those who did
not relate malaria to mosquitoes (OR=l.l). Not knowing the
cause of malaria at all, were also not associated with malaria
prevalence. Most people were aware of the symptoms of
malaria, and almost everyone would contact the modern
health care facility because they think they can cure the
disease.
c) Relation between prevention and malaria
23.6% of the households additionally used other than net to
protect themselves from malaria. And they have a lower
prevalence of malaria compared with people not using any
preventive measures. From table 2 we observe that knowledge
about the severity of malaria and if at least one member of a
neighbour household had malaria is positively associated
with the prevalence of malaria.
140
 Malaria Awareness and Bed Net Use
Table 2. Household experiencing at least one malaria case in
the past 12 months dependent on knowledge attitude and
behaviour.
Variable
OR
U-
CL
L-
CL
p-value
Fully agree that you can die from
malaria vs. less/not agree
2.4
1.2
5.1
0.01
Sure that at least one neighbour
household had malaria last year
4.8
2.3
9.9
<0.001
Using other things than
nets: coil, fire, smoke
0.4
0.1
0.9
0.02
Only 168 households were able to teU when they were last
informed on how to protect themselves from malaria. 47 of
these were informed more than one year prior to the survey.
However, there are no association between time of
information and prevalence of malaria. Likewise, there is no
statistical association between malaria prevalence and if the
surveyors found that the household actually applied with the
recommendations or not.
d) Bed-net use and malaria
Since more than 90% of the household members were using
nets, there are limited possibilities to contrast net usage and
malaria. The prevalence of malaria is not related to using bed
nets in the household (OR=0.9).
There was no association between malaria prevalence and
whether the nets were treated more than two months ago or
recently. Many had irritation of the skin, especially in the face
and on the hands, but irritation is not related to a higher
prevalence of malaria.
The overall picture of the influence of factors on the
prevalence of malaria is shown in figure 3 below. The odds
ratios are transformed to a risk scale where positive and
negative factors have the same scale, and 0 means the factor
has no influence on the outcome. Now a preventive influence
141
 Journal of Bhutan Studies
is shown to the left of the no effect tine, and risk factors with
negative influence are shown to the right.
Figure 3
Bivariate: Risks affecting malaria prevalence during the last year
Ifthe Rjskis 0 there is no difference between the two groups compared (e.g. male vs. female)
[A risk= 1.0 is double the risk of having malaria gwen the e xposure. Likewise, risk=-1.0 is half the risk! ]
Tlie vertical bar is the point estimate ofthe risk, and the bars the lower and upper 95% confidence limits.
Protective/preventive
Harmful/ne gative
Use other preventive measures
Urban population
Male
All sleep under a net
Net treated > 2 months ago
Don't know cause of malam
Mosquitoes causes malaria
Health is better than good
Got information > 1 year ago
Have problems treating nets
> 6 members per household
Know you can die from malaria
Is a farmer
> 1 neighbor had malaria last year
142
 Malaria Awareness and Bed Net Use
Figure 4
Multivariate: Risks affecting malaria prevalence during the last year
Stepwise multivariate regressionkeepingvariables in the nwdel if p<J.lQ
Hosmer and Le meshow Goodness-of-fit test p=0.223, meaning an ac ceptable fit of the model
Use other preventive measures
Urban population
Male
All sleep under a net
Net treated > 2 months ago
Don't know cause of malaria
Mosquitoes causes malaria
Health is better than good
Got information > 1 year ago
Have problems treating nets
> 6 members per household
Know you can die from malaria
Is a farmer
> 1 neighbor had malaria last year
Prote ctive/p reventive Harmful/ne gative
1  -9    -8   -7   -(    5     i   -3   -1   -1    (I    1    1    3     i    S    t    1    8    9   10
To find out how these factors might influence the 12 months
malaria prevalence, a multivariate logistic regression was
performed. The fuU model included aU the factors from the
figure above. The factors that did not influence the outcome
were eliminated from the model (stepwise elimination). The
final model is the ones that are statisticaUy significant.
The factors with a p<0.1 stays in the model. Only four factors
(household with members more than 6, know you can die
from malaria, farmer, knows at least one neighbour had
malaria last year)  stayed in the model (see figure 4).  The
143
 Journal of Bhutan Studies
parameter estimates and confidence limits are shown in the
figure.
In conclusion the most important factor predicting if famtiy
members have had malaria was if at least one member in one
of the neighbouring households had malaria. Farmers were
more often in a risk of getting malaria. Factors like net use,
problems with insecticide treatment of nets, gender, age, had
no influence on the 12 months malaria prevalence. The
majority were using preventive precautions and the few who
didn't were not enough to show any effect on the incidence of
malaria. One third had problems with treated nets. Is it
because people are not applying the insecticide correctly? Or
is it because of insecticide itself?? It should be considered to
repeat this survey to get information on other preventive
measures, and to follow the development of malaria.
Discussion
One third of the respondents got skin irritation using
synthetic pyrethroid (deltamethrin) treated nets. Simtiar side
effects have also been reported where pyrethroid
(deltamethrin) was used to treat bed sheets and blankets
thereby directly coming in contact with the skin. So
pyrethroid (deltamethrin) is actually skin irritating in
practice. Bioassay results showed that deltramethrin is better
to ktil anopheles mosquitoes with an effect of 99.7 to 100%
whtie other insecticides showed a lower efficacy from 80-89%
Field trials conducted in Kenya and Ghana using pyrethroid
treated nets showed reduction in child mortality by one sixth
in Ghana and by one third in Kenya. Therefore we know that
pyrethroid are the most effective impregnation protecting from
mosquito bites. However a low rate of side effects were found
if nets were initiaUy treated with the high dose of
deltramethrin, foUowed by more frequent but lower dosage
and the efficiency was found to be same. An explanation to
the problem of skin irritation may be that people are not
following the optimal treatment requirement with insecticides.
This survey points that it should be possible to reduce side
effects substantially in Bhutan too. This may be very critical
144
 Malaria Awareness and Bed Net Use
to the program if it means that people will stop using nets
because of the side effects. Therefore there is a need to find
out if nets can be treated with pyrethroid in a way where
there are fewer side effects.
The net usage is high in Bhutan and non-compliance was not
associated with increased malaria prevalence since malaria is
also contracted when not covered by a net. Therefore other
exposures must also be considered in the preventive strategy
design. This survey actually points at the structure of houses
as a cause for being exposed to mosquitoes since majority
(97%) has had major crevices. Studies in northern Malawi
have shown that children living in improved housing were
44% less likely to have respiratory, gastrointestinal or
malaria. It is suggested that awareness and prevention
should be more differentiated on how to protect, and when to
protect at aU places.
The problem with the increased incidence of Plasmodiun
falciparium is that it is much more severe with faster effect
and is clearly the most fatal one. This means people should
be aware of early treatment especiaUy when severe symptoms
appear. A study carried out in the region also points that
most falciparium death are encountered where there is delay
in clinical diagnosis and pre-hospital phase. People should be
made aware on the needs of early treatment especially for
places where falciparium incidences are increasing. Therefore
it should be considered whether delay plays an important role
for malaria morbidity and mortality in Bhutan. And if more
efficient measures could be implemented to prevent mortality
and severe morbidity especiaUy in localities where falciparium
incidences are increasing.
References
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 Journal of Bhutan Studies
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