Malaria infection in children in tropical rainforest - ScienceDirect

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Asian Pac J Trop Med 2014; 7(Suppl 1): S97-S103

Contents lists available at ScienceDirect

Asian Pacific Journal of Tropical Medicine journal homepage:www.elsevier.com/locate/apjtm

Document heading

doi: 10.1016/S1995-7645(14)60212-1

Malaria infection in children in tropical rainforest: of Ugbowo Community in Benin City, Nigeria 1

assessments by women

2

Doreen N. Eugene-Ezebilo , Eugene E. Ezebilo * Faculty of Pharmacy, University of Benin, P.M.B. 1154 Benin City, Nigeria

1

Southern Swedish Forest Research Centre, Swedish University of Agricultural Sciences, Sweden

2

ARTICLE INFO Article history:

Received 1 Aug 2014 Received in revised form 20 Aug 2014 Accepted 6 Sep 2014 Available online 17 Sep 2014

Keywords: Children Malaria Mothers Perception Prevention Public health Symptoms

ABSTRACT Objective: To examine how mothers recognize malaria infection in children aged less than five and five years, frequency and duration of the infection in these children as well as measures used to reduce exposure of children to mosquito bites, and to discuss the possibilities of designing a strategy that involves mothers in management and control of malaria infection. Methods: The data were originated from personal interviews which involved mothers in the Ugbowo Community in Benin City, Nigeria who were selected using multi-stage systemic random sampling technique. The data were analyzed qualitatively and by use of percentages, arithmetic mean and bar chart. Results: The results showed that all the interviewees believed that children got malaria infection along with fever or fever and other symptoms. Approximately 30% of interviewee recognized malaria infection through fever and cough while 1% by fever and vomiting. Approximately 72% of the interviewees claimed that their children had malaria infection every three months and 16% claimed that their children had the infection every month. Most of the interviewees reported that the length of time from recognition of malaria symptoms on their children to treatment was between one and three days. Most of the interviewees used insecticide treated bed nets to reduce their children's exposure to mosquito bites and few used mosquito repellent ointment. Conclusions: For malaria management strategy to be effective and sustainable, it is important to empower women with more knowledge on detection of malaria symptoms and they should be involved in planning and designing the strategy.

1. Introduction Malaria infection is caused by a protozoan parasite of the

genus Plasmodium. The species known as Plasmodium faliparum is the most common cause of malaria infection[1]. Malaria kills many young children in sub-Saharan Africa[2]. The disease leads to numerous complications in children such as anaemia, pulmonary oedema, renal failure, hepatic dysfunction and coma[3,4]. Some of the symptoms of malaria infection are fever, vomiting, sweats, chills, cough and fatigue. Although governments of most subSaharan African countries and international community *Corresponding author: Eugene E. Ezebilo, Southern Swedish Forest Research Centre, Swedish University of Agricultural Sciences, Box 49, 230 53 Alnarp, Sweden. Tel: +46 40415197 Fax: +46 40462325 E-mail: [email protected]

have continued to invest in prevention and management of malaria, the disease has remained a major public health problem in Africa[5,6]. For example, about 90% of all deaths related to malaria occurred in sub-Saharan Africa and most affected individuals were children[7]. Malaria has been one of the main causes of death among children in Ethiopia[8]. Several malaria related deaths occurred in Burkina Faso each year[9]. Malaria has been the main cause of deaths in Nigeria especially in children[10-12]. In order to reduce malaria related incidence, several malaria control strategies have been developed such as prompt access to diagnostic testing using rapid diagnostic tests[13], homebased management of malaria[14], and use of insecticide treated bed nets and indoor insecticide sprays [15,16] . However, in order to let the control strategies be effective, locally acceptable and sustainable, it requires a multiintervention approach which involves participation of all

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Doreen N. Eugene-Ezebilo and Eugene E. Ezebilo/Asian Pac J Trop Med 2014; 7(Suppl 1): S97-S103

relevant stakeholders[17]. In recognition of the importance of stakeholders’ participation in the control and management of malaria, health managers have adopted the so called “community-based management of malaria” which aimed at involving local communities in management of malaria[18]. For the effectiveness of “community-based management of malaria”, it is important to have knowledge of local community’s perceptions of malaria and how to integrate their perceptions into management and control of malaria. C ommunity’s perceptions and attitudes are important in management of malaria because they influence the recognition of symptoms and the use of health services[19]. In the literature there are several studies that have focused on community’s perceptions of malaria. F or example, households’ knowledge of malaria [20,21], recognition of malaria related symptoms by households[22], and awareness that mosquito bites has been the main route for transmission of malaria parasites[15,23]. The frequency of malaria infection is important in ascertaining the intensity of the infection in a community. However to the best of our knowledge there is no previously published paper that has focused on frequency of malaria infection in children. This paper contributes to the literature on community’s perceptions of malaria infection in sub-Saharan Africa as well as provides more understanding on the frequency of malaria infection. Although effective treatment for malaria infection is available, the disease still remains one of the main causes of sickness and deaths in children in sub-Saharan Africa[24-26]. In some cases management and treatment of malaria infection in children are taken by parent or next of kin at home but their inability to correctly recognize symptoms related to malaria have led to death of the sick child[27,28]. The effective management and control of malaria infection will require the involvement of individuals, and local community which often bear the burden of the disease and have some experience on issues related to the infection. Since Africa mothers are often the caregivers especially on childhood ailments[11], it is important to expand women’s knowledge to correctly recognize malaria infection in children. This is important due to in most African countries especially in rural areas the nearest health centre is often far away from home. This suggests that correct recognition of malaria infection in children by mothers could help in giving the sick child an appropriate first aid treatment before taking him or her to the health centre. Malaria infection is endemic in the tropical rainforest. People often use different techniques to protect themselves against mosquito bites. These include sleeping in mosquito nets, use of insecticide spray[15,16,29], wearing clothes that could cover most parts of the body especially in

the evenings, and emptying kerosene into stagnant water to help prevent breeding of mosquito by suffocating mosquito larvae as well as getting rid of water in drainage systems. The duration of malaria infection from recognization by mother to treatment will depend on the mother’s ability to correctly identify the symptoms on time, the type of malaria parasite and the immune status of their children[30]. Thus it is important for mothers to be able to recognize the early symptoms of malaria infection to help reduce the death rate. Although in most sub-Saharan African countries the strategy for reducing malaria infection has focused on provision of effective and affordable health care, it has not been very effective. It could be the reason that local communities are rarely involved in designing and implementing malaria control strategy and local contexts, cultural changes and community perceptions are not often considered[31]. Moreover, lack of convergence of local and bio-medical perceptions of malaria contribute to high morbidity and mortality rates in sub-Saharan Africa[32]. Thus it is important to better understand regarding caregivers’ perceptions of malaria and strategy that could help strengthen management of malaria at the community[33]. The aim of this paper was to explore symptoms that mothers’ uses to recognize malaria infection in children aged less than five and five years. It also explores occurrence and duration of the infection among these children as well as measures taken by mothers to reduce their children’s exposures to mosquito bites. The possibilities of designing a strategy that involves mothers in management and control of malaria infection are discussed. T he study reported in this paper involves women of Ugbowo Community in Benin City, Nigeria. It is hoped that the findings will provide women the indigenous knowledge of malaria infection and how to incorporate this in designing an effective and sustainable management of malaria infection. This paper focused on women, for their important roles as primary caregivers at home[31]. 2. Materials and methods 2.1. The study area This study was carried out in Ugbowo located in Egor

Local Government Area of Edo State, Nigeria. The study

area has a tropical climate and has two distinct seasons, i.e. the wet season and the dry season. The wet season lasts for approximately eight months (April to November) and the dry season lasts four months (December to March).

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The area has average annual rainfall of 500 to 2 780 and

temperature between 24 °C to 33 °C[34]. Such climate provides mosquito a potential environment for breeding, i.e. vector for transmission of Plasmodium that causes malaria infection[35]. The cases of malaria incidence are much more in the wet season than in the dry season[36]. Most of the paved and unpaved road in the study area are characterised by pot holes of different sizes and the drainage systems are either faulty or non functional. Thus stagnant water is found nearly in every nook and crannies especially during the wet season, which further provides breeding places for mosquitoes. Several health facilities such as the University of Benin Teaching Hospital, private hospitals, medical laboratory centre, pharmacy and patent medicine stores are found in vicinity of the study area. The people engage in different livelihood activities such as agriculture, trading, teaching and carpentry. 2.2 Data collection and analysis The data collection was made by personal interviews[37],

which were preceded by discussions with experts and pretest interviews. The questions used for the interviews were designed with the help of researchers at the Department of Clinical Pharmacy, University of Benin, Benin City, Nigeria. The potential study was discussed with researchers whose works were related to malaria and some potential questions for the interviews were drafted. Question draft was sent to the researchers for their comments. Their comments prompted modification of the draft which was sent to the researchers again. To test the question draft a pre-test interviews was conducted in January 2002, which involves a randomly selected people from the Ugbowo community including some researchers whose works were related to malaria and those whose works were not related to malaria. They were asked to comment on whether the questions are easy to comprehend and to suggest ways of improving the questions. Some issues were raised which prompted further modification of the questions and the final questions were produced. T he main interviews were conducted from F ebruary to May and during the dry and wet seasons in order to reduce the effect of season on the results. Moreover, all the interviews were carried out from 17:00 and 19:00 in the evening when most women would have returned home. This was a way to increase chances of receiving responses from women under different socioeconomic backgrounds. Participants to the interviews were selected by multi-stage systemic random sampling[38]. Approximately 15 streets

were randomly selected from Ugbowo community and 10 houses from each of the selected street. In each of the selected houses one woman who had a child at about five years old were randomly selected and interviewed. In all 150 women were selected for the interviews. After explaining the purpose of the interview (increasing women participation in management and control of malaria infection) and assuring the confidentiality of interviewees’ responses, they were asked some demographic questions such as age, education, occupation, marital status and number of children aged five years or less. The interviewees were asked about symptoms which they often used to recognize malaria in their children. They were asked about the frequency and the duration of malaria infection in their children for the last 12 months. The interviewees were asked about the measures that they often take to reduce their children’s exposure to mosquito bites. The data generated from the interviews were analysed qualitatively by simple percentages, arithmetic mean and bar charts using the Microsoft Office Excel. 3. Results O f 150 women who were selected for the survey approximately 87% (131) agreed to be interviewed. Out of 131 interviewees, 130 of them answered all questions associated with the variables used in this analysis. The results showed that most of the interviewees were married, had secondary school education and engaged in trading shown on Table 1. Table 1 Characteristics of interviewees. Variable

Description

Marital status The interviewee marital status

93

Divorced

3

The interviewee educational level

41

Post-secondary school

5

The main occupation of interviewee

69

Unskilled e.g. cleaning

2

Student

Housekeeping

Age

54

Trading

Tailoring/hairdressing

Children

4

Primary school

Secondary school Occupation

(%)

Married

Never married Education

Persentage Mean

Civil servant

Number of children≤5 years old at home The interviewee age

15 3 8 3

3

37

Regarding the symptoms through which mothers recognize malaria infection in children, most of the interviewees

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70

Percentage

60 50 40 30 20 10 0

Fever Fever and Fever and Fever and Fever and Fever and Fever and

cough

tiredness loss of yellowing yellowing vomiting appetite of eyes urine

Signs that a child has malaria Figure 1. Symptoms used by mother to recognize malaria in children.

The results in Table 2 showed that most interviewees’

children slept under insecticide treated bed nets to reduce their exposure to mosquito bites. Only few of the interviewees claimed that they applied mosquito repellent ointment on their children. The application of mosquito repellent ointment on children under the age of 12 is forbiden. But the results showed that mosquito repellents are being abused by some residents in the Ugbowo community. Table 2 Preventive used by mothers to protect children against malaria. Preventive Insecticide treated bed nets Insecticide sprays Mosquito repellent ointment Insecticide treated bed nets and insecticide spray

Percentage (%) 60 16 3

21

Regarding the frequency of malaria incidence in children, most of the interviewees claimed that their children had malaria infection approximately four times each year and only few claimed they had malaria once a year shown in Figure 2. It is surprising that some of the interviewees (18%) reported that their children had malaria infection every month. About the duration of malaria infection in children approximately 67% of interviewees reported a duration of 1 to 3 d while approximately 29% reported that it lasted for between 4 to 6 d. Only 4% of the interviewees claimed that

malaria infection lasted for more than 6 d from the time they recognized the symptoms in their children to treatment. 80 70 60

Percentage

reported that the presence of only fever indicates that a child has been infected with malaria (Figure 1). However, other interviewees claimed that the presence of fever and other symptoms such as cough, vomiting, loss of appetite and yellow urine indicated that a child had malaria infection. Among these combinations of symptoms some of the interviewees (32%) claimed that the presence of fever and cough indicated that a child had malaria while only a few of interviewees (1%) claimed that fever and yellowing of eyes or fever and yellow urine indicated that a child had malaria. The results showed that all the interviewees can recognize the major symptoms of malaria (i.e. fever) and some of the interviewees can recognize other symptoms associated with malaria. (59%)

50 40 30 20 10 0

Monthly

Every 3 months Every 6 months

Frequency of malaria incidence

>6 months

Figure 2. Frequency of malaria in children in last 12 months.

4. Discussion Although malaria infection has various symptoms such

as fever, cough, vomiting, fatigue and headache the results from this study showed that 100% of the interviewees can recognize the major symptom of malaria in children, i.e. fever. In Nigeria and elsewhere in Africa once a child appears to be sick the first thing that mothers often do is to place their hands on the child’s skin to explore whether his or her body temperature is above normal. This could be a potential reason that all the interviewees claimed that fever was one of the symptoms of malaria. The result is consistent with findings from elsewhere in Africa. It is found that approximately 99% of urban Douala residents in Cameroon can recognize symptoms of malaria infection[22]. However, the finding from this study differs from that of other studies such as 50% of households around Chad-Cameroon pipeline can recognize malaria symptoms[20]. Also 50% was reported for households in rural Swaziland[21]. A possible reason for difference in the findings could be that this study was conducted in an urban area and focused on mothers who were often primary caregivers. Moreover, all the interviewees had formal education and they lived in the vicinity of several health facilities such as teaching hospital which might help in increasing their awareness of major symptoms related to malaria infection. It is important for health education on malaria awareness to focus more on these less known symptoms. Concerning other symptoms of malaria such as cough, tiredness and vomiting they appear when the malaria infection is not treated at early stage. The results from this study suggest that most of interviewees initiate treatment in their children at the early stages of malaria infectiont. Thus they do not often witness other symptoms at infection later stages. In the case of fever associated with other symptoms such as cough and vomiting, when their children felt feverish they administered analgesic such as paracetamol


and did not take their children to hospital until other symptoms manifested. So it is importance to make correct and timely recognition of malaria infection symptoms in children and to seek medical help as soon as possible. It is also important for mothers, whose houses are located far away from health facilities, to have better knowledge on how to administer initial aid treatment to malaria infected children before taking them to the hospital. It is common practice that among some African women they soak a clean towel in cold water and use it to clean the sick child’s body to lower his or her body temperature to normal. This may reduce the tendency of malaria infection to later dangerous stages that could lead to death of the child. Due to children aged five and less than five years may not be able to say exactly how they feel, it is important for mothers to be well informed about malaria infection. It is important to note that there are other conditions with symptoms similar to malaria infection. This implies that mothers should not administer malaria drugs to a sick child until they had the doctor’s appropriate diagnosis. The results from this study support the premise that mothers could serve as a good primary caregiver especially childhood ailments. Preventive that reduces children’s exposure to mosquito bites lowers the incidence of malaria infection in children. One of the cheapest and most effective methods for reducing children’s exposure to mosquito during night time is to sleep under insecticide treated bed nets. The bed nets can be used for a long time with little maintenance and it will not pose threat to the environment. This could be the reason that most of the mothers who were interviewed claimed that they used bed nets to prevent their children from mosquito bites. The finding is in line with that of Nahum et al.[16], who found that use of bed nets lowers risk of malaria infection. This is also supported by Valea et al.[29], who suggested that women should use insecticide treated bed nets during and after pregnancy to help reduce incidence of malaria infection. The finding of this study differs from that of Jombo et al.[15], which shows approximately 43% of children in Makurdi, north-central Nigeria used bed nets. A possible reason of the difference is that our study focused on most children at five years old and all the interviewees had formal education while the study by Jombo et al.[15], focused on all ages of children and some of the interviewees do not have formal education. Although use of indoor insecticide sprays is effective in reducing children’s exposure to mosquito bites, it is expensive and might pollute the environment and sometimes could risk human health if not properly used. Mosquitoes could develop resistance to chemicals used in producing insecticide sprays[16]. Considering this further increases in malaria infection burden, some mothers may be less willing to use insecticides for controlling mosquitoes.

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Moreover, the effectiveness of insecticide sprays lasts for only few hours. This could be the reason that only 16% of the

interviewed mothers reported that they use only insecticide sprays for reducing children’s exposure to mosquitoes. It is surprising that some mothers use mosquito repellent ointment which is meant for only people from 12 years old on their children. This is a case of drug abuse and may lead to complications in children. It is important to educate residents in the Ugbowo community on the appropriate use of mosquito repellent ointment. The results on frequency of malaria infection among children aged less than five and five years in Ugbowo C ommunity serve as evidence that tropical rainforest provide conditions that promote breeding of mosquitoes. Due to stagnant water is found in every nook and cranny of the Ugbowo Community it further highlights the availability of breeding places for mosquitoes throughout the year which implies that most children who are often exposed to mosquito bites may be infected easily with malaria. It could be that the increase in the frequency of malaria infection among children is due to re-infection from other malaria patient in the Ugbowo community. This suggests that control and management of malaria should focus on individual and community levels. It is worrisome that about onefifth of the women who were interviewed claimed that their children had malaria infection every month. It may be that the women do not often use appropriate preventive measures against mosquito bites. To help reduce frequency of malaria infection in children, it is important for mothers to use different methods that reduces the exposure of children to mosquitoes such as making sure that children put on dresses which covers most part of their body parts especially in late evenings, children should stay indoors in late evenings and children should often sleep under insecticide treated bed nets. The duration of malaria infection in children (i.e. length of time from emergence of symptoms to treatment) will depend on timely recognition of symptoms and administration of appropriate treatment. Inability to identify symptoms of malaria infection on time will increase it negative effects on children[27,28]. Moreover, the duration of malaria infection depends on the species of the malaria parasite, the child’s immune status and whether the child has been infected before[30]. The results from this study revealed that most of interviewees administer treatment within three days of recognition of malaria infection symptoms. This may be due to the presence of different health facilities in vicinity of the Ugbowo Community which might have motivated mothers to seek medical help at the moment that they notice malaria related symptoms in their children. Once mothers noticed malaria related symptoms on their children, they initiated

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treatment at home and moved the children to hospital when their conditions worsened. It is the reason that their children got malaria infection for a few days. It could be the reason that some mothers do not often administer complete drug dose to their children which in turn leads to re-infection. To help reduce infection time, it is neccessary for mothers to identify malaria symptoms in their children as early as possible and seek appropriate medical help immediately. M others should also strive to see whether a sick child completes his or her drug dose. R egarding the methodological aspect in designing questions for survey it is important to involve all interest groups. T he tradition, customs and interests of the participants to the survey should be considered in the design. It is important to test and re-test the questions before carrying out the main survey. This will help increase response rate as well as make the design of the questions more understandable. If the strategy is to promote participation of mothers in the control and management of malaria infection in children women should be trained on recognition of early infection symptoms and the first aid treatment. Women should be well informed on the importance of visiting the hospital immediately when they notice abnormalities in their children and giving sick children complete dose of the prescribed medicine. They should also be informed on the importance of reducing exposure of their children to mosquitoes. It is important for health authorities to make insecticide treated bed nets available at subsidized rates so that women in different income groups could get access to it. This will help in the control and management of malaria at individual and community levels. This study aimed to investigate knowledge which mothers have about malaria infection in children aged five and less than five years in a community of sub-Saharan Africa. The findings showed that most mothers can recognize one of the major symptoms (i.e. fever) related to malaria infection and children mostly had the infection four times each year. Mothers mainly use insecticide treated bed nets to reduce exposure of children to mosquito bites and consequently it lower risks of malaria infection. Although few use mosquito repellent ointment, it is important to note that the repellent is mainly meant for children from 12 years old. The findings contribute to more understanding on mothers’ perceptions of malaria and how to involve them in designing and planning malaria management and control strategy. Conflict of interest statement We declare that we have no conflict of interest.

Acknowledgements We thank all interviewees in Ugbowo Community and the members of staff in the Department of Clinical Pharmacy, University of Benin, Nigeria who spent their valuable time on the interviews and questions modification. We would like to thank Pharm. (Mrs.) O.E. Aghomo, Department of Clinical Pharmacy, University of Benin, Nigeria for her

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