Abstract

Background: Malaria is a major public health problem with about 3.4 billion people at risk worldwide.

This study aimed at assessing the knowledge, attitudes, and practices of Community Health Workers (CHWs) in the prevention and control of malaria in the Bamenda Health District.

Method: A community-based cross-sectional survey involving 135 study participants was conducted using a structured questionnaire focusing on knowledge, attitudes, and practices of CHWs in malaria prevention and control.

Data were analyzed using Epi Info version 3.5.4 and the knowledge, attitudes, and practices of CHWs were measured using frequencies and percentages.

Result: All the participants have heard of malaria, 97.8% of participants knew malaria was transmitted by infected mosquitos, 95.5% knew the most common signs/symptoms of malaria is high temperature/fever, 98.5% of participants knew that sleeping under bed nets protect against mosquito bites.

The attitudes of CHWs regarding malaria prevention and control were somewhat good with 97.0% of participants believing malaria is a life threatening disease and 92.6% believing it is best treated in hospital.

Few CHWs (4.0%) believed that malaria is caused by witchcraft and is best treated by traditional doctors or with herbs (3.3%). CHWs practices regarding malaria were also good with most CHWs involved in the distribution of nets (82.7%). Only being married, divorced, separated, or widowed compared to being single had a statistically significant association with having knowledge on malaria prevention and control.

Conclusion: Participants’ knowledge on malaria was high, their attitudes and practices regarding malaria control were good, and being married, divorced, separated, and widowed when compared to single participants had an association with CHWs knowledge on malaria prevention and control. CHWs need more education and training on malaria and further studies involving many CHWs for longer durations should be done to find other correlates of CHW’s knowledge on malaria prevention and control.

CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Malaria is a global threat to humanity and a major public health problem. Worldwide 3.4 billion people are at risk of malaria. The World Health Organization (WHO) report an estimated 198 million cases of malaria in 2013 which accounted for 584.000 million deaths.

Of these, 54% of cases and 90% deaths occurred in Africa [1].Globally, the prevalence of malaria was 80% in Africa, 13% in South East Asia  and 6% for the Eastern Mediterranean regions.

The international community, therefore, recommended that endemic countries needed to reduce the incidence by 60% in order to achieve the millennium development goals (MDG) six.

Malaria is a major public health problem in Cameroon. It is endemic nationwide and 71% of the population lives in areas of high transmission [2].

Four species of plasmodium are responsible for malaria infection worldwide, namely Plasmodium falciparium, malariae, ovale and vivax [3]. A fifth specie Plasmodium knowlesi [3] was identified in South East Asia.

It is a zoonotic disease. Equally it affects humans and has been responsible for 6 deaths out of 14 in Sabah Malaysia [4, 5]. Plasmodium falciparium is responsible for severe form of malaria (6). Malaria is transmitted by the bite of an infected female Anopheles mosquito.

The mosquitoes find favorable breeding grounds in pool of clean stagnant water usually in old motor tyres, open tins, pot holes, dishes and water logging plants such as cocoyam and plantains etc [7]. It is noted that, malaria infection occurs in the dense equatorial forest of the south as well as in the three northern dry savannah and Sahelian regions of Cameroon.

Worldwide 80% 0f the people who die of malaria are children less than five years [8, 9]. The burden of the disease is high especially in Sub-Sahara Africa [1] and in Cameroon malaria account for 30% morbidity cases, 36% outpatient consultation, 67% childhood death and 48% of hospital admission[8] and families spends their merger resources in the treatment of malaria rather than spending on proper nutrition and education of the children [1]. Globally malaria accounts for an economic loss of 160 -208million USA dollars year [10].

Progress has been made between 2000-2013 in the African region especially endemic areas to combat malaria by implementing effective strategies that has averted about 92% of deaths[11].

Amongst which is the selection and training of community health workers from the endemic zones, to assist through their various practices/activities to prevent and control malaria in their served Communities.

Malaria occurs mostly in poor tropical and subtropical areas of the world, causing about 90% of illness and death [12]. In areas with high transmission, the most vulnerable groups are young children, who have not yet developed immunity to malaria, and pregnant women, whose immunity has been decreased by pregnancy [6, 13].

According to the Centers for Disease Control and Prevention, malaria is the fifth cause of death from infectious diseases (after respiratory infections, HIV/AIDS, diarrheal diseases, and tuberculosis) and the second leading cause of death from infectious diseases in Africa, after HIV/AIDS [14], causing an annual loss of 35 million future life-years from disability and premature mortality.

According to the Roll Back Malaria programme in Abuja, Nigeria 2010, “the world’s malaria burden will be reduced by 50% and 80% in pregnant women if they receive at least two doses of intermittent preventive treatment (IPT) and sleep under an impregnated mosquitoes net”.

Thus, help countries realize the Millennium Development Goal (MDG) five and six which states: “Improving maternal health and Combating malaria” [15]. So to effectively implement this health policy and others, some endemic areas adopted the use of Community Health Worker (CHWs) to achieve the goal.

Community health workers (CHWs) are frontline public health workers who have a close understanding of the community they serve. The trusting relationship enables them to serve as a link between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

They also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as: home visits, environmental sanitation, provision of water supply, first aid and treatment of simple and common ailments, health education, nutrition and surveillance, maternal and child health and family planning activities, TB and HIV/AIDS care (i.e. counseling, peer and treatment support and palliative care), malaria control, treatment of acute respiratory infections communicable disease control, community development activities, referrals, recordkeeping and collection of data on vital events.

And individual CHWs effectively perform, considering their level of education, type and duration of training, health needs of the community and size and geographical spread of the population to be covered [16].

Research shows that programs involving CHWs in China, Brazil, Iran and Bangladesh have demonstrated that utilizing such workers can help improve health outcomes for large populations in underserved regions [17].

Further evidence on CHWs from Gambia, South Africa, Tanzania, Zambia, Madagascar and Ghana suggests that CHWs are not only cost effective but that they can also enhance the performance of community level health programs especially in the prevention and control of malaria, HIV and Tuberculosis [18].

Also, report findings on systematic review analyses started that, Community health workers deliver effective preventive interventions strategies for Maternal, Child Health, malaria prevention and control in low and middle-income countries [19].

However, CHWs provide a range of malaria-related activities including community education on malaria prevention and diagnosis, distribution of insecticide-treated bed nets and provision of home-based management and preventive treatment of malaria [20].

For example, in rural Uganda, the use of CHWs was associated with a 6% reduction in malaria, among other positive outcomes [21].

Nonetheless, in Cameroon the idea of using CHWs to tackle frontline health issues in communities sparked out from the lunching of the existing 1995 health programme: African Programme for Onchocerciasis Control (APOC) in 2005-2007 to distribute ivermectin in endemic areas using the health strategy called Community Directed Intervention (CDI) [22].

In this strategy, 35000 community members were selected and trained as CHWs to carry out Community directed treatment with ivermectin.

This programme initiated, empowers and brought relief to remote and less privileged endemic communities in the Country. This brought about the integration of other interventions among which was malaria prevention and control [23].

However, according to World Health Organization (WHO), Community-directed intervention (CDI) strategy is an approach in which communities themselves direct the planning and implementation of intervention delivery [24].

Despite the efforts made by the National Malaria Control Program (NMCP) and other bodies to prevent and control malaria through the use of CHWs, malaria still stands as the main cause of anemia amongst pregnant women and infant mortality in Bamenda Health District (BHD), causing about 50% of deaths among children under five and is counted to be one of the top three causes of morbidity and mortality in the district [8, 9].

Some contributing factors being lack of compliance to treatment or intervention, lack of adequate knowledge, resistance to behavioral change, poor access to resources, limited support of programmes by CHWs, local communities and authorities, drug resistance and the treatment facilities which are not still accessible by a majority of households  as thus reviewed by studies [25].

So the aim of this study was to assess Knowledge, Attitudes and practices/activities of CHWs in the prevention and control of malaria in the BHD, Cameroon.

1.2 Problem statement

Although the use of community health workers (CHWs) has been in cooperated in the prevention and control of malaria in Cameroon, statistics still reports that, the morbidity and mortality of malaria is still high (29%) especially among children below five years and pregnant women [26].

In Sub Saharan Africa, a study in Uganda reviewed that, 61%, 97.1% of CHWs have good knowledge, attitudes/practices in the prevention and control of malaria respectively [27].

In another study in Ethiopia, only about 20% of CHWs have adequate knowledge in the prevention and control of malaria [28].

Notwithstanding, in the BHD, the proportion of CHWs with good knowledge, attitudes and practices/activities in the prevention and control of malaria is still unknown.

Secondly, programmes (Onchocerciasis programme) have advocated that CHWs should be involved in the prevention and control of malaria at the level of the Community.

In such, CHWs practices/activities range from complex to less complex including home base diagnosis and treatment of malaria, distribution of long lasting mosquitoes bed nets, hygiene and sanitation, referral of complicated malaria [29].

However, the activities of CHWs in Cameroon and especially in BHD with regards malaria prevention and control are not known.

Lastly, some studies have documented the relationship between CHWs knowledge on prevention and control of malaria and their socio-demographic characteristics.

For example in sub Saharan Africa, studies have revealed that there has been an association between age, gender, marital status and knowledge on the prevention and control of malaria [30].

However, in the BHD, the association between CHWs socio-demographic characteristic and their knowledge in the prevention and control of malaria is not known.

1.3 Justification of the study

It was anticipated that the results of this study would show the proportion of CHWs with good knowledge, attitudes with regards to the prevention and control of malaria in the BHD.

If found out that the proportion of CHWs with good knowledge, attitudes regarding the prevention and control of malaria was less than 80%, then we would advocate that, health education should be given to CHWs in the prevention and control of malaria in order to improve on their knowledge, attitudes.

On the other hand, if the study showed that the proportion of CHWs with good knowledge, attitudes was greater than 80%, then there would be no need to advocate for health education to CHWs in the prevention and control of malaria.

Also, this study revealed the various practices/activities carried out by CHWs in the prevention and control of malaria in the Bamenda Health District.

If it was shown that the practices/activities carried out by CHWs were well organized and performed according to set standards, then there would be no need to modify the and practices/activities.

On the other hand if there exist a difference in the way their and practices/activities were organized and performed, then there would be need to draw the attention of program initiators, the CHWs themselves and the community members for the and practices/activities to be revised in order to reduce deaths caused by malaria.

Lastly, results of the study might showed that, socio-demographic characteristics are related to CHWs knowledge. If it was shown that there is no relationship between CHWs knowledge and their socio-demographic characteristics, it may not be necessary to capacitate CHWs to pay attention to such characteristics when serving the Communities.

On the other hand, if it was shown that a significant relationship exist between CHWs knowledge and their socio-demographic characteristics, it may be necessary to raise the awareness of those selecting CHWs to focus on such a relationship so that only those who are likely to gain knowledge and better serve the community in the prevention and control of malaria should be selected.

1.4. Research questions

1. What is the proportion of CHWs with adequate Knowledge, attitudes and in the prevention and control of malaria in Bamenda Health District (BHD)?
2. What is the proportion of CHWs with adequate Attitudes and in the prevention and control of malaria in Bamenda Health District (BHD)?
3. What are the practices/activities of CHWs in the control and prevention of malaria in BHD?
4. What is the relationship between socio-demographic characteristic of CHWs and their knowledge in the prevention and control of malaria in BHD?

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