Social inequalities in malaria knowledge, prevention and prevalence among children under 5 years old and women aged 15-49 in Madagascar

Landscape and Socioeconomic Factors Determine Malaria Incidence in Tropical Forest Countries

Deforestation, landscape dynamics, and socioeconomic factors within the tropical Americas, Africa, and Asia may have different impacts on malaria incidence. To evaluate how these drivers affect malaria incidence at the global and regional scale, we collected malaria incidence rates from 2000 to 2019 from 67 tropical countries, along with forest loss, land use change types, and socioeconomic elements. LASSO regression, linear mixed effect modeling, and k-fold cross validation were used to create and evaluate the models. Regionality plays a role in the significance of varying risk factors. The Tropical Americas model had the highest coefficient of determination (marginal R2 = 0.369), while the Africa model showed the highest predictive accuracy with only a 17.4% error rate. Strong associations between tree cover loss (β = -4037.73, p < 0.001) and percentage forest area (β = 5373.18, p = 0.012) in Africa, and percent of key biodiversity areas under protection (β = 496.71, p < 0.001; β = 1679.20, p < 0.001) in the tropical Americas and Asia with malaria incidence indicates that malaria risk should be considered during conservation policy development, and recommends that individual approaches to policy and investment be considered when implementing malaria interventions on different spatial scales.

Malaria prevalence and associated factors among symptomatic children aged under five years attending Sheko District Health Center, Southwest Ethiopia: A cross-sectional study

BACKGROUND

Malaria is a major cause of morbidity and mortality in children under the age of five worldwide. Although various malaria elimination measures have been implemented over the past decades, malaria remains a serious threat to public health, especially in tropical and subtropical areas. Ethiopia has set targets for eliminating malaria by 2030. No research has been conducted in the study area concerning malaria among children, who are the most malaria-prone segment of a community. The purpose of this study was to assess malaria prevalence and the factors associated with it among children under five years of age who attended the Sheko Health Center, Southwest Ethiopia, from June 1 to October 30, 2022.

MATERIALS AND METHODS

An institutional-based cross-sectional study was employed from June 1 to October 30, 2022, at the Sheko Health Center. Capillary blood samples were collected from 286 randomly selected symptomatic children. Data on socio-demographics and associated factors were collected using a pre-tested structured questionnaire, and data on parents' and guardians' knowledge about malaria was recorded on Excel 2016 Spreadsheets after interviewing them, and their responses were presented by a frequency table. Data were entered into Epi Data Manager (v4.0.2.101) and analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Associated factors of malaria were analyzed using bivariate and multivariable logistic regression, and statistical significance was set at P < 0.05.

RESULT

Overall, 23.4% (95% CI = 18.6-28.8%) malaria infection was recorded among the children whose blood samples were examined, with Plasmodium falciparum, Plasmodium vivax, and mixed infections (both species) representing 52.2%, 34.3%, and 13.4% of the cases, respectively. The majority of the parents or guardians believed that malaria is transmissible but could be prevented, and 80% of them considered mosquito bites to be the main mode of malaria transmission. Insecticide-treated net (ITN) was mentioned as a malaria prevention strategy by more than half of the respondents, while indoor residual spraying (IRS) was considered only by 19.6%. Based on multivariable logistic regression analysis, a significant association was found in children between the ages of 12 and 36 months (adjusted odds ratio = 5.050; 95% CI: 1.964-12.982), children who lived in rural areas (adjusted odds ratio = 2.901; 95% CI: 1.439-5.845), and children who did not use ITN the past two weeks before sample collection (adjusted odds ratio = 3.341; 95% CI: 1.646-6.781).

CONCLUSION

This study revealed a high malaria prevalence among children aged under five years. Attention must be paid to improving the coverage of the ITN and its use in the study area, which could help reduce the risk of mosquito bites. Health education for the guardians of the children could also help to raise awareness about the prevention and control strategies for malaria transmission and further reduce the impact of the disease.

Social divisions and risk perception drive divergent epidemics and large later waves

During infectious disease outbreaks, individuals may adopt protective measures like vaccination and physical distancing in response to awareness of disease burden. Prior work showed how feedbacks between epidemic intensity and awareness-based behaviour shape disease dynamics. These models often overlook social divisions, where population subgroups may be disproportionately impacted by a disease and more responsive to the effects of disease within their group. We develop a compartmental model of disease transmission and awareness-based protective behaviour in a population split into two groups to explore the impacts of awareness separation (relatively greater in- vs. out-group awareness of epidemic severity) and mixing separation (relatively greater in- vs. out-group contact rates). Using simulations, we show that groups that are more separated in awareness have smaller differences in mortality. Fatigue (i.e. abandonment of protective measures over time) can drive additional infection waves that can even exceed the size of the initial wave, particularly if uniform awareness drives early protection in one group, leaving that group largely susceptible to future infection. Counterintuitively, vaccine or infection-acquired immunity that is more protective against transmission and mortality may indirectly lead to more infections by reducing perceived risk of infection and therefore vaccine uptake. Awareness-based protective behaviour, including awareness separation, can fundamentally alter disease dynamics. Social media summary: Depending on group division, behaviour based on perceived risk can change epidemic dynamics & produce large later waves.

Malaria amongst children under five in sub-Saharan Africa: a scoping review of prevalence, risk factors and preventive interventions

INTRODUCTION

Africa has a higher burden of malaria-related cases and deaths globally. Children under five accounted for over two-thirds of all malaria deaths in sub-Saharan Africa (SSA). This scoping review aims to map evidence of the prevalence, contextual factors and health education interventions of malaria amongst children under 5 years (UN5) in SSA.

METHOD

Four main databases (PubMed, Central, Dimensions and JSTOR) produced 27,841 records of literature. Additional searches in Google, Google Scholar and institutional repositories produced 37 records. Finally, 255 full-text records were further screened, and 100 records were used for this review.

RESULTS

Low or no formal education, poverty or low income and rural areas are risk factors for malaria amongst UN5. Evidence on age and malnutrition as risk factors for malaria in UN5 is inconsistent and inconclusive. Furthermore, the poor housing system in SSA and the unavailability of electricity in rural areas and unclean water make UN5 more susceptible to malaria. Health education and promotion interventions have significantly reduced the malaria burden on UN5 in SSA.

CONCLUSION

Well-planned and resourced health education and promotion interventions that focus on prevention, testing and treatment of malaria could reduce malaria burden amongst UN5 in SSA.

Socio-demographic trends in malaria knowledge and implications for behaviour change interventions in Zanzibar

BACKGROUND

Zanzibar is among the few places within East Africa that have documented a significant reduction of malaria morbidity and mortality. Despite tremendous gains over the past decade, malaria transmission still persists in Zanzibar. This study aimed at understanding levels of malaria knowledge to provide recommendations that can be used to reinforce and scale up targeted malaria social and behaviour change interventions.

METHODS

A descriptive cross-sectional survey was conducted through an administered questionnaire to 431 households selected randomly. The interviewees were the heads of household or representative adults above 18 years. This study investigated the levels of knowledge about the causes, symptoms, and prevention of malaria in areas with high (> 1.9 per 1000) and low (< 1 per 1000) incidence of local malaria cases. The Principal Component Analysis (PCA) was used to compute the composite variable of each category. Descriptive statistics were calculated to understand variables of interest between low and high transmission areas. Multinomial logistic regression model was used to compare knowledge on malaria based on key variables.

RESULTS

A total of 431 heads of households were interviewed. Respondent age, education level, and wealth status were significantly associated with variations in level of malaria knowledge. Old age was found to be significantly associated with low knowledge of malaria (P < 0.001). The majority of study participants who had secondary and higher education levels had good knowledge of malaria (P < 0.006). Participants characterized as middle-income had good knowledge compared to those characterized as low-income (P < 0.001).

CONCLUSION

The study identified existing gaps in malaria knowledge in low and high transmission areas. Low levels of malaria knowledge were documented among elderly and populations with lower education and income levels. There is a need to extend mobilization, advocacy, and expand channels of communication to reach all community members. The reported gaps in knowledge are important to consider when designing strategies to engage communities in malaria elimination in Zanzibar. Tailored social and behavioural change interventions aiming to increase malaria knowledge could enhance the uptake of malaria prevention services in the community.

Malaria among under-five children in rural communities of Al-Mahweet governorate, Yemen

Background

Malaria burden among under-five children living in endemic areas of Yemen is largely unknown due to the lack of community-based studies. Therefore, this study determined the prevalence and risk factors associated with falciparum malaria among under-five children in rural communities of Al-Mahweet governorate, Yemen.

Methods

This community-based, cross-sectional study recruited 400 under-five children from two rural districts of Al-Mahweet governorate in December 2019. Demographic characteristics (gender, age, education and occupation of the child’s parents, and household size) and risk factors associated with malaria were collected through interviews with children’s caregivers using a structured questionnaire. Finger-prick blood was screened for Plasmodium falciparum and non-falciparum species using rapid diagnostic tests (RDTs), and duplicate Giemsa-stained thick and thin blood films were examined for malaria parasites. The density of asexual P. falciparum stages was also estimated. Data were then analysed, and the agreement between the results of thick-film microscopy and RDTs for diagnosing falciparum malaria was assessed using the kappa index. Statistical significance was set at a P-value of < 0.05.

Results

Plasmodium falciparum was prevalent among 9.8% (95% CI 7.0–13.1) of under-five children in the rural communities of Al-Mahweet, with a median asexual parasite density of 763 ± 2606 parasites/μl of blood (range: 132–4280) and low-to-moderate parasitaemia levels. Approximately one-third of microscopy-confirmed cases were gametocyte carriers. Multivariable logistic regression analysis confirmed that age of three years or older (AOR = 5.6, 95% CI 1.6–19.8; P = 0.007), not sleeping under a mosquito net the previous night of the survey (AOR = 8.0, 95% CI 2.4–27.4; P = 0.001), sleeping outdoors at night (AOR = 4.4, 95% CI 2.0–10.0; P < 0.001), and absence of indoor residual spraying (IRS) during the last year (AOR = 4.2, 95% CI 1.9–9.4; P < 0.001) were the independent predictors of falciparum malaria among under-five children in the rural communities of Al-Mahweet. The observed percentage agreement between thick-film microscopy and RDTs was 98.5%, with a very good agreement (k-index = 0.9) between the two methods for falciparum malaria diagnosis that was statistically significant.

Conclusion

Approximately one in ten under-five children in rural communities of Al-Mahweet is infected with P. falciparum based on microscopy and RDTs. Age of three years or older, not sleeping under mosquito nets, sleeping outdoors at night and absence of IRS can independently predict falciparum malaria among them. The very good agreement between thick-film microscopy and RDTs for diagnosing falciparum malaria in children supports the usefulness of using RDTs in such resource-limited rural communities.

A malaria knowledge, attitudes and practice survey in a rural community in Guinea

Background

Malaria is the top public health problem in the Republic of Guinea, with more than 4 million cases and 10,000 deaths in 2021 among a population of approximately 13 million. It is also the second highest cause of death there. The purpose of this quantitative survey in a rural area of Guinea was to understand knowledge, attitudes, and practices (KAP) about malaria and to assess water and sanitation practices among community members.

Methods

In 2016, the authors conducted a cross-sectional household survey in Timbi-Touni, Guinea using community workers. The survey included respondent demographic characteristics, malaria knowledge, child health, water and sanitation, and health services access. Malaria knowledge and sleeping under bed nets were the primary outcome variables and multiple logistic regression was used to determine odds ratios.

Results

Majority of the respondents were women (89.41%) and had never been to school (71.18%). Slightly more than half the children were reported to have ever had malaria and 45% reported to have ever had diarrhoea. There was no statistically significant association between gender or level of education and malaria knowledge. Eighty six percent of respondents had received a free bed net during national campaigns and 61% slept under a bed net the night before the survey. Knowing mosquitoes to be the cause of malaria and receiving free bed net were significantly associated with sleeping under a bed net. There was no statistically significant association between drinking water source and malaria or diarrhoea.

Conclusions

Both malaria and diarrhoea were considered to be serious illnesses for adults and children by nearly all respondents. Receiving free bed nets and having correct knowledge about malaria were the greatest predictors of sleeping under a bed net. Insights from this detailed KAP survey—such as focusing on radio to transmit malaria prevention information and reinforcing free malaria treatments—can guide policy makers and practitioners who design and implement malaria control and prevention measures in Guinea.

Experiences and perceptions of care-seeking for febrile illness among caregivers, pregnant women, and health providers in eight districts of Madagascar

Background

Prompt diagnosis and treatment of malaria contributes to reduced morbidity, particularly among children and pregnant women; however, in Madagascar, care-seeking for febrile illness is often delayed. To describe factors influencing decisions for prompt care-seeking among caregivers of children aged < 15 years and pregnant women, a mixed-methods assessment was conducted with providers (HP), community health volunteers (CHV) and community members.

Methods

One health district from each of eight malaria-endemic zones of Madagascar were purposefully selected based on reported higher malaria transmission. Within districts, one urban and one rural community were randomly selected for participation. In-depth interviews (IDI) and focus group discussions (FGD) were conducted with caregivers, pregnant women, CHVs and HPs in these 16 communities to describe practices and, for HPs, system characteristics that support or inhibit care-seeking. Knowledge tests on malaria case management guidelines were administered to HPs, and logistics management systems were reviewed.

Results

Participants from eight rural and eight urban communities included 31 HPs from 10 public and 8 private Health Facilities (HF), five CHVs, 102 caregivers and 90 pregnant women. All participants in FGDs and IDIs reported that care-seeking for fever is frequently delayed until the ill person does not respond to home treatment or symptoms become more severe. Key care-seeking determinants for caregivers and pregnant women included cost, travel time and distance, and perception that the quality of care in HFs was poor. HPs felt that lack of commodities and heavy workloads hindered their ability to provide quality malaria care services. Malaria commodities were generally more available in public versus private HFs. CHVs were generally not consulted for malaria care and had limited commodities.

Conclusions

Reducing cost and travel time to care and improving the quality of care may increase prompt care-seeking among vulnerable populations experiencing febrile illness. For patients, perceptions and quality of care could be improved with more reliable supplies, extended HF operating hours and staffing, supportive demeanors of HPs and seeking care with CHVs. For providers, malaria services could be improved by increasing the reliability of supply chains and providing additional staffing. CHVs may be an under-utilized resource for sick children.

There are no equal opportunity infectors: Epidemiological modelers must rethink our approach to inequality in infection risk

Mathematical models have come to play a key role in global pandemic preparedness and outbreak response: helping to plan for disease burden, hospital capacity, and inform nonpharmaceutical interventions. Such models have played a pivotal role in the COVID-19 pandemic, with transmission models—and, by consequence, modelers—guiding global, national, and local responses to SARS-CoV-2. However, these models have largely not accounted for the social and structural factors, which lead to socioeconomic, racial, and geographic health disparities. In this piece, we raise and attempt to clarify several questions relating to this important gap in the research and practice of infectious disease modeling: Why do epidemiologic models of emerging infections typically ignore known structural drivers of disparate health outcomes? What have been the consequences of a framework focused primarily on aggregate outcomes on infection equity? What should be done to develop a more holistic approach to modeling-based decision-making during pandemics? In this review, we evaluate potential historical and political explanations for the exclusion of drivers of disparity in infectious disease models for emerging infections, which have often been characterized as “equal opportunity infectors” despite ample evidence to the contrary. We look to examples from other disease systems (HIV, STIs) and successes in including social inequity in models of acute infection transmission as a blueprint for how social connections, environmental, and structural factors can be integrated into a coherent, rigorous, and interpretable modeling framework. We conclude by outlining principles to guide modeling of emerging infections in ways that represent the causes of inequity in infection as central rather than peripheral mechanisms.

Mapping socioeconomic inequalities in malaria in Sub-Sahara African countries

Despite reductions in malaria incidence and mortality across Sub-Saharan (SSA) countries, malaria control and elimination efforts are currently facing multiple global challenges such as climate and land use change, invasive vectors, and disruptions in healthcare delivery. Although relationships between malaria risks and socioeconomic factors have been widely demonstrated, the strengths and variability of these associations have not been quantified across SSA. In this study, we used data from population-based malaria indicator surveys in SSA countries to assess spatial trends in relative and absolute socioeconomic inequalities, analyzed as social (mothers’ highest educational level—MHEL) and economic (wealth index—WI) inequalities in malaria prevalence. To capture spatial variations in socioeconomic (represented by both WI and MHEL) inequalities in malaria, we calculated both the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) in each administrative region. We also conducted cluster analyses based on Local Indicator of Spatial Association (LISA) to consider the spatial auto-correlation in SII and RII across regions and countries. A total of 47,404 participants in 1874 Primary Sampling Units (PSU) were analyzed across the 13 SSA countries. Our multi-country assessment provides estimations of strong socioeconomic inequalities between and within SSA countries. Such within- and between- countries inequalities varied greatly according to the socioeconomic metric and the scale used. Countries located in Eastern Africa showed a higher median Slope Index of Inequality (SII) and Relative Index of Inequality (RII) in malaria prevalence relative to WI in comparison to countries in other locations across SSA. Pockets of high SII in malaria prevalence in relation to WI and MHEL were observed in the East part of Africa. This study was able to map this wide range of malaria inequality metrics at a very local scale and highlighted the spatial clustering patterns of pockets of high and low malaria inequality values.

A retrospective on fundamental cause theory: State of the literature, and goals for the future

Fundamental Cause Theory (FCT) was originally proposed to explain how socioeconomic inequalities in health emerged and persisted over time. The concept was that higher socioeconomic status helped some people to avoid risks and adopt protective strategies using flexible resources - knowledge, money, power, prestige and beneficial social connections. As a sociological theory, FCT addressed this issue by calling on social stratification, stigma, and racism as they affected medical treatments and health outcomes. The last comprehensive review was completed a decade ago. Since then, FCT has been tested, and new applications have extended central features. The current review consolidates key foci in the literature in order to guide future research in the field. Notable themes emerged around types of resources and their usage, approaches used to test the theory, and novel extensions. We conclude that after 25 years of use, there remain crucial questions to be addressed.

Protective effects of Olyset® Net on Plasmodium falciparum infection after three years of distribution in western Kenya

Background

Several types of insecticides, treating technologies and materials are available for long-lasting insecticide-treated nets (LLINs). The variations may result in different efficacies against mosquitoes and correspondingly infection risks for the Plasmodium falciparum malaria parasite. This cross-sectional study investigated whether infection risk varied among children who slept under different LLIN brands in rural villages of western Kenya.

Methods

Children sleeping under various types of LLINs were tested for P. falciparum infection using a diagnostic polymerase chain reaction (PCR) assay. Data were collected for other potential factors associated with infection risk: sleeping location (with bed/without bed), number of persons sharing the same net, dwelling wall material, gap of eaves (open/close), proportional hole index, socio-economic status, and density of indoor resting anophelines. Bed-net efficacy against the Anopheles gambiae susceptible strain was estimated using the WHO cone test and the tunnel test. The residual insecticide content on nets was measured.

Results

Seven LLIN brands were identified, and deltamethrin-based DawaPlus® 2.0 was the most popular (48%) followed by permethrin-based Olyset® Net (28%). The former LLIN was distributed in the area about six months before the present study was conducted, and the latter net was distributed at least three years before. Of 254 children analysed, P. falciparum PCR-positive prevalence was 58% for DawaPlus® 2.0 users and 38% for Olyset® users. The multiple regression analysis revealed that the difference was statistically significant (adjusted OR: 0.67, 95% credible interval: 0.45–0.97), whereas the confounders were not statistically important. Among randomly selected net samples, all DawaPlus® 2.0 (n = 20) and 95% of Olyset® (n = 19) passed either the cone test or the tunnel test.

Conclusions

Olyset® was more effective in reducing infection risk compared with DawaPlus® 2.0. Although the data from the present study were too limited to explain the mechanism clearly, the results suggest that the characteristics of the former brand are more suitable for the conditions, such as vector species composition, of the study area.

Study Protocol: A Cross-Sectional Examination of Socio-Demographic and Ecological Determinants of Nutrition and Disease Across Madagascar

Madagascar has experienced significant environmental change since 1960, particularly through forest clearing for agricultural expansion. Climatic patterns are undergoing change in Madagascar as well, with increasing temperatures, droughts, and cyclonic activity. The impact of these environmental and climatic changes will pose threats to food availability, income generation, and local ecosystems, with significant potential effects on the spatial and temporal distribution of disease burden. This study seeks to describe the health status of a large sample of geographically and socially diverse Malagasy communities through multiple clinical measurements, detailed social surveys, and paired data on regional variation in local ecologies. With an increased understanding of the current patterns of variation in human health and nutrition, future studies will be better able to identify associations with climate and anticipate and mitigate the burdens expected from larger, longer-term changes. Our mixed-method approach included an observational cross-sectional study. Research subjects were men, women, and children from 1,125 households evenly distributed across 24 communities in four ecologically and socio-demographically distinct regions of Madagascar. For these 1,125 households, all persons of both sexes and all ages therein (for a total of 6,292 individuals) were recruited into the research study and a total of 5,882 individuals were enrolled. Through repeated social survey recalls and focus group meetings, we obtained social and demographic data, including broad categories of seasonal movements, and characterized the fluctuation of income generation, food production and dietary consumption. Through collection of clinical and biological samples for both point-of-care diagnoses and laboratory analyses, we obtained detailed occurrence (and importantly co-occurrence) data on micronutrient nutritional, infectious disease, and non-communicable disease status. Our research highlights the highly variable social, cultural, and environmental contexts of health conditions in Madagascar, and the tremendous inter-regional, inter-community, and intra-community variation in nutritional and disease status. More than 30% of the surveyed population was afflicted by anemia and 14% of the population had a current malaria infection. This type of rich metadata associated with a suite of biological samples and nutritional and disease outcome data should allow disentangling some of the underlying drivers of ill health across the changing landscapes of Madagascar.

Prevalence and Associated Factors of Malaria among Febrile Children in Afar Region, Ethiopia: A Health Facility Based Study

Background

Malaria is a major public health problem in Sub-Saharan Africa including Ethiopia and it affects children under five and pregnant mothers. Theprevalence of malaria is not well studied though the burden is expected to be high in low lands of Afar region.Therefore, this study attempts to assess the prevalence and associated factors of malaria among under five children in the pastoral community.

Methods

Cross-sectional study design was employed from April 15^th to 15^th May 2018 on a sample of 484 under-five children who visited the randomly selected health facilities of Dubti district, Afar region.The study participants were recruited randomly with the basic assumption that their arrival at health facilities is random. The main outcome variable was parasitological confirmed malaria among under five children and it was measured using either microscopy blood film examination. Binary logistic regression model was done to measure the association between confirmed malaria infection and its predictors. Independent variables with p-value less than 0.25 in the bivariate analysis were entered into multivariable logistic regression analysis model. Statistical significance level was declared at p-value less than 0.05.

Results

The prevalence of malaria among febrile under-five children was 64% (95% CI 59.5%–68.4%). Of these, more than half (66.5%) and one-fifth (22. 2%) of the cases were caused by p.falciparum and p.vivax respectively. The multivariable logistic regression analysis showed thatliving in rural residence [AOR=1.77: 95% CI 1.10–2.85], having educated mother [AOR=0.406: 95% CI 0.26–0.63], age of child ([AOR=2.98: 95% CI 1.41–6.32], sex of child [AOR=1.99: 95% CI 1.29–3.08], not sleep under ITN [AOR=9.10: 95% CI 1.01- 82.58], ITN availability [AOR=2.23: 95% CI 1.01- 4.89] and history of malaria infection among family members [AOR=9.10: 95% CI 1.01–82.58] were the independent predictors of malaria infection among under five children.

Conclusion

The overall prevalence of malaria among under-five children was high compared to the national prevalence of malaria among the general population. Health care providers (HCPs) should educate parents/guardians regarding proper utilization of ITN at night. In addiotion, they should provide early treatment for febrile family members to halt the transmission of malaria. The regional government should give due attention to supply of ITN and enhance the awareness of the community. Additional longitudinal studies are recommended.

Length of maternal schooling and children's risk of malaria infection: evidence from a natural experiment in Uganda

Introduction

An estimated 216 million cases of malaria occurred worldwide every year. Cross-sectional studies have reported negative association between maternal education and child malaria risks; however, no randomised trial or quasi-experimental study using a natural experiment has confirmed a causal relationship between these two factors. I used the free primary education reform in Uganda to assess the causal effects of maternal schooling on children’s risk of malaria infection.

Methods

Malaria biomarkers of children aged <5 years were collected from the 2009 and 2014 Uganda Malaria Indicator Surveys (n=5316). In 1997, the government eliminated tuition requirements in primary schools, which increased the educational attainment of the affected cohorts. Using exposure to the reform as an instrumental variable, I used a two-stage least squares approach to estimate the causal effects of maternal year of education on the probability that a child would contract malaria at the time of the survey. I also evaluated the cost-effectiveness of primary schooling as a malaria control intervention.

Results

One extra year of maternal education reduced children’s risk of malaria infection by 7.5 percentage points (p=0.057) from baseline (34.9%). The length of maternal education was also positively associated with insecticide-treated bednet usage by their children. The results were robust to a variety of sensitivity tests. Primary schooling for women was a cost-effective intervention to reduce children’s malaria infection.

Conclusion

Improving access to primary education could be a cost-effective measure to reduce malaria prevalence among children of educated mothers aged <5 years in malaria-endemic countries.

Malaria-related ideational factors and other correlates associated with intermittent preventive treatment among pregnant women in Madagascar

Background

The Malagasy Ministry of Health aimed to achieve 80% coverage of intermittent preventive treatment of malaria among pregnant women (IPTp) in targeted districts by 2015. However, IPTp coverage rates of have remained fairly static over the past few years.

Methods

During a cross-sectional household survey, mothers of children under the age of 2 years were asked about their most recent pregnancy. The primary outcome of interest was a mother receiving two or more doses of sulfadoxine–pyrimethamine (SP) (IPTp2) during their last pregnancy, at least one of which was obtained from a health provider. Multilevel analysis was used to account for community-level factors. Correlates included exposure to communication messages, the number of antenatal care (ANC) visits made by the woman, her household wealth, and other sociodemographic characteristics.

Results

Over one-tenth (11.7%) of women received two or more doses of SP, at least one of which was obtained during an ANC visit. Two-thirds (68.3%) of women who consulted a health provider but did not take IPTp attributed this to not being offered the medication by their health provider. The odds of a woman receiving IPTp2 varied with her knowledge, attitudes, and perceived social norms related to IPTp and ANC and exposure to malaria messages. General malaria ideation, specifically the perceived severity of and perceived susceptibility to malaria, however, was not associated with increased odds of receiving IPTp2. A large variation in the odds of receiving IPTp2 was due to community-level factors that the study did not examine.

Conclusions

Health communication programmes should aim to improve IPTp/ANC-specific ideation, particularly the norms of seeking regular care during pregnancy and taking any prescribed medication. While ANC attendance is necessary, it was not sufficient to meet IPTp2 coverage. Women surveyed in Madagascar rely on health providers to prescribe SP according to national policy. At the same time, stock-outs prevent health providers from prescribing SP. The large observed community-level variation in IPTp2 coverage is likely due to supply-side factors, such as SP availability and health-provider ideation and practices.

Caregivers' Malaria Knowledge, Beliefs and Attitudes, and Related Factors in the Bata District, Equatorial Guinea

Objectives

Adequate community knowledge about malaria is crucial in order to improve prevention by reducing exposure to the disease. Malaria is a major cause of morbidity and mortality among children of less than five years of age in Equatorial Guinea. However, information concerning the accuracy of community knowledge is insufficient. This study aimed at assessing the depth of caregivers’ knowledge of malaria, their beliefs and attitudes about this disease, and their socioeconomic determinants in the Bata district of Equatorial Guinea.

Methodology

A cross-sectional study was conducted in the district of Bata, involving 440 houses selected from 18 rural villages and 26 urban neighbourhoods. A combined "Malaria Knowledge Score" was generated based on caregivers’ knowledge about transmission, symptoms, prevention, the treatment of children, and best place to seek treatment. Multivariate logistic regressions analyses were performed to assess those factors that are associated with knowledge about malaria.

Results

A total of 428 caregivers were interviewed; 255 (59.6%) and 173 (40.4%) lived in urban and rural areas respectively. Significant differences between rural and urban households were observed in caregivers’ malaria knowledges and beliefs. Almost 42% of urban and 65% of rural caregivers were unaware as to how malaria is transmitted (OR = 2.69; 95% CI: 1.78–4.05). Together with rurality, the factors most significantly associated with the Malaria Knowledge were the level of education of the caregiver and the socioeconomic status of the household.

Conclusions

Improvements in educational programs are needed to empower the most vulnerable households such that they can pro-actively implement malaria control measures. This could be achieved by a comprehensive communication strategy aimed at changing individual and community behaviours, and delivered by suitably trained community health workers and indoor residual spraying personnel.