Soleimani-Ahmadi et al. Malaria Journal 2014, 13:511 http://www.malariajournal.com/content/13/1/511 RESEARCH Open Access Community knowledge and practices regarding malaria and long-lasting insecticidal nets during malaria elimination programme in an endemic area in Iran Mussa Soleimani-Ahmadi1,2*, Hassan Vatandoost3, Mehdi Zare4, Ali Alizadeh5 and Mehrdad Salehi6 Abstract Background: Since malaria is one of the foremost public health problems in Iran, a malaria elimination phase has been initiated and application of long-lasting insecticidal nets (LLINs) is an important strategy for control. Success and effectiveness of this community based strategy largely dependent on proper use of LLINs. In this context, to determine the community’s knowledge and practices about malaria and LLINs, a study was conducted in Rudan County, one of the important malaria endemic areas in southeast of Iran. Methods: In this cross-sectional study, 400 households in four villages were selected by cluster randomly sampling method. Community knowledge and practices about malaria and LLINs including symptoms and transmission of malaria and washing, drying and using of bed nets were investigated using pre-tested structured questionnaires. The data were analysed using SPSS.16 software. Results: In this study nearly 89% of the respondents knew at least one symptom of malaria and 86.8% considered malaria as an important disease. The majority of respondents (77.8%) believed that malaria transmits through mosquito bite and 72.5% mentioned stagnated water as a potential mosquito breeding place. About 46% of respondents mentioned the community health worker as the main source of their information about malaria. Approximately 44.8% of studied population washed the LLINs once in six months and 92% of them mentioned that they dry the bed nets in direct sunlight. While 94% of households reported they received one or more LLINs by government and 60.8% of respondents mentioned that LLINs were the main protective measure against malaria, only 18.5% of households slept under bed nets the night before the survey, this use rate is lower than the targeted coverage (80%) which is recommended by World Health Organization. Conclusion: Although, majority of studied population were aware of the symptoms and cause of malaria, a majority had misconceptions about LLINs. Therefore, appropriate educational intervention by trained health workers should be developed for a behaviour change and motivating people to use LLINs which would improve malaria elimination programme. Keywords: Malaria, Knowledge, Practice, Long-lasting insecticidal nets, Rudan, Iran * Correspondence: [email protected] 1Infectious and Tropical Diseases Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran 2Department of Medical Entomology and Vector Control, School of Public Health, Hormozgan University of Medical Sciences, P.O. Box: 79145–3838, Bandar Abbas, Iran Full list of author information is available at the end of the article © 2014 Soleimani-Ahmadi et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Soleimani-Ahmadi et al. Malaria Journal 2014, 13:511 Page 2 of 7 http://www.malariajournal.com/content/13/1/511 Background achieve sufficient LLINs coverage, a challenge is identify- Malaria is considered to be the most prevalent vector- ing and addressing the behavioural factors that influence borne disease worldwide and is currently endemic in 97 LLINs use. Understanding the community knowledge countries [1]. The disease is endemic in the southeast of about malaria and LLINs would help in designing sustain- Iran, with two seasonal peaks mainly in spring and able malaria control programmes that will lead to behav- autumn. The current strategic approaches to malaria ioural change and adoption of new ideas [13]. The control emphasize prevention through the use of long- participation of the community is one of the major tools lasting insecticidal nets (LLINs), as recommended by the of malaria elimination programmes and improved com- World Health Organization (WHO) [2]. munity knowledge of malaria and its transmission can Iran has initiated measures to improve malaria elimin- promote preventive and personal protective practices ation through using larvicides, indoor residual spraying amongst the target populations [14]. Parallel to implemen- (IRS), LLINs, and early case detection and treatment of tation of malaria elimination in Iran, this study was con- malaria. In this regard, Iran is aiming to eliminate Plas- ducted to determine the community knowledge and modium falciparum by 2015 and to become malaria-free practice regarding malaria and its preventive measures, by 2025 [2,3]. Since 2008, Iran is receiving a Global with an emphasis on the use of LLINs in Rudan County, Fund grant to develop vector control activities, such as southeast of Iran. distributing insecticide-treated nets (ITNs) and targeted use of IRS [2,4]. Adequate knowledge on malaria transmis- Methods sion is essential for effective use of preventive measures. Study area People perceive the direct benefits of bed nets through an The study was carried out in Rudan county of Hormozgan observable reduction of mosquito nuisance and malaria province, one of the malaria endemic areas in southeast- episodes, which may motivate them to use bed nets more ern Iran. The county is located between 27°05′- 27°59′ N effectively [5]. Besides assuring access to LLINs, accept- latitudes and 56°50′ -57°29′ E longitudes with an esti- ability and compliance with net use are the other critical mated population of 118,547 individuals in 2011. The an- issues in the success of any ITNs programme [6]. nual mean relative humidity is 54% and the average of The results of studies in various parts of the world re- annual rainfall is about 250 mm. The average daily tem- vealed that use of insecticide-treated nets is an effective perature ranges from 9°C to 45°C. In the study area nearly tool against anopheline mosquitoes and reduces morbid- all of houses are made of cement blocks and have electricity ity and mortality due to malaria [7,8]. Treated bed nets and water supply. The main economic activities in the area have an influential impact on mosquito density and are agricultural with palm and citrus plantation and live- sporozoite rates. However, effectiveness of bed net use is stock herding. Malaria transmission in the area is endemic dependent on attitudes and socio- cultural context of which occurs year-round with peaks after the two annual population [9]. A high coverage of long- lasting insecti- rainy seasons (April-June and October -December) [3]. cidal nets followed by educational intervention, results in a decrease in malaria morbidity and reduces transmis- Study design and data collection sion, as showed in a study from rural area in southeast The study was a community-based cross-sectional sur- of Iran [10]. A recent study on malaria knowledge in vey conducted between May and July, 2013 in Rudan Iran indicated that populations’ educational level is posi- County, where LLINs had been previously distributed tively associated with knowledge of malaria transmission, for malaria elimination. aetiology and clinical symptoms of the disease [11]. Assuming expected knowledge about malaria and Rudan is a malarious area with local transmission in LLINs to be 50% and a desired precision of 5%, the sam- the southeast of Iran. In this county, 63 cases of malaria ple size calculated by the formula to be 400. Study vil- were reported during 2009–2013. The parasite species lages were selected by a two-stage randomized cluster composition was 91% Plasmodium vivax and 9% Plas- sampling procedure. In the first stage, four villages with modium falciparum (Hormozgan Health Centre, unpub- similar topographical and epidemiological situations lished data, 2014). Previous studies have reported four were selected randomly. In the second stage, 100 house- malaria vectors in this area including: Anopheles culicifa- holds were randomly selected for each village. As the cies s.l., Anopheles dthali, Anopheles stephensi and Anoph- father of family is mostly out of house to work, mothers eles superpictus where, An. stephensi is primary vector and of randomly selected households were interviewed using a other species play role as secondary vectors [12]. pre-tested, structured questionnaire (see Additional file 1). Indoor residual spraying and distribution of long-lasting In case they were absent, the daughter of household or an- insecticide-treated nets have been the main vector control other adult member was interviewed instead. The ques- measures implemented as part of an integrated approach tionnaires were administered by trained field interviewers to malaria elimination in this county [12]. In addition to and supervised by the principal investigator. The questions Soleimani-Ahmadi et al. Malaria Journal 2014, 13:511 Page 3 of 7 http://www.malariajournal.com/content/13/1/511 included respondents’ demographic characteristics, know- Table 1 Socio-demographic characteristics of the study ledge (five items) and practices (10 items)