Report on Malaria Baseline Survey in Two Woredas
of Zone 5 in Afar Region, Northeast Ethiopia
AMREF in Ethiopia
June 2008 Addis Ababa, Ethiopia
Acknowledgements This baseline survey was funded by the AMREF in Ethiopia. We give special thanks to Mr. Samuel Hailu, Mr. Berhane Hailesellassie, and Mr. Tilahun Negatu, all from AMREF in Ethiopia, for their technical assistance throughout the design, questionnaire development, and data collection fieldwork. We are also grateful to Dr. Alemayehu Seifu, Head of Health Programs at AMREF in Ethiopia, for his leadership during all stages of the survey implementation. We also owe a debit of gratitude for the supervisors, data collectors and above all, to the respondents for their participation in this study. We are also grateful to Dr. Wakgari Deressa, from the School of Public Health at Addis Ababa University in Ethiopia, who participated in the design and development of data collection tools, fieldwork data collection, analyzed the data and prepared the draft report of the baseline survey on malaria prevention and control in Zone 5 of Afar Region.
AMREF in Ethiopia Draft Report June 2008 i
Abbreviations ACTs Artemisinin-based Combination Therapies AIDS Acquired Immuno-Deficiency Syndrome AMREF African Medical and Research Foundation BCC Behaviour Change Communication CHWs Community Health Workers
DDT Dichloro-Diphenyl-Trichloroethane DHS Demographic and Health Survey GFATM Global Find to Fight AIDS, Tuberculosis and Malaria HEW Health Extension Worker HH Household HIV Human Immuno-deficiency Virus HMM Home-based Management of Malaria IEC Information, Education and Communication IRS Indoor Residual Spraying ITNs Insecticide Treated Nets LLINs Long Lasting Insecticidal Nets MDGs Millennium Development Goals MOH Ministry of Health NGOs Non-Governmental Organizations PMPT Participatory Malaria Prevention and Treatment RBM Roll Back Malaria RDTs Rapid Diagnostic Tests SD Standard Deviation SPSS Statistical Package for Social Sciences WHO Woreda Health Office
AMREF in Ethiopia Draft Report June 2008 ii Table of Contents Page
Acknowledgements ...... i Abbreviations ...... ii Table of Contents ...... iii List of Tables ...... v Executive summary ...... vii 1. Introduction ...... 1 1.1 Country profile ...... 1 1.2 Malaria situation in Ethiopia ...... 1 1.3 Afar Region ...... 3 1.4 AMREF in Ethiopia ...... 4 2. Objectives of the baseline survey ...... 7 3. Methodology ...... 7 3.1 Study areas ...... 7 3.2 Study design...... 8 3.3 Study population ...... 8 3.4 Sample size calculations ...... 8 3.5 Sampling strategy ...... 9 3.6 Questionnaire development ...... 10 3.7 Training of field personnel and data collection ...... 11 3.8 Data analysis and presentation...... 13 4. Ethical considerations ...... 13 5. Findings ...... 14 5.1 Qualitative findings ...... 14 5.2 Quantitative findings...... 19 5.2.1 Population characteristics ...... 19 5.2.2 Household size ...... 23 5.2.3 Households ownership of basic durables ...... 24 5.2.4 Household’s source of drinking water and sanitation facilities ...... 25 5.2.5 Household’s sleeping area arrangements ...... 26
AMREF in Ethiopia Draft Report June 2008 iii 5.2.6 Exposure to mass media and sources of information about malaria...... 27 5.2.7 Respondent’s perceived major health problems ...... 28 5.2.8 Respondent’s knowledge about transmission and causes of malaria ...... 29 5.2.9 Respondent’s knowledge about mosquito biting time ...... 31 5.2.10 Respondent’s knowledge about malaria symptoms ...... 32 5.2.11 Respondent’s perceived severity of malaria ...... 33 5.2.12 Respondent’s knowledge about malaria treatment and antimalarial drugs .. 34 5.2.13 Respondent’s knowledge and practices about malaria prevention ...... 35 5.2.14 Treatment seeking behaviour for malaria...... 36 5.2.15 Current ITNs ownership and use ...... 39 6. Discussion and conclusions ...... 52 7. Recommendations ...... 54 8. Annexes ...... 55
AMREF in Ethiopia Draft Report June 2008 iv List of Tables Page
Table 1: Type of health facilities and health personnel category by woreda, May 2008 ..15 Table 2: Socio-demographic characteristics of the respondents by woreda, May 2008....20 Table 3: Marital status of the respondents by woreda, May 2008 ...... 21 Table 4: Educational status and literacy of the respondents by woreda, May 2008 ...... 22 Table 5: Occupational status of the respondents by woreda, May 2008 ...... 23 Table 6: Household size of the respondents by woreda, May 2008 ...... 24 Table 7: Households ownership of basic durables by woreda, May 2008 ...... 25 Table 8: Main source of drinking water and latrine possession for survey households by woreda, May 2008 ...... 26 Table 9: Sleeping area arrangements of household members by woreda, May 2008 ...... 27 Table 10: Respondent’s media exposure by woreda, May 2008 ...... 27 Table 11: Respondent’s exposure to sources of information in the last three months by woreda, May 2008 ...... 28 Table 12: Respondent’s perceived major health problems by woreda, May 2008 ...... 29 Table 13: Respondent’s knowledge about transmission and causes of malaria by woreda, May 2008 ...... 30 Table 14: Respondent’s knowledge about transmission and causes of malaria by sex and residence, May 2008 ...... 31 Table 15: Respondent’s knowledge about mosquito biting time by woreda, May 2008...31 Table 16: Respondent’s knowledge about malaria symptoms by woreda, May 2008 ...... 32 Table 17: Respondent’s perceived severity of malaria to different population groups by woreda, May 2008...... 33 Table 18: Respondent’s perception about malaria treatment and antimalarial drugs by woreda, May 2008...... 34 Table 19: Respondent’s perception and household’s practice about malaria prevention by woreda, May 2008 ...... 35 Table 20: Preferred source of initial visit for malaria treatment by woreda, May 2008 ...... 37
AMREF in Ethiopia Draft Report June 2008 v Table 21: Percentage of households with perceived malaria in the past two weeks prior to the survey, and their sex and age structure by woreda, May 2008 ...... 37 Table 22: Treatment seeking behaviour for perceived malaria cases by woreda, May 2008 ...... 38 Table 23: Main reasons for not seeking treatment for the last episode of malaria illness, May 2008 ...... 39 Table 24: Respondent’s knowledge about the use of ITN by woreda, May 2008 ...... 40 Table 25: Respondent’s perceived average duration of ITN to be used in years by woreda, May 2008 ...... 41 Table 26: Respondent’s knowledge about the source of ITN by woreda, May 2008...... 41 Table 27: Household’s ownership of ITN and number per household by woreda, May 2008 ...... 43 Table 28: Percentage of households with ITN hung at the time of the interview and currently used by households with at least one ITN by woreda, May 2008 ..... 44 Table 29: Number of household identified from the surveyed households and percentage slept under ITNs the previous night from households with at least one ITN by woreda, May 2008 ...... 45 Table 30: Percentage shape and colour distribution of ITNs identified among households with at least one ITN by woreda, May 2008 ...... 46 Table 31: Respondent’s distribution of shape and colour preference for ITNs by woreda, May 2008 ...... 47 Table 32: Respondent’s perceived priority for using ITN if the household has only one net, May 2008 ...... 48 Table 33: Percentage of households with one or more tear/hole on ITN by woreda, May 2008 ...... 49 Table 34: Source and length of time the household had had the recent ITN by woreda, May 2008 ...... 50 Table 35: Percentage distribution of respondents who cited reasons for not having ITNs by households by woreda, May 2008 ...... 51 Table 36: Respondents distribution of problems experienced while using ITN by woreda, May 2008 ...... 51
AMREF in Ethiopia Draft Report June 2008 vi Executive summary This report presents findings from the AMREF (African Medical and Research Foundation) in Ethiopia malaria baseline survey carried out in May 2008 in two woredas of Zone 5 in Afar Regional State in Ethiopia. The main purpose of the survey was to assess the status of case management of malaria at health facilities and establish a baseline data on the knowledge, attitudes and practices of a local community about malaria prevention and control. This information will be later on used as a basis for program evaluation. AMREF initiated its operation in Ethiopia in 2004 in the areas of HIV/AIDS and malaria prevention and control, water and sanitation, trachoma prevention and control. AMREF initiated its malaria project in Zone 3 of Afar Region in 2005, and it has recently expanded its program to include two woredas in Zone 5 of the region. Data were collected from health facilities and selected heads of households on the status of case management of malaria at health facilities, socio-demographic characteristics of the respondents, knowledge and perceptions about malaria transmission and treatment, knowledge and perceptions about malaria preventive methods, practices of malaria prevention, sources of information on malaria, treatment seeking behaviour practices of households on malaria in the past two weeks, and insecticide treated nets (ITNs) ownership by household and its utilization particularly by under five children and pregnant women. The survey was carried out in May 2008 in two project woredas (Dewe and Dalifage) of Zone 5 in Afar Region primarily based on quantitative data collection and supplemented by qualitative data obtained through record review and in-depth interview. The quantitative method was conducted based on a structured questionnaire survey of 630 randomly selected households using cluster sampling method. The introduction section of the report presents an overview of the profile of Ethiopia, malaria situation in the country and Afar Region, AMREF’s in Ethiopia objectives and activities, and the baseline assessment. The sections on objectives and methods describe survey aims and methods used in the survey, respectively. The findings section addresses the main component of the report, followed by sections on conclusions and recommendations. The key findings of the survey are summarized below:
AMREF in Ethiopia Draft Report June 2008 vii Health facility data revealed that malaria is the leading cause of morbidity and mortality in the study woredas. Malaria diagnosis and treatment at the health facilities in the study areas was found to be poor due to lack of trained and adequate health personnel, lack of laboratory facilities for microscopic diagnosis at health centers, unavailability of rapid diagnostic tests (RDTs) at health posts, lack of training for health workers at health posts on RDTs and intermittent supply of Coartem and other supplies. Malaria diagnosis was mainly based on clinical criteria that have a low specificity. Inaccessibility of health facilities was identified to be the major barrier in seeking early diagnosis and prompt treatment with effective antimalarial drugs. Although malaria was found to be the major health problem among young children, knowledge of the mothers/caretakers about the symptoms, treatment seeking behaviour for young children, malaria preventive measures such as ITNs was found to be poor as observed through in-depth interviews. AMREF in Ethiopia has initiated the expansion of its malaria project into Zone 5 of Afar Region through training of health workers on malaria prevention and control, ITNs distribution, and training of mother coordinators on HMM and PMPT activities. A total of 630 households (55.1% from Dewe and 44.9% from Dalifage) were involved in the quantitative household survey, with a little more than half (52.9%) of the respondents being males. Almost all of the study participants recognized malaria as the most important health problem in the study areas. The most common channels for receiving information on malaria are radio (21%) and through health workers (20.6%). Radio ownership by households was relatively higher (22.9%), but television ownership was extremely low (1.3%). About nine in 10 (86.2%) of respondents believed that malaria could be transmitted from one person to another (83% in Dewe vs. 90.1% in Dalifage woreda).
AMREF in Ethiopia Draft Report June 2008 viii Knowledge of malaria transmission through mosquito bite was relatively high (67.1%). There was a variation in this knowledge between the woredas and across the residence (72% in Dewe vs. 61.1% in Dalifage woreda and 83.7% in urban vs. 63.1% in rural). The majority of respondents were aware that mosquitoes bite most likely in the evening (56.3%) and night (39.2%) times. Fever (95.7%), headache (81.6%) and shivering/chills (74.3%) were the main symptoms of malaria cited by majority of the respondents. About 40% of the respondents (36% in Dewe vs. 44.5% in Dalifage woreda) were able to identify children as being at risk group for malaria but only 9% of respondents identified pregnant women as being at risk. About 89% the respondents said that malaria is a treatable disease (91.1% in Dewe and 86.6% in Dalifage). Half of the respondents knew Coartem as the currently used first-line antimalarial drug. About 78% of the respondents reported that malaria is a preventable disease. Regarding the best method of preventing malaria, 76% of the respondents mentioned the use of mosquito net, followed by the use of smoking in the house (28.3%). Government health facility was the most preferred source of malaria treatment. The prevalence of self-reported malaria within two weeks prior to the survey ranged from 13.4% in Dalifage to 16.7% in Dewe woreda. Of 96 self-reported malaria patients from the total members of the surveyed households, 51% and 7.3% were reported among under five children and pregnant women, respectively. Only 54.2% of the reported malaria patients sought treatment, of these 88.5% sought it from public health facilities. Only15.4% of the patients sought treatment within 24 hours of the onset of malaria symptoms. Knowledge about the use of ITN was high. About 99% of the respondents claimed that sleeping under ITN protects a person from mosquito bite, 82.5% reported that ITN protects against the bite of other nuisance insects, 84.4%
AMREF in Ethiopia Draft Report June 2008 ix perceived that ITN kills mosquitoes and 88.4% reported that it protects against malaria. About 63% of the households owned at least one ITN (69.2% in Dewe vs. 55.1% in Dalifage). Of the total households, 40.3% owned at least two ITNs and 10.2% owned three or more nets. The mean number of ITNs per household was 1.19. Overall, 53% of all household members, 63.7% of all children under the age of five years and 61% of the pregnant women slept under an ITN the night before the survey. An ITN of rectangular design was the most preferred shape by the respondents. Of households which did not own an ITN, the majority (96.2%) stated that they ever had it in the past. Of these, 95.3% reported that their ITN was aged and became out of use. Based on the above findings, the following recommendations are forwarded: Early diagnosis and prompt treatment of malaria should be strengthened at peripheral health facilities through training of health workers on proper diagnosis and management of the disease. The correction of misconceptions about the role of mosquitoes in malaria transmission through intensive health education program is very critical for malaria control, particularly for promoting the implementation and utilization of ITNs. The community should be informed and educated about the progression of malaria, how to recognize the danger signs of the disease, what to do and where to go for malaria treatment. Malaria related information dissemination through health workers and radio seems to be powerful to reach majority of the population. High priority should be given to provide effective antimalarial drugs such as Coartem at grass roots level through HEWs stationed at health posts. The replacement strategy to sustain the scale-up of ITNs should be initiated and strengthened.
AMREF in Ethiopia Draft Report June 2008 x 1. Introduction
1.1 Country profile Ethiopia is a landlocked country located in East Africa and crossed by the Great Rift Valley from the northern part of Afar Region in the north to the southern part of the country that joins the northern part of Kenya. It is one of the poorest countries in the continent, and about 45% of the total population lives in an abject poverty. The country’s total population was estimated at 77 million in 2006/2007, of which 83.5% resides in rural areas and 16.5% are children under five years of age1. The majority of the population has limited access to modern health care services. Like many countries in developing countries, the gap between the demand and the current health service provision in Ethiopia remains substantially high. The annual population growth rate is 2.7% and the life expectancy at birth is estimated at 54 years2. The recent 2005 Ethiopian National Demographic and Health Survey (DHS) estimates place the maternal mortality ratio at 673 deaths per 100,000 live births, the infant mortality rate at 77 deaths per 1,000 live births and the under-five mortality rates at 123 per 1,000 live births3. The total fertility rate is high at 5.4 children per woman. Large geographic regional disparities in availability of services and resources characterize the Ethiopian health sector. The majority of health services are located in the urban areas while many lowland and arid areas in many parts of the country have limited access to comprehensive health care. These regional differences in access to and availability of health services are reflected in the prevention and control of major communicable diseases like malaria, HIV/AIDS, and tuberculosis. Access to family planning and reproductive health services are also highly limited in these areas.
1.2 Malaria situation in Ethiopia Despite the recent decline in the incidence of malaria particularly during the last 2-3 years4, malaria is still the major cause of morbidity and mortality in Ethiopia. Malaria is a
1 MOH. Health and Health Related Indicators. Planning and Programming Department, Federal Democratic Republic of Ethiopia, Addis Ababa, Ethiopia. 2005/2006. 2 Ibid. 3 Ethiopia Demographic and Health Survey 2005 4 Chambers RG, Gupta RK, Ghebreyesus TA. Responding to the challenge to end malaria deaths in Africa. Lancet, 2008; 371:1399- 1401
AMREF in Ethiopia Draft Report June 2008 1 preventable and curable disease and yet greatly limits productivity, particularly among rural populations. It is also a leading cause of school absenteeism. It is estimated that nearly 68% (≈50 million people) of the total population in Ethiopia is at risk of the disease. According to the most recent annual report of the Federal Ministry of Health (MOH), malaria was the first cause of morbidity and mortality accounting for 18% of all outpatient consultations, 14% of all admissions and 22% inpatient deaths5. Malaria is reported to be the leading cause of mortality among children admitted to hospitals in malarious areas of Ethiopia. There has been no reliable data to estimate the burden of malaria among pregnant women in the country. Effective malaria control activities are lacking in Ethiopia due to the shortage of human, financial and administrative resources. As a result, 5-6 million clinical cases, 600,000 microscopically confirmed cases and 70,000 deaths are estimated to occur nationwide each year6. Although the statistics of hospital inpatient deaths show that about 22% of deaths are caused by malaria, the true mortality attributed to malaria remains hard to measure because most patients die at home. Malaria transmission in the country is generally seasonal and highly unstable because of the variations in topography, climate and rainfall patterns. Hence, large scale epidemics frequently occur particularly in epidemic prone areas of the country. Plasmodium falciparum infections account for about 60% of all malaria infections in Ethiopia, and P. vivax is responsible for the remaining 40%7. P. falciparum is the most dangerous of the malaria parasites. It causes ‘malignant’ or cerebral malaria that can quickly progress to unconsciousness and death, while P. vivax is most often cited for its recurring forms. The most widely distributed species of Anopheles mosquitoes in Ethiopia include An. arabiensis, An. pharoensis, An. funestus and An. nili8. An. arabiensis, one of the siblings of A. gambiae complex, is the most important and widespread vector of malaria in the country, including Afar Region. However, the remaining three species of Anopheles
5 MOH. Health and Health Related Indicators. Planning and Programming Department, Federal Democratic Republic of Ethiopia Ministry of Health, Addis Ababa. 2005/2006. 6 Adhanom et al. Malaria. In: Berhane, Y., Haile-Mariam, D., Kloos, H. (Eds.), Epidemiology and Ecology of Health and Disease in Ethiopia. Shama Books, Addis Ababa, 2006, PP. 556–576. 7 Ibid. 8 Ibid.
AMREF in Ethiopia Draft Report June 2008 2 mosquitoes have minor importance in the transmission of the disease due to their limited geographical distribution. Due to the current global and national interests to prevent and control malaria particularly in sub-Saharan Africa, multiple anti-malaria interventions are currently undergoing in Ethiopia. The four primary interventions currently scaled up in the country to effectively control malaria, and achieving the Millennium Development Goals (MDGs)9 for malaria by 2015 include, 1) early diagnosis and prompt treatment with effective antimalarials; 2) use of insecticide-treated nets (ITNs) to achieve full coverage of populations at risk of malaria; 3) application of indoor residual spraying (IRS) using DDT as a major means of malaria vector control to interrupt transmission; and 4) malaria epidemics early detection and timely containment. Scaling up access and achieving high coverage of effective antimalarial interventions, especially in populations at the highest risk of malaria, and sustaining their implementation, remain a major challenge to Ethiopia. Consequently, different local and international non-governmental organizations (NGOs) including the African Medical and Research Foundation (AMREF) are currently supporting and participating in the implementation of different anti-malaria interventions in Ethiopia. The scope of the involvement of the NGOs in malaria prevention and control activities varies from region to region depending on their capacity and the high burden that malaria imposes on the health of the community. The hard-to-reach and marginalized populations residing in malaria endemic areas are the target of anti-malarial interventions for AMREF in Ethiopia.
1.3 Afar Region With an estimated population of about 1.3 million, the Afar Region is one of the most under-served areas in Ethiopia. The Region is administratively divided into 5 zones and 29 woredas. The Afar people are predominantly nomadic in origin and the majorities are still practicing pastoral and agro-pastoral living style in the arid and semi-arid areas of northeastern Ethiopia. The Afar Region is characterized by the lowland areas (≤1500 m altitude) with hot or warm climate.
9 The UN MDGs by 2015 are: 1. Eradicate extreme poverty & hunger, 2. Achieve universal 1o education, 3. Promote gender equality & empower women, 4. Reduce child mortality 5. Improve maternal health, 6. Combat HIV/AIDS, malaria & other diseases, 7. Ensure environmental sustainability, and 8. Develop a global partnership for development.
AMREF in Ethiopia Draft Report June 2008 3 Malaria is the leading cause of morbidity and mortality in Afar Region. Malaria transmission in the region is perennial due to the availability of large perennial river bodies and hot climate favouring the transmission throughout the year, with seasonal peak extending from August to December. The region is also prone to natural disasters such as droughts and floods and these have in the past contributed to increased malaria transmission, particularly along the banks of Awash River. Since the last decade, flooding of Awash River is on the increase, creating ideal conditions for vector breeding. Almost all parts of the region are malarious and almost all people are considered to be at risk of malaria. More than one-third of the disease burden in the region is attributable to malaria. Plasmodium falciparum (about 65%) and P. vivax (about 35%) are the two dominant malaria parasites prevailing in the region. According to the most recent health and health related indicators issued in 2005/06, of 92,248 blood films examined in the region, 41% were microscopically confirmed to be positive for malaria10. Anopheles arabiensis is a major vector for malaria transmission in the region.
1.4 AMREF in Ethiopia AMREF has been actively involved in the fight against malaria since its inception in 1957. Currently, ITNs and Artemisinin-based Combination Therapies (ACTs) have been proven to significantly reduce malaria related morbidity and mortality. However, the effectiveness of the interventions is highly dependent on proper utilization by the local community especially by young children, pregnant women, and people with poor access to health services residing in hard-to-reach areas. AMREF aims to reduce malaria morbidity and mortality by adopting the Roll Back Malaria (RBM) strategy of ITNs promotion and provision, proper management of cases at health facility level through early diagnosis and prompt treatment with effective antimalarial drugs, and effective home management of cases particularly among under five children. AMREF also works towards creating demand and improving access to affordable antimalarial interventions. The specific objectives of malaria program of AMREF are11:
10 MOH. Health and Health Related Indicators. Planning and Programming Department, Federal Democratic Republic of Ethiopia Ministry of Health, Addis Ababa. 2005/2006. 11 AMREF. Malaria Prevention and Control Strategy (2006-2010).2005. www.amref.org.
AMREF in Ethiopia Draft Report June 2008 4 Case management (including capacity building on diagnostic services), Provision of ITN and/or long-lasting insecticidal net (LLIN) at community level, Malaria control and prevention in pregnancy, and Behaviour and social change communication in support of all interventions AMREF has started its operation in Ethiopia in 2004, and its malaria prevention and control project in Zone 3 of Afar Region, one of the most under- served areas in the country, in 2005. In order to monitor the performance of the malaria prevention and control project in Zone 3 of Afar Region, AMREF conducted a baseline evaluation survey in October 2005 and a midterm evaluation survey in December 200712. The malaria prevention and control goal of AMREF in Ethiopia is to contribute to the improvement of the health status of Afar people through reducing malaria related morbidity and mortality, by specifically targeting young children and pregnant women. AMREF’s in Ethiopia broad strategy to bring about community health development mainly focuses on community partnering, capacity building and health systems research for policy and practice. The malaria prevention and control strategies include primary prevention through vector control and behavioral practices, mortality and morbidity reduction through prompt diagnosis and case management with effective antimalarial drug, epidemic detection and control, health system strengthening and implementation of an effective communication strategy. More specifically, the objectives of Afar malaria project of AMREF in Ethiopia include13: 1. To promote preferential use and coverage of LLINs among young children and pregnant women among pastoralists in Afar. 2. To implement home-based management of malaria (HMM) with artemether- lumefantrine in combination with strengthened diagnostic services using microscopy and RDTs. 3. To develop and utilize participatory communication tools to ensure high LLINs retention and utilization rates, prompt treatment seeking behaviour for malaria
12 AMREF in Ethiopia. Midterm evaluation of malaria project in Zone 3 of Afar Region, northeastern Ethiopia. 2008. 13 Ibid.
AMREF in Ethiopia Draft Report June 2008 5 within 24 hours of illness onset and improved ability to recognize the signs and symptoms of severe and uncomplicated malaria, and 4. To develop and strengthen strategies and partnerships to expand the program to new project areas in Afar Region. AMREF in Ethiopia has recently initiated the expansion of its malaria prevention and control program to include Zone 5 of Afar Region. AMREF in Ethiopia has been successfully working on malaria project in Zone 3 of Afar Region since 2005. Based on the lessons and experiences gained from malaria prevention and control activities carried out in Zone 3 in the past 2-3 years14, AMREF in Ethiopia now intends to expand its malaria prevention and control operation to the neighbouring Zone 5 in the region. In order to develop and implement an appropriate and effective malaria project in Zone 5 in the region, a comprehensive understanding of the population’s knowledge, attitudes and practices, regarding malaria, treatment seeking and use of ITNs was required. In addition, to measure later on whether the objectives have been met, AMREF needs to utilize a number of different monitoring and evaluation methods. Household survey is one of the principal methods used for evaluating the extent to which the project objectives have been achieved. This benchmark baseline survey was carried out in May 2008 before the launch of AMREF’s in Ethiopia malaria control and prevention activities in Zone 5 of Afar Region, and a follow-up survey will be expected after two years of program implementation. In addition to providing baseline data on which the objectives and success of AMREF in Afar Region can be measured against, this household survey will be used to guide program implementation and supplement other monitoring and evaluation activities.
14 AMREF in Ethiopia. Midterm evaluation of malaria project in Zone 3 of Afar Region, northeastern Ethiopia. 2008.
AMREF in Ethiopia Draft Report June 2008 6 2. Objectives of the baseline survey The main objective of this survey was to collect a baseline data on the knowledge, attitudes and practices of a local community about malaria prevention and control in two project woredas (namely, Dewe and Dalifage) in Zone 5 of Afar Region. The specific objectives were to: 1. assess the current status of malaria case management at health facilities 2. assess mother’s or caretakers perception and practice about febrile illness among young children 3. assess the knowledge and perception of the local community towards malaria, and its control 4. investigate attitudes and practices of the community in the prevention of malaria 5. examine the treatment seeking behaviour of the community on malaria, particularly for under five children 6. determine ITNs coverage at household level and utilization by under-5 children and pregnant women, and 7. obtain relevant data that will be used as a benchmark against which to measure changes in malaria prevention and control carried out by AMREF in Ethiopia.
3. Methodology
3.1 Study areas This baseline survey was carried out in May 2008 in Dewe and Dalifage woredas in Zone 5 of Afar Region. Zone 5, with a population of about 400,000, is administratively divided into five woredas (i. e., Telalak, Dewe, Dalifage, Fursi and Semi Robi). A purposive sampling strategy was used to select the two woredas due to the already initiated malaria control activities of AMREF in the woredas. Dewe woreda which has a population of approximately 82,000 in 2007 is sub-divided up into 10 kebeles. Similarly, Dalifage woreda with its estimated 70,000 population in the same year is divided into 11 kebeles. The capital of Dalifage woreda, Dalifage town, also serves as the seat for Zone 5 administration. The overwhelming majorities of the population in the study woredas resides in rural areas, and are basically pastoralists who are primarily dependent on livestock
AMREF in Ethiopia Draft Report June 2008 7 herding. There were two health centers and seven health posts in the two woredas, and one rural hospital was under construction at Dalifage town at the time of the survey (Table 1). Malaria is endemic to the area, and hence, the most common cause of morbidity and mortality.
3.2 Study design This baseline survey utilized a community-based cross-sectional study design with both quantitative and qualitative data collection methods. The quantitative part of the survey was the main data collection method complemented record review, in-depth interviews conducted with community members, kebele leaders, representatives of woreda health offices and health facilities (health centers and health posts), and AMREF team.
3.3 Study population This baseline survey involved both communities and health facilities. At the community level, heads of households residing in the selected villages were the study units. In the absence of the head of the household, the wife or any adult household member able to provide information was selected for interview. Community members and health facilities (health centers and health posts) serving the respective communities were also included particularly for the assessment of malaria case management.
3.4 Sample size calculations The required sample size for the quantitative data collection was calculated using Epi Info 2002 software package population survey formula and was based on the following assumptions. The calculation involved a single proportion for cross-sectional survey to calculate the minimum sample size required for the study, taking into account that 50% of the respondents surveyed could cite at least one of malaria preventive measures (namely, sleeping under ITNs, elimination of mosquito breeding sites, indoor house spraying with insecticide such as DDT or aerosol). This key behavioural indicator was selected because if they were knowledgeable with the current interventions used to prevent malaria, they could easily utilize the interventions by themselves or their families.
AMREF in Ethiopia Draft Report June 2008 8 Hence, 50% knowledge on malaria preventive methods with 55% worst acceptable result (5% margin of error) at 95% confidence level were employed to get a minimum sample size of 384. Non-response rate was estimated at 5% and design effect was assumed to be 1.5. The final sample size computed for the two woredas was 605 households. The number of in-depth interviews used to complement the quantitative household survey was based on rule-of-thumb.
3.5 Sampling strategy This household survey utilized cluster sample survey methods. Dewe and Dalifage woredas are the two new sites in Zone 5 of Afar Region previously selected for the expansion of AMREF malaria project. Hence, they were purposively included in this survey. In each woreda, the sampling frame was created from the list of kebeles with population sizes provided by woreda administrations/health offices (Annex I). The frame contained all kebeles in each woreda. Each kebele was further sub-divided into villages. The number of the villages in each kebele was obtained, but, information on the number of households in each village was unavailable. Although the population size for each woreda and kebele was obtained, we noticed that the figures were exaggerated and did not reflect the actual size of the population, and might not be helpful for the application of probability proportionate to size sample size allocation. All kebeles in each woreda were not equally accessible due to lack of road, remoteness and security problems. Accordingly, three kebeles from the total of 10 in Dewe woreda and five kebeles from the total of 11 in Dalifage woreda were dropped from the sampling frame. The reviews of the selection of kebeles were done with data collectors recruited from the two woredas during training. The data collectors were health workers selected from the woreda health offices, health centers and health posts, and knew the overall situation of each kebele in the study woredas. Study households were selected using a two-stage cluster sampling strategy. For the first stage, three kebeles were randomly selected from the sampling frame in each woreda. From each selected kebeles, two villages were randomly selected for the study. Finally, six kebeles and 12 villages in total were selected for this baseline survey. The calculated sample size was equally divided for the two woredas since there was no big
AMREF in Ethiopia Draft Report June 2008 9 difference between their estimated population sizes. Accordingly, 303 households were allocated for each woreda, and then, equally distributed to kebeles and villages. In Dalifage woreda, the household size of the kebeles was not highly varied and we assumed equal allocation of the sample size for the selected three kebeles [i. e., Gewane and Fer Hirus (household size = 1073), Hado and Bidare (household size = 1154) and Wolgeli and Jara (household size = 1251)]. However, the three selected kebeles in Dewe woreda were different in their household sizes [i. e., Adelile and Woderage (household size = 1713), Wahilo and Gedelea (household size = 3316) and Dewebora and Kubet (household size = 1149)]. We noted that most of the highly malarious kebeles in Dewe woreda were excluded from the sampling frame due to lack of access and security problems. The only kebele selected from these areas was Dewe Bora and Kubet, and we did not intend to base the proportional sample size allocation for this kebele, and we equally allocated for it similar to those with higher household sizes. All the heads of the households or the spouse in the household in the selected villages were finally interviewed until the allocated sample size for each village was completed. If both head of household and spouse were not present, a representative adult person (≥18 years old) in the household was interviewed. Purposive sampling was applied for selecting respondents of the in- depth interviews.
3.6 Questionnaire development The questionnaire used for this survey was based on a structured individual household interviewer-administered questionnaire developed by AMREF in Ethiopia during the midterm evaluation of malaria project in Zone 3 of Afar Region in December 200715. The questionnaire was developed in English and then translated into Amharic by an independent consultant. Based on the lessons and experiences during the field data collection, changes and modifications were made on some questions and adapted for this survey. Then, consensus was reached with the AMREF in Ethiopia staff for final use of the questionnaire for data collection. The full questionnaire in English and Amharic can be found in Annexes II and III, respectively.
15 AMREF in Ethiopia. Midterm evaluation of malaria project in Zone 3 of Afar Region, northeastern Ethiopia. 2008.
AMREF in Ethiopia Draft Report June 2008 10 A questionnaire consisting of 76 questions was used for data collection in this baseline survey and addressed the following major categories: socio-demographic characteristics knowledge and perceptions about malaria transmission and treatment knowledge and perceptions about malaria preventive methods malaria prevention practices sources of information on malaria treatment seeking behaviour practices of households on malaria in the past two weeks, and ITN ownership by household and its utilization particularly by under five children and pregnant women. The majority of the questionnaire consisted of questions designed to investigate respondents’ knowledge, attitudes and practices related to malaria. The answers to these questions will serve as baseline data to monitor the effectiveness of AMREF in Ethiopia malaria project over the coming years. In addition to the structured questionnaire, check- list was developed to assess the status of malaria case management at health facilities focusing on the areas of availability of Coartem, RDTs, trained health worker, availability of antimalarial drug treatment guidelines, and microscope if it is at the health center level. For the qualitative part of the study, interview guide was developed to guide the discussions with key informants.
3.7 Training of field personnel and data collection The baseline survey team was composed of a team of 10 data collectors, two supervisors and survey organizers from AMREF and an independent consultant (Annex IV). Except two, eight data collectors were health workers selected from the two woredas. They were nurses or environmental health experts working at woreda health offices, health centers and health posts. The remaining two data collectors were 10th or 12th grade graduate local interviewers who had prior experience in data collection, and they replaced those data collectors selected from Dalifage woreda, but unable to attend the training due to transportation problems. Most of the interviewers are knowledgeable with the local language (i. e., Afarigna), and for those who have a difficulty with the local language, local translators
AMREF in Ethiopia Draft Report June 2008 11 were used. Although the final questionnaire for the data collection was prepared in Amharic, the interview was conducted with the local language (i. e., Afar language) during the interview. Therefore, the questionnaires were administered either in the language in which both the interviewers and the respondents communicate or by translation into the local language that the respondents speak. For the purpose of field guide and translations, seven local people who are fluent both in Amharic and Afarigna were recruited from each woreda. The use of translation definitely may have implications for the accuracy of data. The qualitative component of the baseline survey with key informants from the community and health facility was conducted by an external consultant. During key informant interview from the community, translation with local guides was used. Except for the initial planning of the survey and the final preparation of this report, the entire fieldwork was conducted during the period of May 15th – 24th, 2008. Before fieldwork, training for data collectors and supervisors on data collection instruments was conducted for two days (May 16th – 17th) at Awash Buffet Hotel by the survey organizers and an external consultant. A training manual was prepared and used to train the data collectors for the household survey (Annex V). The training focused on thorough familiarization with the questionnaire, interview techniques, household selection and filling of the questionnaire. As a result of the adaptation of the previously pre-tested structured questionnaires, we did not conduct a pre-testing of the questionnaires used during the present survey. Actual data collection in the field was carried out between May 20th and 23rd, 2008. Data collection started first in Dewe woreda and then, all data collectors moved to Dalifage woreda for the final data collection. Completeness and accuracy of filled questionnaires were cross-checked by supervisors in the field to maintain the quality of the data. Quality control was done by frequently checking on the correct application of the household selection and administration of the questionnaire during the data collection in the field. The supervisors were responsible for supervising data collection, providing guidance and administrative roles to the team, field checking and editing completed questionnaires. In addition, the consultant was involved in the organization and supervision of the fieldwork during data collection. The key informant interviews and the health facility assessments were carried out by the external consultant.
AMREF in Ethiopia Draft Report June 2008 12 3.8 Data analysis and presentation Quantitative data generated from the survey were entered and analyzed using Epi Info version 6.04d (Centers for Disease Control and Prevention, Atlanta, GA) and SPSS version 12 (SPSS, Inc., Chicago, IL) statistical software packages, respectively. Each filled questionnaire was checked and edited before data entry, and data were further cleaned electronically after data entry. Data entry was done by two experienced data clerks from the School of Public Health at Addis Ababa University. Development of data entry templates, data cleaning, processing, analysis and the overall management of the data were performed by the external consultant. This baseline survey report was exclusively written by the consultant. Proportions, means, medians and graphs or cross-tabulations were used for data summarization and presentation. Degree of association was measured by Chi Square (Χ2) test and P-value. The data from the in-depth interviews and health facility assessments were summarized and interpreted manually by the consultant, and used to complement the quantitative data. The final report of this baseline survey includes the findings of both the quantitative and qualitative data collection methods.
4. Ethical considerations Permission to undertake this survey was obtained from every relevant authority at all levels in the Afar Region. Official letters from AMREF in Ethiopia were written to Zone 5 administration office, Dewe and Dalifage woredas respective administration and health offices. All authorities at different levels were informed about the survey. At the community level, local leaders such as kebele and village leaders, and community elders were informed about the study. At the household level, the teams explained the purpose of the study and oral informed consent was obtained before the interview. Participation of all respondents in the survey was strictly voluntary. Measures were taken to assure the respect, dignity and freedom of each individual participating in the survey. During training of data collectors, emphasis was placed on the importance of obtaining informed consent (orally), and avoiding coercion of any kind. Names of respondents were not recorded anywhere on the questionnaire. Appropriate measures were taken to assure confidentiality of information both during and after data collection. Data collectors had taken additional responsibilities of informing the study participants
AMREF in Ethiopia Draft Report June 2008 13 and communities about malaria prevention and control, particularly about early treatment seeking and proper utilization of ITNs after the end of the interview.
5. Findings
5.1 Qualitative findings The qualitative results presented in this report are based on the findings of the health facility assessment and in-depth interviews conducted during the quantitative data collection. The report on the health facility assessment focuses on the number and type of health services and health personnel, availability of laboratory diagnosis/RDT for malaria diagnosis, availability of antimalarial drugs particularly artemether-lumefantrine (Coartem) and on the status of the training of health workers on malaria case management or the use of RDTs. The in-depth interview, on the other hand, emphasized on the perception of the mothers or caretakers on malaria in general and their specific practice with regard to febrile illness among under-five children. A. Malaria case management at health facilities Prompt and accurate diagnosis of malaria is part of the effective disease management. Malaria diagnosis is based on either clinical criteria or detection of the parasite in the blood film or the combination of both methods. In Ethiopia, the diagnosis of malaria based on clinical criteria (clinical diagnosis) mostly relies on the basis of fever or history of fever and the detection of the parasite in the blood using microscopy or RDT. Clinical diagnosis has a very low specificity since the signs and symptoms of malaria are non- specific, while microscopic or RDT diagnoses are not available in many areas. Therefore, most malaria patients in Ethiopia do not have access to laboratory-based diagnostic services. The numbers of health facilities in Afar region in general and in Dewe and Dalifage woredas in particular are highly limited. There were three health posts and one health center in Dewe woreda. Similarly, four health posts (one was not functional at the time of the survey), one health center and one hospital (under construction) were found in Dalifage woreda at the time of the survey. No physician was found in the two woredas and both health centers were headed by the health officers. In each woreda, one BSc nurse was also available. The summary of the health personnel and type of health
AMREF in Ethiopia Draft Report June 2008 14 facilities in each woreda is presented in Table 1. The heads of the health centers complained that there was a severe shortage of manpower as presented below using health staff to population ratio, compromising the quality of the services.
Table 1: Type of health facilities and health personnel category by woreda, May 2008
Type of Woreda Health personnel Woreda health facility Dewe Dalifage Total category Dewe Dalifage Total Health officer 1 1 2 BSc nurse 1 1 2 Health center 1* 1 2 Sen. Clinical nurse 3 2 5 Health post 3 4 7 Jun. Clinical nurse 1 0 1 Midwifer 0 1 1 Hospital 0 1** 1 Public health nurse 0 1 1 Health assistant 1 0 1 Lab. Technologist 1 2 3 Druggist 1 0 1 Frontline 5 0 5 HEW*** 5 6 11 Health staff to population ratio Health officer to population 1:82,000 1:70,000 BSc nurse to population 1:82,000 1:70,000 Diploma nurse to population 1:27,000 1:35,000 HEW to population 1:16,400 1:11,667 * Nucleus health center, **Hospital under construction, *** Health extension worker
Malaria is a major public health problem in Dewe and Dalifage woredas. According to the 1997 EC and 1998 EC record review of Dewe Health Center, 33% and 24% of the outpatient attendants were due to malaria, respectively. The corresponding figures at Delifage Health Center were also similar, ranging between 22% to 25%. There was neither generator nor electricity in Dewe Health Center, and only solar microscope had been used for blood film examination of malaria diagnosis. The problem was also exacerbated by lack of appropriate room for laboratory diagnosis and reliable RDTs. The RDTs were available but most of them were not reliable due to temperature effect as they could not stay longer in hot climate. Adequate amount of Coartem was available at Dewe Health Center and the three health posts in the woreda, but only one month was remained for expiry (June 2008). RDTs were not available at the health post level in Dewe woreda because none of the health workers at these levels were trained on how to use it. Therefore, treatment of malaria with Coartem at health post level in Dewe woreda was based on clinical criteria, which might increase unnecessary use of
AMREF in Ethiopia Draft Report June 2008 15 antimalarials. This was also assumed to be true at the Dewe Health Center due to irregular use of solar microscope and the unreliability of the RDTs. Besides, no training on RDT was been given for the laboratory technologist. At Dalifage Health Center, there was a generator and a standard microscope. Therefore, the usual microscopic diagnosis of malaria was performed at the health center. Adequate amount of Coartem was also available at the health center, but the drug was only available at two health posts. The remaining health posts did not have Coartem. Similar to the problem in Dewe woreda, the health workers at the health post level in Dalifage woreda did not receive any training on RDTs, and therefore, they did not use it for malaria diagnosis. Chloroquine and quinine were available both at Dewe and Dalifage Health Centers for the treatment of vivax malaria and complicated falciparum cases, respectively. Malaria diagnosis and treatment is not only provided at health facilities. Mother coordinators also play a major role in teaching the community about malaria, its prevention and treatment. As a result, AMREF in Ethiopia trained 31 mother coordinators (15 from Dewe and 16 from Dalifage) on participatory malaria prevention and treatment in April 2008. In addition, 14 health workers from Dewe and 15 from Dalifage were trained for three days on malaria vector control and case management in early May 2008. To strengthen the capacity of health extension workers (HEWs), training on vector control and RDT was given to 10 HEWs from Dewe and 11 HEWs from Dalifage for two days in early May 2008. However, it is not clear whether the trainings given for HEWs on the use of RDT enables them to properly use RDTs for malaria diagnosis at health post level. In summary, the health facilities in both woredas suffered from lack of adequate manpower, lack of training of health workers particularly at the health posts level for using RDTs, and unavailability of standard microscope at Dewe Health Center. Malaria diagnosis was mainly based on clinical criteria that have low specificity. Therefore, we can conclude that malaria case management at health facilities in the two woredas was poor at the time of the survey. However, it is possible to improve case management of the disease at health facilities in the woredas by training health workers on how to use RDTs, supplying adequate amount of RDTs and Coartem particularly for health posts, and supplying generator for Dewe Health Center to enable it to use the standard microscope
AMREF in Ethiopia Draft Report June 2008 16 for malaria diagnosis. The laboratory technologists found in the woredas, if properly trained and guided on RDTs, could also be used as resource persons for training of HEWs and other health workers on RDT for malaria diagnosis. B. Mother’s or caretakers perception and practice about febrile illness among under five children A total of 10 people (3 mothers and 2 fathers from each woreda) participated in the in-depth interviews to explore information on beliefs, opinions, perceptions and practices of the community about malaria and their experiences on febrile illness management among under five children. All the participants were married, in the age group of 20-40 years, followers of Islam, non-educated rural people, and all had under five children. The most common diseases in the study area mentioned by the in-depth interview participants were malaria, diarrhea, respiratory tract infections, skin and eye diseases. Malaria was particularly mentioned as the most common and serious disease; and almost all participants mentioned fever, headache, joint pain, loss of appetite and vomiting as the main symptoms of the disease. They also indicated that malaria could be fatal particularly among children and pregnant women if not properly treated. Very few in-depth interview participants said that malaria is transmitted through mosquito bite. The majority did not know how malaria is caused. Some believed that malaria is caused by drinking unclean water, when people do not get adequate food, raw milk, and stagnant water. All of the participants said that they had heard of mosquito nets. Almost all had clear understanding about the use and purpose of ITNs. Most of them said that it is used to protect against mosquito bite. Some reported that it is used to protect both from mosquito bite and malaria. Only few respondents mentioned that their households had an ITN at the time of the survey. They ever had nets, but they did not possess it currently as it was aged out or lost. All participants were aware of the dangers and severity of malaria among under five children. Some said that there is a drug for malaria treatment, but others believed that the disease has no cure except Allah. The most common practices at home for a malaria patient before seeking treatment from health facilities as mentioned by most of them included drinking camel milk, eating food, feeding butter, and taking tablets at home.
AMREF in Ethiopia Draft Report June 2008 17 Some also reported the availability of traditional healers for malaria using herbal remedies. All these practices were performed both for children and adults. Respondents were asked what they do after home treatment if febrile illness among children does not improve. Among the alternative care providers in the area, health centers and health posts were the most commonly sought treatment sources for malaria. The most common problems related to treatment seeking from health facilities for children included the unavailability of health services within a reasonable distance, and sometimes unavailability of drugs at the health facilities. Due to these problems, the mothers or caretakers most often opted to practice home treatment using traditional remedies or/and modern drugs. Improving community access to health services, raising awareness of the people on malaria prevention and control and the importance of early diagnosis and prompt treatment with effective antimalarial drug particularly using health workers at peripheral health facilities and village-based mother coordinators seem to be the most effective intervention. AMREF in Ethiopia should focus on strengthening the capacity of peripheral health workers and community-based mother coordinators for effective malaria prevention and control.
AMREF in Ethiopia Draft Report June 2008 18 5.2 Quantitative findings
5.2.1 Population characteristics A total of 630 households (55.1% from Dewe and 44.9% from Dalifage) were visited and a questionnaire was administered to the household’s head or representative from six kebeles in the woredas. A little more than half (52.9%) of the respondents were males. The mean age of the respondents was 33.48 years, with a range of 18-80 year, and a median age of 30 years. The informants were mainly between 25-44 years (70.4%), rural residents (80.5%), Islam (96.5%) and from the Afar ethnic group (91.6%) (Table 2). About 51% and 41% of the respondents were heads of households and spouse of the head of the households, respectively. Of 630 study households, 503 (79.8%) had a male as the head of the household than females (20.2%). The percentage of female headed households was greater in Dewe (22.2%) than in Dalifage (17.7%) woreda.
AMREF in Ethiopia Draft Report June 2008 19 Table 2: Socio-demographic characteristics of the respondents by woreda, May 2008
Woreda Variable (n=630) Dewe, n (%) Dalifage, n (%) Total, n (%) Sex Male 176 (50.7) 157 (55.5) 333 (52.9) Female 171 (49.3) 126 (44.5) 297 (47.1) Head of the household Male 270 (77.8) 233 (82.3) 503 (79.8) Female 77 (22.2) 50 (17.7) 127 (20.2) Status of the respondent in the household Head of the household 162 (46.7) 160 (56.5) 322 (51.1) Spouse of the head of HH 157 (45.2) 102 (36.0) 259 (41.1) Son or daughter 17 (4.9) 14 (4.9) 31 (4.9) Other 11 (3.2) 7 (2.5) 18 (2.9) Age (in years) 15-24 59 (17.0) 54 (19.1) 113 (17.9) 25-34 124 (35.7) 117 (41.3) 241 (38.3) 35-44 121 (34.9) 81 (28.6) 202 (32.1) 45-54 29 (8.4) 18 (6.4) 47 (7.5) ≥55 14 (4.0) 13 (4.6) 27 (4.3) Mean (±SD) 33.87 (±10.45) 33.0 (±10.62) 33.48 (10.52) Range 18-80 18-75 18-80 Residence Rural 271 (78.1) 236 (83.4) 507 (80.5) Urban 76 (21.9) 47 (16.6) 123 (19.5) Religion Islam 336 (96.8) 272 (96.1) 608 (96.5) Orthodox Christian 11 (3.2) 11 (3.9) 22 (3.5) Ethnicity Afar 320 (92.2) 257 (90.8) 577 (91.6) Amhara 17 (4.9) 14 (4.9) 31 (4.9) Oromo 10 (2.9) 11 (3.9) 21 (3.3) Other 0 (0.0) 1 (0.4) 1 (0.2) N 347 (55.1) 283 (44.9) 630 (100.0)
Further demographic characteristics of the respondents are also shown in Table 3. About 83% of the respondents were married at the time of the survey, and of 522 married participants, about 30% were engaged in polygamous marriage (29.9% in Dewe vs 29.8% in Dalifage). There was no significant difference in the proportion of married respondents in both woredas. More widowed respondents were reported from Dewe (8.6%) compared with Dalifage woreda (4.2%). The majority of the never married respondents were sons or daughters who were interviewed when their parents were unavailable at home.
AMREF in Ethiopia Draft Report June 2008 20 Table 3: Marital status of the respondents by woreda, May 2008
Woreda Characteristics Dewe, n (%) Dalifage, n (%) Total, n (%) Marital status (n=630) Married 284 (81.9) 238 (84.1) 522 (82.8) Never married (single) 19 (5.5) 20 (7.1) 39 (6.2) Divorced 14 (4.0) 11 (3.9) 25 (4.0) Widowed 30 (8.6) 12 (4.2) 42 (6.7) Separated 0 (0.0) 2 (0.7) 2 (0.3) N 347 (55.1) 283 (44.9) 630 (100.0) Polygamous/monogamous marriage (n=522) Monogamous 199 (70.1) 167 (70.2) 366 (70.1) Polygamous 85 (29.9) 71 (29.8) 156 (29.9) N 284 (54.4) 238 (45.6) 522 (100.0)
Table 4 depicts educational level of the respondents. Educational level was generally low, and only 177 (28.1%) respondents ever attended school. Of those who attended school, the majority (42.9%) attended Koran, 23.7% received primary education and about 20% attended junior and secondary education. Very few respondents had high levels of education, with only 11.9% reporting any level of secondary education and 2.8% with college education. This may be due to the predominance of respondents from rural areas, who in the Ethiopian setting have lower levels of education than their urban counterparts. As a result, there was significant urban-rural disparity in education: 76.9% of rural respondents attending no school versus 52% of urban respondents (P<0.005). In this study, significant gender disparity in attending school was not revealed. This may be due to the generally low level of educational status in the study area.
AMREF in Ethiopia Draft Report June 2008 21 Table 4: Educational status and literacy of the respondents by woreda, May 2008
Woreda Characteristics Dewe, n (%) Dalifage, n (%) Total, n (%) Ever attended school (n=630) Yes 99 (28.5) 78 (27.6) 177 (28.1) No 248 (71.5) 205 (72.4) 453 (71.9) N 547 (55.1) 283 (44.9) 630 (100.0) Highest level of school or grade completed (n=177) Only read/write 10 (10.1) 7 (9.0) 17 (9.6) Koran 45 (45.5) 31 (39.7) 76 (42.9) Elementary (grade 1-4) 22 (22.2) 20 (25.6) 42 (23.7) Junior (grade 5-8) 9 (9.1) 7 (9.0) 16 (9.0) Senior (grade 9-12) 9 (9.1) 12 (15.4) 21 (11.9) College 4 (4.0) 1 (1.3) 5 (2.8) N 99 (55.9) 78 (44.1) 177 (100.0)
Of 630 respondents, 63% reported that they had some sort of regular work or job at the time of the survey (Table 5). However, it is likely that those respondents who reported job may be involved in pastoral way of life in one way or another since the majority of the community in the study areas are pastoralists. The most common occupation reported for those who reported any form of work was pastoralist, accounting for 51.6% of the respondents. About 23% of the respondents said that they were housewives (22.9%), while a minority of respondents reported that they were government or NGO employees (13.6%). Housewives are also expected to participate in other activities in addition to their household duties. Only few respondents reported that they were traders, farmers, or private employees.
AMREF in Ethiopia Draft Report June 2008 22 Table 5: Occupational status of the respondents by woreda, May 2008
Woreda Characteristics Dewe, n (%) Dalifage, n (%) Total, n (%) Currently working (n=630) Yes 228 (65.7) 169 (59.7) 397 (63.0) No 119 (34.3) 114 (40.3) 233 (37.0) N 347 (55.1) 283 (44.9) 630 (100.0) Main work/occupation (n=397) Pastoralist 123 (53.9) 82 (48.5) 205 (51.6) Housewife 58 (25.4) 33 (19.5) 91 (22.9) Government/NGO employee 30 (13.2) 24 (14.2) 54 (13.6) Daily labourer 3 (1.3) 19 (11.2) 22 (5.5) Student 5 (2.2) 5 (3.0) 10 (2.5) Trader 4 (1.8) 4 (2.4) 8 (2.0) Farmer 4 (1.8) 2 (1.2) 6 (1.5) Private employee 1 (0.4) 0 (0.0) 1 (0.3) N 347 (55.1) 283 (44.9) 630 (100.0)
5.2.2 Household size Table 6 presents information on the number of permanent residents and family members who stayed in the household the previous night. The mean household size (permanent members) was 5.17 (5.24 in Dewe and 5.1 in Dalifage woreda). It was slightly higher in Dewe than Dalifage. The mean number of permanent residents of the households was slightly higher than that of those stayed in the household the night preceding the survey. The average number of under five children in both woredas was about 1 per household. However, the number of pregnant women identified in the visited households was lower. Information about the household size, the number of under five children and pregnant women is very important to calculate the RBM coverage indicators for ITN use among the target population.
AMREF in Ethiopia Draft Report June 2008 23
Table 6: Household size of the respondents by woreda, May 2008
Woreda Characteristic Dewe, n (%) Dalifage, n (%) Total, n (%) Permanent residents Total no. of residents 1818 1439 3257 Mean (±SD) HH size 5.24 (±2.46) 5.1 (±2.46) 5.17 (±2.46) Median 5.0 5.0 5.0 Range 1-15 1-15 1-15 Children under five years Total no. of children 376 277 653 Mean (±SD) 1.08 (±1.05) 0.98 (±0.99) 1.04 (±1.03) Median 1.0 1.0 1.0 Range 0-5 0-5 0-5 Pregnant women Total pregnant women 45 57 102 Mean (±SD) 0.13 (±0.34) 0.2 (±0.4) 0.16 (±0.37) Median 0.0 0.0 0.0 Range 0-1 0-1 0-1 Residents stayed in the household the previous night Total no. of residents 1754 1404 3158 Mean (±SD) HH size 5.05 (±2.4) 4.96 (±2.44) 5.01 (±2.42) Median 5.0 5.0 5.0 Range 1-15 1-15 1-15 Children under five years Total no. of children 373 277 650 Mean (±SD) 1.08 (±1.03) 0.98 (±0.99) 1.03 (±1.02) Median 1.0 1.0 1.0 Range 0-4 0-5 0-5 Pregnant women Total pregnant women 45 57 102 Mean (±SD) 0.13 (±0.34) 0.2 (±0.4) 0.16 (±0.37) Median 0.0 0.0 0.0 Range 0-1 0-1 0-1
5.2.3 Households ownership of basic durables Data were collected on the possession of basic household durables. Table 7 presents information about basic durables such as lantern, radio, refrigerator and television. Among the study households, 65.6% had water storage plastic jerry can, 47.9% had lantern and 22.9% had radio. The households from Dewe woreda had relatively higher percentage of plastic jerry cans and lanterns, but there was no difference between the households in both woredas in possession of radio. Very few respondents had telephone including cell phone (4.3%), refrigerator (2.5%) and television (1.3). Radio
AMREF in Ethiopia Draft Report June 2008 24 and television are very important in dissemination malaria related information, but the coverage of television, in the rural Ethiopian context is almost non-existing.
Table 7: Households ownership of basic durables by woreda, May 2008
Type of durables owned* Woreda (n=630) Dewe, n (%) Dalifage, n (%) Total, n (%) Water storage plastic jerry can 237 (68.3) 176 (62.2) 413 (65.6) Lantern 187 (53.9) 115 (40.6) 302 (47.9) Radio 81 (23.3) 63 (22.3) 144 (22.9) Electricity supply 11 (3.2) 43 (15.2) 54 (8.6) Telephone including cell phone 13 (3.7) 14 (4.9) 27 (4.3) Refrigerator 8 (2.3) 8 (2.8) 16 (2.5) Television 6 (1.7) 2 (0.7) 8 (1.3) N 347 (55.1) 283 (44.9) 630 (100.0) * Multiple responses possible
5.2.4 Household’s source of drinking water and sanitation facilities Household’s access to safe and adequate water supply is an important factor affecting the health and wellbeing of the family members, especially young children. Information regarding the main source of drinking water supply and the possession of pit latrine is presented in Table 8. River and unprotected well were the major source of drinking water in both woredas, supplying 33% and 29.4% of households, respectively. River and unprotected well are generally the main sources of drinking water for the majority of the households in rural Ethiopia. Water is generally inadequate in the Afar Region, and the majority of the people are based on the Awash River for human as well as livestock. In the study area, river and unprotected well were followed in importance by piped water (24%) and protected well (13.3%). Households in Dewe woreda tended to have less access to piped water than those in Dalifage. In the contrary, households in Dalifage had less access to protected well as the source of water. Sanitation facilities were very limited in the study area. Only 6.2% of the households (4.9% in Dewe and 7.8% in Dalifage) had pit latrines. It is of great concern that the possession of latrines does not necessarily imply the use of them by household
AMREF in Ethiopia Draft Report June 2008 25 members. Open field defecation is the main type of toilet facility for the majority of rural households in Ethiopia.
Table 8: Main source of drinking water and latrine possession for survey households by woreda, May 2008
Woreda Water supply and sanitation Dewe, n (%) Dalifage, n (%) Total, n (%) Source of water supply River 109 (31.4) 99 (35.0) 208 (33.0) Unprotected well 97 (28.0) 88 (31.1) 185 (29.4) Piped (tap) 74 (21.3) 77 (27.2) 151 (24.0) Protected well 65 (18.7) 19 (6.7) 84 (13.3) Pond 2 (0.6) 0 (0.0) 2 (0.3) N 347 (55.1) 283 (44.9) 630 (100.0) Households with pit latrine 17 (4.9) 22 (7.8%) 39 (6.2)
5.2.5 Household’s sleeping area arrangements The mean number of total beds/mats per household was 1.8 compared, with 1.5 indoor and 0.3 outdoor (Table 9). There was no significance difference in the number of beds between the two woredas. In a typical Afar house, bed with a metal frame or mattress is barely found, and it is traditionally done from wood. More than a quarter of the house is occupied with a bed. Mat is also placed on a floor either indoor or outdoor for sleeping because the climate is hot and people particularly adults prefer to sleep outdoor during the non-rainy season. The type of sleeping area arrangement has an implication for malaria control. For people to protect themselves from mosquito bite and prevent malaria, sleeping or staying outdoor during night should be discouraged. The number of beds per household is also a proxy to estimate the number of ITN required for the household. The majority of the households (95.4%) did not share their house with livestock (i. e., calf, goat or sheep) during night. Households in the study area generally keep their cattle during night in an enclosure around their house.
AMREF in Ethiopia Draft Report June 2008 26 Table 9: Sleeping area arrangements of household members by woreda, May 2008
Woreda Variable Dewe Dalifage Total Sleeping area Bed/mat per household (Total) 1.9 1.7 1.8 Bed/mat per household (Indoor) 1.6 1.5 1.5 Bed/mat per household (Outdoor) 0.3 0.3 0.3 n (%) n (%) n (%) Primary living room shared with livestock during night Yes 21 (6.1) 8 (2.8) 29 (4.6) No 326 (93.9) 275 (97.2) 601 (95.4) N 347 (55.1) 283 (44.9) 630 (100.0)
5.2.6 Exposure to mass media and sources of information about malaria Respondents were asked whether their households had radio or television, whether they listened to radio or watched television, and how often they did so. Table 10 presents the distribution of respondents exposed to each of these media. Only 22.9% and 1.3% of the respondents claimed that their households had a radio and television, respectively, at the time of the survey.
Table 10: Respondent’s media exposure by woreda, May 2008
Malaria treatment and Woreda antimalarials Dewe, n (%) Dalifage, n (%) Total, n (%) Household owned radio 81 (23.3) 63 (22.3) 144 (22.9) Household owned television 6 (1.7) 2 (0.7) 8 (1.3) Radio - frequency of listening Almost every day 77 (22.2) 59 (20.8) 136 (21.6) At least once a week 15 (4.3) 8 (2.8) 23 (3.7) Less than once a week 3 (0.9) 1 (0.4) 4 (0.6) Not at all 252 (72.6) 215 (76.0) 467 (74.1) TV - frequency of watching Almost every day 7 (2.0) 4 (1.4) 11 (1.7) At least once a week 11 (3.2) 8 (2.8) 19 (3.0) Less than once a week 8 (2.3) 0 (0.0) 8 (1.3) Not at all 321 (92.5) 271 (95.8) 592 (94.0) N 347 (55.1) 283 (44.9) 630 (100.0)
Overall, nearly 2 of 10 respondents (21.6%) listened to radio almost everyday, with nearly 4% doing so at least once a week and 0.6% doing so less than once a week (Table 10). The majority of the respondents (74.1%) did not listen to radio at all. There was little variation in exposure to mass media between the two study woredas particularly
AMREF in Ethiopia Draft Report June 2008 27 in terms of the frequency of listening to radio. The percentage having exposure to radio at least once a week is higher in Dewe (4.3%) than Dalifage (2.8%). About 6% of the respondents watched to television (1.7% almost everyday, 3% at least once a week and 1.3% less than once a week). Exposure to mass media is very important to increase the uptake of health and health related information disseminated through the media. Table 11 lists respondent’s sources of information on malaria in the past three months. One hundred thirty two respondents (21%) heard of malaria from radio (22.5% in Dewe vs. 19.1% in Dalifage) and 130 (20.6%) received information from local health workers. Other sources of information on malaria included school students (5.7%), health extension workers (3.5%), and television (2.2%). Information regarding malaria obtained through reading newspaper, magazine or pamphlet was only cited by 2.1% of the respondents. The effectiveness of malaria control interventions depends on the type and nature of information disseminated to the community. Appropriate channels that reach the majority of the rural population should be sought to promote effective utilization of malaria prevention and control interventions.
Table 11: Respondent’s exposure to sources of information in the last three months by woreda, May 2008
Sources of information on Woreda malaria* Dewe, n (%) Dalifage, n (%) Total, n (%) Radio 78 (22.5) 54 (19.1) 132 (21.0) Health worker 78 (22.5) 52 (18.4) 130 (20.6) School students 25 (7.2) 11 (3.9) 36 (5.7) Health extension worker 13 (3.7) 9 (3.2) 22 (3.5) Television 6 (1.7) 8 (2.8) 14 (2.2) Newspaper/magazine/pamphlet 6 (1.7) 7 (2.5) 13 (2.1) Mosque or church 5 (1.4) 0 (0.0) 5 (0.8) N 347 (55.1) 283 (44.9) 630 (100.0) * Multiple answers possible
5.2.7 Respondent’s perceived major health problems The most common diseases in the study area reported by the respondents were malaria (99.4%), respiratory diseases including tuberculosis (81.7%), diarrheal diseases (62.7%) and gastro-intestinal diseases (27.3%) (Table 12). Malaria was particularly mentioned as the most common disease affecting the people. Skin diseases and malnutrition were also mentioned as the major health problems by few respondents.
AMREF in Ethiopia Draft Report June 2008 28 Knowledge of the community about a particular health problem in the area is very critical in ensuring community participation and partnership in disease prevention and control. Almost all of the participants in in-depth interviews perceived malaria as the most common health problem in the study area, and also knew that it can be fatal particularly among children and pregnant women if left untreated.
Table 12: Respondent’s perceived major health problems by woreda, May 2008
Woreda Source of water supply Dewe, n (%) Dalifage, n (%) Total, n (%) Malaria 345 (99.4) 281 (99.3) 626 (99.4) Respiratory diseases including TB 270 (77.8) 245 (86.6) 515 (81.7) Diarrhoeal diseases 202 (58.2) 193 (68.2) 395 (62.7) Gastro-intestinal diseases 104 (30.0) 68 (24.0) 172 (27.3) Skin diseases 48 (13.8) 23 (8.1) 71 (11.3) Malnutrition 10 (2.9) 3 (1.1) 13 (2.1) N 347 (55.1) 283 (44.9) 630 (100.0)
5.2.8 Respondent’s knowledge about transmission and causes of malaria When asked about whether malaria can be transmitted from one person to another, 543 respondents (86.2%) stated “yes”, 2.2% said “no” and the remaining 11.6% gave “did not know” responses (Table 13). Respondents from Dewe woreda were less likely to state that malaria can be transmitted from person to person than Dalifage (83% vs. 90.1%, P<0.01). Table 13 also lists the perceived causes of malaria by the respondents. Of the total respondents, 67.1% (543 of 630) correctly identified mosquitoes as the main vector of malaria transmission. There was a statistically significant difference between the knowledge of the respondents about the role of mosquitoes in malaria transmission, 72% in Dewe vs. 61.1% in Dalifage woreda (P<0.01) (Table 13). Incorrect responses about the cause of malaria included through breathing (27.9%), exposure to cold (17%), physical contact with a person who has malaria (16.8%), exposure to dirty swampy areas (4.8%) and drinking contaminated water (4.4%).
AMREF in Ethiopia Draft Report June 2008 29
Table 13: Respondent’s knowledge about transmission and causes of malaria by woreda, May 2008
Malaria transmission Woreda and causes Dewe, n (%) Dalifage, n (%) Total, n (%) Malaria can be transmitted from one person to another Yes 288 (83.0) 255 (90.1) 543 (86.2) No 13 (3.7) 1 (0.4) 14 (2.2) Did not know 46 (13.3) 27 (9.5) 73 (11.6) Causes of malaria* Mosquito bite 250 (72.0) 173 (61.1) 423 (67.1) By breathing 80 (23.1) 96 (33.9) 176 (27.9) Exposure to cold 52 (15.0) 55 (19.4) 107 (17.0) Sleeping with a person who has malaria 44 (12.7) 62 (21.9) 106 (16.8) Exposure to dirty swampy areas 26 (7.5) 4 (1.4) 30 (4.8) Drinking contaminated water 19 (5.5) 9 (3.2) 28 (4.4) Did not know 25 (7.2) 14 (4.9) 39 (6.2) N 347 (55.1) 283 (44.9) 630 (100.0) * Multiple responses possible
Comparisons were also made between the knowledge of males/females and rural/urban on malaria transmission from one person to another and the cause of malaria (Table 14). Males were found to be more knowledgeable than females on the transmission of malaria from one person to another (88% vs. 84.2%, P<0.02), but no significant difference between rural and urban residents was observed (85% vs. 91.1%). Urban respondents were more likely to cite mosquito bite as the main mode of malaria transmission than their rural counterparts (83.7% vs. 63.1%, P<0.001). There was no significant difference between males and females as to whether mosquito bite is incriminated as the cause of malaria.
AMREF in Ethiopia Draft Report June 2008 30 Table 14: Respondent’s knowledge about transmission and causes of malaria by sex and residence, May 2008
Sex Residence Malaria transmission Male, Female, Rural, Urban, Total, and causes n (%) n (%) n (%) n (%) n (%) Malaria can be transmitted from one person to another Yes 293 (88.0) 250 (84.2) 431 (85.0) 112 (91.1) 543 (86.2) No 2 (0.6) 12 (4.0) 12 (2.4) 2 (1.6) 14 (2.2) Did not know 38 (11.4) 35 (11.8) 64 (12.6) 9 (7.3) 73 (11.6) Causes of malaria* Mosquito bite 226 (67.9) 197 (66.3) 320 (63.1) 103 (83.7) 423 (67.1) By breathing 101 (30.3) 75 (25.3) 157 (31.1) 19 (15.4) 176 (27.9) Exposure to cold 51 (15.3) 56 (18.9) 90 (17.8) 17 (13.8) 107 (17.0) Sleeping with a person who has malaria 63 (18.9) 43 (14.5) 97 (19.1) 9 (7.3) 106 (16.8) Exposure to dirty swampy areas 18 (5.4) 12 (4.0) 19 (3.7) 11 (8.9) 30 (4.8) Drinking contaminated water 15 (4.5) 13 (4.4) 24 (4.7) 4 (3.3) 28 (4.4) Did not know 15 (4.5) 24 (8.1) 31 (6.1) 8 (6.5) 39 (6.2) N 333 (52.9) 297 (47.1) 507 (80.5) 123 (19.5) 630 (100.0) * Multiple responses possible
5.2.9 Respondent’s knowledge about mosquito biting time When asked, “when do mosquitoes usually bite a person?” the majority of respondents were aware that mosquitoes bite most likely in the evening (56.3%) and night (39.2%) times (Table 15). Respondents from Dalifage woreda were more likely to say “during evening” (61.8%) than those in Dewe woreda who were more likely to perceive “during night” (44.4%).
Table 15: Respondent’s knowledge about mosquito biting time by woreda, May 2008
Woreda Usual biting time Dewe, n (%) Dalifage, n (%) Total, n (%) Evening 180 (51.9) 175 (61.8) 355 (56.3) Night 154 (44.4) 93 (32.9) 247 (39.2) Day and night 10 (2.9) 7 (2.5) 17 (2.7) Day 0 (0.0) 8 (2.8) 8 (1.3) Did not know 3 (0.9) 0 (0.0) 3 (0.5) N 347 (55.1) 283 (44.9) 630 (100.0)
The female Anopheles mosquitoes are responsible for transmitting malaria. They usually bite from dusk to dawn although in some situations they will bite earlier than this. In many localities the principal vectors of malaria are late night biters and the older mosquitoes (more likely to be infected) are often found to be biting after the midnight. However, different species of Anopheles mosquitoes may have different peak biting
AMREF in Ethiopia Draft Report June 2008 31 times. Knowledge of the usual biting time of mosquitoes is important in the choice of appropriate personal preventive measures such as protective clothing and ITN.
5.2.10 Respondent’s knowledge about malaria symptoms Most respondents in the present study correctly identified the typical clinical symptoms associated with malaria illness. Table 16 lists the main symptoms associated with malaria illness. Six hundred three respondents (95.7%) reported fever as a primary indicator of malaria illness, followed by headache (81.6%) and shivering/chills (74.3%). Vomiting (63.5%), sweating (54.8%), loss of appetite (39%), backache (31%), and other symptoms were also cited by the respondents.
Table 16: Respondent’s knowledge about malaria symptoms by woreda, May 2008
Woreda Main sign or symptom* Dewe, n (%) Dalifage, n (%) Total, n (%) Fever 338 (97.4) 265 (93.6) 603 (95.7) Headache 281 (81.0) 233 (82.3) 514 (81.6) Shivering/chills 262 (75.5) 206 (72.8) 468 (74.3) Vomiting 223 (64.3) 177 (62.5) 400 (63.5) Sweating 182 (52.4) 163 (57.6) 345 (54.8) Loss of appetite 145 (41.8) 101 (35.7) 246 (39.0) Backache 141 (40.6) 54 (19.1) 195 (31.0) Body /joint pains 113 (32.6) 71 (25.1) 184 (29.2) Bitterness in the mouth 114 (32.9) 56 (19.8) 170 (27.0) Weakness/ tiredness 107 (30.8) 49 (17.3) 156 (24.8) Thirsty 79 (22.8) 45 (15.9) 124 (19.7) Convulsion 56 (16.1) 29 (10.2) 85 (13.5) Splenomegally 45 (13.0) 19 (6.7) 64 (10.2) N 347 (55.1) 283 (44.9) 630 (100.0) * Multiple responses possible Three hundred seventy eight respondents (60%) cited the three main symptoms of malaria (fever, headache and shivering/chills). There was no significant difference about the knowledge of the main symptoms of malaria between the two study woredas. Convulsion as a sign for severe and complicated malaria was reported by 13.5% of the respondents. The main symptom of malaria is fever, often accompanied by chills and sweating. Other symptoms may be headache and joint pains. Jaundice, anaemia or diarrhoea may also be signs of malaria. A definitive diagnosis of malaria can only be made by examination of a blood sample using a microscope or RDT. This is a relatively simple procedure requiring a finger prick of blood. However, microscopy facilities are needed to
AMREF in Ethiopia Draft Report June 2008 32 examine the blood slide and these are often not available. In addition, the reliability of RDTs is most often uncertain. In many highly endemic areas a large proportion of the population may have parasites in their blood but no symptoms of malaria, making diagnosis difficult even if a blood sample is taken. Given the seriousness of the disease however, it is accepted as appropriate in most endemic countries to treat all cases of fever with antimalarial drugs based on the signs and symptoms of the disease. High knowledge of malaria symptoms helps respondents to seek immediate antimalarial treatment at a health facility or from a trained health worker as early as possible.
5.2.11 Respondent’s perceived severity of malaria When asked to which group of the population group malaria is more serious, children were identified as the main risk group by about 40% of the respondents (36% in Dewe woreda vs. 44.5% in Dalifage, P<0.001) (Table 17). All age groups were mentioned equally affected by malaria by 23.3% of the respondents, while both children and pregnant women were mentioned as malaria risk groups by 20.3% of the respondents, with 23.3% in Dewe and 16.6% in Dalifage. Only 9% of the respondents identified pregnant women as the group most at risk of malaria and this is an important area that needs to be addressed through IEC/BCC messages. The awareness that children are at increased risk of malaria helps to seek early treatment before the progression of the disease into its severe forms. Understanding respondent’s knowledge about the severity of malaria to specific population groups is vital to give them priority in terms of treatment seeking or use of preventive measures.
Table 17: Respondent’s perceived severity of malaria to different population groups by woreda, May 2008
Woreda Severity of malaria Dewe, n (%) Dalifage, n (%) Total, n (%) More serious to children 125 (36.0) 126 (44.5) 251 (39.8) Equally serious to all 79 (22.8) 68 (24.0) 147 (23.3) More serious to women and children 81 (23.3) 47 (16.6) 128 (20.3) More serious to pregnant women 33 (9.5) 24 (8.5) 57 (9.0) More serious to elderly 17 (4.9) 15 (5.3) 32 (5.1) More serous to adults 5 (1.4) 0 (0.0) 5 (0.8) Did not know 7 (2.0) 3 (1.1) 10 (1.6) N 347 (55.1) 283 (44.9) 630 (100.0)
AMREF in Ethiopia Draft Report June 2008 33 5.2.12 Respondent’s knowledge about malaria treatment and antimalarial drugs Respondents were asked, “is malaria a treatable disease?” and 89% replied “yes” (91.1% in Dewe and 86.6% in Dalifage) and 9.8% did not know whether malaria is treatable or not (Table 18). However, about half of the interviewees (50.2%) in both study woredas had a precise knowledge about the name of the currently recommended first-line antimalarial drug (i. e., Coartem) (54.2% in Dewe and 45.2% in Dalifage).
Table 18: Respondent’s perception about malaria treatment and antimalarial drugs by woreda, May 2008
Malaria treatment and Woreda antimalarials Dewe, n (%) Dalifage, n (%) Total, n (%) Is malaria a treatable disease? Yes 316 (91.1) 245 (86.6) 561 (89.0) No 3 (0.9) 4 (1.4) 7 (1.1) Did not know / not sure 28 (8.1) 34 (12.0) 62 (9.8) Name of the currently used new antimalarial drug Coartem 188 (54.2) 128 (45.2) 316 (50.2) Chloroquine 32 (9.2) 21 (7.4) 53 (8.4) Fansidar (SP) 8 (2.3) 6 (2.1) 14 (2.2) Did not know 119 (34.3) 126 (44.5) 245 (38.9) N 347 (55.1) 283 (44.9) 630 (100.0)
The knowledge of the name of SP (2.2%) was very low probably due to the change in antimalarial drug policy in 2004 from SP to artemether-lumefantrine for the treatment of falciparum malaria16. However, chloroquine remains the treatment of choice for P. vivax in Ethiopia. A considerable proportion (38.9%) of the respondents did not know any name of the currently used antimalarial drugs. Artemether-lumefantrine is currently dispensed free of charge to all malaria patients in the study area through public health facilities. Health facility assessment in the study area revealed that artemether-lumefantrine was available in all public health facilities such as health posts and health centers. The correct knowledge of antimalarial drugs by caregivers or malaria patients themselves is critical in saving the life of people particularly children in the present Ethiopian setting where basic health services are inaccessible to the majority of the population.
16 MOH. Malaria Diagnosis and Treatment Guidelines for Health Workers in Ethiopia. Federal Democratic Republic of Ethiopia Ministry of Health, 2nd Edition. Addis Ababa, Ethiopia. 2004.
AMREF in Ethiopia Draft Report June 2008 34 5.2.13 Respondent’s knowledge and practices about malaria prevention Four hundred ninety three respondents (78.3%) reported that malaria is a preventable disease (79.3% in Dewe and 77% in Dalifage) (Table 19). Although knowledge that malaria is transmitted through mosquito bite was relatively lower (67.1%), knowledge that sleeping under mosquito net prevents malaria was higher (76%). When asked, “what are the different malaria preventive methods that you know?” 76% (79.8% in Dewe vs. 71.4% in Dalifage) mentioned mosquito nets, 28.3% (24.8% in Dewe vs. 32.5% in Dalifage) reported smoking in the house and 11.4% cited indoor residual spraying. Table 19: Respondent’s perception and household’s practice about malaria prevention by woreda, May 2008
Woreda Malaria prevention Dewe, n (%) Dalifage, n (%) Total, n (%) Is malaria a preventable disease? Yes 275 (79.3) 218 (77.0) 493 (78.3) No 17 (4.9) 20 (7.1) 37 (5.9) Don’t know 55 (15.9) 45 (15.9) 100 (15.9) Perceived malaria preventive methods* Sleep under mosquito net 277 (79.8) 202 (71.4) 479 (76.0) Smoking in the house 86 (24.8) 92 (32.5) 178 (28.3) Eat good food 45 (13.0) 29 (10.2) 74 (11.7) Spray house with insecticide (DDT) 49 (14.1) 23 (8.1) 72 (11.4) Remain indoors at night 35 (10.1) 25 (8.8) 60 (9.5) House spray with aerosol 35 (10.1) 22 (7.8) 57 (9.0) Drain mosquito breeding sites 37 (10.7) 7 (2.5) 44 (7.0) Keep house clean 34 (9.8) 7 (2.5) 41 (6.5) Window screening 22 (6.3) 2 (0.7) 22 (3.8) Apply ointment/ use repellent 12 (3.5) 6 (2.1) 18 (2.9) Don’t know 44 (12.7) 45 (15.9) 89 (14.1) Household’s current use of malaria preventive measures* Use mosquito net 231 (66.6) 153 (54.1) 384 (61.0) Burn dung or leaves to keep mosquitoes away 122 (35.2) 92 (32.5) 214 (34.0) Use aerosol spray 30 (8.6) 16 (5.7) 46 (7.3) Close doors and windows on time before evenings 35 (10.1) 2 (0.7) 37 (5.9) Drain mosquito breeding sites nearby house 18 (5.2) 7 (2.5) 25 (4.0) Block mosquito entry holes to houses 16 (4.6) 4 (1.4) 20 (3.2) Did not use any method 55 (15.9) 70 (24.7) 125 (19.8) N 347 (55.1) 283 (44.9) 630 (100.0) * Multiple responses possible
AMREF in Ethiopia Draft Report June 2008 35 The percentage of respondents who reported the use of indoor residual spraying of houses with DDT was low (11.4%) due to limited application of this malaria prevention strategy in Ethiopia particularly in lowland pastoral communities. However, currently there is a renewed interest to use DDT for malaria prevention in the country. A significant proportion (14.1%) of the respondents was unable to cite any malaria preventive measures, and this has an important implication in the up-take of malaria preventive measures. When the question was rephrased latter as “what do you or your family members currently do to prevent mosquito biting?”61% (66.6% in Dewe vs. 54.1% in Dalifage) replied using mosquito net, 34% replied burning dung of leaves in the house, 7.3% mentioned that they were using aerosol spray (Table 19). Quite a significant proportion of respondents (19.8%) replied that their households did not use any malaria preventive measures, with a significant difference between the two woredas (15.9% in Dewe vs. 24.7% in Dalifage, P<0.001). In general, the use of mosquito net was most frequently reported by the majority of the respondents as a primary means of malaria preventive method. This is a very good indication that the community has high knowledge about the use of mosquito net for malaria prevention.
5.2.14 Treatment seeking behaviour for malaria Access to basic health services has been shown to determine early diagnosis and prompt treatment of malaria. Respondents were asked about their preferred source of initial visit for malaria treatment when they or their family members had malaria illness. Table 20 presents the most preferred source of malaria treatment by the respondents. The majority of the respondents (90.3%) mentioned that they preferred to visit government health facility for malaria treatment, distantly followed by the use of traditional remedy at home (5.2%).
AMREF in Ethiopia Draft Report June 2008 36 Table 20: Preferred source of initial visit for malaria treatment by woreda, May 2008
Preferred source of malaria Woreda treatment Dewe, n (%) Dalifage, n (%) Total, n (%) Government health institution 306 (88.2) 263 (92.9) 569 (90.3) Traditional remedy at home 22 (6.3) 11 (3.9) 33 (5.2) Traditional healer 7 (2.0) 2 (0.7) 9 (1.4) NGO clinic 2 (0.6) 2 (0.7) 4 (0.6) Self-medication at home 0 (0.0) 2 (0.7) 2 (1.4) Other 10 (2.9) 3 (1.1) 13 (2.1) N 347 (55.1) 283 (44.9) 630 (100.0)
The percent of households with self-reported malaria illness within two weeks prior to the survey in one or more members ranged from 13.4% in Dalifage to 16.7% in Dewe (Table 21). Of 96 self-reported malaria patients identified from the total households, 51% and 7.3% were reported to be among under five children and pregnant women, respectively. Of the total identified self-reported malaria patients from the study households, 41.7% were among males and the remaining 58.3% among females.
Table 21: Percentage of households with perceived malaria in the past two weeks prior to the survey, and their sex and age structure by woreda, May 2008
Woreda Variable Dewe, n (%) Dalifage, n (%) Total, n (%) Perceived malaria among household members Yes 58 (16.7) 38 (13.4) 96 (15.2) No 289 (83.3) 245 (86.6) 534 (84.8) N 347 (55.1) 283 (44.9) 630 (100.0) No. of households with perceived malaria Total sick 58 38 96 Sick under five 29 20 49 Sick pregnant women 5 2 7 Sex Male 27 (46.6) 13 (34.2) 40 (41.7) Female 31 (53.4) 25 (65.8) 56 (58.3)
Based on the above information it is possible to calculate the prevalence of reported malaria among the total population, under five children and pregnant mothers. A total of 3257 people, 653 under five children and 102 pregnant women were identified from the survey households, resulting in two weeks malaria prevalence of 3%, 7.5% and 6.9%, respectively, in the specific groups. These findings suggest that the prevalence of
AMREF in Ethiopia Draft Report June 2008 37 malaria was highest both among under five children and pregnant women, which is in line with the general understandings of the high burden of the disease among the specified population groups. Of 96 reported cases of malaria, 52 (54.2%) sought treatment (Table 22). The primary sources consulted for malaria treatment were public health facilities, followed by others such as drug vendor and traditional remedies at home. Public health facilities were more likely to be cited by respondents from Dewe woreda. Table 22 also shows the number of days after malaria symptoms were recognized until treatment was sought. Of 52 patients who sought any form of treatment, 40 (77%) sought it within three days of the onset of illness, while only 15.4% sought treatment within 24 hours of the onset of malaria symptoms.
Table 22: Treatment seeking behaviour for perceived malaria cases by woreda, May 2008
Woreda Variable Dewe, n (%) Dalifage, n (%) Total, n (%) Sought antimalarial treatment 33 (56.9) 19 (50.0) 52 (54.2) Yes 25 (43.1) 19 (50.0) 44 (45.8) No N 58 (60.4) 38 (39.6) 96 (100.0) Source of treatment (n=52) Public health facility 31 (93.9) 15 (78.9) 46 (88.5) Other* 2 (6.1) 4 (21.1) 6 (11.5) N 33 (63.5) 19 (36.5) 52 (100.0) Treatment initiation in days after onset of illness by all patients (n=52) ≤ 1 5 3 8 2-3 20 12 32 4-5 4 2 6 >5 5 1 6 N 34 18 52 Treatment initiation in days after onset of illness by under five children (n=23) ≤ 1 2 2 4 2-3 9 4 13 4-5 3 1 4 >5 2 0 2 N 16 7 23 * Other includes drug vendor, traditional remedies at home
AMREF in Ethiopia Draft Report June 2008 38 Of 49 under five children with febrile illness, 23 (47%) sought treatment, but only 17.4% sought it within 24 hours of illness onset. Most waited until the second or third day of illness onset before seeking treatment. The majority of children who sought treatment were within 2-3 days after the onset of illness (56.5%). Of 7 pregnant women with reported malaria illness, 4 (57.1%) sought treatment from public health facilities. Reasons for not seeking treatment were also asked for patients who did not seek any care at the time of the interview (Table 23). The most common reason given for not seeking treatment was financial constraint (34.1%), followed by inaccessible health facility (31.8%), mild illness (11.4%) and shortage of time due to work overload (9.1%).
Table 23: Main reasons for not seeking treatment for the last episode of malaria illness, May 2008
Reasons for not seeking treatment Frequency Percentage Financial constraint 15 34.1 Inaccessible health facility 14 31.8 The illness was perceived to be mild 5 11.4 Shortage of time due to work overload 4 9.1 Other 6 13.6 N 44 100.0
5.2.15 Current ITNs ownership and use Insecticide treated nets (ITNs) are now recognized as an effective intervention against malaria in all areas of Africa where malaria is endemic. As a result, ITN has been extensively scaled-up in malarious areas of Ethiopia particularly since 2005. Most people are now familiar with mosquito net and its use. In this study, almost all (99.4%) of the respondents (98.8% in Dewe and 100% in Dalifage) reported that they had heard of mosquito nets (Table 24). Overall, a considerable proportion of the respondents highly valued ITN with regard to protection against mosquitoes, other nuisance insects, and malaria. About 99% of the respondents claimed that sleeping under ITN protects a person from mosquito bite, 82.5% reported that ITN protects against the bite of other nuisance insects, 84.4% perceived that ITN kills mosquitoes and 88.4% reported that it protects against malaria. There was no major variation in the percentages of respondents about the benefits of ITN between the two woredas. With regard to the use of ITN, people usually respond
AMREF in Ethiopia Draft Report June 2008 39 first about protection against mosquito bite than about prevention of malaria. Correlation between the use of ITN and the perceived role of mosquitoes in transmitting malaria is an important indication for scaling-up the implementation of the nets.
Table 24: Respondent’s knowledge about the use of ITN by woreda, May 2008
Woreda Awareness and use of ITN Dewe, n (%) Dalifage, n (%) Total, n (%) Heard about ITN Yes 343 (98.8) 283 (100.0) 626 (99.4) No 4 (1.2) 0 (0.0) 4 (0.6) Sleeping under ITN protect a person from mosquito bite Yes 345 (99.4) 278 (98.2) 623 (98.9) No 2 (0.6) 5 (1.8) 7 (1.1) Sleeping under ITN protect a person from the bite of other nuisance insects Yes 282 (81.3) 238 (84.1) 520 (82.5) No 65 (18.7) 45 (15.9) 110 (17.5) ITN can kill mosquitoes Yes 296 (85.3) 236 (83.4) 532 (84.4) No 4 (1.2) 2 (0.7) 6 (1.0) Don’t know 47 (13.5) 45 (15.9) 92 (14.6) Sleeping under ITN protect a person from malaria Yes 312 (89.9) 245 (86.6) 557 (88.4) No 35 (10.1) 38 (13.4) 73 (11.6) N 347 (55.1) 283 (44.9) 630 (100.0)
The use-life or average duration of ITN for use was also asked and about 80% of the respondents estimated that ITN can be used for about 1-2 years, with a mean duration of 1.45 years, with a range of 0.17 to 6 years (Table 25). The perceived median use-life of an ITN was found to be 1 year. Forty-eight (7.6%) respondents reported that the duration of an ITN for use was less than a year. Most people in the study area perceive that the average use-life of ITN was not more than two years although the Ministry of Health claims that it can be effectively used for 3-4 years. In fact, recall problems and lack of experience about how long an ITN would last are two factors that affect the response of the respondents. However, there was no evidence on the average use-life of ITN at community level in the Ethiopian rural settings. In addition, the quality and the type of ITN also maters about its duration for use.
AMREF in Ethiopia Draft Report June 2008 40 Table 25: Respondent’s perceived average duration of ITN to be used in years by woreda, May 2008
Average duration in years for Woreda an ITN to be used Dewe, n (%) Dalifage, n (%) Total, n (%) <1 year 31 (8.9) 17 (6.0) 48 (7.6) 1 year 193 (55.6) 160 (56.5) 353 (56.0) >1-2 years 81 (23.3) 74 (26.1) 155 (24.6) >2-3 years 30 (8.6) 23 (8.1) 53 (8.4) >3-4 years 7 (2.0) 9 (3.2) 16 (2.5) >4 years 5 (1.4) 0 (0.0) 5 (0.8) Mean (±SD) 1.47 (±0.94) 1.48 (±0.81) 1.45 (±0.88) Median 1.0 1.0 1.0 Range 0.17-6.0 0.17-4.0 0.17-6.0 N 347 (55.1) 283 (44.9) 630 (100.0)
About two-third (65.2%) of the respondents replied that they knew the place where an ITN can be obtained (Table 26). Of these, 71.6% cited government health center, followed by health station or health post (21.4%). Shop as a potential source of ITN was only reported by very few respondents (5.1%) and none mentioned the involvement of NGOs in the distribution of ITNs to households.
Table 26: Respondent’s knowledge about the source of ITN by woreda, May 2008
Woreda Source Dewe, n (%) Dalifage, n (%) Total, n (%) Know the place where ITN can be obtained (n=630) Yes 242 (69.7) 169 (59.7) 411 (65.2) No 105 (30.3) 114 (40.3) 219 (34.8) N 347 (55.1) 283 (44.9) 630 (100.0) Perceived source of ITN (n=411)* Government health center 145 (59.9) 148 (87.6) 293 (71.3) Health post/station 76 (31.4) 12 (7.1) 88 (21.4) Shop 10 (4.1) 11 (6.5) 21 (5.1) Woreda health office 15 (6.2) 0 (0.0) 15 (3.6) Other 2 (0.8) 0 (0.0) 2 (0.5) N 242 (58.9) 169 (41.1) 411 (100.0) * Multiple answers possible
Since the last 2-3 years, the distribution of ITN in the study area had been mainly carried out by the Woreda Health Offices (WHO). The Regional Health Burea delivered ITNs to woredas and the WHOs distributed them to kebeles and households through
AMREF in Ethiopia Draft Report June 2008 41 health workers at woreda offices, health centers, health posts and HEWs. In fact, there is a committee composed of the local people and run by the peripheral health workers in each woreda to facilitate the distribution of the nets in the specific areas. List of households who had not received ITNs and who would deserve it is prepared and organized by the committee. The WHO acts according to the request of the committee in each kebele. In Zone 5 of Afar Region, AMREF in Ethiopia also distributed ITNs to households in 2006/07 in all woredas except Fursi, mainly due to security problems. From a total 630 surveyed households, 396 (62.9%) owned at least one ITN at the time of the survey (Table 27). The coverage of households at least by one ITN was more likely in Dewe woreda than Dalifage (69.2% vs. 55.1%, P<0.001). Of the total households, 40.3% owned at least two ITNs and 10.2% owned three or more nets. Considering all visited households, the mean number of ITNs per household was equal to 1.19 across the two woredas (1.43 in Dewe and 0.90 in Dalifage). Among ITN owning households, 35.9% had one ITN, 48% owned two and 16.2% had three or more, and the overall mean number of ITNs per household was 1.89 (2.06 in Dewe and 1.63 in Dalifage). In all parameters, household’s ownership of an ITN was higher in Dewe than Dalifage woreda. ITN ownership was more common in urban households, where 106 (86.2%) owned nets, compared with 290 (57.2%) of rural households (P<0.001).
AMREF in Ethiopia Draft Report June 2008 42 Table 27: Household’s ownership of ITN and number per household by woreda, May 2008
Ownership and number Woreda Total, of ITN per household Dewe, n (%) Dalifage, n (%) n (%) Household owned ITN Yes 240 (69.2) 156 (55.1) 396 (62.9) No 107 (30.8) 127 (44.9) 234 (37.1) N 347 (55.1) 283 (44.9) 630 (100.0) Number of ITN owned per household 1 75 (31.3) 67 (42.9) 142 (35.9) 2 109 (45.4) 81 (51.9) 190 (48.0) 3 28 (11.7) 7 (4.5) 35 (8.8) ≥4 28 (11.7) 1 (0.6) 29 (7.3) N 240 (60.6) 156 (39.4) 396 (100.0) Mean # of ITNs per household 1.43 0.90 1.19 Mean # of ITNs per household among ITN-owning households 2.06 1.63 1.89 All households % of households with at least 1 ITN 69.2 55.1 62.9 % of households with at least 2 ITN 47.6 31.4 40.3 % of households with at least 3 ITN 16.1 2.8 10.2 Households with >3 members % of households without ITN 32.9 52.7 41.7 % of households with at least 1 ITN 67.1 47.3 58.3 % of households with at least 2 ITN 45.7 29.0 38.3 % of households with at least 3 ITN 14.7 1.9 9.0
According to the national implementation plan of ITNs distribution in Ethiopia, the family size should be taken into consideration. Accordingly, households with family size ≤3 members deserve one ITN and those with more than three members can get two ITNs. The current ITN coverage of households is measured with at least two ITNs, and it is assumed to be logical to exclude households with smaller family size. Considering households with greater than three members, the present study revealed that 41.7% of the households did not own any net (32.9% in Dewe vs. 52.7% in Dalifage), 58.3% owned at least one ITN, 38.3% had two ITNs and 9% possessed three or more nets (Table 27). Of ITN-owning households, direct observation by the data collectors revealed that 35.9% had one ITN hung and 9.3% had two nets hung over the bed or mat, while 54.5% of the households had no ITN hung at the time of the interview (Table 28). Overall, the percentage of households with ITN hung over the bed or mat was higher in Dewe than households in Dalifage woreda. However, the results on the number of ITN hung over the sleeping area in the household at the time of the interview may under estimate the real
AMREF in Ethiopia Draft Report June 2008 43 utilization of nets by the households because many households may not leave their nets hung over the bed particularly during the day time.
Table 28: Percentage of households with ITN hung at the time of the interview and currently used by households with at least one ITN by woreda, May 2008
ITN-owning households Woreda (n=396) Dewe, n (%) Dalifage, n (%) Total, n (%) # of ITNs hung None 120 (50.0) 97 (62.2) 217 (54.8) 1 89 (37.1) 53 (34.0) 142 (35.9) 2 31 (12.9) 6 (3.8) 37 (9.3) N 240 (60.6) 156 (39.4) 396 (100.0) # of ITNs currently used by households None 50 (20.8) 30 (19.2) 80 (20.2) 1 108 (45.0) 93 (59.6) 201 (50.8) 2 64 (26.7) 29 (18.6) 93 (23.5) ≥3 18 (7.5) 4 (2.6) 22 (5.6) N 240 (60.6) 156 (39.4) 396 (100.0) Total # of ITNs identified 495 254 749 % of ITNs currently used 30.5 25.6 26.8
With regard to the number of nets currently used by ITN-owing households, 50.8% and 23.5% households used 1 and 2 nets, respectively (Table 28). About 20% of the households did not use their households. Of the 749 ITNs identified, 26.8% were found to be currently used by household members. Of those households owning at least one ITN, about 60% of the respondents, with equal proportion in the two woredas, slept under an ITN the night before the survey and about 40% stated that they did not personally sleep under a net the previous night (Table 29). About 63% of the respondents reported that at least one member of the household slept under the ITN the night before the survey and 37% reported no ITN use among household members. A total of 1871 people, 375 under five children and 59 pregnant women had slept in the ITN-owning households the previous night. Accordingly, 53% of all household members, 63.7% of all children under the age of five years and 61% of the pregnant women slept under ITN the night before the survey.
AMREF in Ethiopia Draft Report June 2008 44 Table 29: Number of household identified from the surveyed households and percentage slept under ITNs the previous night from households with at least one ITN by woreda, May 2008
Households with at least one net Woreda (n=396) Dewe Dalifage Total % of respondents slept under an ITN the previous night 60.4 60.3 60.4
% of households who reported that at least one of the household members slept under an ITN 62.1 63.5 62.6 Total # of residents slept in the house the previous night 1188 683 1871
Total # of <5 children slept in the house the previous night 248 127 375
Total # of pregnant women slept in the house the previous night 30 29 59 % of household members slept under an ITN the previous night 51.9 54.8 53.0
% of <5 children slept under an ITN the previous night 61.3 68.5 63.7
% of pregnant women slept under an ITN the previous night 60.0 62.1 61.0
The percentages of under five children and pregnant women slept under an ITN the previous night are the two most important RBM coverage indicators for ITN use. The National Five-Year Strategic Plan for Malaria Prevention and Control (2006-2010) in Ethiopia has set the target of achieving 100% use of an ITN by under five children and pregnant women the previous night in the target areas. Although there is a long way to go to ensure that children and pregnant women benefit from this low cost and highly effective intervention, the results of this study reflect the feasibility of achieving the national targets if intensive scaling-up of ITNs is accompanied by effective IEC/BCC messages. Effective malaria transmission control can be achieved only if almost all household members within a given area are sleeping under the ITNs. The coverage of at least 80% of people within a community sleeping under the ITNs is usually suggested to achieve transmission control. The higher coverage of sleeping under the ITNs has an
AMREF in Ethiopia Draft Report June 2008 45 advantage of the mass-effect, where they also provide some protection not only for those who sleep under them, but also those in the same household and those living nearby. This is achieved by the added value of the insecticide used for treatment of nets that results in the reduction of the longevity of the mosquitoes to such an extent that they are unable to transmit malaria. Of the 749 ITNs identified, 92.7% were rectangular, 7.3% were conical, 74.5% were blue, 13.5% were green and 12% were white (Table 30). The rectangular and blue or green ITNs were more widely used in the rural areas, and the white conical nets were more commonly used in the urban areas. There was some cross-over in coverage, with some urban households using rectangular nets and some rural households using conical nets.
Table 30: Percentage shape and colour distribution of ITNs identified among households with at least one ITN by woreda, May 2008
Woreda Shape and colour (n=396) Dewe, (%) Dalifage, (%) Total, (%) Shape % Rectangular 92.1 93.7 92.7 % Conical/ round 7.9 6.3 7.3 Colour % Blue 69.9 83.5 74.5 % Green 16.8 7.1 13.5 % White 13.3 9.4 12.0 Total # of ITNs identified 495 254 749
Respondents were also asked about their most preferences with regard to the shape and colour of ITNs, and 62.1% most preferred the rectangular shape, followed by conical (21%) and any shape (11.1%) (Table 31). In terms of colour, 29.5% preferred blue, 26.8% white and 14.4% green. The proportion of respondents who preferred different shapes and colours of the ITNs varied considerably by residence (71.7% and 47.9% of the rural respondents preferred rectangular and blue or green ITN compared to the urban counterparts where 66.3% and 50% preferred rectangular and white ITNs, respectively). As it was observed in the field, blue or green ITNs were more preferred particularly by the rural community due to their resistance to dirty, while white nets become dirty very quickly due to indoor smoking and tucking under mats or mattress on
AMREF in Ethiopia Draft Report June 2008 46 the floor. Similarly, the rectangular designs were more preferred because they are easier to hang from strings on wall or beams and accommodate more people than conical nets. A prior understanding of people preference for ITN colour is important before embarking on the distribution of nets to the community.
Table 31: Respondent’s distribution of shape and colour preference for ITNs by woreda, May 2008
Woreda Preference (n=396) Dewe, n (%) Dalifage, n (%) Total, n (%) Most preferred shape Rectangular 153 (63.8) 93 (59.6) 246 (62.1) Conical/ round 45 (18.8) 38 (24.4) 83 (21.0) Both rectangular or conical 5 (2.1) 2 (1.3) 7 (1.8) Any shape 25 (10.4) 19 (12.2) 44 (11.1) Don’t know 12 (5.0) 4 (2.6) 16 (4.0) Most preferred colour Blue 80 (33.3) 37 (23.7) 117 (29.5) White 57 (23.8) 49 (31.4) 106 (26.8) Green 37 (15.4) 20 (12.8) 57 (14.4) Green or blue 17 (7.1) 8 (5.4) 25 (6.3) Any colour 49 (20.4) 42 (26.9) 91 (23.0) N 240 (60.6) 156 (39.4) 396 (100.0)
Respondents were asked, “if you have only one mosquito net, whom would you allow to use it?”, and 45.7% replied that mother with youngest child should be allowed to use it, followed by young children (44.7%) in the household (Table 32). More respondents from Dewe (49.4%) than those from Dalifage (41.7%) preferred young children to use the net. In fact, many young children in the rural Ethiopian settings sleep with their mother and it is assumed that children share ITN in most occasions with their mothers.
AMREF in Ethiopia Draft Report June 2008 47 Table 32: Respondent’s perceived priority for using ITN if the household has only one net, May 2008
Woreda Priority given to (n=396) Dewe, n (%) Dalifage, n (%) Total, n (%) Mother with youngest child 111 (46.3) 70 (44.9) 181 (45.7) Young children 100 (41.7) 77 (49.4) 177 (44.7) Husband and wife 14 (5.8) 3 (1.9) 17 (4.3) Elderly/ grand parents 7 (2.9) 3 (1.9) 10 (2.5) Pregnant women 3 (1.3) 1 (0.6) 4 (1.0) Husband 3 (1.3) 1 (0.6) 4 (1.0) Wife 2 (0.8) 1 (0.6) 3 (0.8) N 240 (60.6) 156 (39.4) 396 (100.0)
Given the high vulnerability of pregnant women to malaria, very few respondents (1%) mentioned them that they should get priority for using nets (Table 32). Children under the age of five years and pregnant women are generally vulnerable group of the population who deserve especial attention for protecting them from malaria. Accordingly, ITN promotion and use should be geared towards this group of population through intensive IEC/BCC messages. Physical status of ITNs in the households was also examined through observation about the existence of tears or holes that allow mosquito entrance. In fact, we neither measured the size nor counted the number of the tears/holes on the nets. Among ITN- owning households, about 31% had at least one net that had tears/holes in it (Table 33). Of 123 households with at least one ITN with tear/hole, the majority of the households (76.4%) had one ITN with tear/hole, 20.3% of the households had two nets and the remaining (3.3%) households had three or more ITNs that had tears or holes. One of the reasons that reduce the use-life of ITNs is the damage that happened to them through tearing or holes. Once tear or hole happened to the net, mosquitoes can easily get into the bed to bite the sleepers. Therefore, such nets should be repaired and used, and the community should also be aware of the maintenance through health education programs.
AMREF in Ethiopia Draft Report June 2008 48 Table 33: Percentage of households with one or more tear/hole on ITN by woreda, May 2008
Woreda Number of ITN that has one or more Dewe, Dalifage, Total, tear/hole per household n (%) n (%) N (%) At least one net has tear or hole per household (n=396) Yes 83 (34.6) 40 (25.6) 123 (31.1) No 157 (65.4) 116 (74.4) 273 (68.9) N 240 (60.6) 156 (39.4) 396 (100.0) Number of nets that have tear/hole per household (n=123) 1 60 (72.3) 34 (85.0) 94 (76.4) 2 19 (22.9) 6 (15.0) 25 (20.3) ≥ 3 4 (4.8) 0 (0.0) 4 (3.3) N 83 (67.5) 40 (32.5) 123 (100.0)
Respondents from the ITN-owning households were also asked questions relating to the duration and source of the most recently obtained ITNs in the households. The mean duration of the most recent net ownership was 1.13 years, with a range of 2 months to 3 years (Table 34). The majority of the most recently obtained ITNs were between 1-2 years, with 23.5% less than one year old. Five respondents stated that the duration of their recent ITN was three years or older. Most respondents stated that they obtained their ITNs from a health facility (82.8%), with other sites much less common: 8.1% from CHWs, 3.5% from NGOs, 0.5% bought from shop or market and 5.1% did not know.
AMREF in Ethiopia Draft Report June 2008 49 Table 34: Source and length of time the household had had the recent ITN by woreda, May 2008
Households with at least one net Woreda Total, n (%) (n=396) Dewe, n (%) Dalifage, n (%) Length of time for the most recently obtained ITN < 1 year 81 (33.8) 12 (7.7) 93 (23.5) 1-2 year 157 (65.4) 141 (90.4) 298 (75.3) ≥ 3 years 2 (0.8) 3 (1.9) 5 (1.3) Mean (±SD) years 1.02 (±0.58) 1.29 (±0.51) 1.13 (±0.57) Source of the most recently obtained ITN Health facility 199 (82.9) 129 (82.7) 328 (82.8) Provided by CHWs 20 (8.3) 12 (7.7) 32 (8.1) Provided by NGO 10 (4.2) 4 (2.6) 14 (3.5) Bought from shop/ market 2 (0.8) 0 (0.0) 2 (0.5) Don’t know 9 (3.8) 11 (7.1) 20 (5.1) N 240 (60.6) 156 (39.4) 396 (100.0)
Of 234 households which did not own an ITN at the time of the survey, the majority (96.2%) stated that they ever had it in the past (Table 35). Of these, 95.3% reported that the ITN that they had was aged and became out of use. Ten respondents (4.3%) reported that they did not know where ITN could be obtained, and 2.6% listed other reasons. Lack of money and affordability problems were not cited as reasons for not owning ITNs because nets in Ethiopia are currently distributed to rural households in malarious areas of the country free of charge through the support from Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). These findings indicate that households which did not currently own ITN but had it in the past signal immediate action for net replacement.
AMREF in Ethiopia Draft Report June 2008 50 Table 35: Percentage distribution of respondents who cited reasons for not having ITNs by households by woreda, May 2008
Woreda Total, Households with out any net (n=234) Dewe, n (%) Dalifage, n(%) n (%) Have your household ever had ITN before Yes 102 (95.3) 123 (96.9) 225 (96.2) No 5 (4.7) 4 (3.1) 9 (3.8) Reasons for not having ITN by households* ITN got old and worn out 100 (93.5) 123 (96.9) 223 (95.3) Not know where to get ITN 5 (4.7) 5 (3.9) 10 (4.3) Not aware of ITN’s use 2 (1.9) 1 (0.8) 3 (1.3) Had not initially received any net 2 (1.9) 1 (0.8) 3 (1.3) N 107 (45.7) 127 (54.3) 234 (100.0) *Multiple answers possible The question relating to the disadvantages or problems associated with using ITNs was also posed to the respondents. Only 29 (7.3%) respondents from ITN-owing households stated that they ever experienced a problem while using an ITN (Table 36). Of these, the majority (62.1%) complained about skin irritation that is caused through exposure to the chemical used to treat the net. Five respondents (17.2%) mentioned the problem of heat and the corresponding inconvenience during the night. In addition, 17.2% of the respondents reported the difficulty of mounting and tucking the net every night. Identifying and understanding the main barriers that hamper the use of ITNs by the community is very instrumental in taking corrective measures.
Table 36: Respondents distribution problems experienced while using ITN by woreda, May 2008
Woreda Problems experienced (n=396) Dewe, n (%) Dalifage, n (%) Total, n (%) Ever experienced any problem while using ITN Yes 19 (7.9) 10 (6.4) 29 (7.3) No 221 (92.1) 146 (93.6) 367 (92.7) N 240 (60.6) 156 (39.4) 396 (100.0) Type of problem experienced* ITN gives skin irritation 12 (63.2) 6 (60.0) 18 (62.1) Gives too warm to sleep in it 2 (10.5) 3 (30.0) 5 (17.2) Tucking ITN every night is boring 3 (15.8) 2 (20.0) 5 (17.2) Other 3 (15.8) 0 (0.0) 3 (10.3) N 19 (65.5) 10 (34.5) 29 (100.0) * Multiple answers possible
AMREF in Ethiopia Draft Report June 2008 51 6. Discussion and conclusions This paper has presented useful information about malaria baseline survey conducted in the two woredas of Zone 5 in Afar Region. The results have also showed a number of issues that are important in understanding the knowledge, attitudes and practices of the community towards malaria prevention and control interventions. Furthermore, it highlighted important areas within the health care system in the area that could be targeted for improvement through appropriate interventions. Malaria has been recognized as the most important health problem in the community of the two woredas, indicating the importance of directing malaria control efforts based on the priority problems of the community. Our understanding is that in the study woredas, people describe malaria as a killer disease that commonly occurs in the areas. The success of malaria control measures such as early diagnosis and prompt treatment, and the proper use of preventive measures such as ITNs depend on an understanding of the roles of families and communities in the prevention and control of the disease. This report underscores the importance of understanding the perceptions and practices of the community towards malaria prevention and control interventions. The findings highlight discrepancies between perceptions of the community about malaria and malaria control interventions carried out in the study area. The health facilities in the study area are weak and require much emphasis for better performance. In conclusion, the key findings are summarized below: Malaria is the major public health problem in the study woredas. Malaria diagnosis and treatment at the health facilities in the study areas was found to be poor due to lack of adequate health personnel and appropriate diagnostic facilities. As a result, malaria diagnosis was mainly based on clinical criteria that have a low specificity. The community recognized malaria as a widespread and serious health problem in the area. Although the majorities of the study population are knowledgeable about malaria transmission through identifying the role of mosquitoes, misconceptions about the cause of malaria were also not uncommon.
AMREF in Ethiopia Draft Report June 2008 52 AMREF in Ethiopia has initiated the expansion of its malaria project into Zone 5 of Afar Region through training of health workers on malaria prevention and control, ITNs distribution, and training of mother coordinators on HMM and PMPT activities. The most common channels for receiving information on malaria are radio (21%) and through health workers (20.6%). About nine in 10 (86.2%) of respondents believed that malaria could be transmitted from one person to another (83% in Dewe vs. 90.1% in Dalifage woreda). Knowledge of malaria transmission through mosquito bite was relatively high (67.1%). The majority of respondents were aware that mosquitoes bite most likely in the evening (56.3%) and night (39.2%) times. About 40% of the respondents were able to identify children as being at risk group for malaria but only 9% of respondents identified pregnant women as being at risk. About 89% the respondents said that malaria is a treatable disease (91.1% in Dewe and 86.6% in Dalifage). Half of the respondents knew Coartem as the currently used first-line antimalarial drug. Regarding the best method of preventing malaria, 76% of the respondents mentioned the use of mosquito net, followed by the use of smoking in the house (28.3%). Government health facility was the most preferred source of malaria treatment. The prevalence of self-reported malaria within two weeks prior to the survey ranged from 13.4% in Dalifage to 16.7% in Dewe woreda. Only 54.2% of the reported malaria patients sought treatment, of these 88.5% sought it from public health facilities. Only15.4% of the patients sought treatment within 24 hours of the onset of malaria symptoms.
AMREF in Ethiopia Draft Report June 2008 53 Knowledge about the use of ITN was high. About 99% of the respondents claimed that sleeping under ITN protects a person from mosquito bite, and 88.4% reported that it protects against malaria. About 63% of the households owned at least one ITN. Of the total households, 40.3% owned at least two ITNs and 10.2% owned three or more nets. The mean number of ITNs per household was 1.19. Overall, 53% of all household members, 63.7% of all children under the age of five years and 61% of the pregnant women slept under an ITN the night before the survey. Of households which did not own an ITN, the majority (96.2%) stated that they ever had it in the past. Of these, 95.3% reported that their ITN was aged and became out of use.
7. Recommendations Based on the above findings, the following are recommendations for AMREF in Ethiopia to consider: Malaria early diagnosis and prompt treatment should be strengthened at health facilities through training of health workers on proper diagnosis and management of the disease. The correction of misconceptions about the role of mosquitoes in malaria transmission through intensive IEC/BCC is very important for malaria control, particularly for promoting the implementation and utilization of ITNs. The community should be informed and educated about the progression of malaria, how to recognize the danger signs of the disease, what to do and where to go for malaria treatment. Malaria related information dissemination through health workers and radio seems to be powerful to reach majority of the population. High priority should be given to provide effective antimalarial drugs such as Coartem at grass roots level through HEWs stationed at health posts. The replacement strategy to sustain the scale-up of ITNs should be initiated and strengthened.
AMREF in Ethiopia Draft Report June 2008 54 8. Annexes Annex I. List of kebeles and their estimated population size used during sampling Annex II. English version of household survey questionnaire Annex III. Amharic version of household survey questionnaire Annex IV. List of data collectors and supervisors Annex V. Training manual for data collectors and supervisors
AMREF in Ethiopia Draft Report June 2008 55