Perception and Practices on Malaria Control among Pregnant Women in Machakos Central Division, Kenya

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among Pregnant Women in Machakos Central

Division,

Kenya.

By:

Kyania Martin Mulala, BSc.N(UoN),

157/12642/2005

Thesis submitted in partial fulfillment for the requirement

of the award of a Degree of Master of Public Health in the

"-School of Health Sciences of Kenyatta University.

May, 2013

-Xyama, Martm MuJaIa -Perception and practices on malaria control among

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2013/431922

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DECLARA TION

This thesis is my original work and has not been presented for a degree inany other University.

Signature ...

Date ...:2-.0. (. . .,. ?""o.13. Kyania Martin Mulala,

157/12642/2005.

Supervisors:

This thesis has been submitted for examination with our approval as University supervisors.

.

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'

Signature.Lj ."'..,/ . f\fI ~.

Date ..I:. ~(;~)....7..'/' .?to.I.?J. .. Professor Michael Otieno,

Department of Medical Laboratory Sciences, Kenyatta University.

Signature

j~.:.

Date ....•

51..

l{/ .?-:-:':?7.3

Dr. George O. Orinda,

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DEDICATION

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ACKNOWLEDGEMENT

I would like to thank members of the Department of Community Health of the School of

Health Sciences, Kenyatta University, for providing a conducive environment which ultimately enabled me complete this study. I register very special thanks to my

supervisors; Dr. Michael Otieno from the department of Medical Laboratory Sciences,

Dr. George Orinda of the Department of Biochemistry and Biotechnology, and Dr.

Syprine A. Otieno from the department of Zoological Sciences for giving valuable advice

in writing the thesis. Very special thanks go to the Chairman of the Department, Dr. Isaac Mwanzo, for his advice and encouragement throughout the research process. Without

their support it would have been difficult to complete my research work and write up this

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ACT

AL

ANC CDC CME DDT DOT FGD

EIR

GDP GoK I-lIV lEC IPTi IRS !TN KDHS KMOH KMOMS MCI-I MDGs MOT--!

NGO

ABBREVIATIONS

Arternisininf.ombination Therapy

Arternetherl.umenfantrine

Antenatal Care

Centers for Diseases Control

Continuous Medical Education

Dichlorodiphenyltrichloroethane

Directly Observed Therapy

Focus Group Discussion

Entomological Inoculation Rate

Gross Domestic Product

Government of Kenya

Human Immunodeficiency Virus

Information Education and Communication

Intermittent Preventive Treatment in infants

Indoor residual Spraying

Insecticide Treated bed Nets

Kenya Demographic Health Survey

Kenya Ministry of Health

Kenya Ministry of Medical Services

Maternal and Child Health

Millennium Development Goals

Ministry of Health

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PfEMPi

RBM

RDTs

SP

SSA

SPSS

Plasmodiumfalciparum Erythrocyte Membrane Protein 1.

Roll Back Malaria

Rapid Diagnostic Tests

SulphadoxinePyrimethamine(Fansider)

Sub-Saharan Africa

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DEFINITION OF TERMS

Anthropophily: Tendency to target humans for blood meal.

Awareness: Interested in and knowing about something especially current events. Endemic: Regularly found in a particular area or country or particular group of

people.

Endophily: Tendency to enter and rest inside of houses.

Epidemic: The rapid spread of a disease among many people inthe same place. Factor: Underlying dimension that positively or negatively influences other

observed variables.

Incidence: Number of new episodes of illness arising in a population over an

estimated period.

insecticide: Chemical substance used to kill or inhibit insect vectors. Morbidity: The state of being diseased

Mortality: The incidence of death in apopulation in a given period Parasite: A living thing that lives in or on another living organism.

Perception: This is the ability to see, hear or understand things. A deeper natural understanding and awareness than isusual. Awareness increases

perception.

Prevalence: A measure of morbidity based on the current sickness ina population estimated either at a particular time or over a stated period.

Strategy:

Vector:

A plan designed for aparticular purpose.

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TABLE OF CONTENTS

DECLARA1'ION i

DEDICATION ii

ACI(NOWLEDGEMENrr iii

ABB]~E\!IA'I'lONS iv

DEFINITION OF TERMS vi

TA.BLE OF CON'fEN1'S viii

LISrr OF 'I'ABLES xiv

LIS1' OF FIG··UT{ES xv

A.BS'rn.AC'r xvi

CHAPTER ONE: INTRODUCTION 1

J.J Background of the study 1

J.2 Problem statement 3

1.3 Justification 4

1.4 Research questions 5

J.5 Hypothesis 5

1.6 Objectives of the study 5

1.6.1 Broad objective : 5

1.6.2 Specific objective 5

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CH

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PT

E

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W

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TE

R

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EVIEW

7

2.1 Malaria: History, etiology and morbidity 7

2.2 Occurrence and distri bution of malaria in Kenya 12

2.2.1 Lakeside endemic malaria 13

2.2.2 Coastal endemic malaria 13

2.2.3 Highlandmalaria 13

2.2.4 Arid, seasonal malaria 14

2.2.5 Low malaria risk 14

2.3 Parasitology '" 14

2.3.1 Life cycle of plasmodium parasite 14

2.4 Pathogenesis 17

2.5 Clinical features 18

2.5.1 Uncomplicated malaria 18

2.5.2 Severe malaria 19

2.6 Diagnosis 19

2.6.1 Microscopy 19

2.6.2 Rapid diagnostic tests 20

2.7 Management 20

2.8 Prevention and Control 21

2.8.1 Intermittent preventive treatment in pregnancy 22

2.8.2 Insecticide treated bed nets 22

2.8.3 Chemoprophylaxis in the non-immune population 23

2.8.4 Community education on behavior change 23

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CHAPTER THREE: MATERIALS AND METHODS 26

3.1 Research design 26

3.2 Study site 26

3.3 Study population 26

3.4 Sample size determination 27

3.5 Study variables 28

3.6 Data collection procedures 28

3.7 Ethical considerations 28

3.8 Data management, analysis and presentation 29

CHAPTER FOUR: RESULTS AND DISCUSSION 30

4.1 Results 30

4.1.1 Introduction 30

4.1.2 Socio-demographic/economic factors 30

4.1.2.1 Age of respondents 30

4.1.2.2 Marital status 31

4.1.2.3 NUJ11ber of children 31

4.1.2.4 Level of education 32

4.1.2.5 Religion 33

4.1.2.6 Residence 33

4.1.2.7 Occupation 35

4.1.3 Perceptions about malaria 35

4.1.3.1 Perceived common diseases 35

4.1.3.2 Perceived risky practices 36

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4.1.3.2 Perceived risky practices 36

4.1.3.3 Perceived reasons for malaria spread 37

4.1.3.4 Perception on treatment and control.. 37

4.1.3.5 Perception on group at high risk of malaria infection 39

4.1.3.6. Danger of malaria during pregnancy .40

4.1.4 Awareness on causes, signs and symptoms of malaria 40

4.1.4.1 Associated causes of malaria .40

4.1.4.2 Proportion of respondents having suffered malaria 43

4.1.4.3 Local methods of diagnosing malaria .43

4.1.5 Health seeking behavior and access to healthcare 44

4.1.6 Resources availability 46

4.1.6.1 ITN availability 46

4.1.6.2 Awareness of free IPTs , 47

4.1.6.3 Other methods for mosquito control .48

4.2 Discussion 50

4.2.1 Perceptions about malaria 50

4.2.2 Awareness of causes, signs and symptoms ofmalaria 52

4.2.3 Health seeking behavior and access to care 53

4.2.4 Resources availability for malaria control 54

CHAPTER FIVE: SUMMARY,CONCLUSIONS AND

RECOMMENDATIONS 57

5.1 Introduction 57

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5.3 Conclusions 59

5.4 Recommendations 60

5.5 Further research 61

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APPENDICES

6

7

Appendix I: Interview Schedule 67

Appendix II: Focus Group Discussion guide 71

Appendix Ill: Map of malaria distribution in Kenya 72

Appendix IV: Letter of approval , , 73

Appendix V: Map of the study area 74

Appendix VI: Current global malaria distribution 75

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LIST OF TABLES

Table Page

Table 4.1 Number of children 32

Table 4.2 Occupation 35

Table 4.3 Risky practices to malaria infection 36

Table 4.4 Perception on treatment ofmalaria 38

Table 4.5 Perception on control ofmalaria 48

Table 4.6 Perception on the most risky group 39

Table 4.7 Perception of danger during pregnancy .40

Table 4.8 Level of malaria awareness .41

Table 4.9 Availability of ahealth facility .46

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LIST OF FIGURES

Figure Page

Figure 4.1 Age of respondent. 30

Figure 4.2 Marital status 31

Figure 4.3 Education level 32

Figure 4.4 Religion 33

Figure 4.5 Residence .34

Figure 4.6 House status 34

Figure 4.7 Perceived common diseases 36

Figure 4.8 Awareness on malaria spread 37

Figure 4.9 Reasons for malaria spread .41

Figure 4.10 Persistency of malaria .42

Figure 4.11 Period when malaria is high .43

Figure 4.12 Previous malaria attacks .43

Figure 4.13 Diagnosing malaria .44

Figure 4.14 Action taken during sickness .45

Figure 4.15 Time to walk to the nearest health facility .45

Figure 4.16 ITN ownership .46

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ABSTRACT

Malaria is endemic in Kenya. It is the most important cause of morbidity and mortality in

children under five years of age. It accounts for 30% of outpatient visits and nearly 20% of admissions to health facilities here Kenya. In Machakos District, Malaria has been the

top cause of morbidity and mortality particularly in children under 5 years and women in the reproductive age. Records from the Machakos District hospital show that malaria cases have been steadily increasing from a low of 151,181 in the year 2002 to a high of 435,987 in the year 2010. The main objective of the study was to establish the perception and practices of pregnant women on malaria control in Machakos Central Division. The research design used was a descriptive survey and the study was done at Machakos

District Hospital. A sample of 384 pregnant women from the division was interviewed using an interview schedule. In addition three focus group discussions of eight respondents each were conducted. Results showed that factors that were found to influence perceptions and practices of pregnant mothers on malaria control were education (X2=8.J5!, df=J, p<0.004), occupation (l=4.029, df=l , p<0.045), believe that malaria can be treated/controlled through medical intervention (X2=!7.703, df=l , p<O.OOOJ), perception that children under five years and pregnant women are at a high risk of malaria infection (X2=8.909, df=l , p<0.003), accessibility of health facility (X2=5.096, df=l , p<0.024), and knowledge on associated causes of malaria(x2=1.8!5, df= 1, p<O.O 18). Focus group discussion revealed that lack of proper information on part of pregnant women on causes and diagnosis of malaria, and availability of control

measures hindered successful control. The study also found that stigma surrounding teenage pregnancy was a major obstacle for pregnant teenagers in their efforts to seek medical care. The study concludes that education and occupation are important factors in

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1.1 Background of the study

Malaria is a major public health problem in Kenya, causing an enormous burden to

health and economy. The disease remains a leading cause of morbidity and mortality in

the country, especially in children under five years and pregnant women (KMOH, 2006).

Malaria accounts for 30% of out patient attendances and 19% of admissions to our health

facilities. In Machakos Hospital, cases of reported malaria in the out patient department

stood at 30.8 %, being the highest reported disease by the end of year 20) 0 (KMOMS,

20 I0). The disease is prevalent despite several measures put in place to prevent its

spread.

The main focus of malaria control measures in Kenya include case management (early

diagnosis and prompt treatment with effective drugs), vector control using insecticide

treated mosquito nets (lTNs), malaria intermittent treatment in pregnant women, malaria

epidemics prevention and control, information, education and communication, and

operational research (Mboera et al., 2007). Despite these strategies, malaria cases and

deaths have been increasing in the country, mainly due to injudicious use of antimalarial

drugs, delayed health seeking, and reliance on clinical judgment without laboratory

confirmation in most of the peripheral health facilities(Mboera et al., 2007).

Whilst antimalarial interventions are undoubtedly important, it is also well recognized

that accessibility to anti-malaria interventions alone will not bring about the desired

change. Several studies have demonstrated that compliance to anti-malaria interventions

depends substantially on social, behavioral and cultural factors that affect understanding

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and practices about prevention (Agyepong, 1992a; Ahorlu et al., 1997;Espino et al.,

1997; Agyepong and Manderson, 1999b). In addition, factors such as vulnerability,

economic constraints, inadequacy or unavailability of appropriate health services, and

other related factors play an important role in explaining health seeking behavior of the

people (Hausmann et al., 2003)

Studies in the past have mainly been carried out in high malaria risk areas such as the

lakeside and coastalareas due to the overwhelming burden of the disease among young

children and pregnant women in those areas. Recently, however, there has been an

increased need to understand perceptions and practices of the women about the disease,

particularly health and treatment seeking behaviors in low malaria risk areas in Sub

Saharan Africa (Tanner and Vlassoff, 1998; Nuwaha, 2002; Guyatt and Snow, 2004;

Ndyomugyenyi et al., 2007).

Due to the huge burden of malaria among pregnant women and children under the age of

five years, targeting women in the reproductive age group to deal with the disease has

recently been widely recognized. It has been acknowledged that the success of malaria

control inchildren and pregnant women depends on the understanding of the local

socio-cultural factors affecting women's perceptions of causes and modes of transmission of

the disease, health seeking behavior and practices of malaria prevention measures

(Reuben, 1993; Kengeya et al., J994; Rahman et al., 1995; Tarimo et al., 2000; Camara

et al., 2003; Launiala and Kulmala, 2006; Mbonye, 2006). However, research focusing

on malaria issues among women in the reproductive age group with children under the

age of five years in low risk malaria areas has been scarce(Tanner et al., J998; Rahman

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Understanding the local perceptions and practices of women is of utmost relevance in

terms of enhancing community's potential to deal with village-based malaria

interventions. This particular study was carried out in a low malaria risk area to examine

women's perceptions and practices related to malaria transmission, symptoms/recognition, treatment, prevention, and treatment seekingbehaviour. The purpose of the study was to generate information that might support the design and implementation of appropriate interventions as part of broader malaria control strategies.

There has been a considerable number of reports about knowledge, attitudes, and

practices relating to malaria and its control from different parts of Africa. These reports

concluded that misconceptions concerning malaria still exist and that practices for the

control of malaria have been unsatisfactory (Vundule and Mharakurwa, 1996; Hla

-Sheinel al., 1998; Miguel et af., 1999). Thus, an advanced knowledge of the community

beliefs and practices with respect to the disease is required to obtain and maintain its

participation insurveillance and control activities (Reubushet af., 1994).

1.2 Problem statement

There has been a steady increase of malaria cases reported in Machakos General Hospital

since the year 2002. Hospital records indicate that malaria cases reported steadily increased from a low of 151,182 in 2002 to a high of 436,500 in 20 IO(KMOMS, 20 I0). Majority of these were pregnant women and children under five years. These cases

accounted for up to 34% of the disease burden inthe district.As such the overall problem addressed in this study is that despite the availability of effective and proven control

methods for malaria, the disease has been on the increase and this therefore calls for the

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particularly in the vulnerable groups, namely pregnant women and children under five years.lf the underlying factors are not identified urgently and the incidences of this

disease curbed, we shall continue losing women and children as a result of maternal and

infant mortalities related to malaria. This in the long run will defeat intervention efforts towards the attainment of the 2015 Millennium Development Goals particularly on reduction on child mortality, improvement of maternal health and combating HIV/AIDS, malaria and other diseases.

1.3Justification

Mothers in general are the first persons to identify the fever or health changes on their children and thereby seek healthcare, thus playa major role as they protect themselves and their children. The participation of mothers in fighting malaria plays a vital role not

only for them and their children, but to the entire community in which they live. If

mothers protect themsel ves and their ch iIdren against mosqu ito bites and also seek medical care appropriately, then morbidity and mortality related to malaria are likely to

reduce.

Malaria continues to be the top cause of morbidity and mortality in pregnant women and children under five years of age in spite of available effective and proven control

measures. There is still no effective vaccine for the disease. ln the last five years

approximately 34% of the entire disease burden in Machakos district was due to malaria,

75% of which were children under the age of five years(KMOMS, 20I 0). Cases of this

disease continue to increase every year. These figures are alarming and every option for control ought to be instituted.This study thereforeattempts to fully establish the

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1.4Research questions

1.What perceptions do pregnant women inMachakos Central Division have concerning malaria?

2. What is the awareness level of the pregnant women 111Machakos Central Division concerning malaria infection?

3. What actions do pregnant women 111Machakos Central Division take to combat malaria?

4. What necessaryresources do pregnant women in Machakos Central Division possess for malaria control?

1.5 Hypothesis

There is no significant relationship between mothers' perception on malaria and malaria prevalence in Machakos Central Division.

1.60bjectivcs of the study

1.6.1 Broad Objective

To establish theeffect of the perceptions, awareness and practices of pregnant women in Machakos Central Division on malaria control.

1.6.2 Specific Objectives

I. To establish the perceptions of pregnant women In MachakosCentral Division

concerning 11l~laria.

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3. To find out the actions taken by pregnant women in Machakos Central Division 111

curbing malaria.

4. To establish availability of resources needed by the pregnant women in Machakos

Central Division for malaria control.

1.6Significance of the study

This study hasestablished the underlying factors hindering pregnant women from

combating malaria. This knowledge may assist policy makers in drawing guidelines that

would also help in controlling malaria.The report will be useful to service providers such

as nurses and doctors in the district in their efforts towards malaria control. Also,

stakeholders in the humanitarian field involved in malaria control will be highlighted

more on malaria control issues and hence provide more support to empower women in

the tight against the disease. And finally, health educators will be provided with extra

information that they would use in teaching the community alternative ways of

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CHAPTER TWO:LITERATURE

REVIEW

2.1 Malaria: Historical background, etiology and burden of the disease

Malaria, a mosquito-borne, protozoan disease, is older than recorded history, and

probably plagued prehistoric man (Lambert et 01.,2002). The first record of treatment for the disease dates from 1600 A.D. in Peru, and utilized the quinine-rich bark of the Cinchona tree (Lambert et al., 2002). Scientifically therefore, it is not a newly described disease. The French physician Charles Louis Alphonse Laveran first identified the parasite under the microscope in 1880. Ronald Ross and Giovanni Grassi recognized the

mosquito as the malaria vector in 1897 (Good and Marsh, 2002). Four Nobel prizes have been awarded for work associated with malaria; to Sir Ronald Ross (1902), Charles

Louis Alphonse Laveran (1907), Julius Wagner-Jauregg (1927) and Paul Hermann Muller (1948) (CDC, 2004). However, despite enormous and diverse efforts to control

this disease, malaria is among the top three most deadly communicable diseases and the

most deadly tropical parasitic disease today(Sachs and Maloney, 2002).

Approximately 40% of the world's population lives in regions where malaria transmission is endemic, mainly tropical and sub-tropical regions (Altman et al., 2002). Malaria has been successfully controlled, in fact effectively eliminated, in temperate regions of the world (Sachs and Maloney, 2002). The control strategies employed in temperate regions included changes in agricultural and construction practices, reducing

the availability of standing water, and targeted vector control using insecticides such as

DOT (Greenwood and Mutabingwa, 2002). Industrialization and improved housing

conditions were instrurriental in the elimination of the' disease in temperate countries (Budiansky, 2002). Windows and walls reduce the amount of contact people have with

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another factor for the success of erad ication programs as well. The role of the mosqu ito in the life cycle of P. falciparum requires that the parasite be able to maintain an

extended infection in order to ensure transmission ability during the following season

(Kyes et 01.,200 I). Strong seasonality results in lower basal levels of case reproduction

(Sachs and Maloney, 2002). Now that the sequences of the three participants in the life

cycle of human malaria, P. falciparum, Anopheles gambiae, and Homo sapiens, are all

completed and available, perhaps new strategies of disease control will succeed.

Anopheles gambiae, Anopheles arabiensis and Anopheles funestustransmit most of

human malaria and are all found in Africa (Besansky et 01., 2004). Anopheles gambiae,

the most famous and significant of these three, is one of sixty anopheline mosquitoes

able to transmit malaria to humans (Budiansky, 2002). Anopheles gambiae is the

primary malaria vector; this can be attributed, in part, to its relatively long life, strong

anthropophily and endophily (the tendency to target humans for blood meal and the

tendency to enter and rest inside of houses, respectively(Besansky et al., 2004).

Malaria occurs in endemic or epidemic form throughout the tropics except for areas

above 2000metres above sea level: Australia, the USA, and most of the Mediterranean '-'::;"fli"u/

littoral are malaria free (Kumar and Clark, 2002).Although many efforts have been put to

control malaria and been successful to varying degrees, approximately 500 million

clinical cases of malaria are reported each year (Alnwick, 200 I)and mortality estimates

range between 0.7 and 2.7 million. Most of these deaths, (75%) , are young African

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In sub-Saharan Africa, where malaria mortality is highest, 90% of reported

malaria-related deaths are children under the age of five (Gardner, 2002). However, the actual

figures of iIIness, morbid ity and mortal ity may be very different from those cited above.

Accuracy is impeded by the fact that most malarial deaths occur at home, many cases are

misdiagnosed and functional microscopes are not available to most clinics (Greenwood

and Mutabingwa, 2002).Unfortunately, the disease burden is on the rise.

Despite the fact that strong attempts to eradicate malaria have been made, the disease

burden isstill on the rise and some estimate that the number of cases could double in the

next twenty years without the development of new methods of control (Sachs and

Maloney, 2002). Aside from the human tragedy this predicts, an economic disaster is

also likely for the stricken countries. Gallup and Sachs (200 I) report that, during the

period 1965 - 1990, the annual growth rates in malarious countries are 1.3% lower

compared to non-malarious countries. This corresponds to a 50% decrease in per capita

Gross Domestic Product (GDP) (Gardner, 2002). Maloney and Sachs (2002)

hypothesize that this apparent correlation between poverty and malaria runs both ways.

Poverty may increase the incidence of malaria; malaria may also increase the likelihood

of poverty. An increase in population in malarious regions, compounded by weak public

health systems in developing countries, climate changes (Hay e/ al., 2004), new

agriculture practices such as irrigation and dam construction (Sachs and Maloney, 2002),

increased resistance-to antimalarial treatments and insecticides and the complexity and

flexibility of the genetics (Gardner, 2002) have all contributed to the increase in malaria.

During the period between 1975-1996, only 3 of 1,223 drugs developed were

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outstripped supply. This can be explained, in part, by the fact that the large number of

people suffering from malaria and other diseases commonly found in Africa are not

customers (Kettler and Marjanovic, 2004). They can .not purchase new drugs and therefore do not exist as a viable market for a biotechnology company's investment.

The involvement of biotechnology companies is crucial in the fight against malaria.

When the Plasmodium falciparum sequence became available, the biotechnology

companies acted quickly to advance this knowledge into products. Aside from the new

vaccine candidates developed, biotechnology companies produced both a needle-free

injection device (Bioject Medical Technologies) and kits for parasite detection (AMRAD

corp.) (Kettler and Marjanovic, 2004). The contribution of their research power is

essential for the success of malaria control campaigns. The difficulty of involving the

biotechnology companies lies in their dependency upon earning a profit and in the fact

that they mostly receive outside funding. Funding is not easily procured when a viable

market does not exist. Most biotech companies would be interested in researching these diseases, even if only for public relations purposes, if they were given any compensation

incentive. Policy changes must be made to make the production of these drugs possible.

These policies would need to be enacted on a global scale. Models based on national

laws such as the American Orphan drug act have been proposed (Kettler and Marjanovic,

2004). These would lower the cost and risk for the companies while increasing the

expected return.

Additionally, more specific regions need to be identified as regions In need of more

resources. One study in Kenya showed that the insecticide-treated bed net (ITN)

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organizations (NGOs) were present, rather than to areas where malaria transmission was

highest (Greenwood and Mutabingwa, 2002). Organized strategies need to be employed

to achieve the highest possible efficacy. Four studies of home management of malaria

revealed large reductions in severe illness when children were treated at early stages.

Intermittent preventive treatment in infants (IPTi) was tried in conjunction with normal

vaccine schedules. Healthy babies were given full treatments of antimalarial drugs and

this reduced the amount of malaria and anaemia(Toure and Oduola, 2004). One

important element of this study was the Lise of organizations involved in vaccine

distribution to administer malaria treatment. This type of cooperation is cost-effective and could cover extensive areas. These studies suggest that improvements can be made

by training local healthcare workers to educate themselves and people in their

communities about appropriate drugs to prescribe (Toure andOduola, 2004). With the

cooperation of science, government and charitable foundations itmay soon be possible to

bring malaria under control.

Malaria is endemic in Kenya. It remains a leading cause of morbidity and mortality

especially in young children and pregnant women. It accounts for 30% of outpatient

visits and nearly 19% of admissions to health facilities in the country (KMOH, 2006). Its

incidence is still on the increase despite available and effective control tools. Malaria in

Kenya varies from region to region largely due to climate and temperature, including the

effects of altitude.

The KMOH Annual Health Sector Report 2005- 2007 indicated clearly that malaria has

been the top cause of out patient morbidity and that there has been a steady increase in

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malaria infection rate in the year 2007 reporting a rate of 52] cases per 1000 population

of people. It was followed by Nyanza and Coast provinces which reported 473 and 270

cases per 1000 population of people respectively. This is contrary to reports that Nyanza

and Coast provinces are more malarious than Eastern province.

In Machakos District, malaria has been the top cause of morbidity and mortality.

Hospital records indicate that malaria cases have been on the increase for the last six

years consecutively. Cases of reported malaria increased from 15 1,184 in the year 2002

up to 363,122 in 2006 and to 436,500 in 2010. Malaria accounted for approximately 34%

of the disease burden in the district. Since not all people visit health facilities when they fall sick, there are many more that die at home and thus the true figures of death and

disease from malaria are likely to be higher. It continues to be a top killer disease in Kenya. It accounts for 34,000 deaths annually among children under five years of age

and more than 8 mill ion out-patient treatments at heal th faci lities, majority being

pregnant women and children under the age of five years (KMOH, 2006a). During

pregnancy, malaria causes anemia, miscarriages and can result in low birth weight

babies. The Roll Back Malaria (RBM) initiative where Kenya is a member is a global

response that recognizes the disease malaria as an economic burden and barrier to

development for m ill ions of Africans.

2.2 Occurrence and distribution of malaria in Kenya

Malaria endemicity in Kenyavaries from region to region and there has been a huge

diversity of risk of malaria infection largely driven by climate and temperature including

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broadly categorized into one of the five malaria ecological zones(Appendix II/).These

categories are stated below as has also been noted inKMOMS 2010.

2.2.1 Lakeside endemic

This occurs mainly among many districts close to lake Victoria. Malaria transmission

here occurs throughout the year. The community acquires immunity before adulthood

and the risks of disease and death from malaria are concentrated among children and

pregnant women. Transmission is perennial and the parasite prevalence among children

often exceeds 50%.

2.2.2 Coastal endemic

Coastal region of Kenya is similar in endemicity to the lakeshore region with parasite

prevalence often exceeding 50%. However, the transmission and maximal disease risk

period exhibit strong seasonality and the intensity of transmission is lower as you move

towards Soma Ii boarder.

2.2.3 Highland

These cover areas around mount Kenya; Nanyuki, Meru, Embu, Kirinyaga, and

Muranga. A common feature of malaria in the highland districts is that while there is

always a potential for limited transmission lending itself to an overall low disease risk on

an average year, variations in rainfall and ambient temperatures between years can lead

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2.2.4 Arid, Seasonal

Many districts in a large part of North Eastern, North Western, parts of Eastern and

southern part of the Rift valley provinces mostly experience malaria where communities

are located near water(KMOH, 2006b).The arid and rainfall limited effects upon

transmission lend the transmission of parasites only to a few months of the year or absent

during occasional years. Other districts might experience transmission every year for a

few months. All districts in this category will experience low infection prevalence rates

in childhood. The study area for this research lies on this region.

2.2.5 Low malaria risk

This region covers highlands within Central province and Nairobi provmce.

Parasitological surveys in these areas on the whole suggest low parasite prevalence

among chiIdren aged below 14 years. Many areas here experience no malaria risk, for

instance, the central areas of Nairobi, Nyeri and Nakuru.

2.3 Parasitology

Human malaria results from infection with Plasmodium falciparum, Plasmodium vivax,

Plasmodium ovale or Plasmodium malariae. Plasmodium falciparum causes a large

majority of the clinical cases and mortalities (Bozdech et al., 2003). The protozoan

Plasmodium is transmitted to humans by mosquitoes of the genus Anopheles. The

mosquito picks up the parasite during a blood feeding from a person with parasitaernia.

2.3.1 Lifecycle of plasmodium parasite

To understand the challenges biologists face in combating this disease, and the strategies

(31)

this parasite.

Plasmodium

parasites are protozoa of the Phylum

Apicomplexa(

often

referred to as sporozoans). These arc animal parasites which exist in two hosts, have

sexual and asexual stages, alternate between haploid and diploid phases and must be able

to survive inside both hosts. The life cycle begins with the bite of an infected female

anopheline mosquito. The mosquito takes her blood meal from the vertebrate (in this

case a human) and injects both anticoagulant and haploid sporozoites into the human

blood stream (Yartey, 2006). The sporozoites quickly travel to the hepatocytes (liver

cells), where they mature.

The complex life cycle stages influence malaria vaccine development, each stage has different antigens that lead to protective immunity.

Source of diagram: http:

//

ww

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torg

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malaria.

In the hepatocyte the sporozoites undergo multiple asexual fissions, or schizogony, to

produce thousands of infective, haploid merozoites. TIle rnerozoites are released into the

(32)

from this that the immunity provided by the sickle cell trait can be explained. These

parasites have high metabolic demands and cannot survive in the compromised red blood

cells of a human with sub-optimal oxygen carrying-capacity. At this point, the patient is

still in the prepatent period and does not exhibit any clinical symptoms(Kyes et al.,

200 I).

Inside the erythrocyte, the rnerozoites again begin to replicate and divide asexually.

Each merozoite gives rise to 6-32 daughter merozoites (Kyes et al., 200 I)) during 24-72

hours, depending on the species. Ultimately the infected erythrocytes lyse and

merozoites are again released into the bloodstream and invade more cells. This cycle

continues until the patient dies or the parasite is slowed by either the host immune

system or chemotherapeutic agents. The destruction of the erythrocyte and release of

merozoi tes corresponds to the hallmark cl inical presentation of the disease, the period ic

fevers.

The other possible life cycle for the merozoites isdifferentiation into macrogarnetocytes

and microgarnetocytes that do not destroy the erythrocyte they inhabit while in the

human host. They are ingested by anopheline mosquitoes and develop into male and

female gametes. Inside the gut of the mosquito the erythrocytes do lyse and the gametes

meet and fuse into diploid zygotes (the ookinete). This is the only diploid stage during

the life time of the Plasmodium parasite. The ookinetes develop into oocysts and

migrate to the salivary gland of the mosquito (Good and Marsh, 2002). The cycle isthus

(33)

2.4 Pathogenesis

The pathology of malaria is related to anaemia, cytokine release and in the case of P.

falciparuni, widespread organ damage due to impaired microcirculation. The anaemia

seen in malaria is multifactorial: haernolysis of infected red blood cells, haernolysis of

non-infected red cells(blackwater fever), dyserythropoiesis, splenomegaly and

sequestration, and folate depletion (Kumar and Clark, 2002). In P.falciparum malaria,

red cells containing schizonts adhere to the lining of capillaries in the brain, kidneys, gut,

liver and other organs. By causing mechanical obstruction, schizonts rupture, release

toxins and stimulate further cytokine release.

The classic example of the strong selective pressure malaria puts on the human

population is the high incidence of the potentially fatal sickle cell gene reported in

regions with endemic malaria. People with one allele for sickled blood cells, the sickle

cell trait, have a survival advantage in regions with endemic malaria. They are more

likely to survive an infection by P. falciparum. Therefore, people with the sickle cell

trait are more likely to survive to a reproductive age. However, the offspring of two

people with sickle cell trait have a 25% chance of bearing offspring with sickle cell

anaemia, which is often fatal and greatly reduces a person's expected longevity. The

enormous effects that malaria has on countries where it is endemic explains this

selection.

The virulence patterns of malaria were being documented as early as the 1920s. Malaria,

specifically the fevers induced by infection with Plasmodium, was used at the time as

treatment for syphilis. It was also noted that reproducible virulence patterns were seen

(34)

was achieved by infecting previously naive patients (Kyes et al., 200 1). Even through

these most rudimentary types of experiments it was observed that immunity to a certain

strain of Plasmodium was not equivalent to immunity to the disease malaria. More

recently, controlled studies indicate that immunity to severe malaria is acquired more

rapidly than immunity to mild malaria, especially in regions where transmission is high

(Gupta et al., 1999).

2.5 Clinical features

Typical malaria is usually seen in non-immune individuals. This includes children in any

area, adults in hypoendemic areas and any visitors from non-malarious regions (KMOT-I,

2006b). The incubation period is between 10-21 days, but can be longer. The common symptoms are fever, general malaise, headache, muscle pains, joint pains, abdominal

pains, diarrhea, vomiting, irritability and refusal to feed. At first the fever may be

continuous or erratic. The temperature usually reaches 41 degrees celcious, and is

accompanied by rigors and drenching sweats. Malaria caused by P. [alciparum IS

typically more severe than that caused by the other plasmodium species. The vast

majority of deaths are due to P.falciparum. Patients can deteriorate rapidly, and children

can change from reasonable health to coma and death within hours.The clinical course of

malaria may present as uncomplicated or severe.

2.5.1 Uncomplicated malaria

This is usually characterized by fever in the presence of peripheral parasitaemia, Other

features may include chills, profuse sweating, muscle pains, joint pains, abdominal pain,

diarrhea, nausea, vomiting, irritability and refusal to feed. These features may occur

(35)

2.5.2 Severe malaria

This is a life-threatening manifestation of malaria and is defined as the detection of

Ffalciparum in the peripheral blood in the presence of any of the following clinical or

laboratory features: Alteration in the level of consciousness(ranging from drowsiness to

deep coma, cerebral malaria (unarousable coma not attributable to any other cause in a

patient with falciparum malaria), prostration (inability to sit upright, stand or walk

without support in a child who normally does so, or inability to drink in children too

young to sit), respiratory distress, multiple generalized convulsions ( 2 or more episodes

within a 24 hour period), pulmonary oedema, circulatory collapse (shock, septicaemia),

abnormal bleeding (Disseminated Intravascular Coagulation), jaundice, haemoglobinuria

(black water fever), acute renal failure - which present as oliguria or anuria, severe

anaemia (Hb <Sgrams per deciliter or haematocrate< IS%), and hypoglycaernia (blood

glucose level < 2.2 mmol/l).

2.6 Parasitological Diagnosis of malaria

The commonly used confirmatory tests to detect the presence of malaria parasites are

microscopy or rapid diagnostic tests (ROTs). Quality assurance of microscopy and ROTs

isvital for the sensitivity and specificity of the results.

2.6.1 Microscopy

Microscopy is the standard method for parasitological diagnosis of malaria. This isdone

by examining a stained thick or thin blood smear for the presence of malaria parasites.

Thick films are recommended for parasite detection and quantification and can be used

to monitor response to treatment. Thin films are recommended for species identification.

(36)

2.6.2 Rapid Diagnostic Tests

These tests are immunochrornatographic tests based on the detection of specific parasite

antigen, either parasite lactate dehydrogenase (pLOH) activity or the presence of

Histidine-Rich Protein? (HRP2). Most of the RDT tests available are specific for

Ffalciparum. However, there are a few tests with the ability to differentiate between P.

falciparum and non Pfalciparum (vivax, malariae and ova/e). ROTs are simple to use

and are sensitive in detecting low parasitemia. Use of ROTs is not recommended for

follow-up as 1110stof the tests remain positive for upto two weeks following effective

antimalarial treatment and clearance of parasites. They also can not be used to determine

parasite density.

2.7 Management

Worldwide, great and varied efforts are being made to learn about this disease and to

determine how to manage and control it.The official malaria eradication program, run by the World Health Organization (WHO), was cancelled in the late 1960s because of

growing difficulties, given that the complex and persistent nature of this disease became

increasingly obvious. Management strategies today include the development of vaccines

and chemotherapeutic agents, vector control, insecticides, education, and insecticide

treated bed nets. Resistance to drugs by both the mosquito and the parasite is a growing

obstacle inthe battle against malaria. Combination therapy has been shown to increase

the efficacy of treatment (Toure and Oduola, 2004).

.Currently, management of malaria is based on severity of the illness and the individual's

immune status. Generally, treatment regimen is based on whether the malaria is

(37)

malaria in Kenya is artemether-Iumefantrine, currently available as co-formulated tablet

containing 20 mg of Arternether and 120 mg of lumefantrine. This is administered as a 6

-dose regimen given over three days.The recommended medicine of choice for severe

malaria is parenteral quinine, preferably route of administered intravenously. However,

the intrarnascular route can be used as an alternative where intravenous route is not

feasible(KMOH ,2006b).

2.8 Prevention and control

Currently, malaria control programs do not attempt to eliminate malaria totally.

Complete elimination of the parasite (and thus the disease) would constitute eradication

(COC, 2004). While eradication would be more desirable, it's not currently a realistic

goal for most of the countries where malaria is endemic. Certain barriers to effective

malaria control have been identified. These include, drug resistance, insecticide

resistance, inadequate health infrastructure in poor countries, poverty and lack of

education (COC, 2004). An effective vaccine for this disease has not yet been produced.

Controlling malaria has remained aformidable task.

There are several strategies currently used in the prevention and control of malaria.

These include; intermittent preventive treatment in pregnancy, use of insecticide treated

nets, chemoprophylaxis in the non-immune population, community education on

(38)

2.8.1 Intermittent preventive treatment inpregnancytfl'Tp)

Pregnant women are usually at a particular risk of malaria infection(Mbonye et al.,

2006). The consequences of malaria in pregnancy include anaemia and febrile illnesses

in the mother, foetal death and low birth weight. Women at their first and second pregnancies are at a greater risk. Pregnant women therefore are advised to take IPTs

during pregnancy. All pregnant women attending health facilities should receive two

doses of IPT starting at quickening time and with a four weeks interval. This is given free in government health facilities. The current recommended medicine for IPT is

Sulphadoxine 500mg Pyrimethamine 25mg given as a dose of three tablets. This

treatment reduces the amount of malaria parasites in the individual to a level that would

not cause the disease. Through IPT the number of still births due to malaria is likely to

reduce. IPT should be given under directly observed therapy (DOT) in an antenatal clinic

and can be given on an empty stomach. This is so to avoid chances that some women

would forget to take if given to go home with the tablets.

2.8.2 Insecticide treated bed nets (ITNs)

Bed nets are encouraged to be used by all and more so to populations living in high

malaria transmission. The nets block contact between people and the mosquito. The

insecticide in the net helps kill and also repel the vector. Treated nets are being provided free in the government hospitals to all pregnant women. it is expected that all pregnant

women and children under five years old should sleep under an ITN. Use of ITN should

be encouraged early and consistently throughout pregnancy and after delivery. By so

doing malaria burden shall be greatly reduced in the vulnerable group, pregnant women

(39)

2.8.3 Chemoprophylaxis in the non-immune population

Chemopropylaxis is recommended in various groups of people who are at a high risk of

malaria infection. These include visitors from malaria free countries such as Europe,

patients with sicle cell disease, and patients with tropical splenomegaly syndrome or

hyperimmune malaria splenomegaly. Such people should use appropriate propylaxis to

boost their immunity against malaria. They should also use other barrier methods to

protect themselves against mosquito bites. Early treatment should also be sought incase

such persons fall ill of the disease even if a prophylaxis has been taken.Travelers should

carry a full course of arternether-lumefantrine for use incase they develop a fever and

have no immediate access to health services.

t8.4 Community education 011 behavior change

Health information, education and communication are a critical intervention for behavior

change towards improved health practices. The people should be informed on the

following: to seek prompt treatment for fevers, how to recognize symptoms and signs of

severe disease, that they should adhere to treatment plan, and that they should use the

appropriate prevention measures. Many women in the community are unaware of the

free services offered in government health facilities. Public health campaigns to address

these issues should continuously be done. This way the people are made aware of the

available tools provided to combat malaria.

2.8.5 Vector control

Anopheles gambiae, Anopheles arabiensis and Anopheles funestus transmit 1110Stof

human malaria and are all found in Africa (Besansky, 2004). Anopheles gambiae, the

(40)

transmit malaria to humans (Budiansky, 2002). It isthe primary malaria vector; this can

be attributed, in part, to its relatively long life, strong anthropophily and endophily (the

tendency to target humans for blood meal and the tendency to enter and rest inside of

houses, respectively) (Besansky, 2004). Adult mosquitoes normally rest during the day

inside human habitats and emerge to feed at night (Holt and Patrick, 2002). Their larvae

tend to develop in temporary bodies of water, such as those typically found near

agricultural sites or even in flooded hoof prints(Vogel, 2002). All of these characteristics

combine to make P.falciparum asuccessful vector.

That this behavior is remarkable can be highlighted with a comparison of the

entomological inoculation rate (ElR) of infectious mosquitoes in Asia or South America

compared to sub-Saharan Africa. The 'EIR measures how often one person is bitten by

an infectious mosquito. In Asia or South America a person's EIR rarely exceeds 5 bites

per year. In sub-Saharan Africa a person may have an EIR of over 1,000 bites per

year(Greenwood and Mutabingwa, 2002). The authors also report that during a single

night insub-Saharan Africa, hundreds of mosquitoes typically collect in a room occupied

by humans; 1-5% of these are infectious.

Some disease control strategies deal with these anopheline mosquitoes rather than the

parasite. One strategy for attacking mosquitoes is to develop more effective insecticides.

The main obstacles to this line of attack are growing insecticide resistance and

environmental concerns. The publication of the Anophels gambiaegexvsttv: (Holt and

Patrick, 2002) should help to locate genes involved in resistance and to design chemicals

for attacking new targets in the mosquito. The failure of the WHO's malaria eradication

program was, to a significant degree, due to increasing resistance to DDT and the fact

(41)

The current, most widely used, technique for vector control is bed nets treated with the

insecticide pyrethroid. However, it is only amatter of time before pyrethroid, like DOT,

loses its efficacy. Genomics may prove key in the development of new insecticides and

may also improve the longevity of available insecticides (Hemingway et al., 2002).

The viability of introducing genetically modified mosquitoes, which are either unable to

transmit malaria to humans or are sterile, is also being investigated. The completed

genome of Anopheles gambiae has encouraged comparative studies between these

mosquitoes and other arthropods and model organisms such as Drosophilia

melanogaster. These studies may provide clues to account for their great effectiveness

as aPlasmodium vector and could prove to be an effective tool for disease control. Ito et

al., (2002)reported the creation of a stable strain of transgenic mosquitoes that were

unable to transmit Plasmodium under laboratory conditions. Using bacteriophages they

identified a peptide that blocks the parasite from crossing the epethelia of the mosquito.

During a successful life cycle ofa Plasmodium parasite they must cross the epethilium of

both the midgut and the salivary glands. Attaching units of this peptide to a promoter

activated by a blood meal, they were able to inhibit the development of the majority of

parasites. This laboratory success is great but there remain many challenges before

genetically modified mosquitoes could be considered a viable method for malaria

control.

Other methods used to control the vector include indoor residual spraying and selective

larviciding in specific sites, screening of house inlets with mesh wire to reduce entry of

(42)

CHAPTER THREE:MATERIALS

AND MET

H

OD

S

3.1 Research Design

The research design used in this study was a descriptive survey. The study was aimed at

collecting information from pregnant mothers in Machakos Central Division on their

perceptions and practices regarding malaria control. The tools employed in gathering

information were an in depth researcher administered questionnaire (interview guide)

and a Focus group discussions (FGDs) guide.

3.2Study Area

The study area was Machakos Central Division, Machakos District in Eastern Province

of Kenya (Appendix V).The research was carried out atMachakosGeneral Hospital.The

area is south east of the capital city of Nairobi, approximately 68 kilornetres away. The

area is characterized by hills on its north, east and south eastern side. These hills are

Mua, Kyeveti and Kiirna Kimwe respectively. The southern side and the western side are

the plains of Konza and Kaviti. The area experiences seasonal rainfall. Short rains occur

between November and December while the long rains occur between March and May.

The area is generally warm with mean temperatures ranging between 22 - 30 decrees

celcious. Machakos Central Division has an estimated population of 160,254 residents as

at end of year 20 IO. Estimated number of women of child bearing age is 54,330 (KDHS

2009).

3.3 Study population

These were pregnant women visiting the health facility's antenatal care clinic. They were

selected randomly.Those included in the study were residents of Machakos Central

(43)

years were excluded from the study. All pregnant women from within this division and

fall in the reproductive age were subjects to this study.

3.4 Sample size determination

Purposive sampling technique wasin selecting study subject. Pregnant women 11'0111 within the division attending antenatal care or otherwise at the health facilities were considered in sample selection. Machakos Central Division has an estimated population

of 160,254 residents as at end of year 2010. Estimated number of women of child

bearing age is 54,330 (KDI-IS 2009). (Fisher et 01., 1998) formula was used to determine

the sample size. 11

=

(Z2)(pq) / (d2)

Where:

n= the desired sample size (if the target population ismore than 10,000) z =the standard normal dev iate at the requ ired confidence level (1.96)

p = the proportion in the target population estimated to have the characteristic being

measured q = I-p

d =the level of statistical significance set at 0.05

Note:ln this study there isno estimate of the proportion in the target population assumed

to have the characteristic of interest i.e. perceptions and practices on malaria. Therefore 50% was used as recommended by (Fisher e/ 01., 1998).

Requiring accuracy at 0.05 level, then the sample size thus was:

(44)

3.5 Study Variables

The independent variables for this study were: education level, occupation, presence of a

health facility, pregnancy, age of child, knowledge of signs and symptoms, belief that

malaria is treatable and improved housing.The dependent variables were health seeking

behaviors and malaria control practices. These included the following: visiting a health

facility, possession of ITN, using ITN, using mosquito coils, repellants and sprays,

draining of swamps and closing of windows in the evening.

3.6 Data collection procedures

To obtain data, a research instrument wasdeveloped, pre-tested and used. For this

purpose a researcher administered questionnaire (interview schedulejwasused. The

structured interview guide consisted of both open-ended and closed-ended questions. In

addition three Focus Group Discussions (FGDs) were conducted. The FGDs consisted of

8 members each: Adolescent pregnant women aged between 14 and 19 years, pregnant

women with tertiary level of education aged between 20 and 49 years, and pregnant

women with no tertiary level of education also aged between 20 and 49 years.

Discussions and interviews focused on four thematic areas; perception of disease,

awareness of disease, control methods and constraints or difficulties faced by women in

malarial control.

3.7 Ethical considerations

Research begun after the relevant authorities issued clearance: Kenyatta University

graduate school, Ministry of Higher Education, Science and technology and Ministry of

Health permits. Participants in this participated voluntarily and on request. Informed

(45)

to withdraw from the research at any stage without victimization whatsoever. Ail information given was held in confidence and the study subjects were made aware of

this, Research findings will be made available to the relevant authorities,

3.8 Data management, analysis and presentation.

The data was double entered in Microsoft Excel data sheets, cross checked and

transferred, and analyzed using SPSS for Windows version 11,5 (SPSS, Atlanta, GA,

USA), Descriptive statistics were carried out to measure relative frequencies,

percentages, averages, and relative frequencies of the variables, Cross tabulations of

variables were done, and chi-square test was used to determine the statistical significance

or differences of relative frequencies.Results were presented in frequency tables, bar

(46)

4.1 Results

CIlAYfER FOUR:RESULTS AND DISCUSSION

4.1.1 Introduction

This chapter presents both qualitative and quantitative findings of the study. The section

covered the following findings: Socio-demographic and Socio-economic factors,

perceptions on Malaria illness, awareness,actions/practiceslhealth seeking behavior and

resource availability. The data is presented using frequency tables, charts and graphs.

4.1.2 Socio-demographic and Socio-economic factors

4.1.2.1 Age of respondents

Seven percent of the respondents were in the age between 14 and 19 years. Thirty seven

percent were in the age of between 20 and 25 years. Twenty sevenpercent were :in the

age ranging from 26 to31 years. Twenty one percent were between 32 and 37 years. Five

percent were between 38 and 43 years. The rest,three percent were between 44 and 49

years (FigA.l). Modal age was 20 to 25 years while mean age stood at 28 years.

40

--35

30

IV b.O 25 CU

-

=

20

~ 15

~ 10

g.

.

5

o

14-19 20-25 26-31 32-37

Age (years)

44-49 38-43

(47)

4.1.2.2 Marital Status

Seventy four percent of respondents were married, 24% percent were not married, 1%

widowed and 1% was divorced or separated.

l

Widowed Divon:ed/sep<mlted

r }~~ 1%

. ",

Key

-Married

•••Not married

Widowed

'"Divorced/separate d

Figure

4

.

2Distribution of respondents by marital status

4.1.2.3 Number of Children

Ninety six percent of the respondents had 1-5 children, 3% had 6-10 children and 1%

(48)

Table 4.1Distribution of respondents by number of children

Number of children Frequency Percent

1-5 Children 372

96

6-10 Children 8 3

Above 10 Children 4

1

Total 384 100

4.1.2.4 Level of education

Forty four percent of the respondents had attained primary level of education, 33% had

secondary education, and 22% had college/university education (Figure 4.3).

,---

--I No formal

I

~education

I

C"

.

1%

I

L

_

Key

•••No formal education

.".Primary

Secondary

Secondary 33%

.•Tertiary

I

Figure 4.3Distribution of respondents by level of education

In

this study education level was observed to be associated with perception and practices

of malaria control OC=8.51, df-=l, P=O.004). Secondary and tertiary education levels

(49)

4.1.2.5 Religion

Seventy percent of the respondents were Protestants while 30% was Roman

Catholic(Figure 4.4).

80 ~

t::: 70

<l.> '0

t::: 60

o

~ 50

<l.>

.:: 40

o

<l.> 30 OJ:)

J3 20

t::: ~ 10 ~

<l.>

0.. 0

Roman Catholic Protestant

Religion

Figure 4.4Distribution of respondents by religion

4.1.2.6 Place of residence and housing status

Thirty live percent of respondents lived in urban areas, 65% lived in rural area (Figure

4.5). Seventy four percent lived in houses made of modern iron sheetslcorrugated, 24%

(50)

r

---

-

-Key

Ii!Urban

• Rural

Figure 4.5Distribution of respondents by place of residence

, c

;

~tXs

thatched

285

mIron sheets/corrugated

roof

iii!Stone built. tiled roof

100

o

200 300

Number

of respondents

L. _

----

---_._--Figure4.6 Distribution of respondents by house status

(51)

4.1.2.7 Occu pation

According to occupation, thirty eight percent of the respondents were housewives, 24%

were business ladies, 18% were students, II % were civil servants and 9% were peasant

farmers (Table 4.2).

Table 4.2Distribution of respondents by occupation

Occupation Frequency Percentage

House wife 146 38

Business 92 24

Student 69 18

Civil servant 42 11

Peasant farmers

3

S

9

-Total 384 100

Occupation was observed to be associated with perception and malaria control

practices (X2=4.029, df=I, P<0.04S). It was observed that all employed women

had an ITN and sought medical care unlike those not employed.

4.1.3 Perceptions about Malaria

4.1.3.1 Perceived common diseases

Eighty seven percent of the respondents said that malaria was common, 10% mentioned

(52)

Key

",Malaria

ii.iHlV/Aids

Pneumonia

••Tuberculosis

••Diarrhoea

Figure 4.7Distribution of respondents onperceived common diseases

4.1.3.2Perceived risky practices predisposing the community to malaria

Eighty two percent(82%) of the respondents indicated that sleeping without mosquito net

was a risk behavior, 13% said living near swamps/lakes/rivers was risky, 3% mentioned

drinking un boiled water and 2% said that eating dirty mangoes was a risky practice

(Table 43).

Table 4.3Distribution of respondents by risky practices to malaria

Risky practice Frequency Percent

Not using mosquito net 315 82

Drinking untreated water 13 3

Eating mangoes 7 2

Living near swamps/lakes/rivers 49 13

(53)

4.1

.

3

.

3

Perceived reasons

for

spread

of

malaria.

Eighty five percent of the respondents indicated that malaria spreads due to presence of

mosquitos, 13% attributed the spread

ofmalaria

to rain and 2% said they did not know

why malaria spread(Figure 4.8).

cRain

61Mosquitoes

ODon'tknow Key

2%

13%

Figure 4.8Distribution of respondents on awareness on malaria spread.

4.1.3

.

4Perception on treatment and control of mala ria

Ninety eight percent of the respondents believed that malaria could be treated or

controlled,

t%

said malaria could not be treated or controlled and 1% said that they did

(54)

Table 4.4 Perception on treatment of malaria.

Perception on treatment Frequency Percentage

Can be treated 376 98

'--.

Can't be treated 4 I

Not aware 4 I

Total 384 lOa

Fifty four percent of respondents said that malaria could be treated or controlled through

medical intervention, 42% mentioned use of ITNs, I% said taking of herbs and 3% said

that all the listed methods could be used to treat or control malaria (Table 4.5). It was

observed that the believe that malaria can be treated was associated with malaria control

practices Ci=17.703, df=l, P<O.OOOI)

Table 4.5 Perception on control of malaria

Perception on control Freq uency Percentage

Medical intervention 207 54

"

ITN use 161 42

f--.

Herbal medicine 4 1

AII methods 12 3

Total 384 lOa

From majority of the FGDs, participants indicated that malaria can be treated and

(55)

malaria drugsfrom the pharmacy or go to the hospital and get well. Ialso use mosquito

net 01night while asleep ",a28year old woman said.

4.1.3.5Pcrccption on group that has high risk of malaria

The l11ajority(46%) of the respondents said that pregnant women were the most affected

group, 29% said children, and 22% said all people were at high risk (Table 4.6).

Table 4.6Distributionof respondents by perception on most risky group of people for malaria infection.

Most affected group Frequency Percentage

Children <S years 112 29

Children> or =S years 9 2

Pregnant women 176 46

People >SO years 4 I

All people 83 22%

Total 384 100%

Most respondents in the FGDs indicated that pregnant women and children are more

easiIy attacked by malaria than the rest of the people. "When we are pregnant malaria comes 11I0,;eeasily than when we are not. Have seen many children/all illa/malaria but when they are older they rarely get the disease ",a34year old woman had said.

It was observed that the perception that children under five years and pregnant women

are at high risk of malaria infection was associated with malaria control practices

Figure

Table 4.1Distribution
Table 4 1Distribution. View in document p.48
Figure 4.7Distribution
Figure 4 7Distribution. View in document p.52
Table 4.3Distribution
Table 4 3Distribution. View in document p.52
Figure 4.8Distribution
Figure 4 8Distribution. View in document p.53
Table 4.4 Perception
Table 4 4 Perception. View in document p.54
Table 4.8: Awareness of Malaria
Table 4 8 Awareness of Malaria. View in document p.57
4.1.4.3Figure 4.12Method
Figure 4 12Method. View in document p.59
Figure 4.13Distribution of respondents by method used to tell when one wassuffering from malaria.
Figure 4 13Distribution of respondents by method used to tell when one wassuffering from malaria . View in document p.60

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