Knowledge and treatment-seeking behavior among malaria suspected patients in two hospitals of district Malakand


 BackgroundMalaria remains a significant public health problem over the last two decades in Pakistan. to prevent malaria infection and develop malaria-free zones, understanding the knowledge, treatment-seeking behavior, and preventive measures toward the malaria infection of the inhabitant are necessary. This study is designed to assess the knowledge, malaria preventive measures, treatment-seeking behaviors, and socio-economic profiles, among suspected malaria patients in district Malakand, Pakistan.MethodsCurrent research was a hospital-based cross-sectional study, in which patients attending DHQ hospital Batkhela and THQ hospital Dargai were recruited. A pre-tested semi-structured questionnaire was used to collect demographic characteristics, knowledge, and treatment-seeking behavior of the patients for malaria infection. Data were analyzed using SPSS version 20.ResultsA total of 1100 malaria suspected individuals were interviewed. The respondent’s ages ranged from 3-80 years, with a mean of 19.5 years. Participation of Males was more than female, 54.3% and 45.6% respectively. Participants belonging to education departments were more participated in the survey (55%) than others, while most of the individuals were from rural areas (78.1%), and the number of individuals >8 is higher than below <8 members. The majority of the respondents (76.2%) were voted to sleep uncovered than covered (23.7%). Most of the individuals (83.36%) were of the view to use allopathic treatments after getting malaria while only 16.63% were used homeopathy, and financial issues were reported as the major reason for the delay in treatment. Regarding treatment time after getting malaria, 68.8% were received within a week and, 31.3% were within 24 hours. Most of the infected individuals (87.9%) were known that mosquitoes as the causing source of malaria infection, and can be controlled by eliminating breeding grounds, using mosquito repellents and bed net 86%, 7.2%, and 6.6% respectively. ConclusionsMalakand is one of the malaria-endemic regions of Pakistan. The present study highlighted that the majority of the respondents have good knowledge about malaria infection, mode of transmission of the plasmodium parasite, and preventive measures. Further strategies are required for the control of malaria infection.


Introduction
Historic background of malaria Regardless of great progress, globally malaria is still a severe vector-borne infectious disease that affects nearly half of the world's population [1]. the Malaria parasite is an endemic species in 109 countries and is widespread throughout the developing countries of the sub-tropic and tropic region [2]. According to World Health Organization (WHO) report, in 2015, globally 212 million cases were recorded, among this 90% were from African Region, 7% from South-East Asia, and about 2% from Eastern Mediterranean Region [3]. Because of malarial infection every year, more than 400,000 people die around the world, the majority of them are children under the age of ve. [4].
Pakistan is a malaria-endemic country, with over 670,000 cases and 3159 deaths reported in 2013 [5]. in Pakistan Malaria is the second most common infectious disease [6]. round-about 150 million people are living in malaria-endemic sites [7]. Almost 37% of malaria cases were particularly in the shared border region of Pakistan with Iran and Afghanistan [8] In 2015, malaria-related deaths occurred in nearly 13 nations, accounting for nearly 75 percent of all deaths. The four nations that account for 81 percent of malaria deaths are Pakistan, India, Ethiopia, and Indonesia [9]. According to the most recent WHO survey, in 2019, Pakistan is affected by approximately 700,000 malaria cases [10]. According to the previous studies, travelers and returning travelers from Pakistan having greater contribution in importing malaria cases to Saudi Arabia [11,12] the United Arab Emirates [13], Bahrain [14], Qatar [15,16] Kuwait [17], Jordan [18] and Egypt [19].
According to WHO report 2020, regardless of great progress in decreasing malaria-related morbidity and mortality, the target for the decrease in malaria cases is not yet obtained, further strategies and struggles are required to obtain the malaria-free zone and zero mortality and morbidity rate associated with malaria. Lack of knowledge and public health facilities, poverty, migration of people across the border (including IDPs) are the factors that contribute to malarial infection in district Malakand. The present study is designed to assess the knowledge and treatment-seeking behavior of the people living in district Malakand of Pakistan, and increase the awareness of the inhabitants of district Malakand.

Objectives of the study
The current study bears the following objectives To know the level of knowledge of the local residents regarding malaria and its vector To know the treatment behavior of the local residents regarding malaria infection

Study design and data collection
We carried out a cross-sectional, well-organized, descriptive, community-based survey among malariasuspected patients visiting two sort-out hospitals of District Malakand, Khyber Pakhtunkhwa, Pakistan, to determine knowledge and treatment-seeking behavior regarding malaria among the general population of the study area. The included hospitals were District Headquarter Hospital (DHQ) Batkhela and Tehsil The majority of the people in the area depending on agricultural products for survival. The principal source of income for the local inhabitants is agriculture. Wheat, sugarcane, tobacco, rice, and maize are the main cash crops grown in the area. In addition, the Malakand area is home to a variety of vegetables and an orchard. Wheat takes up the majority of agricultural land in the project area. The overall cultivated area for wheat in district Malakand is 26727 hectares, with 9715 hectares of irrigated land and 17012 hectares of unirrigated land [21].
On the other hand, agricultural products, are insu cient to meet the needs of native residents. As a result, people must turn to different sources of income to support themselves. A particular amount of the people are performing their duties in different government and private sectors of the country. A large number of people also move outside of the country for trading and occupations. Women do housekeeping responsibilities and manufacture handicrafts such as hats, bedsheets, and baskets, while a large number of males labor in the civil armed forces and other regions of the state. It's a huge hilly region, and women help their men by caring for cattle, cutting wood for the re, and working in the elds [22].

Data collection tool
A self-administrated questionnaire was used for the data collection because it was easy to conduct a community-based survey during the pandemic of the COVID-19 outbreak. The questionnaire was drafted in English and translated to the local language for the facilitation of uneducated participants, and backtranslated into English to check the validity and accuracy of the questionnaire. After correction, the questionnaire was sent to statistics expertise to check their reliability, after that the questionnaires were distributed randomly among malaria suspected patients who were visited the two referral hospitals DHQ Batkhela and THQ Dargai of district Malakand to assess the malaria knowledge and treatment-seeking behavior of the residents. The questionnaires were composed of mainly three sections. The rst section containing sociodemographic characteristics of the respondents comprising questions such as age, gender, locality, family size, sleeping habit, the animal type they have, education level, occupation, and the drugs previously used. The second section is composed of questions regarding knowledge of malarial infection, mode of transmission, and the preventive measures, with two multiple options. The third section included questions about the treatment-seeking behavior of participants regarding malarial infection, like measures taken after getting malaria, treatment after getting malaria, and the reason for the delay of treatment. Participants were assured that the information collected would remain con dential. The questionnaire-based survey enables the research team to collect community-based data and extract the opinions of a huge number of participants.

Data analysis
A descriptive, well-organized, community-based, cross-sectional study was carried out. 1100 participants were chosen through random sampling from the district Malakand region. The data completeness was assessed before analysis. SPSS statistical software version 20 was used for data analyses, o was coded for No while 1 for Yes. At least two times, the questionnaire was evaluated to ensure the accuracy of data entry, before the actual analysis. Descriptive statistics tools such as frequency, percentage were used to describe and summarize the data & make it more comprehensible. P values less than 0.05 were considered to be statistically signi cant.

Socio-demographic information of study participants
Regarding age 59.63% of respondents were 3-16 years old, 25.18% were 17-34 years old, 10.81% were 35-50 years old and 4.36% respondents were 51-80 years old. According to the data below in Table1, the maximum of the participant was 3-16 years old at the time of the research, because younger respondents can be easily interviewed than elder people because of their more social contacts than old age people.
Gender-wise the respondent are distributed into two categories, male and female. The majority of the respondent (54.36%) were male and 45.63% were female. A higher ratio of male respondents than females is due to cultural and religious boundaries. Concerning the area, 21.81% of the respondent were the inhabitant of the urban area and 78.18% of the respondent were belonging to the rural areas because most of the people of the study area are living in villages. On the other hand majority of the participant (71.90%) family size is less than 8 members and 28.09% of the participant's family size is greater than 8 members because most of the people living in the form of joint family.
Most of the respondents (55.09%) were related to the education department, 16.18% of respondents were related to agriculture and 28.72% were laborers. Majority of the respondent home is mud made, while some of the respondents were living in the house made of bricks ( Table 1).Inhabitants of the area are most farmers having different types of animals.56.63% of people having cattle in their homes, 35.72% having pet animals and 7.63% of the people do not have any animal in their homes. On the other hand 23.72%of, the people are covering their bodies during sleeping, and 76.27% of people who are not covering their bodies have high chances of malarial infection. According to data collected from the respondent, show that 50.81% of respondents were matric as education level, 29.63% of respondents were primary education level and19.54% were at Middle level at the time of the study. The researcher explored that majority of the respondents were Matric level at the time of the research. On the other hand, most of the participants (92.09%) does not previously use any drug for the treatment, and 7.90 % have previously used drugs. Results are shown in Table 1. Knowledge Majority of the respondent having good knowledge about malaria. Most of the patients (87.9%), were agreed that malaria can be transmitted through mosquitoes bites, 5.34% of the respondents answer that malaria can be transmitted by y/insects bite, and according to 6.90% of the respondent, lack of cleanliness is the main cause of malaria. Similarly, 86.09% of the respondent suggest that eliminating breeding grounds is the best way of preventing malaria, 6.63% of the respondent were agreed with using bed nets, and 7.27% think that using mosquito repellents is the best way of malarial prevalence. Information related to the knowledge of the respondent is shown in Table 2. Treatment seeking behavior Regarding treatment-seeking behavior, 83.36% of the respondents take allopathy clinic measures, 11.63% were taken homeopathy clinic measures, 5% were taken home remedy measures after getting malaria. 100% of the respondent take some sort of measures after getting the infection ( Table 3). Most of the respondents (68.8%) start treatment within a week after getting malaria, 31.3% of the respondent take treatment after 24hours. Each and everyone gets some type of treatment, it may be allopathy, homeopathy, or home remedy (Table 3). In relation to the reason for the delay in treatment, 46.36% of the respondents described the reason for the delay in treatment as their nancial problem, 29.36% show selfmedication, and 24.27% of the respondents were not aware of the infection. It was known by the researchers that nancial problem is the main reason of delay treatment (Table 3).

Discussion
The prevalence of malaria in the Malakand region is possibly high because of the high density of mosquito population due to changing climate factors. However, there was a lack of data on the knowledge, attitude, and health-seeking behavior regarding malaria in this region [6].
In the present study, a total of 1100 participants were included. According to the study of Zahid et al 2018, a total of 3840 malarial patients along the Pak-Afghan boarding areas were included, High prevalence of malaria infection may be due to traveling across the border [23]. Another study is carried out in 2018 by Umar and his colleagues, in this study they included a total of 1,593,409 respondents across the whole country of Pakistan [24]. Similarly, another study is conducted in 2013 by Khan [29]. Another study was carried out on the student of a religious school in Bannu district Pakistan, whose age ranged was from 5-19 years [30].
Participation of the male is greater than females in the present study, shown in Table 2. A similar study is carried out among Ugandan rural women, for malaria detection, Treatment seeking behavior, and perceptions about the causes of Malaria. In contrast to the present study, the female to male ratio was around 1.2:1 respectively [31]. Less participation of the female than males in the present study is due to religious and cultural customs and traditions.
In this study majority of the respondent (71.18%) were from the rural areas of district Malakand and most of them having more than 8 members in their family. A similar study was conducted by Deressa and his coworkers ta access household socio-economic factors about childhood fever illnesses and treatmentseeking behavior in an endemic malaria region of rural Ethiopia [32]. While another study conducted in Mandura District, West Ethiopia by Mitiku et al, in which 25.7% of the respondent having a family size less or equal to 6 while 60.4% of the respondent having a family size <6 members [28]. The high number of individuals in the family is due to the joint family system in the Pashtun culture.
In this study majority of the participants were education-related, followed by farmers and day labor. In northwest Ethiopia, Workineh et.al conducts a study to access treatment-seeking behavior for malaria, more than half of the respondents were composed of Farmer (54.4%), followed by day labors, (12.9%) [33]. Another study was conducted in Ethiopia in which 32.9% of the participant were Housewife, 19.3% were Merchant,10.2% were farmers, 9.3% were daily laborers, 7.7% were government employees, 6.9% were factory workers, 5.2% were seeking a job, 5% were students, and 4% were others [34].
In the present study most of the respondents having houses made of bricks (78.09%) followed by mud (21.90%). In contrast as a study conducted in Savannakhet Province, Lao PDR (Laos) to access the Treatment-seeking behavior for febrile illnesses and its suggestions for malaria control and eradication, according to the sociodemographic information of the study, 44.8% of the respondent houses were made of Bamboo, 67.3 % were made of wood, 0.4% of the concrete, 3.6% were made of plastics and 2.8% of the house's wall were made of metals [27]. By comparison, in Laos, the majority of the home is made of wood due easily availability of wood and large scale forests. in contrast, bricks are cheap and easily available in Pakistan.
In this study, most of the respondents (56.4%) having cattle's, 35.4% of the respondent having pet animals, and 8.10% does not have any domesticated animals. While the majority of the respondent (92.2%) have previously used drugs for their treatment and the other respondent (7.74%) doesn't use drugs previously for their treatment. Previously conducted studies for the assessment of malaria knowledge and treatment-seeking behavior, don't provide any attention to these two factors.
In the present study, most of the patients (50.81%) of respondents were matric as education level, 29.63% of respondents were primary education level and 19.54% were at Middle level at the time of the study while according to a study conducted earlier, maximum of the participant were poor, mostly belonging to remote villages and their level of education is relatively poor due to lack of facilities [35]. Urama  were of Above 12 grade 6.1 and only 8% of the respondent can read and write [34].
Unfortunately, only a few researchers have successfully identi ed the malaria parasite as the causative agent of malarial infection. [37,41,44], and also act as a source of infection transmission [45][46][47]. It is also communicated that male participants were generally more knowledgeable as compared to female participants about the transmission and cause of malaria [37]. However, a study conducted in Afghanistan stated that Afghan women were unexpectedly knowledgeable (>75%) than males about transmission, causative agent, and prevention of malaria [48]. in the present study Knowledge about malaria is divided into two categories, which are knowledge about the mode of transmission and preventive measures.
Most of the respondents (shown in table 7) were in favor that mosquito is the causing source of malarial infection. In comparison to another study, 93% of the respondent claimed that malaria can be transmitted by mosquitos [34]. Dambhare et al., 2012 conducted a study among school adult students and other staff members, reporting that only 8.6 percent of the students were aware of the causal agent and over 33% of the participant claimed that house ies are involved in malaria transmission [46]. A similar study is conducted in Khyber Girls Medical College, Peshawar, Pakistan, and a total of 51 respondents have participated. Most of the participant (76%) knew that mosquitoes are the vectors of the malarial parasite, and only 20% 0f the participant was agreed that using of mosquito nets are necessary for the control of malarial infection [49]. another study was conducted in Ethiopia and 1933 participants were included, About 93% of the participants knew that malaria can be transmitted through mosquito bites and the majority of the participant (92.5%) were interested in using mosquito nets in the future to control malarial infection [34]. A similar study is conducted in the tehsil Bandagai, district lower Dir, which is situated to the south of district Malakand, in which 108 participants were included and 57.41% of the respondent replied that mosquito bite is the source of malarial transmission [50]. While in the present study very low number of participants voted for lack of cleanliness 6.85% and y/insect bite was voted by 5.34%.
Another study stated that polluted water, food, contact with an infected individual, and rain are the source of malaria transmission, 24 percent of respondents properly answer that mosquitoes are transmitting malaria [35].
The National Malaria Control Programmed (NMCP) has made signi cant progress in malaria control during the last 20 years [51]. In the present study eliminating breeding grounds was the factor mostly voted by the individuals 86.09%, A very less number of participants(7.27%) favored the use of mosquito repellents and bed net 6.63%. According to previously conducted studies, malaria can be prevented by eliminating breeding grounds [45].
The uses of mosquito nets and their e ciency were mentioned in previous researches, however, their uses are limited due to lack of availability, prices, and safety concerns [48]. According to a study of Jima in Ethiopia, only 4.8% of participants voted for DDT and chemotherapy as a preventive measure against malarial infection individually [34]. According to certain studies people are covering their entire body, using repulsive coils and sprays, removal of stagnant water from the environment as preventive strategies [38,44,52].
Traditional methods, such as applying lamp or motor oil on the skin, building camp res, burning grass, and sleeping wrapped in a damp blanket, applying herbal oil, were chosen by speci c ethnic groups in some parts of Saudi Arabia. To minimize mosquito bites, the most prevalent traditional method is to burn wood and cow dung. [35,48].
In the present 23.72% of the participant respond that they are covering their body during sleeping, while the majority of the respondent does not cover their body during sleeping. Another study is carried out in Tanzania to access the KAP of the symptomatic patients attending Tumbi Referral Hospital, they attended a total of 277 patients, 38.63% of the participant responded that they are wearing long-sleeved clothes during sleeping, while 61.37% are sleeping without covering their body [53].
Limited data is available on treatment-seeking behavior [54]. According to the available data Selftreatment and obtaining support from drug salespersons were the most common practices in Teikkyi township and Shan Special Region II [55]. It is predicted that about 70-80% of the population accesses the private sector for treatment [57].
According to the Responses of the respondent of a survey, that most of the individuals are seeking treatment from traditional health works, due to lack of public mobility, therefore people are walking considerable distances to acquire basic healthcare at primary healthcare centers [58] Regarding treatment time after getting malaria, 68.8% were said within a week and 31.3% were of the view to treat within 24 hours. In the China Myanmar border area, only 32.0% of malaria patients sought treatment within 24 hours and 20.1% were tested for con rming the diagnosis [54]. According to other studies, Malaria patients would rather wait a few days and treat themselves with home treatments, if the condition did not seem to improve, then the victims sought treatment from traditional healers [41,59].
When asked about the reason for the delay in treatment, most of the respondents (46.36%) described the reason for the delay in treatment as their nancial problem, 29.36% show self-medication, and 24.27% of the respondents were not aware of the infection. Some of the studies reported that delays in treatment and health-seeking practices were primarily due to remote health facilities, long waiting times, unfriendly health workers, a lack of money, a loss of faith in the medical profession, and a lack of people to accompany patients in health services. [37,59,60].
Due to socioeconomic and cultural characteristics, the current study ndings disclosed that participants'

Conclusions
The present study highlighted that the majority of the respondents have good knowledge about malaria infection, mode of transmission of the plasmodium parasite, and preventive measures. According to the present study results, the rural population was more infected by malaria than the urban population. Most malaria suspected patients were farmers and having cattle in their homes, followed by pet animals. Most of the individuals were of the view to use allopathic clinics after getting malaria while only a few respondents were favored to use homeopathy and home remedy for malaria infection. The majority of the respondents started treatment within a week after getting the malarial infection and the major cause for delay in treatment is due to nancial issues.

Limitations of the study
In the current study, the data was collected from only malaria suspected patient, because of the limited resource is available in the area like transport and a suitable source for nding the individual who is at high risk of getting malaria. Only questionnaire-based data collection was carried out due to limited lab facilities. Majority of the respondents in the present study was education-related, due to the limited literacy individual in society. Environmental factors like climate, temperature, seasonal variation, humidity, rain, and snowfall were not taken into consideration. Association of the malaria infection with the daily activates of the respondents was not considered.

Recommendations
The present study nding was insu cient to answer some of the questions. Therefore further studies are required to cover the gap between the present study and the questions that arose during the study. On behalf of the present study results, the researcher recommends the following to the newcomers in the eld. Study the association between the demographic information, with the prevalence of malaria in this particular area. Correlation between the altitudinal variation and the prevalence of malaria and the association of malarial infection with other lethal diseases. Public health workers, health care providers, and policymakers can help in the implementation of an effective intervention approach to raising malaria awareness among the general population especially parents of children under ve and other malaria suspected individuals and encourage them to seek treatment. To nd the relation between the blood group and the malaria prevalence. The local population of the area must be ensured the cleanliness of their environment to prevent the transmission of plasmodium by eliminating the breeding site of the plasmodium. All of this needs education and training, cooperation of public-private sector organizations, and regional community awareness.

Declarations
Ethics approval and consent to participate This research was approved by the Ethical Review Panel, Department of Zoology, University of Malakand and consent from the participants was obtained during data collection.

Consent for publication
Not applicalble for that section

Availability of data and materials
The data is available in the custody of 1 st author of the article

Competing interests
Authors have declared that they have no competing intrest