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 .
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 . 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 . Similarly, another study is conducted in 2013 by Khan and his company in the highly affected district Bannu, of Khyber Pakhtunkhwa province, Pakistan, in whom they included 823 participants . Outside Pakistan recently a study was conducted in the Democratic Republic of the Congo by Ntamabyaliro, in which a total of 1732 household participants were included . A high number of cases show that particular areas are endemic for malarial parasites (plasmodium). The high rate of prevalence may be due to factors like the migration of internally displaced peoples (IDPs) from unrest regions, socio-economic conditions, overcrowding, and other environmental issues.
In the current study age of the respondents ranging from 3-80 years, out of 1100 participants, 656 (59.63%) respondents were 3-16 years old, 277(25.18%) respondents were 17-34 years old, 119 (10.18 %) respondents were 35-50 years old and 48 (4.36%) were 51-80 years old. The mean age of the respondents was 19.5 years. In 2019 Adhikari et al studied treatment-seeking behavior for febrile illnesses and its implications for malaria control and elimination in Savannakhet Province, Lao PDR (Laos), the age range of the respondent were 18-80 years with mean = 37.58 ± 12.719 . A cross-sectional study was carried out by Mitiku to study the Caregiver's perception about malaria and treatment-seeking behavior for under the age of five years children in the Mandura district of West Ethiopia, the age ranging of the included participants was from 18-55 years . In 2010, Khan and his colleagues study the KAP of malaria during their study in Khyber girl’s medical collage Peshawar, Pakistan. The mean age of all the patients was 41 + 14.9 years . Another study was carried out on the student of a religious school in Bannu district Pakistan, whose age ranged was from 5-19 years .
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 . 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 treatment-seeking behavior in an endemic malaria region of rural Ethiopia . 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 . 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%) . 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 .
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 . 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 . Urama et.al conducted a similar study in 2021 for the determination of choice and treatment-seeking behavior of rural households in south-east Nigeria, 41.7 percent of household heads having no proper education, 35.2 percent only have a primary school education, and 15.9 percent have secondary school education . Jima et .al conduct a study on the uses of insecticide-treated mosquitos nets as a preventive measure, in which 41.9% of the respondent were literate,22.3% were of Grades 1-6, 21.7% were of Grades 7-12, 6.1% were of Above 12 grade 6.1 and only 8% of the respondent can read and write .
Knowledge about malaria is the most important risk factor in Malaria control and prevention [37–43]. Unfortunately, only a few researchers have successfully identified the malaria parasite as the causative agent of malarial infection. [37, 41, 44], and also act as a source of infection transmission [45–47]. It is also communicated that male participants were generally more knowledgeable as compared to female participants about the transmission and cause of malaria . However, a study conducted in Afghanistan stated that Afghan women were unexpectedly knowledgeable (>75%) than males about transmission, causative agent, and prevention of malaria . 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 . 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 houseflies are involved in malaria transmission . 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 . 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 . 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 . While in the present study very low number of participants voted for lack of cleanliness 6.85% and fly/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 .
The National Malaria Control Programmed (NMCP) has made significant progress in malaria control during the last 20 years . 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 .
The uses of mosquito nets and their efficiency were mentioned in previous researches, however, their uses are limited due to lack of availability, prices, and safety concerns . 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 . 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 campfires, burning grass, and sleeping wrapped in a damp blanket, applying herbal oil, were chosen by specific 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 .
Limited data is available on treatment-seeking behavior . According to the available data Self-treatment and obtaining support from drug salespersons were the most common practices in Teikkyi township and Shan Special Region II . A study is carried out in southeast Nigeria, In this study among 471 patients, 84 patients used traditional mediation, and the remaining obtained medication from Pharmacy, Health center, Hospital, and Chemist 45, 65, 74, and 203 respectively . Another study is carried out in the Democratic Republic of the Congo in 2021, in which 1732 households participants were included, 70.1% knew the recommended antimalarial drugs, and 58.6% were habituated to self-medication . Similarly study by Ahmed and his companions in 2009 observed that the participants preferred homeopathic treatment over allopathic medicine. Even when a fever was detected, this resulted in delays in getting medical care . In the current study, most of the respondents 83.36% were of the view to use the allopathic treatment after getting malaria, while only 16.9% were used homeopathic treatment.
It is predicted that about 70–80% of the population accesses the private sector for treatment . 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 
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 confirming the diagnosis . 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 financial 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 findings disclosed that participants' knowledge of malaria is similar to earlier studies conducted in Nigeria , Zimbabwe , and the southern Nigerian community . Similar data have been published in Ethiopian studies, indicating that malaria primarily affected poor and underserved tribal populations living in faraway forest areas, from health facilities.[61, 62].