A total of 300 households were investigated, and 262 qualified questionnaires were finally included in the analysis after checking for questionnaire completion and logic. The survey covered 1645 residents, with approximately 6 persons per family. The average cost of meals per day was approximately 30000 Leones in each household (one US dollar was equal to 8000 Leones in December 2018). Three groups were established according to the cost of meals. Group 1 was defined as families paying ≤ 20000 Leones/household per day for meals, and this group contained 475 persons in 97 households; Group 2 was defined as families paying ≤ 40000 and ≤ 20000 Leones/household per day, and this group contained 778 persons in 123 households; and Group 3 was defined as families paying > 40000 Leones/household per day, and this group contained 392 persons from 42 households.
Malaria infection, diagnosis and treatment
A total of 308 persons in 87 households, 430 persons in 106 households and 191 persons in 39 households in Group 1, 2 and 3, respectively reported having had a fever in 2018 (P = 0.594, Fisher’s exact test). The distribution of individuals with malaria among the groups in 2018 is shown in Table 1.
Table 1. The distribution of individuals with malaria in households in the three communities in the Western Area Rural District, Sierra Leone, 2018
Group
|
Number of respondents suffered from malaria/households
|
Once
|
Twice
|
3 times
|
> 3 times
|
1
|
46/20
|
62/29
|
29/12
|
107/38
|
2
|
68/32
|
52/24
|
31/13
|
133/43
|
3
|
15/12
|
32/13
|
1/1
|
35/10
|
Moreover, approximately 79.4%, 79.7% and 88.1% of the respondents in Groups 1, 2 and 3, respectively, sought professional advice or treatment for the illness from any source (P = 0.421, Fisher’s exact test). Additionally, 76.6%, 71.4% and 64.9% of the respondents in Groups 1, 2 and 3, respectively, reported preferring to seek advice and treatment from the public medical sector (P = 0.117, Fisher’s exact test) (Table 2). No significant differences were found among the three groups with respect to the decision to seek assistance from the public sector (P = 0.765, Fisher’s exact test) or the private sector (P = 0.468, Fisher’s exact test) (Table 3).
Table 2. The distribution of medical sectors people seeking health advice or treatment in the three communities in the Western Area Rural District, Sierra Leone, 2018
Medical sector
|
|
Group
|
|
Total
|
1
|
2
|
3
|
Public sector only
|
59
|
70
|
24
|
153
|
Private medical sector only
|
14
|
17
|
12
|
43
|
Both sectors
|
3
|
11
|
1
|
15
|
Don't answer
|
1
|
0
|
0
|
1
|
Total
|
77
|
98
|
37
|
212
|
Table 3. The detail of public or private medical sectors people selected for health care seeking in the three communities in the Western Area Rural District, Sierra Leone, 2018
Group
|
Public medical sectors
|
|
Private medical sectors
|
Government Hospital
|
Government Health Center
|
Mobile Clinic
|
Community health worker
|
Other Public Sector
|
Subtotal
|
|
Private Hospital
|
Private Clinic
|
Mission/Faith-based Hospital
|
Mission/Faith-based Clinic
|
Pharmacy
|
Mobile Clinic
|
Other Private Medical Sector
|
Subtotal
|
1
|
42
|
9
|
5
|
0
|
3
|
59
|
|
7
|
0
|
0
|
1
|
2
|
3
|
1
|
14
|
2
|
44
|
13
|
6
|
4
|
3
|
70
|
|
9
|
1
|
1
|
1
|
4
|
0
|
1
|
17
|
3
|
17
|
4
|
2
|
1
|
0
|
24
|
|
6*
|
0
|
0
|
4*
|
2
|
1
|
0
|
12
|
*: there was one respondent seeking advice or treatment in private sectors of private hospital and Mission/Faith-based Clinic.
Furthermore, 84.5%, 84.6% and 83.3% of the respondents in Groups 1, 2 and 3, respectively, reported that they and their family members always visited a health care worker or doctor when they suspected they had contracted malaria (P = 0.487, Fisher’s exact test). Among the individuals who went to see a health care worker or doctor, they reported visiting a professional every time or most of the times they suspected they had contracted malaria, and there were no differences among the three groups (χ2 = 2.882, df = 6, P = 0.830) (Table 4).
Table 4. Malaria diagnosis and anti-malarial medicine taking in the three communities in the Western Area Rural District, Sierra Leone, 2018
Question & Answer
|
Group
|
Total
|
Percentage
|
1
|
2
|
3
|
1. When you and your family suspected you were infected with malaria, did you always go to see a health worker/doctor?
|
Yes
|
82
|
104
|
35
|
221
|
84.4%
|
No
|
10
|
8
|
2
|
20
|
7.6%
|
Don't answer
|
5
|
11
|
5
|
21
|
8.0%
|
1.1 How often?
|
Every time
|
38
|
42
|
16
|
96
|
43.4%
|
Most of time
|
26
|
44
|
13
|
83
|
37.6%
|
Seldom
|
11
|
12
|
3
|
26
|
11.8%
|
Only when they showed severe condition
|
7
|
6
|
3
|
16
|
7.2%
|
2. When you or any member of your family suspected that they had malaria, did the health worker/ doctor conduct a malaria test?
|
Yes
|
76
|
98
|
36
|
210
|
80.2%
|
No
|
15
|
14
|
2
|
31
|
11.8%
|
Don't answer
|
6
|
11
|
4
|
21
|
8.0%
|
3. Did the Doctor / health worker explain to you the test to be done?
|
Yes
|
53
|
69
|
22
|
144
|
55.0%
|
No
|
25
|
24
|
8
|
57
|
21.8%
|
Don't remember
|
9
|
15
|
7
|
31
|
11.8%
|
Don't answer
|
10
|
15
|
5
|
30
|
11.5%
|
4. What type of test did they say they were going to perform?
|
RDT
|
51
|
66
|
26
|
143
|
54.6%
|
Microscopy
|
1
|
3
|
1
|
5
|
1.9%
|
Don't remember
|
30
|
37
|
9
|
76
|
29.0%
|
Don't answer
|
15
|
17
|
6
|
38
|
14.5%
|
5. When you and your family were infected with malaria, did you take the anti-malarial medicine?
|
Every time
|
49
|
40
|
19
|
108
|
41.2%
|
Most of time
|
30
|
49
|
15
|
94
|
35.9%
|
Seldom
|
9
|
15
|
2
|
26
|
9.9%
|
Never
|
0
|
2
|
0
|
2
|
0.8%
|
Only when they showed severe condition
|
5
|
7
|
3
|
15
|
5.7%
|
Don't answer
|
4
|
10
|
3
|
17
|
6.5%
|
6. What anti-malarial medicines did you take?
|
Sp/Fansidar
|
3
|
3
|
0
|
6
|
2.3%
|
Combination with Artemisinin
|
1
|
2
|
0
|
3
|
1.1%
|
Artesunate+Lumafantrine
|
58
|
69
|
24
|
151
|
57.6%
|
Artesunate+Amodiaquine
|
17
|
28
|
9
|
54
|
20.6%
|
Amodiaquine
|
4
|
4
|
1
|
9
|
3.4%
|
Quinine
|
0
|
1
|
1
|
2
|
0.8%
|
Others: specify
|
16
|
18
|
5
|
39
|
14.9%
|
Don't answer
|
7
|
8
|
3
|
18
|
6.9%
|
7. When did (NAME(S)) take the anti-malarial medicine?
|
Same day after fever
|
87
|
91
|
32
|
210
|
80.2%
|
Next day after fever
|
4
|
15
|
5
|
24
|
9.2%
|
Two day after fever
|
0
|
0
|
0
|
0
|
0.0%
|
Three or more day after fever
|
1
|
7
|
1
|
9
|
3.4%
|
Don't know
|
0
|
2
|
0
|
2
|
0.8%
|
Don't answer
|
5
|
8
|
4
|
17
|
6.5%
|
8. Are the antimalarial drugs FREE which you and your family took?
|
Yes, they are free for all
|
29
|
33
|
8
|
70
|
26.7%
|
No, only for children, pregnant women and breast-feeding women
|
1
|
6
|
2
|
9
|
3.4%
|
None is FREE
|
64
|
76
|
29
|
169
|
64.5%
|
Don't answer
|
3
|
8
|
3
|
14
|
5.3%
|
9. When you and your family were infected with malaria, did you take the full dosage of antimalarial drugs which was prescribed by doctor/health worker?
|
Yes, take full dosages every time
|
78
|
96
|
35
|
209
|
79.8%
|
No, sometimes some dosage was left
|
15
|
15
|
3
|
33
|
12.6%
|
No, some dosages were left every time
|
1
|
3
|
0
|
4
|
1.5%
|
Don't answer
|
3
|
9
|
4
|
16
|
6.1%
|
9.1 If not all drugs taken, please explain why:
|
We got recovery before finishing all of them
|
15
|
15
|
3
|
33
|
89.2%
|
The drugs made me have headache, nausea
|
0
|
0
|
0
|
0
|
0.0%
|
I am too busy to remember taking all the dosage
|
0
|
2
|
0
|
2
|
5.4%
|
Others: specify
|
1
|
1
|
0
|
2
|
5.4%
|
Don't answer
|
0
|
0
|
0
|
0
|
0.0%
|
As recalled by the respondents, the health care worker or doctor performed a malaria test when they visited because they suspected that they had contracted malaria (80.1%) (P = 0.435, Fisher’s exact test), and the malaria rapid diagnostic tests (RDT) was the most commonly used test (P = 0.882, Fisher’s exact test); however, approximately half of the respondents reported that the doctors or health care workers did not explain the test to them (χ2 = 2.783, df = 6, P = 0.841) (Table 4).
Most respondents took anti-malarial medicine every time or almost every time they were diagnosed with malaria (P = 0.344, Fisher’s exact test), and approximately 79.8% of them took the full course of treatment every time as prescribed by the doctor or health care worker (P = 0.489, Fisher’s exact test). Artesunate and lumefantrine (51.7%) and artesunate andamodiaquine (19.1%) were the top two choices of combination therapy. The most common reason given for the early termination of a course of treatment was having recovered prior to finishing all the doses (P = 0.815, Fisher’s exact test). Moreover, approximately 80.2% of the respondents reported starting anti-malarial medicine on the same day that they noted the fever (P = 0.095, Fisher’s exact test), and approximately 64.5% of them responded that not all kinds of anti-malarial medicine were free (P = 0.399, Fisher’s exact test) (Table 4).
Malaria prevention measures
In this survey, 188 households had long-lasting insecticidal nets (LLINs) (χ2 = 1.466, df = 2, P = 0.482), but more nets were required because 189 respondents said that they did not have enough LLINs in their households (P = 0.253, Fisher’s exact test), so resulting in children under the age of 5 years in 66 households not having LLINs to sleep under (P = 0.410, Fisher’s exact test). Only 146 respondents had slept under nets the night before the survey (P = 0.331, Fisher’s exact test). Furthermore, some members in 162 households with nets did not sleep under LLINs, which could lead to cross-infection (χ2 = 4.359, df = 4, P = 0.363). The LLINs were mainly distributed by the governmental hospital/health centers and community health centers (Table 5).
Table 5. Malaria prevention practices in the three communities in the Western Area Rural District, Sierra Leone, 2018
Question & Answer
|
Group
|
Total
|
Percentage
|
1
|
2
|
3
|
1. Do you have a mosquito treated bed nets in your home?
|
|
|
Yes
|
70
|
91
|
27
|
188
|
71.8%
|
No
|
27
|
32
|
15
|
74
|
28.2%
|
2. Did you sleep under a mosquito net last night?
|
Yes
|
57
|
71
|
18
|
146
|
55.7%
|
No
|
37
|
46
|
23
|
106
|
40.5%
|
Don't answer
|
3
|
6
|
1
|
10
|
3.8%
|
3. Is there anyone in your household who did not sleep under treated bed nets last night?
|
Yes
|
53
|
81
|
28
|
162
|
61.8%
|
No
|
37
|
34
|
13
|
84
|
32.1%
|
Don't answer
|
7
|
8
|
1
|
16
|
6.1%
|
4. Are there enough treated bed nets in your household?
|
Yes
|
31
|
25
|
9
|
65
|
24.8%
|
No
|
62
|
95
|
32
|
189
|
72.1%
|
Don't answer
|
4
|
3
|
1
|
8
|
3.1%
|
5. Do all children under 5 years in your household sleep under treated bed nets at night?
|
Yes
|
36
|
52
|
14
|
102
|
38.9%
|
No
|
25
|
28
|
13
|
66
|
25.2%
|
No children under 5
|
36
|
41
|
13
|
90
|
34.4%
|
Don't answer
|
0
|
2
|
2
|
4
|
1.5%
|
6. Where did you get the treated bed nets?
|
Government Hospital/Health Center
|
56
|
57
|
17
|
130
|
49.6%
|
Mobile Clinic
|
1
|
0
|
0
|
1
|
0.4%
|
Community Health Center
|
8
|
23
|
9
|
40
|
15.3%
|
Private Hospital/ Clinic
|
0
|
7
|
1
|
8
|
3.1%
|
Pharmacy
|
1
|
0
|
0
|
1
|
0.4%
|
Shop
|
2
|
5
|
3
|
10
|
3.8%
|
Traditional Healer
|
0
|
0
|
0
|
0
|
0.0%
|
Others
|
13
|
12
|
1
|
26
|
9.9%
|
Don't answer
|
16
|
24
|
13
|
53
|
20.2%
|
7. Did you spray insecticide to kill mosquitoes in your house?
|
Often
|
13
|
13
|
7
|
33
|
12.6%
|
Sometimes
|
9
|
20
|
8
|
37
|
14.1%
|
Seldom
|
13
|
27
|
8
|
48
|
18.3%
|
Never
|
61
|
63
|
19
|
143
|
54.6%
|
Don't answer
|
1
|
0
|
0
|
1
|
0.4%
|
8. Did you spray insecticide to kill mosquitoes outside your house?
|
Often
|
0
|
4
|
1
|
5
|
1.9%
|
Sometimes
|
3
|
1
|
2
|
6
|
2.3%
|
Seldom
|
6
|
6
|
8
|
20
|
7.6%
|
Never
|
87
|
110
|
28
|
225
|
85.9%
|
Don't answer
|
1
|
2
|
3
|
6
|
2.3%
|
9. Does your house have doors or windows screen which could stop the mosquitoes to go into the house?
|
Yes
|
13
|
34
|
11
|
58
|
22.1%
|
No
|
83
|
89
|
30
|
202
|
77.1%
|
Don't answer
|
1
|
0
|
1
|
2
|
0.8%
|
10. Do you and your family often stay outside of the house at night (such as for walk, exercises, enjoy the cool air, work, etc)
|
Often
|
68
|
85
|
31
|
184
|
70.2%
|
Sometimes
|
19
|
26
|
6
|
51
|
19.5%
|
Seldom
|
5
|
8
|
2
|
15
|
5.7%
|
Never
|
4
|
2
|
3
|
9
|
3.4%
|
Don't answer
|
1
|
2
|
0
|
3
|
1.1%
|
In addition, a total of 143 households never sprayed insecticide indoors to kill mosquitoes (P = 0.217, Fisher’s exact test), and 225 households never sprayed insecticide outside (P = 0.003, Fisher’s exact test); the proportions of households that did not take implement these preventive measures were especially high in Group 1 (89.7%) and Group 2 (89.4%). Furthermore, more than three quarters of the respondents reported that they did not have a door or window screen to prevent mosquitoes from entering their houses (P = 0.020, Fisher’s exact test), and the proportion of respondents without screens was especially high in Group 1 (85.6%). Additionally, most families reported staying outside of the house at night (P = 0.800, Fisher’s exact test) (Table 5).
Knowledge of malaria
In this survey, almost all the respondents had heard about malaria (98.1%, 257/262) and knew that the main route of transmission was through mosquito biting (86.6%, 227/262). Fever, body aches or joint pain, and loss of appetite were the top three clinical manifestations they reported (Table 6). A total of 173 respondents reported that they would always go to see a doctor or health care worker when they suspected they had malaria, while 48 interviewees said they would take some of the anti-malarial medicine kept in their houses first. The expensive costs (mentioned by 176 respondents) and the long distance (mentioned by 26 respondents) were the main factors preventing people from visiting the doctor or health care worker (Table 6). Sleeping under LLINs (198), keeping their surrounding clean (84) and using insecticide spray intended for use against mosquitoes (20) were the most common methods of malaria prevention employed(Table 6).
Table 6. Knowledge of malaria transmission, symptom and prevention in the three communities in the Western Area Rural District, Sierra Leone, 2018
Question & Answer
|
Group
|
Total
|
Percentage
|
1
|
2
|
3
|
1. Have you or any member of your family ever heard of an illness called malaria?
|
Yes
|
94
|
121
|
42
|
257
|
98.1%
|
No
|
3
|
2
|
0
|
5
|
1.9%
|
2. In your opinion, what cause malaria?*
|
Mosquito bites
|
82
|
106
|
39
|
227
|
86.6%
|
Eating immature sugarcane
|
0
|
0
|
0
|
0
|
0.0%
|
Eating dirty food
|
3
|
3
|
1
|
7
|
2.7%
|
Drinking beer/palm Wine
|
0
|
0
|
0
|
0
|
0.0%
|
Drinking dirty water
|
7
|
8
|
1
|
16
|
6.1%
|
Getting soaked with rain
|
0
|
0
|
0
|
0
|
0.0%
|
Cold or changing weather
|
1
|
1
|
1
|
3
|
1.1%
|
Witchcraft I. injections/drugs
|
0
|
1
|
0
|
1
|
0.4%
|
Eating oranges or mangos
|
0
|
2
|
1
|
3
|
1.1%
|
Eating plenty oil
|
2
|
1
|
0
|
3
|
1.1%
|
Sharing razors/blades
|
0
|
0
|
0
|
0
|
0.0%
|
Don't answer
|
8
|
11
|
2
|
21
|
8.0%
|
3. Can you tell any symptoms of malaria?*
|
Fever
|
39
|
59
|
18
|
116
|
44.3%
|
Excessive sweating
|
7
|
10
|
2
|
19
|
7.3%
|
Feeling cold
|
32
|
29
|
11
|
72
|
27.5%
|
Headache
|
24
|
27
|
4
|
55
|
21.0%
|
Nausea and vomiting
|
10
|
18
|
3
|
31
|
11.8%
|
Dizziness
|
21
|
29
|
16
|
66
|
25.2%
|
Loss of appetite
|
34
|
46
|
16
|
96
|
36.6%
|
Body ache or joint pain
|
43
|
45
|
14
|
102
|
38.9%
|
Body weakness
|
33
|
43
|
12
|
88
|
33.6%
|
Refusing to eat or drink
|
1
|
0
|
1
|
2
|
0.8%
|
Jaundice
|
5
|
1
|
0
|
6
|
2.3%
|
Dark urine
|
12
|
9
|
5
|
26
|
9.9%
|
Others
|
6
|
2
|
2
|
10
|
3.8%
|
Don't answer
|
1
|
0
|
0
|
1
|
0.4%
|
4. What should you do when you suspect getting malaria infection?*
|
Must go to see the doctor/health worker
|
65
|
77
|
31
|
173
|
66.0%
|
Take some anti-malarial drugs kept in house
|
17
|
26
|
5
|
48
|
18.3%
|
Not necessary to see the doctor/health worker and take drugs
|
1
|
2
|
0
|
3
|
1.1%
|
Go to see the doctor/health worker only when shown severe condition
|
4
|
6
|
5
|
15
|
5.7%
|
Others: Specify.
|
6
|
9
|
3
|
18
|
6.9%
|
Don't answer
|
4
|
3
|
0
|
7
|
2.7%
|
5. What are the reasons you think that someone would not go to see the doctor/health worker when he or she gets malaria infection?*
|
We are all used to it and no necessary to see the doctor
|
0
|
0
|
2
|
2
|
0.8%
|
Prayers could make us recover
|
0
|
0
|
0
|
0
|
0.0%
|
They are strong enough and could recover even if they do not see the doctor
|
0
|
0
|
0
|
0
|
0.0%
|
They have anti-malarial drugs and take it when necessary
|
4
|
11
|
4
|
19
|
7.3%
|
It is unnecessary to see the doctor/health worker for recovering from malaria
|
0
|
0
|
2
|
2
|
0.8%
|
It is too expensive to see the doctor/health worker
|
68
|
82
|
26
|
176
|
67.2%
|
It is too far to go to see the doctor/health worker
|
23
|
1
|
2
|
26
|
9.9%
|
Other reasons
|
0
|
24
|
7
|
31
|
11.8%
|
Don't answer
|
5
|
7
|
1
|
13
|
5.0%
|
6. How can someone protect themselves against malaria?*
|
Sleep under treated bed net
|
71
|
93
|
34
|
198
|
75.6%
|
Untreated mosquito net
|
0
|
1
|
0
|
1
|
0.4%
|
Use mosquito repellent
|
1
|
2
|
1
|
4
|
1.5%
|
Use mosquito insecticide spray (Shelltox)
|
10
|
7
|
3
|
20
|
7.6%
|
Take preventive medication
|
4
|
4
|
3
|
11
|
4.2%
|
Indoor residual spray (IRS)
|
1
|
3
|
3
|
7
|
2.7%
|
Use mosquito coils
|
5
|
8
|
2
|
15
|
5.7%
|
Cut grass around house
|
6
|
5
|
0
|
11
|
4.2%
|
Eliminate stagnant water
|
7
|
9
|
5
|
21
|
8.0%
|
Keep surroundings clean
|
27
|
44
|
13
|
84
|
32.1%
|
Don't drink dirty water
|
1
|
1
|
1
|
3
|
1.1%
|
Contaminated food
|
2
|
3
|
2
|
7
|
2.7%
|
Use mosquito screens on windows and doors
|
2
|
1
|
3
|
6
|
2.3%
|
Others: specify
|
11
|
10
|
3
|
24
|
9.2%
|
Don't answer
|
1
|
1
|
1
|
3
|
1.1%
|
7. Where do you think the mosquito larvae live? DO NOT PROMPT ANSWER
|
In water
|
49
|
77
|
27
|
153
|
58.4%
|
In weed
|
0
|
4
|
0
|
4
|
1.5%
|
In rubbish
|
25
|
20
|
9
|
54
|
20.6%
|
I don't know
|
16
|
16
|
4
|
36
|
13.7%
|
Don't answer
|
7
|
6
|
2
|
15
|
5.7%
|
*: it is a multiple-choice question.