Publics’ Malaria Knowledge, Prevention and Treatment Practices, A Cross-sectional Survey From Khartoum, Sudan

Background: Malaria is one of the major health problems in Sudan with high prevalence among children under ve years age and pregnant women. Effective control of the disease needs contribution of the community, health authorities as well as political commitment. This research was conducted to assess the public’s knowledge, and practice regarding malaria prevention and treatment. Methods: A cross-sectional survey was conducted among publics in Khartoum State. Data was collected using a self-administered questionnaire. Publics were assessed for their knowledge about malaria symptoms and complications, knowledge and utilization of prevention methods and drugs knowledge and treatment behaviors. Results: About 457 of the public participated in the survey. Despite that the publics showed good knowledge regarding malaria symptoms, complications and drugs knowledge, self-treatment practices were there. Noncompliance to treatment in form of stopping treatment upon symptoms relieve and upon developing adverse drug reactions was also reported. Underuse of prevention methods was reported. Conclusions: Inappropriate treatment and prevention practices among the community could be an obstacle in the way of malaria elimination in Sudan. More efforts towards involvement of the community in malaria control through community education are needed.


Background
Malaria is a serious disease with the highest prevalence in Sub Saharan African countries in which more than ninety percent of malaria cases and deaths were reported [1]. In Sudan, the latest Malaria Indicator Survey showed that almost all the people in Sudan are at risk of malaria. The highest prevalence was reported among males, pregnant women, children less than ve years of age and in rural areas [2].
Malaria knowledge, treatment and prevention practices could affect the process of malaria control. Malaria knowledge, treatment seeking behaviors, use of treatment and prevention methods vary among communities of different countries [3][4][5]. Even the communities in one country may show different patterns of knowledge and practices regarding malaria prevention and treatment [6,7]. In Sudan, the community knowledge about malaria was not studied in big communities and not many of the research that has been published investigated the public knowledge of antimalarial drugs and their drugs use behavior. In this research, our objective was to assess the public knowledge about malaria causes, symptoms and complications, to assess their treatment seeking behavior, antimalarial drugs knowledge, use and compliance to treatment. The research was also investigated the public knowledge and use of prevention methods.

Study setting
This survey was carried out in Khartoum State, Sudan between September to December 2016.

Study population
Publics of different socioeconomic classes, educational levels, and jobs in different public places were targeted for the study.
Study design and sampling procedure A descriptive cross-sectional survey was carried among the public in Khartoum state. The sample size was calculated by Raosoft sample size calculator based on 95% con dence level and 5% con dence interval. The sampling frame was the population of Khartoum state. The calculated sample was 385 participants. [8,9] Adults (18 and above) who agreed to participate in the study were included after verbal consent.
Healthcare professionals and students of any health-related institutes were excluded.
Adults with hearing, visual and mental problems and those who refused to participate in the study were excluded. Illiterates excluded as they were unable to complete the self-administered questionnaire.

Data collection
Data was collected via a structured self-administered questionnaire. The questionnaire was developed by the researcher after reviewing the literature, piloted and tested for reliability and internal consistency (Cronbach's alpha (0.744). The questionnaire then translated to the Arabic language since it is the mother tongue language of the surveyed population. Forward and backward translation was carried. Different public places were approached for sample collection (two public markets, school, engineering workshop, a private company, bank, Quran learning center, industrial complex and military complex). Data was collected by the researcher and two trained data collectors. About 500 questionnaires were distributed and 457 were retrieved giving a response rate of 91.4%.

Data Analysis
Data was entered checked and analyzed using Statistical Package for Social Sciences (SPSS version 23).
Descriptive statistics were conducted such as frequencies and percentages. Chi-square test was used to test correlations between categorical variables. Probability values of < 0.05 considered as statistically significant for all results.

Ethical approval
Ethical approval was obtained from the National Ethical Committee, Federal Ministry of Health, Sudan.
Verbal consent was obtained from the surveyed publics after they were informed about the research objectives.

Demographics
Publics from the three cities (Khartoum, Omdurman and Khartoum North ) participated in the survey. The majority of the respondents were university graduates and Private-employees. About 53 participants did not report their monthly income and most of them those who were not working (Table 1). About 86.9% of the public could relate malaria to mosquito bites however wrong believe about contaminated food as a cause of malaria was mentioned by 11.2% of the respondents. Fever, headache and body aches were known malaria symptoms among the public. Dehydration, anemia and cerebral malaria were the most mentioned malaria complications ( Malaria treatment Diagnosis of malaria by symptoms was practiced by near thirteen percent of the surveyed publics and 6.1% practice self-treatment mainly due to nancial reasons. Self-treatment with drugs was common. About 17.7% seek malaria treatment at the community pharmacy because they perceive the pharmacist as a knowledgeable health care provider who could manage malaria. About 79.2% mentioned that their drugs were selected mainly by the pharmacist at the community pharmacy and near one-quarter of the surveyed population (24.7%) claimed that the pharmacists dispensed the antimalarials for them upon their request without asking about prescription or laboratory result. A signi cant relationship between malaria treatment and the level of education was reported. Less educated publics were more likely to practice self-treatment (Tables 3,4,5,6). Seek pharmacist advice at a community pharmacy 81 17.7 Seek medical advice at the hospital or health center 348 76.1 Reasons for self -treatment Financial reasons 14 50 Unavailability of health facility 5 17.9 Other reasons Do not want to discover other diseases 1 3.6 Know the disease and treatments 3 10.7 Lack of con dence in doctors 1 3.6 Lack of con dence in lab results 1 3.6 Prefer herbalist 1 3.6 What used for self-treatment Self-treatment using drugs 18 66.7 Self-treatment using herbs 10 37 Why seek pharmacist advice Pharmacists knowledgeable to manage malaria 67 82.7 Cannot afford to go to the hospital or clinic 26 32.1 *Inaccurate percentages due to missing data  Antimalarial drugs were available (93.9%) and available (82.5%) for the majority of the respondents. (  Table 11)

Malaria Prevention
The public in Khartoum State showed good knowledge regarding prevention methods. Insecticide-treated bed nets and indoor house spraying was mentioned by 81.1% and 70.2% respectively. However ner thirty percent (28.9%) did not use any prevention method. Of those who did not use prevention methods, none availability (40%) and unaffordability (21.7%) were of the main reasons mentioned of not using prevention methods (Table 12, 13). Being a female and receiving education on malaria prevention and treatment were signi cant predictors of prevention methods use (P-value 0.006 and 0.001 respectively) Table 14).
Slightly more than half (54.3%) the surveyed publics received education on malaria prevention and treatment. The media (42.7%) and friends and family members (38.5%) were the main providers of education (Table 15).

Discussion
The public in Khartoum state showed good knowledge about malaria causes, symptoms, and complications. The majority of the public in malaria-endemic countries could mention most of the malaria symptoms. Fever and headache were the most known symptoms and with or without different levels of knowledge about malaria causes and complications [10][11][12][13]. Two researchs in Sudan one among the public in one of the rural parts of Khartoum and in Estren Sudan revealed poor knowledge on malaria complications [10,14]. Sudan is a big country with different sociodemographic and educational levels among different State. More research is needed for assessment of malaria knowledge among communities of different Sudanese states to help the policymakers in setting control programs in accordance of the needs of different communities.
Malaria self-diagnosis and self-treatment were reported in the current study. Malaria self-diagnosis and treatment was documented in other studies conducted in Khartoum state [15,16] and in many other malaria-endemic countries [17,18]. The main reason mentioned by the respondents who practiced selftreatment was nancial reasons. A study from Khartoum also showed that people do seek treatment from community pharmacies because they could not afford to pay for consultation fees and that they were not satis ed by the services at the public health facilities [19]. Although the percentage that practiced self-treatment in the current study was 6.1%, part of the 17.7% who seek malaria treatment at community pharmacies could also be considered as practicing self-treatment because they mentioned that the community pharmacist dispensed antimalarials upon their request.in the current study, primary educated people were more likely to go for self-treatment however in the study carried by Awad et al, medical students were practicing malaria self-treatment more than other university students [16]. Self-treatment using herbal drugs was of the practices reported in Sudan [20,21] as well as many African communities such as in Cameroon [6] and in Kenya [22].
Regarding drug knowledge, 75.1% of the public could recognize the drug used as 1 st line treatment at the study period. The publics mentioned doctors and pharmacists as sources of information and could be reliable sources. Family members and friends were mentioned as a source of information for 36.5% of the respondents, however, the accuracy of information provided by them was questionable. Different studies showed different patients information sources [23,24] but providing patients with adequate information on drugs and treatments from reliable sources is very important as it could affect the cure of their disease.
The majority of the reported adverse drugs reactions (ADRs) were gastrointestinal system related and was mainly caused by the combination of Artesunate+ sulphadoxine/Pyrimethamine as it was the most used drug. Although some patients consulted physicians and pharmacists when they developed ADRs it was not investigated if these ADRs were reported or not. Patients can contribute to the process of ADRs reporting and determination of drugs safety. However, inadequate patients knowledge and practices were reported in many communities [25,26]. Lack of patients awareness about reporting systems and reporting skills could be of the barriers to patients contribution in ADRs reporting [27]. About 20.5% of those who experienced the adverse effects stopped treatment. Stopping of treatment upon improvement of symptoms was reported by 22.8%. Discontinuation of treatment after the development of ADRs or symptoms improvement indicated a problem of patients compliance which may lead to poor prognosis and development of drugs resistance. The results showed that there was no signi cant relationship between patients demographics and their compliance with antimalarial drugs treatment and that was consistent with the ndings of a study carried out in Uganda [28]. Stopping treatment after symptoms improvement [29] and upon the development of ADRs [30] was shown in some studies and it was found that drug knowledge and previous experience of drug use were signi cant predictors of adherence to treatment [31]. Patient education on noncompliance to treatment and its drawbacks not only for the patients but also for the whole country as a risk of drug resistance is very crucial.
The publics showed good knowledge about prevention methods but still near one third (28.9%) of the surveyed publics did not use the prevention methods. The difference between knowledge of prevention methods and use behavior was reported in many malaria-endemic countries such as in Cameroon [32] in Ethiopia [33] and in Ghana [34]. In Sudan underuse of preventive measures in many states [35] and inappropriateness in availability, affordability and use of preventive measures in terms of public's behavior and stakeholder's implementation was reported [36]. Of those who did not use prevention methods, 40% and 21.7% attributed that to nonavailability and unaffordability of it respectively. The recent Malaria Indicator Survey in Sudan showed the same ndings of this study. Khartoum State and the Red Sea state were reported as having the lower ownership and use of insecticides treated nets (ITNs) and indoor house spraying. The highest rates of using ITNs were reported in the refugee's camps and the some targeted states in which it is distributed free of charge. Nonavailability and unaffordability were also reported as the reasons for not using prevention methods [2]. Females and those who received education in malaria prevention and treatment were more likely to use prevention methods (P-values 0.006 and 0.001 respectively). Despite the effect of education on patients, knowledge and preventive methods use behavior, slightly more than half of the surveyed people( 54.3%) received education on malaria prevention and treatment. The media (42.7%) and family and friends (38.5%) were mentioned in the top list of education providers to public. The media (radio, television and newspapers) could play an important role in malaria education [37,38]as well as other sources of information such as books, internet and the procedures distributed in the clinics [39]. Continuous education was underscored by community members as an important tool in malaria elimination [40]. Generally, health education could help individuals and communities in improving their health conditions with extended positive habits of a healthy life to future generations [41]. More efforts in public education on malaria prevention and treatment is required for achievement of malaria elimination targets in Sudan

Conclusion
Although the public in Khartoum state showed good knowledge on malaria prevention and treatment, there are many inappropriate practices among the public. Self-diagnosis and treatment, noncompliance to treatment and underuse of prevention methods were of the barriers to effective control of malaria in Sudan.

Study Limitations
Majority of the respondents in the surveyed publics were university graduate which may not re ect the actual community knowledge. More socioeconomic status and illiteracy level and access to media and education may differ among the different Sudanese states which make the results not generalizable and the survey should be carried in different state to re ect the actual situation. Ethics approval and consent to participate Declarations Consent for publication The authors agreed to submit this paper for publication Availability of data and material Data and materials used in the study are available and will be provided by the corresponding author whenever needed.

Competing interests
The authors declared that they have no competing interest.

Funding
This research did not received funding from any sponsor or organization.

Authors' contribution
Elkhanssa Abdelhameed designed the study, trained data collectors and contributed in data collection, performed the data analysis and interpretation of results. Syed Azhar contributed in interpretation of the results, provided advice and critically reviewed the study results. All authors read and approved the nal manuscript