Knowledge, Attitude and Treatment Seeking Behavior for Malaria in May-Aynee Administration, Eritrea

Malaria is known to be a major cause of morbidity and mortality globally, with an estimated 3.2 billion people living in malarious areas, mostly in low-income countries [1]. According to the 2015 World Malaria Report, around 214 million cases and 438,000 deaths of malaria were reported [2]. Similarly, in 2016, there were nearly 215 million patients and 435, 000 deaths worldwide [3]. An estimated 88% of cases and 90% deaths of malaria were reported from Africa [4]. Early diagnosis and prompt treatment can cure the disease and reduce mortality attributed from malaria [5]. World Health Organization has emphasized to reduce the burden, complication and transmission of malaria through diagnosis and treatment within 24 hours and states that a delay would increase Received: October 10, 2019

the already high impact of the disease [6][7][8]. Malaria is a great public health concern in all endemic areas of Eritrea. Around 70% of the Eritrean population live in areas where malaria is transmitted [9].
The government of the state of Eritrea has been constructing several health facilities to attain sustainable development goal (SDG-3) objectives by reducing the burden and eventually eliminating malaria [10]. Besides many health professionals have been trained to offer an equitable, easy and smooth delivery of healthcare to all communities in the country. In addition, the ministry of health has introduced community health agents (CHA) in villages and towns to provide primary care services. The cumulative effect of these approaches has reduced the incidence, health facility admission and deaths attributable to malaria [6,8,[11][12][13][14]. Despite the reduction in malaria morbidity and mortality, the disease remains a public health concern in most parts of the country threatening economic development. Success of malaria control efforts depends on knowledge, attitude and treatment seeking behaviors of people living in malarious areas [15]. Several countries have achieved significant progress in malaria control and elimination by empowering communities with knowledge so as to recognize the symptoms and to seek early treatment through health facilities [16][17][18]. The aim of this study was to investigate the level of knowledge, attitude and practice of community on early treatment seeking behavior on malaria.

Study Design
Community based cross-sectional study was conducted in May-Aynee administration. A structured questionnaire was used to collect information from representatives of households.

Study Area
May-Aynee is a subzone located about 78 km southeast of Asmara. It is one of the 12 subzones in Southern region of Eritrea.
May-Aynee administration is one of the 11 administrations in May-Aynee subzone. It consists of four villages and the town of May-Aynee. Malaria is endemic in the administration. Rainfall is seasonal and extends between the months of June and September with the greatest intensity during July-August.

Study Population
May-Aynee administration has 575 households. There are three ethnic groups: Tigre, Tigrigna, and Saho. The livelihood of the population primarily relies on agriculture, pastoralism, and trade.

Sample Size Determination
A sample size of participants was determined using the formula. n=z 2 qq/d 2 , where n is sample size, p (where is p in the formula) is the proportion of a population with the attribute of interest (0.5), q is 1-p, d is the degree of precision (0.05), z is the standard normal deviation (1.96), giving 384. 16. Since the population size is small in comparison to the sample size, the population correction factor was introduced (n 2 = n/1+n/N). Adding 5% contingency for non-response; 243 households were included. Using a systematic random sampling technique, households (Interval = 575/243 ≈2.36) were selected and one member of the household family (the husband, wife or adult>15years old) was interviewed (Table 1).

Overall Knowledge Scores
Knowledge on malaria was assessed based on three components: causes, signs and symptoms, and prevention of malaria. Each respondent got one score for correctly answering a question and zero otherwise. For questions with multiple responses, a score was given based on the number of correct responses. An overall knowledge score was calculated by adding up the scores of each respondent across all questions. Seventeen points were considered for malaria knowledge score. Using median as cutoff point, score greater than the median was considered as satisfactory and less than the median as unsatisfactory. Furthermore, a percent knowledge index (PKI) was calculated for each participant by summing the number of correct answers from the 17 items.

Data Processing and Analysis
Data were entered and analyzed using SPSS version 20.
Categorical variables were described using frequencies and percentages while continuous variables were described using appropriate measures of central tendency and dispersion and were presented in the form of tables and graph. Chi-square and binary logistic regression were used to test for associations. Crude and adjusted odds ratio along with their 95% confidence intervals were presented, and p<0.05 was considered statistically significant.

Percent Knowledge Index
The median knowledge score of study participants was 10.
Majority (75.4%) of the respondents had adequate knowledge on causes, signs and symptoms and prevention methods of malaria. knowledge on prevention methods of malaria and distance from the health facility of respondents (Table 4).   [19], Ghana [20], and Colombia [21]. However, ing was reported by a study from Ethiopia [22].
A good knowledge of respondents on the frequent signs and symptoms of malaria was reported in the present study. Fever, shivering/chills, headache, joint pain, and vomiting were stated as the cardinal signs of malaria. Fever was the predominantly (84%) recognized symptom of malaria in this study, consistent with studies from India [19], Uganda [23], and Kenya [24]. This may be due to the existence of high malaria infections since long time in the area. Sensitization of the community at different occasions by health workers or CHA could also have had significant role in awareness rising of the community.
Regarding the knowledge on prevention of malaria, all study participants mentioned that malaria is preventable, similar to a study from Ghana (92.3%) [20]. Majority (Table 3) [21,23].In this study, a significant association was found between perceptions of the study subjects on seriousness of malaria with occupation (p < 0.05) ( Table 5). Farmers and businessmen thought that malaria was not serious. This may be due to lack of knowledge attributed to limited access to information as compared with government employees.
Ninety percent of the present study participants, who had experienced signs and symptoms of malaria six months prior the study, have visited health facility for consultation. This is much higher compared to other studies, only 38.5% in Nigerians [27] and 54.2% in Ghanaians [20]  and Myanmar [28].
Needless to mention, a small proportion (5.1%) of the respondents used traditional remedies like Aloe Vera, Teketater, eating bitter food and others to treat malaria. This is similar to a study from Myanmar [28], where 7.3% sought treatment from traditional healer as well as a friend or relative. Another study from Ghana [20] revealed that some of the respondents used Neem or Pawpaw, bark of Mahogany trees to treat malaria at their home.
However, in Nigeria, a large proportion (61.5%) of study participants in preferred to seek traditional healers for being not expensive [27]. Therefore, an understanding of community's knowledge and practice regarding malaria prevention and treatment are important in assessing the situation before designing intervention projects.

Limitation
For the reason of limited budget, we did not conduct large household sample size besides of the distance from the workplace of the researchers.

Conclusion
It is evident that communities' knowledge, attitudes and practices about malaria often remains unobserved during malaria control efforts. Knowledge on causes, signs and symptoms and prevention aspects of malaria was found to be high, but early treatment seeking behavior within the recommended time was low. Some misconceptions were also prevalent among the residents of May-Aynee administration. Further, the distance to reach health facilities was an impediment to seeking treatment promptly.
Thus, effective health promotion and education activities should be implemented to increase the likelihood of timely treatment of malaria. Simultaneously, efforts should be made to reduce the distance between home and health care facilities. This can also be done by increasing the number of health facilities.

Ethical Consideration
Ethical approval was obtained from the ethical committee of the Asmara College of Health Sciences. A letter of consent was written to the local administrators. Before the interview, a verbal consent was obtained from participants, and were assured on confidentiality of the information.