|ORIGINAL RESEARCH REPORT
|Year : 2018 | Volume
| Issue : 1 | Page : 48-54
Knowledge and implementation of the National Malaria Control Programme among health-care workers in primary health-care centers in Ogun State, Nigeria
Temitope Wunmi Ladi-Akinyemi1, OE Amoran2, AO Ogunyemi1, OJ Kanma-Okafor1, AT Onajole1
1 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
2 Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
|Date of Web Publication||23-Feb-2018|
Dr. Temitope Wunmi Ladi-Akinyemi
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background: Lack of capacity to implement programs effectively and low public education about malaria is some of the factors that Nigeria governments must address to effectively combat malaria. Methods: This descriptive cross-sectional study assessed the knowledge and implementation of the National Malaria Control Programme (NMCP) among health-care workers in the primary health-care centers in Ogun state. Three hundred and twenty-five respondents were recruited into the study using cluster sampling method. A pretested self-administered questionnaire was used to collect necessary information. Analysis and statistical calculation was done using SPSS version 20.0. Relationships between categorical variables were tested using Chi-square test with P value at 0.05. Results: One hundred and twenty-five (38.5%) of the respondents were from Ado-odo/Ota local government areas (LGAs), 120 (36.9%) of the respondents were from Ijebu-ode LGA and 80 (24.6%) were from Ewekoro LGA. About 37.8% of the respondents were within age range of 45–54 years, with mean of 41.7 ± 8.5. Over 90% of the respondents knew the mode of transmission of malaria, <50% of them could identified case definition of simple and complicated malaria. Large percentage of the respondents knew the signs and symptoms of simple malaria. The respondents who were older (P = 0.004) with more than 15-year work experience (P = 0.006) had good knowledge score of the NMCP. Conclusion: Knowledge and implementation of NMCP by health-care workers in some of the LGAs in this study was inadequate. Regular visit to the health facilities, especially those in the remote areas by the staff of malaria control unit were recommended.
Keywords: Health-care workers, implementation, knowledge, National Malaria Control Programme, primary health care
|How to cite this article:|
Ladi-Akinyemi TW, Amoran O E, Ogunyemi A O, Kanma-Okafor O J, Onajole A T. Knowledge and implementation of the National Malaria Control Programme among health-care workers in primary health-care centers in Ogun State, Nigeria. J Clin Sci 2018;15:48-54
|How to cite this URL:|
Ladi-Akinyemi TW, Amoran O E, Ogunyemi A O, Kanma-Okafor O J, Onajole A T. Knowledge and implementation of the National Malaria Control Programme among health-care workers in primary health-care centers in Ogun State, Nigeria. J Clin Sci [serial online] 2018 [cited 2019 Sep 23];15:48-54. Available from: http://www.jcsjournal.org/text.asp?2018/15/1/48/226038
| Introduction|| |
Malaria is an acute or chronic infection of red blood cells caused by protozoa parasites of the genus plasmodium: Plasmodium vivax, Plasmodium malariae, Plasmodium falciparum and Plasmodium ovale. Each year, the world experiences 300–500 million cases of malaria. Approximately, 90% of the cases occur in Sub-Saharan Africa, where over one million children under the age of five years die of malaria annually. Countries with a high number of cases of malaria are among the poorest in the world and typically have very low rates of economic growth.
In Nigeria, malaria is responsible for 60% outpatient visits to health facilities, 30% childhood deaths, 25% of death in children under 1 year and 11% maternal death. Malaria's economic effects in Nigeria are large, with an estimated 132 billion naira (US$ 835 million) lost annually due to prevention and treatment costs, absenteeism, loss of productivity, and disability. Nigeria also has one of the world's highest rates of all-cause mortality for children under five: Approximately one in six children die before their fifth birthday. In Ogun State, malaria accounts for over 80% of outpatient attendance and is the most common cause of death at the primary health-care facilities. The most vulnerable groups are under-fives, pregnant women, visitors from nonendemic areas, those with sickle cell anemia, HIV/AIDS.
Malaria control can be defined as reducing malaria morbidity and mortality to a locally acceptable level through deliberate efforts using the currently available preventive and curative tools. Malaria control relies on effective prevention and case management. Oftentimes substandard treatments are given by untrained health workers and sometimes by trained health personnel who refused to update their knowledge. Malaria situation in Nigeria is deteriorating despite numerous interventions that had been instituted so far. An evaluation of the malaria prevention strategies using drugs among Nigerian obstetricians revealed that the majority were deficient in the current evidence-based recommendation. The most frequently prescribed anti-malaria drugs in the primary health centers (PHC) are chloroquine, sulfadoxine-pyrimethamine, and artesunate only, and some of the diagnosis is based on clinical assessment and not from laboratory investigations.
PHC is the first tier of health services in Nigeria providing an essential health care. It is the level of health care that has full community participation and constitutes the first element of a continuing health-care process. The community health-care givers have access at all times to the PHC and are expected to refer all cases of illness that do not respond to home management and all cases that present with danger signs or other referral signs. Thus, the National Malaria Control Programme (NMCP) at local government areas (LGA) level should be well implemented. Following the implementation of the national guidelines and strategies for Malaria Prevention and Control; there has been inadequate documentation on the progress made so far. Most studies in the literature assessed the implementation of NMCP among pregnant women, among children <5 years old  and among other members of the community  with relatively few among the health workers. The study serves as a feedback on the assessment of implementation of NMCP by health workers in Ogun State because such assessment tools does not exist
| Methods|| |
This study was conducted in Ado-odo/Ota, Ewekoro and Ijebu-ode LGA in Ogun state, Nigeria. It was a descriptive cross-sectional study assessing the knowledge and implementation of the NMCP among health-care workers in the primary health-care centers in the state. The study was between June 2013 and May 2014. The estimated sample size was 300 using the formula for cross-sectional study. The respondents were recruited using the cluster sampling methods.
Health-care workers who had been working in each of the selected LGAs for at least 6 months were included in this study.
Health-care workers on leave and those who do not manage patients were excluded from the study.
Data collection methods
A pretested self-administered questionnaire was used to collect necessary information by the research assistants. The questionnaire was drafted from module 2 of the case management of malaria at the primary health-care centers, Trainee content. Federal Ministry of Health, NMCP, Abuja, Nigeria. All health-care workers in all the PHCs in each of the selected LGA were part of the study.
primary outcome measured was the knowledge and implementation of the NMCP by the health-care workers in PHC.
Information obtained from the questionnaire was entered into SPSS (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp) for analysis and statistical calculation. Data were summarized using means, standard deviation, and proportions. The data were presented using tables and compared between the three LGAs. Relationships between categorical variables were tested using the Chi-square test (likelihood ratio were reported instead of person Chi-square if any of the cell have expected count cell less than five) while ANOVA was used for comparison between means. The level of significance was set at 95% confidence interval with P = 0.05. Each respondent's level of knowledge on malaria infection (parasite responsible for transmission, mode of transmission, and signs and symptoms of simple and complicated malaria) and NMCP were determined with a scoring system. Questions on perception and practice of the NMCP by the health-care workers were also scored. Each correct answer given one point and wrong answers no point. Those who scored <40% were classified as having poor knowledge, those who scored between 40%–60% were classified as having fair knowledge and those with scores greater than 60% were classified as having good knowledge.
The study was approved by the Health Research and Ethic Committee of the Olabisi Onabanjo University Teaching Hospital Sagamu, Ogun State Primary Health Care Board, Ogun State Ministry of Health Abeokuta. Respondents' informed consent was obtained verbally and by signature, before the commencement of the study. Strict confidentiality of all information and results of findings were maintained throughout the course of the study.
| Results|| |
There were 330 health workers in the three LGAs as at the time of the study, a total of 325 health workers participated in the study. The remaining five health-care workers were on leave (two maternity and three annual). The response rate was 98.5%. One hundred and twenty-five (38.5%) of the respondents were from Ado-odo/Ota LGA, 120 (36.9%) of the respondents were from Ijebu-ode LGA and 80 (24.6%) were from Ewekoro LGA.
The sociodemographic characteristics and the occupation history of the respondents are shown in [Table 1]. There were statistically significant differences in highest level of education (P = 0.016), job designation (0.019), and the difference in mean years of work (0.015) among the health workers in the three LGAs.
|Table 1: Sociodemographic characteristics and occupation history of the respondents (n=325)|
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Higher percentage of the healthcare workers in all the three LGAs knew the organism responsible for malaria infection as well as the vector that transmit the organism. However, less than 50% of them could identify correctly a case of simple malaria and complicated malaria. There were no statistical significant differences between the LGAs [Table 2].
|Table 2: Knowledge of respondents on signs and symptoms and mode of transmission of malaria (n=325)|
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The health-care workers in all the LGAs had good knowledge and perception of the NMCP. However, about 50% of the health-care workers identified the program has been a case management program only but the program is both preventive and case management. Furthermore, there were no statistically significance differences between the health-care workers in the LGAs regarding their knowledge and perception of the program [Table 3].
|Table 3: Knowledge and perception of respondents on National Malaria Control Programme (n=325)|
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[Table 4] depicts the implementation of the NMCP by the respondents. There were statistically significant difference in the distribution of LLINs to all patients treated for malaria (P = 0.006) and the use of clinical suspicion in the diagnosis of malaria (P = 0.032) among the health-care workers in the three LGAs. Over ninety percent of the respondents gave intermittent preventive treatment to pregnant women, distribute LLINs, use Rapid Diagnostic Test kits to diagnosis malaria and use artemisinin-based combination therapy (ACT) to treat malaria.
|Table 4: Implementation of the National Malaria Control Programme by respondents (n=325)|
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In all the three LGAs, the older health-care workers as well as health workers who had 15 or more year of work experience had good knowledge score of the NMCP. The doctors and the community extension workers, then the nurses also had good knowledge score of the program. Higher percentage of the health-care workers who implemented the program correctly also had good knowledge score of the program. All these differences were statistically significant [Table 5].
|Table 5: Sociodemographic characteristics of the respondents, Implementation of the National Malaria Control Programme by respondents and their knowledge score of the National Malaria Control Programme (n=325)|
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| Discussion|| |
This study demonstrates that higher percentage of health-care workers in the PHC had good knowledge on the mode of transmission of malaria and signs and symptoms of simple malaria. Less than half and less than one-third of the health-care workers had good knowledge of case definition of simple and complicated malaria respectively. The mean age of the respondents was the same with a similar study in southeastern part of Nigeria, but differ from a study in southwest LGA in Nigeria. Older respondents were statistically significantly more knowledgeable on the implementation of the malaria control (P< 0.001).
Academic qualification of respondents revealed that higher percentage had diploma, less than one-third had bachelor degree and very few of them had postgraduate degree. This could explain why majority of them do not have good knowledge of case definition of simple and complicated malaria. Respondents with diploma/certificate were statistically significant more frequent than respondents with bachelor degree and postgraduate degree (P = 0.016).
Majority of the health-care workers in the PHCs were Community Health Officers/Community Health Extension Workers (CHOs/CHEWs), followed by the nurses, other health workers and very few were doctors, this finding is different from a similar study in Ibadan. The CHEWs were statistically significantly more than other health workers (P = 0.019). The community health extension workers stay more in the community and do more of on the job learning, this could explain why more of the respondents had good knowledge of signs and symptoms of simple malaria.
A significantly higher proportion of health workers with ≥15 years' work experience at the PHC had good score of the knowledge of the NMCP (P = 0.006). More than two-third of the respondents already had training on NMCP, this is different from finding from similar studies within and outside Nigeria.,, Majority of respondents in Ewekoro already had training on NMCP while only two-third in Ijebu-ode and 62.4% in Ado-odo/Ota had training on NMCP, this is different from finding from similar study in Jos, Nigeria.
Higher proportion of the respondents knew the goals of the NMCP, almost all the respondents identified that NMCP intervention comprises of both prevention and case management, these findings is higher than result from similar study in India where only few of the respondents were aware and had knowledge of the drug policy. More than two-third of the respondents perceived that NMCP had reduced the prevalence of malaria and had benefited member of the community. In addition, most of the respondents in each of the LGA knew the goals of NMCP. Large percentage of respondents in each of the three LGA perceived that the NMCP had reduced the prevalence of malaria in their PHCs. Majority of the respondents in each of the LGA disagreed that NMCP is not health worker friendly and does not have any benefit to the member of the community.
A large proportion of the respondents implemented IPT and LLINs. Majority of the respondents in each of the LGA used intermittent prevention treatment and long lasting insecticide nets (LLINs) as malaria prevention intervention. Most of the respondents gave IPT to pregnant women during ANC. The knowledge and use of IPT to prevent malaria in pregnancy by the respondents in this study was better when compared with poor knowledge documented by a study from Southwest LGA of Nigeria  and another study from Ibadan. This fair assessment may be due to several training undertaken by the health workers. Respondents who gave IPT to pregnant women were statistically significantly more knowledgeable on the implementation of the NMCP (P< 0.001).
Furthermore, less than half of the respondents would give LLINs to all patients treated for malaria. This is not in the guidelines for the prevention of malaria and will result in stock out (a situation in which the demand or requirement for an item cannot be fulfilled from the current inventory) of LLINs in these LGAs. The gap in between the knowledge and implementation may be due to the fact that health workers at the implementation level were not the health workers at the training. This was statistically significant (P = 0.006). Less than half of the respondents used clinical suspicion to make diagnosis. This was statistically significant (P = 0.032). This finding is consistent with report on malaria treatment in Ogun State where it was revealed that cases treated were far higher than those who got tested.
Larger percentages of the respondents use ACT to treat malaria; this shows that use of ACT in treatment of uncomplicated malaria is widely accepted by most health workers. This is in keeping with the Nigeria's NMCP target of at least 80% of fever/malaria patients receive appropriate and timely treatment according to national treatment guidelines. The findings were similar to another study in Uganda  but differ from the result of finding in another study in Tanzania where only few of the health workers prescribed ACT for the treatment of uncomplicated malaria.
Limitation of the study
The study was conducted toward the end of the year when some of the health-care workers were on leave. This led to an extension of the study till May 2014. Some of the health facilities were inadequately staffed, the health workers were on (MAN– morning, afternoon, and night) and some were on one week off and one week on. It was very difficult to see the health workers, especially those in the rural areas.
| Conclusion|| |
Knowledge of health-care workers regarding mode of transmission of malaria was good but their knowledge about case definitions of simple and complicated malaria was inadequate. The inability of health-care workers to correctly recognize and differentiate simple and severe malaria could influence patient management and prognosis. Therefore, there should be more supervisory visit to the health facilities, especially in the remote areas by the health workers at the malaria control unit Ogun state Ministry of Health and Federal Ministry of Health and more of the younger health workers who actually manage the patients should be sent for training.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]