Health Promotion to Promote Use of Prophylactic Anti-Malaria Agents in Rural Enugu State, Nigeria: Dislodging the Malaria-Typhoid Concurrency Myth ()
1. Introduction
In 2020, malaria caused numerous deaths worldwide, and about 27% of all these deaths happened in Nigeria, with rural areas having a higher share of malaria cases and deaths compared to their population [1]. Malaria remains highly prevalent in Enugu State, especially among pregnant women and children under five [2]. While interventions such as insecticide-treated nets (ITNs), intermittent preventive treatment in pregnancy (IPTp), and indoor residual spraying (IRS) have been proven effective, their uptake remains low in rural communities [3] [4]. Many people incorrectly believe malaria and typhoid always co-occur. This misconception leads to frequent misdiagnosis, often using the unreliable Widal test, which drives unnecessary antibiotic use and reduces focus on preventive measures [5].
This article outlines a comprehensive health promotion strategy to strengthen the use of prophylactic anti-malaria agents and dismantle the malaria-typhoid concurrency myth in rural Enugu State.
2. Aim and Objectives
Aim
To promote effective use of prophylactic anti-malarial interventions and correct misconceptions in rural Enugu communities.
Specific Objectives
Enhance community understanding of the true relationship between malaria and typhoid fever.
Increase uptake of IPTp, ITNs, and related preventive measures.
Address socio-cultural and healthcare-related barriers undermining trust in evidence-based malaria prevention.
2.1. Background and Literature Review/Malaria in Pregnancy and
IPTp Uptake
Recent data confirm persistently low IPTp uptake in Southeast Nigeria. In Ebonyi State, only 24.0% of pregnant women received the recommended three or more doses of IPTp-SP [6]. In a rural Abia State study, 80.8% of women were aware of IPTp, but just 26.3% completed the full regimen [7]. Furthermore, a study found that increased IPTp uptake significantly improves birth outcomes, such as higher birth weights and reduced neonatal mortality [8].
2.2. Socioeconomic Disparities
Analysis of the 2018 Nigeria DHS reveals notable inequalities: while wealthier women are more likely to receive three or more IPTp doses, rural areas exhibit a pro-poor pattern, indicating complexity beyond simple wealth gradients [9]. This means that malaria prevention is not determined by income alone. Other factors such as education, distance to health facilities, women’s decision-making power, and cultural beliefs also influence whether a woman receives preventive treatment during pregnancy [6] [10] [11]. For example, a woman who lives far from a clinic or depends on her husband to approve medical visits may miss IPTp doses even if the drugs are free [4]. Poor road networks, limited transport, and low awareness about malaria prevention make the problem worse, especially in isolated rural communities [12]. Recognizing this complexity, the proposed framework emphasizes community and faith-based engagement to ensure preventive interventions reach women across all social and economic groups [13].
2.3. Misdiagnosis via Widal Test
Although the Widal test is still widely used in Nigeria’s rural settings, it has notoriously poor diagnostic accuracy. For instance, a study from a tertiary hospital found the test’s sensitivity to be only 35% and specificity at 51%, with a low positive predictive value (17%), meaning it frequently produces false positives and falsely classifies non-typhoid cases as typhoid, especially in malaria-prevalent contexts [14]. This inaccuracy contributes to misdiagnoses, unnecessary antibiotic use, and ongoing confusion over malaria–typhoid co-infection. Blood culture remains the reference standard for confirming typhoid fever, as it directly detects Salmonella Typhi [15]. Nevertheless, newer rapid diagnostic assays, such as Typhidot and TUBEX-TF, have demonstrated greater accuracy and reliability than the traditional Widal test in several studies [5] [14].
2.4. Addressing Health Beliefs via Promotion
Recent literature emphasizes the importance of community engagement, improved diagnostics, and targeted behavioral interventions to counteract misbeliefs like malaria-typhoid co-infection and to enhance IPTp uptake and preventive behavior [6] [9].
3. Health Promotion Strategies and Implementation
Framework
We base our approach on the Health Belief Model (HBM), which explains how people’s beliefs influence their health behaviors [16] [17]. By applying this model, health promotion activities can be tailored to address the reasons why pregnant women and rural households either adopt or fail to adopt preventive malaria measures. The adapted HBM framework for malaria prevention in rural Enugu is provided in Appendix (Figure A1).
This aims to make people aware of their risk of contracting malaria and how serious the disease can be. For example, women are reminded that pregnancy weakens immunity, making them more likely to suffer complications from malaria, such as miscarriage, stillbirth, or severe anemia [13]. Similarly, communities are educated on the fact that children under five face a higher risk of death if they contract malaria [12]. This creates a sense of urgency for prevention.
Here, the strategy emphasizes what people gain from preventive actions. Health workers highlight that taking Intermittent Preventive Treatment in pregnancy (IPTp) with SP (sulfadoxine-pyrimethamine) and using Insecticide-Treated Nets (ITNs) can drastically reduce malaria cases, improve pregnancy outcomes, and protect both mothers and babies [13]. Linking prevention to tangible benefits such as fewer hospital visits, lower costs, and healthier children helps motivate adoption.
Even when people know prevention is important, barriers such as fear of side effects from IPTp, poor access to drugs, myths about “malaria-typhoid co-infection,” or distrust in public health facilities often stop them from acting. The strategy directly addresses these concerns. For example, community dialogues clarify that IPTp is safe, health campaigns explain the ineffectiveness of Widal tests, and health workers are trained to improve service delivery.
Building self-efficacy and providing consistent cues to action are essential for encouraging sustained malaria prevention in rural Enugu. Pregnant women are empowered to confidently request IPTp during antenatal visits, reinforcing the belief that prevention is within their reach. Community-based reminders such as Igbo-language radio jingles, posters, and village meetings serve as practical triggers that keep malaria prevention at the forefront of women’s daily lives. Trusted community figures, including village leaders, women’s associations, and Traditional Birth Attendants (TBAs), act as role models and motivators, showing that every woman has the ability to protect herself and her baby [18].
Faith-based platforms add a powerful layer of reinforcement. Church announcements reminding women to attend ANC or collect IPTp, as well as religious gatherings used for health talks, poster distribution, and even ITN sharing, ensure that preventive messages are consistently echoed by respected spiritual leaders [19] [20]. These approach linking community and faith-based cues creates a supportive environment where women not only know what to do but also feel motivated, capable, and encouraged to take action.
The HBM-based framework makes malaria prevention personal, beneficial, feasible, and actionable, ensuring that strategies not only spread information but also change behavior.
Key Strategy Components
This involves holding structured discussions with village leaders, women’s groups, traditional birth attendants (TBAs), and church leaders, who play central roles in shaping community opinions. Since pastors and priests are respected voices of authority in rural Enugu, involving them in dispelling the malaria-typhoid concurrency myth ensures that accurate information is trusted and widely shared [19]. In addition, men and husbands will be actively encouraged to participate in malaria prevention activities. Through community meetings and faith-based programs, they can learn about the importance of IPTp, regular ANC visits, and the dangers of self-medication. Their involvement supports women in attending clinics, taking preventive drugs, and following health advice without delay.
Antenatal clinics (ANC) remain the primary platform for delivering malaria prevention measures such as IPTp, while also providing opportunities to educate pregnant women about malaria and dispel myths. In remote areas, community health workers (CHWs) can extend this service using models like TIPTOP, which has proven effective in neighboring Ebonyi State [3] [14], ensuring that even women far from health centers receive preventive care. To further enhance uptake, collaboration with faith-based groups is encouraged. Religious leaders can motivate women to attend ANC, provide reassurance about preventive measures, and even organize transportation or offer encouragement during church services, thereby reinforcing medical advice with trusted religious endorsement.
Behavior Change Communication (BCC) uses culturally appropriate tools to influence knowledge, attitudes, and practices. In rural Enugu, interventions include Igbo-language radio messages, community dramas, and posters that clarify misconceptions about malaria-typhoid co-infection and promote preventive behaviors, such as ITN use and adherence to IPTp schedules. These campaigns are further strengthened by the involvement of faith leaders, who use pulpits, crusades, and women’s fellowships to reinforce prevention messages, encourage ITN use, and discourage reliance on the unreliable Widal test. Religious dramas and songs in Igbo during church events also serve as powerful reinforcements, ensuring that malaria-prevention messages are not only culturally relevant but also delivered through trusted community voices [18].
Capacity building is central to improving malaria prevention and diagnosis in rural Enugu. Healthcare providers are trained to prioritize rapid diagnostic tests (RDTs) over the unreliable Widal test for malaria-typhoid diagnosis, and to counsel patients accurately on prevention, the proper use of IPTp, and the correct interpretation of test results. At the same time, faith leaders are given basic training on malaria prevention messages so they can reinforce accurate information within their congregations and communities. Evidence shows that when church leaders are directly engaged alongside trained health workers, communities are more likely to adopt preventive behaviors and reduce reliance on ineffective practices [20].
To track the effectiveness of the interventions, measurable indicators are used. These include:
The proportion of pregnant women receiving at least three IPTp doses.
Reduction in the number of cases labeled as “malaria-typhoid” in health facilities.
Increases in community knowledge scores regarding malaria prevention practices.
4. Expected Outcomes
Through improved ANC integration, provider training, and community engagement, we expect a measurable rise in IPTp coverage. Specifically, at least 60% - 70% of pregnant women should receive the recommended three or more doses within two years of implementation.
By discouraging the use of the Widal test and strengthening RDT-based malaria diagnosis, we anticipate a 40% - 50% reduction in malaria-typhoid co-diagnoses in rural health facilities. This should be accompanied by a significant drop in inappropriate antibiotic prescriptions, especially among pregnant women.
With increased IPTp uptake, maternal anemia is expected to decline by 15% - 20%, while adverse outcomes, including low birth weight, preterm births, and neonatal mortality, are projected to decrease by at least 10% - 15%, consistent with evidence from similar interventions in sub-Saharan Africa.
As communities experience more accurate diagnoses and observe better health outcomes, confidence in formal health services is expected to increase. This trust should be reflected in higher antenatal clinic attendance (by ≥20%) and greater rates of facility-based deliveries, thereby strengthening overall maternal and child health service utilization.
Although this framework focuses on rural Enugu State, it recognizes that communities within the state differ in culture, beliefs, and access to health services. Therefore, its implementation may require small local adjustments to fit each community’s unique context. These local differences also influence how easily the framework can be applied in practice, as discussed below.
4.1. Implementation Challenges and Limitations
While the proposed health promotion framework is practical, some challenges may affect its success. Limited funds, few health workers, and poor roads in rural Enugu could make outreach difficult. Some community or faith leaders may resist new ideas because of cultural beliefs or mistrust. Getting husbands to take part may also be hard, as traditional gender roles often limit men’s involvement in maternal health. Sustaining the program after the initial phase could also be difficult without local and government support.
4.2. Recommendations
To overcome these issues, the framework promotes early engagement of community leaders, use of existing local structures, and integration into primary health care programs for long-term success. To make the impact last, the framework encourages communities to take ownership of activities. Trained faith leaders, health workers, and volunteers can keep sharing malaria-prevention messages during church events and local meetings. By using existing health and community systems, the program can continue even after outside support ends
5. Conclusion
Rural Enugu faces a dual challenge of high malaria burden and persistent misconceptions about malaria-typhoid co-infection. An evidence-based health promotion framework built on community dialogue, ANC integration, behavior change communication, provider training, and community health worker engagement is essential. The active involvement of religious leaders will provide a unique opportunity to reinforce accurate health messages, dismantle harmful myths, and motivate preventive action among rural households. If implemented effectively, this strategy has the potential to advance maternal and child health outcomes while contributing to Nigeria’s progress toward the Sustainable Development Goals on health and well-being.
Appendix
Designed with canvas by Author # 3.
Figure A1. Health belief model framework diagram.