Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. It is preventable and curable. In 2020, there were an estimated 241 million cases of malaria worldwide. The estimated number of malaria deaths stood at 627,000 in 2020. [1].

Malaria has been a scourge of humanity since antiquity and remains so today. Despite being preventable and treatable, malaria continues to have a devastating impact on people’s health and livelihoods around the world in 2019, about 4 billion people were at risk of the disease in 87 countries [2] [3].

Over the past twenty years, the scale-up of malaria control efforts has led to marked reductions in morbidity and mortality. However, global progress has slowed in recent years, particularly in the WHO African Region, which accounted for 94% of the world’s 229 million cases in 2019 [4] [5]. The world is now committed to an ambitious goal for malaria elimination by 2040-2050 using cost-effective participatory public health interventions [6] [7] [8] [9]. Malaria remains the major cause of disease and death in the world, especially among children and pregnant women [10] [11] [12] [13] [14]. Some population groups are at considerably higher risk of contracting malaria, and developing severe disease, than others. These include infants, children under 5 years of age, pregnant women and patients with HIV/AIDS, as well as non-immune migrants, mobile populations and travelers [1]. In Yemen, where is 60% of the total population living in malarious areas, the disease remains a significant health problem [14] [15] [16]. Malaria has historically been a major public health concern in Yemen, noted to be the country of highest prevalence in the Eastern Mediterranean Region [15]. Three Plasmodium species (P. falciparum, P. vivax and P. malaria) are reported in Yemen with P. falciparum being the predominant species [14] [17] [18]. As more and more children attend school, governments are increasingly recognizing the importance of child health for educational achievement [19] [20]. School-age children represent (25%) of Yemen’s population and an increased proportion of these children are going to school, who could benefit from a systematic approach to school-based malaria control [21]. The study aimed to assess baseline knowledge, attitude and practice of pupil towards malaria before the health education activities.

We conducted a cross-sectional study, in four randomly selected districts (rural and urban) of Taiz governorate, Yemen. The study was conducted in Feb. 2013. The study population was 2130 pupils of primary schools. The sample size was calculated using Epi Info. version 3.5.1 (August2008). According to the following criteria:

1) The population size of Taiz basic school children = 593,246 pupils [22].

2) The expected prevalence = 50% (since we don’t have previous study that showed behavior change, so select 50% to give us maximum sample size.

3) The worst acceptable results = 3% (percent that we can accept the deviation of the study result (sample statistics) from population parameters.

4) Corresponds to the level of significance 95%.

Based on that, calculated sample size was found to be 1065 pupils.

A larger sample size is needed, because of the design effect. Since we will use (Urban-Rural), the design effect (DEFF) was estimated as 2. The including criteria are: 1) Pupils of 6, 7 and 8 grades, 2) Participant voluntary agreed to participate in the study. The excluding criteria are: 1) Pupils from other grades of the same schools, 2) Students from other than selected schools.

(N.B: This is the first research (base line study). In the second research the sample sized was divided in to two group intervention group (1065) and non-intervention group (1065). The control group (non-intervention group), half of them (533) which had pre-intervention questioner) and the other half (532) we distributed to them a questionnaire post intervention only to avoid the effect of the questionnaire questions (reactive effect of instrument) we only took their demographic characteristic. So, the sample sized in this research was 1065 + 533 = 1598). Specially designed Arabic questionnaire was prepared by principle investigator, the questions related to bed net was taken from previous study, that conducted in Yemen about BN [23]. The questionnaire includes demographic, knowledge, attitudes and practice data. The variables are: Demographic (age, sex). Knowledge about mode of malaria transmission, cause of disease, symptoms, complication of disease, prevention, information about bed net and sources of information. Attitude and practice (what are group you think are at high risk in malaria, is bed net prevent from malaria, do you think health education about malaria is important, sleeping under bed net, and washing of bed net). The questionnaire was validated by experts from Sana’a University and from the Ministry of Public Health & Population. The questionnaire includes demographic, knowledge, attitudes and practice data, the same questionnaire was used. One pilot study was conducted before implementation of the study in two schools urban and rural. Data collectors were trained to ensure the standardization of data collection. At the end of each day of data collection, the completed questionnaires were checked for errors, and completeness, the data was coded to be suited for computer feeding.

We used mean and standard deviation for continuous quantitative variables such as age, others categories of variables were presented in form of tables.

Interpretation:

Very good knowledge = correct answer for (75%) and above of questions.

Good knowledge = correct answer for questions (50% to 74%).

Poor knowledge = correct answer for questions (less than 50%).

We used 5 points Likert scales to measure the attitude (strongly agree, agree, uncertain, disagree and strongly disagree).

Informed consent was obtained from parents/caretakers along with the children’s assets. Institutional approval was obtained from the Ministry of Education Office in Taiz Governorate, district education offices, and headmasters of targeted schools before the start of data collection.

The knowledge of correct mode of transmission was (48.2%), we observed that (51.9%) of pupils believed that drinking dirty water and eating dirty food cause malaria. This misconceptions among our study population was more than the misconceptions observed in previous studies conducted in India [24], Zimbabwe [25] and in Nigeria [26] where the misconceptions were (32.8%), (19.2%) and (42.7%) respectively. The percent of pupils who know that the fever is the most important symptom of malaria was (49.2%), and (18%) for headache, while in Nigeria the most obvious symptoms of malaria to the students when they fell ill due to malaria was fever (22.3%), while headache was (49.6%) [26]. The percent of knowledge in our study findings is less than the findings of a study conducted in Loags in Nigeria [27], Our results in this regard are much less than other study conducted in Uganda where the knowing of fever was (91.3%) [28]. More than one third of pupils in our study (37.4%) don’t know any of malaria complications, while (17.6%) mentioned convulsion and (3.9%) mentioned anemia. The main source of BN information in our study was radio and TV (36%) of those who had heard about BN, while the schools represent only (0.7%) as a source of information. A study conducted in Nigeria obtained that (33.8%) had heard about BN over the radio, (22.5%) through the television, (11%) had heard about malaria from their teachers [29]. While in Tanzania the sources of information about malaria and its control were mainly from their teachers (47.4%) [30]. Our findings regarding the school as a source of bed net information is noticeably less than finding of studies conducted in Nigeria (47%) [29], India (26.7%) [24] and in Tanzania (47.3%) [30]. in our study revealed that (48.6%) agreed that health education was useful in malaria prevention, this was less than a study conducted in India that obtained (76.5%) of the respondents affirmed that health education is the best way to promote the prevention of malaria [31]. Factors such as vulnerability, economic constraints, inadequacy or unavailability of appropriate health services, and other related factors play an important role in explaining health seeking behavior of the people [26]. Personal protection is widely used and accepted to prevent mosquito bites [29]. We observed that, (55.3%), (4.9%), (29.2%) and (12.3%) of pupils mentioned the cover of the water tank, IRS, BN and used repellent were a protective method respectively. This result was similar to a result in the MIS (Malaria Indicator Survey in 2009) in Yemen, where one third of respondents (34.2%) identified sleeping under the bed net as a malaria preventive method and (9.5%) for used repellent. Our result was also similar to the study conducted in Tanzania [30], which obtained the knowledge of malaria preventive methods was varied among districts ranging from (19.4%) to (93%) to residual house spraying, and low (0.2%) to (22.7%), (8.1%) to (24.5%) to mosquito nets and repellents, respectively. Regarding usage of BN as personal protection, in our study only (12.3%) identified sleeping under the bed net as a malaria preventive method, this was less than studies conducted in Nigeria that showed (70.5%) of the respondents were aware that insecticide-treated nets kills mosquitoes [29]. Study conducted in Tanzania revealed that availability of mosquito nets was relatively high (70%), but only (38%) of the pupils were using insecticide treated nets [30]. And study conducted in Ghana, where were the most children under five years of age have yet to be protected by ITNs [20], revealed that (96.3%) believe that the BN are effective, another studies conducted in Ghana [32], and Nigeria [33], showed that (32.7%), (54.7%) of the respondents that owned ITN respectively did not use them. The schoolchildren who answered correctly more than 12 of the 23 knowledge questions were (4.9%) while it was (10.7%) in China [34]. Regarding to the perception of pupils toward importance of BN in prevention of malaria, (24.8%) of pupils were strongly agreed, while in Ghana (96.3%) believed that BN are effective [20]. In our study the positive attitude toward the seeking medical care was (40.2%). This is less percentage than the study in China conducted that obtained (78 %) of the respondents were had the positive attitude toward seeking medical care [34]. Our study revealed that availability of mosquito nets was relatively low less than 10%, It was less than the findings of MIS Yemen 2009, which showed that the percentage of households who own at least one BN was (15%). May be this is due to limited study area of our study (Taize).

School pupils must have time for health activities due to activities that are not based on the curricula increased teachers work load.

The percentage of malaria knowledge and methods of prevention was low (24.5%). Also, the positive attitude and practice of malaria prevention was 45%. The rate of having bed-nets was very low (10.1%). There are still misconceptions of malaria cause and transmission (48.1%). There is a need for the conduct of health education activities that will focus on increasing the knowledge, attitude and practice levels of malaria among school pupils. Shifting the perceptions and attitude of schoolchildren in a positive mode will improve the best methods towards malaria prevention between school pupils and reflects that to the community on the whole.

Authors deeply acknowledge facilitation made by the education office in Taiz Governorate, targeted districts, and headmasters of targeted schools, thanks to all participants (school children) and their caretakers for their cooperation in conducting this KAP study.

Informed consent was obtained from each pupil enrolled in the study.

Approval was obtained from the health office authority and education office in each district in Taiz governorate.

The authors declare no conflicts of interest regarding the publication of this paper.

Farea, B.A., Aljasari, A.N., Baktayan, N.A., Farea, A.A. and Assabri, A.M. (2022) A Cross-Sectional Survey of Knowledge Attitude and Prevention Practice towards Malaria among Basic Schools Pupils Prior to Health Education Campaign. Journal of Biosciences and Medicines, 10, 143-157. https://doi.org/10.4236/jbm.2022.104013

A questionnaire on the impact of health education of malaria disease on the knowledge and behavior of school students in Taiz governorate

Dear student, put a mark (√) or (x) on the phrase you deem appropriate.

Date:

Serial number:

District:

Al-Qahera Sala Ataazya Ashamayatean

First: the demographic characteristics

1) Age in years:

2) Sex:

Male Female

3) The educational level of the student) class): 6 7 8

4) The educational level of father:

Illiterate Basic High school University

5) The educational level of mother:

Illiterate Basic High school University

6) Average household income per month:

10,000 - 19,000 20,000 - 29,000

30,000 - 39,000 40,000 and more

The profession of the head of the family:

Farmer Employee Retired Other: mention

Second: Knowledge:

1) Malaria is transmitted to humans by: -

Flies Eating contaminated food Mosquitoes bite

Other: mention Don’t know

2) What are the symptoms of malaria? (More than one answer can be chosen)?

Fever Vomiting sweating headache anemia

Joint pain Loss of appetite Shivering

Other: mention Don’t know

3) Malaria complications are (more than one answer can be chosen

High fever Spasm Coma Cerebral malaria abortion

Kidney failure The birth of low-weight baby Other: mention

All of above Don’t know

4) How can we protect ourselves from malaria (more than one answer can be chosen)?

Covering tanks Backfilling ponds Draining stagnant water

Making nets on windows Using impregnated nets with insecticide

Spraying with residual pesticide using repellent

Don’t know Other (mention)

5) Do you have information about the impregnated bed nets?

Yes No

If no, go to Question 7

6) If the answer is yes to the previous question, then what is the source of this information (more than one answer can be chosen)?

Mosquito nets distribution team Television

Imam of the mosques Radio The health office/health facilities

Schools newspapers poster and leaflet

7) Do you know anything about the treatment of malaria?

Yes No

8) If yes, mention some of the treatments used

---------------------------1-----------------------------------------2

Third: Attitudes, beliefs and behavior:

1) Who are the most vulnerable groups to severe malaria (more than one answer can be chosen)?

Adult children elderly pregnant women

Other: mention Don’t know

2) Do you think you are at risk of malaria this year?

Agree Strongly agree Disagree Strongly disagree

Don’t know

3) Do you think the most important symptom of malaria is fever?

Agree Strongly agree Disagree Strongly disagree

Don’t know

4) From your point of view, is awareness of malaria useful?

Agree Strongly agree Disagree Strongly disagree

Don’t know

5) Do you belief that the insecticide-impregnated bed nets protect from malaria?

Agree Strongly agree Disagree Strongly disagree

Don’t know

6) Do you belief that the spraying with residual pesticide protects from malaria infection?

Agree Strongly agree Disagree Strongly disagree

Don’t know

7) Do you belief that taking malaria treatment immediately after diagnosis and in a correct way can protects from malaria complications?

Agree Strongly agree Disagree Strongly disagree

Don’t know

8) If you get infected with malaria, where do you take the treatment of malaria?

From the pharmacy From doctor or near health center

From home without a prescription Traditional healer others

9) Do you have a mosquito net at home (in the absence of a net, do not complete the questionnaire)

Yes No

10) Does anyone sleep under the net?

Yes No

11) How many people usually sleep under a net?

2 3 4 5

12) What is the time to use the mosquito nets?

After sunset After Isha’a prayer After 10 O’clock

Other: mention

13) Who usually sleeps under a mosquito net?

Head of family Mothers Pregnant women

Children less than 5 years Any one

14) Did the pregnant woman sleep under the bed net last night?

Yes NO Not applicable (no pregnant woman)

15) Did children under five years of age sleep under the bed net last night?

Yes NO Not applicable (no children under 5 years)

16) Is it a habit in this home for people to sleep under an impregnated net?

Yes NO

17) If the answer is “yes” to Question 16, why?

Protect from mosquitoes

Protect from the harm of flies and other insects

Other: mention Don’t know

18) If the answer is “NO” to Question 16, why?

NO mosquitoes and other insects Need fixation

Chemicals cause allergies and diseases for pregnant women and children

Other: mention Don’t know

19) What is the season for using mosquito nets in a year?

Summer Winter Other: mention

20) Where the nets are placed after use? (Can choose more than one answer)?

The cupboard Hangs over the crib

Other: mention Don’t know

21) How to protect impregnated net from damage (more than one answer can be chosen).

Keep away from children Keep away from fire

Keep out of the sun Other: mention

22) What do you do if the mosquito nets are torn?

Leave it as it Sew it Don’t know

23) How many times have you washed the impregnated nets?

Never One to two times Three to five times

When becoming dirty Don’t know

Other notes:

Data Collector:

Supervisor: