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Keywords:

  • knowledge;
  • attitude;
  • practice;
  • KAP;
  • mass drug administration (MDA);
  • compliance;
  • malaria;
  • Africa;
  • The Gambia

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

To test the hypothesis that widespread treatment with artemisinin derivatives can reduce malaria transmission, a mass drug administration (MDA) campaign was undertaken in an area of The Gambia in 1999. Coverage of 85% of the target population was achieved, but the intervention did not reduce overall malaria transmission. We studied the perceptions, knowledge and attitudes of the community to the MDA campaign. A validated questionnaire was administered to randomly selected MDA participants (n=90) and MDA refusers (n=71). Individuals who believed in the importance of the MDA (adjusted OR 58.3%; 95% CI 17.4–195.8) and those who were aware that a high level of participation was needed for the MDA to be successful (adjusted OR 28.1; 95% CI 10.3–75.9) were more likely to participate. Understanding that the purpose of the MDA was to reduce malaria (adjusted OR 13.9; 95% CI 5.5–35.1) and knowledge of the fact that malaria is transmitted by mosquitoes and of the clinical signs of malaria (adjusted OR 3.4; 95% CI 3.1–9.0) were associated with participation. Individuals who discussed the MDA with other villagers (adjusted OR 5.5; 95% CI 2.2–13.5) and those who attended the sensitization meeting (adjusted OR 2.6; 95% CI 1.1–6.0) were also more likely to participate. Women were significantly more likely to participate in the MDA than men (adjusted OR 3.1; 95% CI 1.5–6.2). Individuals who refused to participate were unlikely to plan participation in future MDAs. One of the most difficult challenges in the implementation of a malaria control strategy such as an MDA is to convince villagers to participate and to make them aware that a high level of participation by the community is needed for success. We found that our sensitization meetings could be improved by giving more information on how the MDA works and finding means to generate small group discussions after the meeting.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Close to a million individuals in sub-Saharan Africa were estimated to have died from Plasmodium falciparum malaria in 1995 alone (Snow et al. 1999). Current control strategies have not produced large-scale and sustainable decreases in malaria-related morbidity and mortality. New methods to fight malaria in sub-Saharan Africa are urgently needed. The use of artemisinin derivatives, which not only kill asexual parasites but also reduce gametocyte prevalence, has been suggested as a major factor in decreasing malaria transmission in Northern Thailand. Following the introduction of an artemisinin derivative plus another antimalarial as a component of first line therapy for uncomplicated malaria, a drop in malaria attack rates has been observed (Price et al. 1996).

Decreasing malaria transmission by reducing gametocyte prevalence could perhaps be applied as a control strategy in sub-Saharan Africa. However, unlike Thailand, widespread prompt treatment of a high proportion of infections is unlikely to be achieved as inoculation rates are much higher, parasitaemias are often subclinical, and the majority of infections go untreated (Thera et al. 2000). Furthermore, sub-Saharan Africa does not have the strong infrastructure of Thailand's Malaria Control Programme, which ensures prompt diagnosis and same-day treatment (Wongsrichanalai et al. 2000). To treat most P. falciparum infections in sub-Saharan Africa and to reduce gametocyte prevalence, mass drug administration (MDA) may be required.

To test the hypothesis that mass administration of the combination artesunate and pyrimethamine/sulfphadoxine (PSD) can reduce malaria transmission, a village randomized, double blind, placebo controlled trial was undertaken in a defined area of the Gambia in 1999. After two rounds of drug administration, 85% of the individuals residing in the study area had received the study drugs. After an initial reduction in malaria attack rates and parasite prevalence in treated villages compared with control villages, no overall benefit was observed (von Seidlein L, Walraven G, Alexander N et al., unpublished data). It is possible that very high coverage is one of the factors needed to have an impact on malaria transmission.

Unlike other malaria control strategies such as the use of impregnated bed-nets or chemo prophylaxis during pregnancy that benefit the individual, an element of altruism is required for a successful MDA. Altruistic behaviour in public health interventions implies the willingness to participate not necessarily for one's own benefit but for the benefit of the community at large. Altruistic community co-operation is a key factor in preventing malaria transmission by reducing gametocyte prevalence through strategies such as mass administration of gametocyte-reducing drugs or immunization using a transmission-blocking malaria vaccine. An understanding of how communities perceive a mass distribution campaign is important to achieve greater support in future MDAs or other interventions that require a high level of participation. We studied the knowledge, attitudes and perceptions of the community to the MDA campaign in 1999, particularly the factors associated with participation or nonparticipation.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The study was approved by the Ethics Review Boards of Gambia Government/Medical Research Council Laboratories.

Mass drug administration

The study was undertaken in 42 villages (total population of 16 442) east of Farafenni, a rural area in the Gambia 170 km from the capital. Eighteen of the 42 villages, called here `surveillance villages', were selected according to size and location within the area to measure the impact of the intervention. These 18 villages were randomized to receive PSD plus artesunate or an inactive placebo in a double blind, village randomized fashion. In the remaining 24 villages PSD combined with artesunate was distributed in an open fashion. Prior to the drug administration, the alkalo (chief) of each village and the village elders were invited for a whole-day orientation workshop. Subsequently sensitization meetings were organized in each village in the second and third weeks of May 1999. During these meetings, the purpose and the conduct of the MDA campaign was explained by the district health team and discussed with the villagers.

Informed consent was obtained at the community level at the time of these meetings and subsequently from each individual at the time of the drug distribution. The drugs administered consisted of a single dose of artesunate and PSD, a total of seven tablets for each adult. The dose for children was calculated on a mg/kg basis. The safety and efficacy of a 3-day regimen had been compared with a single dose regimen in the year preceding the MDA (von Seidlein et al. 2000). There was no statistically significant difference in effect between the two regimens. Because of the logistic difficulties to supervise drug administration for 3 consecutive days and the expected drop in compliance the single day regimen was chosen for the drug administration. All individuals residing in the study area were eligible for treatment except children under 6 months of age and pregnant women, who received an iron and folic acid supplement.

To have a maximum impact in reducing gametocyte prevalence and subsequent malaria transmission, the MDA was scheduled at the end of the dry season. Malaria is highly seasonal in The Gambia. An increase in malaria transmission follows the start of the rains, which typically lasts from July to September. The rainy season is also the period of most intense agricultural activity. The existing census was updated in May and the initial round of MDA took place during the first 2 weeks of June, including travellers and migrant workers returning to the study area for farming. The MDA team chose a central location in the village, usually the bantaba (a shady resting-place) or the Primary Health Care building. The villagers were requested to take the drugs under direct observation. A repeat drug dose was given if vomiting occurred within 1 h of drug administration.

Using the census database in which every individual residing in the study area has a unique identification, the level of participation in the MDA was recorded. The de jure population, which excluded the deceased, individuals who had moved away permanently and infants under 6 months of age, made up the denominator. All individuals who were observed taking the study drugs were included in the numerator. Infants under 6 months of age were not included because they were protected by maternally acquired immunity, had not been exposed to a malaria transmission season, and were less likely to carry gametocytes. In contrast, as pregnant women are at risk of being gametocyte carriers, they were included in the denominator. In the 42 villages, the coverage was 73% (range 25–93%) after the first MDA round. A mop-up round was carried out during the third and fourth weeks of June. During the mop-up round census sheets indicating the treatment status of each individual were used to locate untreated individuals in house to house visits. Following the second round of drug distribution, the coverage in the 42 villages was 88% (range 60–100%).

Study of knowledge, attitudes and practices

The research tool was a structured, previously validated questionnaire used to explore knowledge, attitudes and practices about malaria (Agyepong & Manderson 1994). The questionnaire was modified to include questions on the MDA and piloted in villages not included in the present study until a comprehensive, easy to use version had been developed. Two interviewer-interpreters administered the questionnaires independently after a period of training and supervision. The interviews were conducted during the month of August, two months after the administration of the drugs, while the evaluation of the intervention was still ongoing.

We excluded 24 villages with less than five individuals who had refused to participate in the MDA and conducted the study in the remaining 18 of 42 villages (43%). Four of the 18 were surveillance villages. Five individuals who participated in the MDA (called here `participants') and five individuals who refused (called here `refusers') were interviewed in each village. Interviewees were selected using random numbers based on the participation status recorded in the census database (Smith & Morrow 1996). If a randomly selected individual could not be found or declined to be interviewed, a second attempt was made to interview the individual. If the second attempt failed, the participant or refusal with the next highest census number was used as replacement. It was not always possible to replace refusers as their number was limited in many villages. An effort was made to interview the alkalo of each of the 18 villages.

Analysis

Comparisons of categorical data were made using Fisher's exact or χ2 test as appropriate and continuous data were compared using Student's t-test. A logistic regression model adjusted for gender, age and being an alkalo was used to test the association between predisposing variables and outcome. Statistical analyses were performed using EpiInfo 6.04 and Stata 6.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Socio-demographic characteristics

During July and August 1999, 161 of 180 selected individuals (89%) were interviewed. Table 1 shows their socio-demographic characteristics, which were similar between the 90 participants and the 71 refusers. Most individuals had a minimum of formal education and were engaged mainly in farming.

Table 1.  Socio-economic and demographic characteristics of the study population Thumbnail image of

General understanding of malaria and malaria control measures

In response to the question of what is the most important health problem in the village, the most frequent answer was general body pain (151/161; 94%), followed by malaria (119/161; 74%), diarrhoea (113/161; 70%), chest infection (50/161; 31%), tuberculosis (31/161; 19%) and sexually transmitted diseases (1/161; 1%). The signs and symptoms most frequently associated with malaria were headache (155/161; 96%), general body pain (155/161; 96%), fever (152/161; 94%), dizziness (146/161; 91%), vomiting (123/161; 76%), shivering (120/161; 75%) and diarrhoea (104/161; 66%). Overall, 134/161 (83%) of the individuals interviewed knew that malaria is transmitted by mosquitoes. Unhygienic surroundings, rains, and God were mentioned as causes for malaria by the rest.

Malaria preventive measures included keeping the home dark (147/161; 91%), burning churai, a locally produced insect repellent (138/161; 86%), cutting the surrounding grass (103/161; 64%), keeping the environment clean (98/161; 61%), bed net use (91/161; 57%), draining puddles (82/161; 51%), mosquito coil use (61/161; 38%), spraying the household with insecticide from a canister (35/161; 22%) and use of local herbs or traditional medicines (9/161; 6%). 57% slept under a bednet, giving reasons such as protection against mosquito bites (89/91; 98%), prevention of malaria (4/91; 4%) and privacy (1/91; 1%). Only 4 of the 91 bednet users (4%) had impregnated their net by the time of the interview, which was after the malaria transmission season had started. Twenty-five percent (23/91) stated they had treated their bednet during the preceding year; 51 of 91 bednet owners (56%) had never treated their nets. Reasons for nonimpregnation included a shortage of insecticide (46/86; 54%), no money to buy insecticide (20/86; 24%) or the use of alternative insect repellents.

Factors associated with participation or refusal to participate in the MDA

The belief that the MDA is important and awareness that a high level of community participation is needed for an MDA to be successful were strongly associated with participation (Table 2). Understanding the aetiology of malaria, malaria control measures and the reasons for the MDA were associated with participation. Participants were more frequently women than men.

Table 2.  Factors associated with participation or refusal to participate in the mass drug administration (MDA) ranked by adjusted Odds Ratio (OR) Thumbnail image of

Participants were two and a half times more likely to have attended the sensitization meeting than those who refused to participate. Those who were unable to attend the sensitization meeting gave the following reasons: working at the farm or in the compound (46/112; 41%), not knowing about the meeting (19/112; 17%), travelling on the day of the meeting (18/112; 16%), being intimidated by the presence of village elders or husbands (14/112; 13%), old age or poor health (12/112; 11%), unwillingness (3/112; 3%), attending school (2/112; 2%) and being forbidden by the husband (1/112; 1%). 50/103 (49%) of individuals who did not attend the sensitization meeting did not participate in the MDA. Alternative sources of information on the MDA were compound members (63/152; 41%), household members (30/152; 20%), health care workers (15/152; 10%), fellow villagers (9/152; 6%) the alkalo (6/152; 4%) and village elders (6/152; 4%). Individuals who had learned about the MDA from healthcare workers (14/15; 93%) were more likely to be aware that a high level of participation is important for success of the MDA than individuals informed by other sources (53/88; 60%; P=0.013).

Perceptions about the present and future MDAs

Eighty-six of the 90 participants interviewed (96%) received the drugs at the bantaba or Village Health Post and the remainder during house to house visits. Of these, 84/86 (98%) thought the setting was appropriate. Participants remembered that the waiting time was less than 10 min in 87% of the cases. P-value=< 0.001, OR=52.8 (95% CI 17.4, 185.7)]. The reasons for compliance in future MDAs included: `it is for prevention of malaria' (43/77, 56%), `we want to have good health' (8/77, 10%), `the medicine is good' (7/77, 9%) and `so that I can be protected from mosquito bites' (1/77, 1%). Various reasons were given by the 9 participants who were unwilling to participate in future MDAs. Two said `malaria is not a problem for me' and one each said `I was sick after taking it', `I only take medicine when I am ill', `I never take any medicines', `I never take medicines in the form of tablets' and `I can't take 7 tablets'. A group of individuals said that they would only take MDA in the future under certain conditions. These included the following: if they could see the benefit from MDA in that they did not get malaria this year (18/35, 51%), if other individuals take it (8/35, 23%), if they have time (3/35, 9%), if the subject knows what the medicine is for (1/35, 3%), if the drug is given as an `injection' (1/35, 3%) and if no blood is taken (1/35, 3%). Overall, 97/161 (60%) of the individuals interviewed would recommend the MDA to someone else, with MDA participants nearly 40 times more likely to do so than MDA refusers (P-value=< 0.001, OR=38.3, 95% CI 14.0, 108.6).

The reasons for refusing to participate in the MDA are presented in Table 3. Three individuals were told not to take the medicine: two women were warned not to do so by their husbands and one was a man advised by village youths not to participate because he was too old. Three individuals suggested `if we take MDA the Medical Research Council people will come and take our blood later', and one individuals each said `I do not want to have the medicine tested on me' and `I do not have any business with your medicine', `I do not take drugs by mouth, only injections', `I only want eye medication', and `medicine cannot do anything for me'. Two individuals thought that they could not receive MDA as they were nonambulatory.

Table 3.  Reasons given for not participating in the mass drug administration (MDA)* Thumbnail image of

Asked how the village could help in future MDA programmes, the villagers suggested that they should discuss the programme amongst themselves or that the alkalo should call a meeting at the bantaba and discuss the programme. The villagers should be asked whether they wanted to accept or decline, discuss how the programme should be implemented and how to inform the individuals about its importance. The villagers should explain the programme to each other and especially to those who do not want to co-operate. The alkalo should also visit each compound. When the drugs are distributed, the villagers should gather at the predetermined place and take an active part in the programme.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Considerable resources are directed at biomedical research that aims to develop improved malaria control strategies. It has been more recently acknowledged that understanding psychological factors is important in the successful implementation of these strategies. Following a mass drug administration aimed at reducing the transmission of malaria we identified reasons why some villagers had refused to participate. Ignorance of the disease and insufficient understanding of the MDA were the paramount reasons for refusal to take antimalarials during the campaign. Individuals who considered malaria a health problem and/or understood the basic biology and signs and symptoms of the disease were significantly more likely to participate in the drug administration than those who did not.

Overall, 101/161 (63%) of the individuals interviewed were aware of the need for a high level of community participation for success of the MDA. This awareness was highly associated with participation. Individuals who were aware of the need for community participation did not differ in gender, age, educational level or attendance at sensitization meetings from individuals who were not. Awareness of the need for a high level of community participation for success of the MDA may be interpreted as altruism. However, the concept of altruism implies a range of individual choices. In reality, individual choices may be limited in rural communities in The Gambia and as found in Malawi, social factors such as pressure from elders or officials may be more important in determining compliance with malaria control procedures (Ager 1992).

Individuals who had learned about MDA from healthcare workers were more likely to know that a high level of participation is important for success of the MDA than people informed by other sources. It is possible that the healthcare workers were able to influence individuals. Alternatively, villagers who believed in community participation may also have closer links with health workers.

A negative attitudinal set to nontraditional medicine and medical research appear to be the reason for some of the nonparticipation. We encountered a hostile attitude on an individual level as well as on the village level. In many, but not all, villages one or more individuals refused to take medication and clearly indicated that he or she did not want anything to do with the drug administration or the healthcare workers. The observation that only 7% of refusals in contrast with 80% of the participants would consider participation in future MDAs illustrate this antagonistic attitude. In some villages, opinion makers and decision makers were antagonistic to the proposed undertaking and influenced the initial decision of the villagers. This may have been the underlying cause of the wide variation in coverage after the first round of MDA (25–93%). The recognition of a hostile attitudinal set is important particularly in planning the specific contents of sensitization meetings or educational activities.

Alternative explanations for the variation in participation have to be considered. Differences in the effect of sensitization meetings on the individual as well as village level may have also been an important factor. While the conduct and contents of the sensitization meetings had been discussed during training sessions, it was not prerecorded and the quality of the presentations may have varied between meetings. The contents of the meetings may have been insufficient to allow the villagers to understand the need for participation to make the MDA work.

The mass drug administration campaign conducted in 1999 in The Gambia did not reduce malaria transmission. A participation of 85% of the target population may not be sufficient to reduce the infectious reservoir of P. falciparum. The level of coverage achieved in this study is higher than that achieved in the mass administration of antimalarials in Uganda (50%) (De Zulueta et al. 1964) or Nicaragua (70%) (Garfield & Vermund 1983), similar to coverage achieved in Garki (85%) (Molineaux & Gramiccia 1980), but lower than the coverage rates achieved in Asia (above 88%) (Doi et al. 1989; Kaneko et al. 1994). The outcomes of these previous mass administrations are difficult to evaluate because there were no comparable control groups. A malaria control programme in Aneityum, Vanuatu succeeded in permanently interrupting malaria transmission using nine rounds of MDA with a coverage above 90% in addition to insecticide treated bed nets and larviverous fish (Kaneko et al. 2000). Mass drug administration is likely to be more successful in highland areas in Africa or other regions with low exposure rates to vectors similar to Northern Thailand or Vanuatu. However, even in regions with low malaria endemicity, MDA requires high community participation to affect malaria transmission.

It is not clear whether a different treatment or a 3-dose regimen of artesunate combined with PSD instead of the single-dose regimen can overcome the limitations of MDA in reducing malaria transmission. We found during the interviews that a third of the individuals who took the treatment complained of temporarily associated adverse events, including stomach pain, vomiting and diarrhoea (data not shown). In addition to the logistic challenge involved in administering a three-dose regimen, a significant drop in compliance for the second and third dose should be expected.

Our experience suggests that large sensitization meetings should have been followed by smaller group discussions guided by healthcare workers. Because all villagers cannot attend the main meeting, discussion of malaria and the MDA in smaller groups seem to be very important. The presentations should be reproducible on many occasions without a decrease in quality. One possibility is to record the presentation and play it on the radio or show it on video. Messages can also be related in the form of drama or play-acting. Our sensitization meetings were attended by 49/152 (32%) of the individuals interviewed. The attendance could be improved by advertising and prudent scheduling. Evening sessions may be considered because farming and other household duties take precedence during daytime. Targeting males for educational interventions may be an effective approach to increase participation. Men not only participated less frequently in the campaign, but also have the power to obstruct the participation of other family members.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We would like to thank the villagers who took time to answer our questions, Jane Rowely, Mayira Sojo Milano and Shabbar Jaffar who gave us essential advice, and the anonymous reviewers who gave the discussion new perspectives. We are most grateful for Oumie Fattie's and Awa Bah's fieldwork and translations.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  • 1
    Ager A (1992) Perception of risk for malaria and schistosomiasis in rural Malawi. Tropical Medicine and Parasitology 43 , 234 238.
  • 2
    Agyepong IA & Manderson L (1994) The diagnosis and management of fever at household level in the Greater Accra Region Ghana. Acta Tropica 58 , 317 330.
  • 3
    De Zulueta J, Kafuko G, McCrae A et al. (1964) A malaria eradication experiment in the highlands of Kigezi (Uganda). East African Medical Journal 41 , 102 120.
  • 4
    Doi H, Kaneko A, Panjaitan W, Ishii A (1989) Chemotherapeutic malaria control operation by single dose of Fansidar plus primaquine in North Sumatra Indonesia. Southeast Asian Journal of Tropical Medicine and Public Health 20 , 341 349.
  • 5
    Garfield RM & Vermund SH (1983) Changes in malaria incidence after mass drug administration in Nicaragua. Lancet 2 , 500 503.
  • 6
    Kaneko A, Taleo G, Kalkoa M et al. (2000) Malaria eradication on islands. Lancet 356 , 1560 1564.DOI: 10.1016/s0140-6736(00)03127-5
  • 7
    Kaneko A, Taleo GK, Rieckman KH (1994) Island malaria control in eastern Melanesia: (1) Malaria eliminated from a small island by 9-week mass drug admistration and impregnated bednets. Japanese Journal of Parasitology 43 , 358 370.
  • 8
    Molineaux L & Gramiccia G (1980) The Garki Project. Research on the Epidemiology and Control of Malaria in the Sudan Savanna of West Africa. WHO, Geneva.
  • 9
    Price RN, Nosten F, Luxemburger C et al. (1996) Effects of artemisinin derivatives on malaria transmissibility. Lancet 347 , 1654 1658.
  • 10
    Smith PG & Morrow R (1996) Field Trials of Health Interventions in Developing Countries. A Toolbox. Macmillan, London.
  • 11
    Snow RW, Craig M, Deichmann U, Marsh K (1999) Estimating mortality, morbidity and disability due to malaria among Africa's non-pregnant population. Bulletin of the World Health Organization 77 , 624 640.
  • 12
    Thera M, D'Alessandro U, Ovedraogo A et al. (2000) Child malaria treatment practices among mothers in the district of Yanfolila, Sikasso region, Mali. Tropical Medicine and International Health 5 , 876 881.
  • 13
    Von Seidlein L, Milligan P, Pinder M et al. (2000) Efficacy of artesunate plus pyrimethamine-sulphadoxine for uncomplicated malaria in Gambian children: a double-blind, randomised, controlled trial. Lancet 355 , 352 357.DOI: 10.1016/s0140-6736(99)10237-x
  • 14
    Wongsrichanalai C, Thimasarn K, Sirichaisinthop J (2000) Antimalarial drug combination policy: a caveat. Lancet 355 , 2245 2247.DOI: 10.1016/s0140-6736(00)02416-8