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Perceptions of Malaria in Limpopo Province, South Africa Daniel Brooks1*and Kate Abney2 Each year, approximately one million people die from malaria, and more than 90% of these people are from Sub-Saharan Africa (World Health Organization 2011). Despite the magnitude of this epidemic, people in this region of Africa, particularly those who live in rural areas, are still largely unaware of the characteristics of this disease. The aim of this study is was to assess malaria awareness in the HaMakuya District, located in the Limpopo Province of South Africa. Thirteen households were randomly interviewed using an open-ended questionnaire. The level of malaria awareness in respondents was analyzed in four key areas: transmission, initial symptoms, treatment, and prevention. The participants’ knowledge was then linked to the source of their information.. Although respondents were knowledgeable about the initial symptoms and treatment of malaria, based on discrepancies in personal knowledge and scientific facts outlined in government publications from the Center for Disease Control and World Health Organization, the data indicated that few people understood the means of malaria transmission, as well as the methods of prevention preferred by the medical community.. Out of both personal and institutional sources of information, the Department of Health and the Makuya Clinic were the most effective institutions in conveying mosquitoes as the vector of malaria. INTRODUCTION Malaria is a mosquito-borne disease responsible for approximately 2.7 million deaths annually, and is thus recognized as a serious threat to public health (Govere 2000). The disease itself, however, is not equally distributed across the globe. Due to Africa’s sub-tropical climate and its inability to prevent the spread of infected mosquitoes (due to economic difficulties), malaria has thrived in this continent (Blumberg 2007). Africa has the highest malaria incidence and mortality rates of the world with 85% of cases and 90% of deaths globally (Blumberg 2007). In South Africa, the regions containing the highest number of cases include the Limpopo, Mpumalanga, and Kwazulu-Natal provinces (Gerrtison 2008). The area of study, HaMakuya, located within the Limpopo Province (south of the Zimbabwe border) has a high incidence of malaria. On average, the Makuya Clinic, which currently serves the 22 villages of HaMakuya, sees around 3to 5 cases of malaria per week during the rainy season (December to March) (Makuya Clinic pers. comm.). Although policy makers and health care officials, who seek to implement programs and policies to reduce malaria incidence and mortality, understand the disease itself, the perceptions of those who are most often affected are not entirely understood (Govere 2000). These perceptions must be recognized in order to have meaningful educational interventions to combat malaria. Using the local clinic’s informational pamphlet, World Health Organization (WHO) standards, and previous research conducted in this field, the translators and I 1

University of Pennsylvania, 423 Guardian Drive #175, Philadelphia, PA 19104 2

University of Cape Town, Private Bag X3, Rondebosch 7701, South Africa *

To whom correspondence should be addressed: [email protected]

formulated guidelines for appropriate and inappropriate methods of malaria treatment and prevention (Makuya Clinic pers. comm., World Health Organization 2011, Opiyo 2007). This project primarily focused on analyzing the awareness and various perceptions of malaria based on knowledge of mode of transmission, initial symptoms, preventative measures and treatment of the disease. It also analyzed the source of people’s knowledge of the disease to better understand the origins of these perceptions and to provide a basis for appropriate malaria education strategies. After analyzing the data, findings were compared to a project (with a similar research protocol) conducted by researchers from the University of Cape Town in the previous year on perceptions of malaria in the nearby Dotha Village (also located in the HaMakuya District). Even though the villages are located only 50 miles apart, the results from last year’s research closely resembled the data gathered from this study - gaps in knowledge of malaria continue to persist, even though the local government has increased efforts to promote awareness of the disease in the region. Location of Study The study was conducted in Tshambuka Village of the HaMakuya District, in the Limpopo Province of South Africa. The village, located about two kilometers away from the Makuya Clinic, is near the Mutale River, which is a potential breeding site for infected mosquitoes. The primary language spoken is TshiVenda. The village consists of 23 households, of which 13 were surveyed. Socio-Demographic Characteristics of Respondents Of the 13 respondents, 2 were male and 11 were female. The age of participants ranged from 23 to 72 (mean=44, median=42, SD=7.89). The level of education varied:31% of participants completed primary school, 46% completed secondary school and 23% completed senior secondary school. Ten out of thirteen 5

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respondents were born in HaMakuya. Three respondents were born in South Africa’s capital city, Johannesburg.

contracted malaria, and one respondent said his neighbor had the disease.

Experimental Design and Protocol A team of four interviewers and a translator conducted the survey with the head of each household, asking 11 open-ended survey questions and gathering socio-demographic information. Questions were asked in English and then translated into TshiVenda, and translations were kept consistent throughout the survey process. (Appendix A). The questions were used to determine basic knowledge of malaria, including transmission, symptoms, prevention, and treatment. Respondents were also asked where they had extensive knowledge about malaria, and if they had received any contradicting information about malaria transmission.

Knowledge of Malaria Transmission 9 out of 13 respondents identified mosquitoes as the cause of malaria. 3 respondents identified dirty water or sugar cane as the mode of malaria transmission, while one respondent did not know how the disease was transmitted (see Figure 1).

Data Analysis The researchers recorded responses in a general-purpose notebook. Descriptive statistics, including a distribution analysis, were also assembled in with Microsoft Excel software based on the collected data.

Knowledge of Prevention In response to a question about preventative measures, 10 out of 13 participants only provided knowledge of one preventative measure, while 3 participants mentioned two preventative measures (a total of 16 )7 of these 16 were considered appropriate methods of prevention, based on guidelines outlined by the Makuya clinic and previous research (Makuya Clinic pers. comm., Opiyo 2007). Out of 13 participants, only 4 were able to identify a recommended preventative method, while 2 of respondents were not able to identify any of these measures (see Figure 3). The remaining 7 respondents identified an undesirable preventative measure (according to WHO guidelines).

Ethical considerations This research was approved by the Limpopo Provincial Department of Health. Prior to each interview, the translator explained the background and purpose of the study and each participant gave written informed consent. At the conclusion of each interview, participants were asked if they had any questions regarding malaria. If they desired more information regarding the disease, researchers responded to their questions.

Figure 1 Number of respondents who mentioned each mode of transmission (Green denotes the correct vector; red denotes incorrect answers regarding modes of transmission).

Knowledge of Initial Symptoms The most commonly mentioned symptoms of malaria were headache, vomiting, and fatigue. 7 of 13 participants were able to identify three or more initial symptoms of malaria. 5 participants were able to identify one or two symptoms, while 2 participants did not know any symptoms of the disease (see Figure 2).

Figure 2 Number of respondents who listed each symptom (Green denotes initial symptoms of malaria; red denotes no knowledge regarding initial symptoms)

RESULTS Overall Awareness of Malaria in the Tshambuka Community 9 out of 13 of participants reported their view of malaria as the most prevalent disease within the village, while 10 out of 13 participants stated that they knew someone who was diagnosed malaria. Nine participants said that a family member had

Knowledge of treatment When asked to consider an onset of initial symptoms of malaria, all 13 respondents said they would go to the clinic for treatment. In a separate question, when asked to consider a diagnosis and subsequent treatment of malaria, all participants again said they would go to the clinic for treatment. . When asked, on average, the participants would wait on 1.5 days to seek treatment, and all 6

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Journal of Young Investigators respondents remarked that they would wait no more than 3 days to go to the clinic. Source of Knowledge about Malaria Participants were asked where they had learned about the disease of malaria. 4 of 13 participants said that representatives from the Department of Health came to their homes and taught them about the disease. Another 4 of 13 mentioned that they had learned about malaria from their local clinic. The next common source of information was the school (for 2 out of 13), followed by personal experience (for a single participant). Education meant knowledge about malaria obtained anytime from primary through post-secondary education and personal experience could denote a family member contracting the disease or knowledge obtained through word of mouth passed down from one generation to the next. 2 of 13 respondents did not obtain any knowledge about malaria from any type of source (see Figure 4).

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Contradicting Sources of Malaria Education In order to assess the effectiveness of different educational sources in accurately communicating the modes of malaria transmission, each participant’s answer to the question regarding how malaria is transmitted was also linked to the source of their information. All 4 participants who had learned about malaria from the clinic correctly answered that mosquitoes are the vector for disease transmission. 3 of 4 respondents who had learned about malaria from the Department of Health’s educational outreach program also correctly answered this question. Only 1 of 2 participants who had learned about malaria from their school education correctly answered this question. 1 respondent who learned about malaria through personal experience was not able to correctly identify how malaria was transmitted (see Figure 4). Due to the variations in responses for other questions, it was difficult to quantify and correct for the effectiveness of sources of knowledge about symptoms of malaria, preventative methods and methods of treatment. When asked if they had received any contradictory or conflicting information about how malaria is transmitted, 5 of 13 of participants responded “yes.” The most common sources of contradicting knowledge came from parents (3 of5 participants), followed by personal experiences (1of 5 participants), and school (1 of 5 participants). When asked what conflicting information was received, the individuals within this group only provided remarked that this conflicting information was about the mode of transmission of malaria. This indicated which sources were not effective in communicating that mosquitoes are the primary mode of malaria transmission (see Figure 5).

Figure 3 Number of respondents who mentioned each method of malaria prevention (Green denotes preferred methods of prevention: red denotes all other reported methods of prevention).

Figure 5 Number of respondents who had received conflicting information about malaria transmission from each source, and the percentage of respondents who had received information on each mode of transmission from each source (Green denotes the correct vector; red denotes incorrect identification of modes of transmission). Figure 4 Number of respondents who learned about malaria from each source, and the percentages of respondents who correctly identified each mode of transmission within each source (Green denotes the correct vector; red denotes incorrect answers regarding modes of

DISCUSSION While analyzing the categories of malaria awareness, we discovered that there were several gaps in knowledge in the community. Though participants generally understood initial symptoms and treatment methods, they lacked knowledge of 7

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Journal of Young Investigators malaria’s modes of transmission and preventative methods. We concluded that this gap in knowledge was related to the source of information. Overall, about 40% of participants misidentified the source of the disease or did not know the origin of malaria. The recent study in the nearby village of Dotha found that 40% of respondents correctly identified mosquitoes as the source of transmission of malaria, compared to 60% of respondents from Tshambuka (Croll et al. 2011: 3). Therefore, despite the fact that the local government has increased education efforts, respondents are still failing to understand the source of transmission and proper prevention techniques. Assessing awareness of the initial symptoms of malaria also played a significant role in understanding the villagers’ knowledge of the disease. The three most common symptoms that respondents reported were headache, vomiting, and fatigue. Community members were well educated about the symptoms of the disease: 85% knew at least one symptom and more than half of the respondents were able to identify three or more symptoms of malaria. Only 15% those that were interviewed were unable to state any symptoms of the disease. This is similar to the data from obtained from Dotha village.(Croll et al. 2011). All participants in the survey practiced the recommended treatment-seeking behaviors for malaria. All participants stated that they would go to the clinic if they noticed any symptoms of the disease. None of the respondents said they would wait more than three days for treatment, and the average response time was 1.5 days. This is strikingly different from the findings reported in last year’s research in Dotha where people would wait an average of 10 days prior to seeking treatment. Possible explanations to these findings include the distance to the clinic, and the villagers’ general awareness of malaria. Particularly, since the clinic is located 30 miles away from Dotha, and there is no form of public transportation, it may be that people would find it difficult to transport themselves to the clinic. In contrast, the clinic is only five miles away from Tschambuka. In addition, government institutions, including the local public hospitals and clinics, have not been able to reach certain villages because of decreased funding from the federal government as they focus on other widespread epidemics like HIV/AIDS. In regards to methods of prevention, only 30% of participants were able to identify an appropriate measure for prevention. Furthermore, 55% of respondents cited preventative methods unrelated to mosquitoes and 15% could not identify any methods of prevention. It could be deduced that these respondents had not yet received information about the recommended preventative measures of malaria. This contradicts the fact that 60% of participants were able to identify mosquitoes as the vector of transmission. Therefore, we conclude that there is a gap in respondents’ understanding of malaria; they may understand the symptoms and treatment, but not the modes of transmission and prevention. Policymakers must take this into consideration when formulating educational strategies to combat the disease. Respondents were more likely to know that mosquitoes

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are the vector of malaria if they had been educated by the Clinic or Department of Health. Other sources of information tended to create confusion about the transmission of the disease. 5 out of 13 respondents had inaccurate information from personal experiences, school, and parents, (parents being the most common conflicting source of information). This information must also be considered in order to create appropriate malaria education strategies. The Department of Health’s education program and the Makuya clinic’s educational efforts were the most common sources of reliable malaria knowledge. Based on this information we concluded that these efforts are vital to improving the community’s awareness of malaria. There were several limitations affecting our research results. Due to time constraints, we were limited in our ability to collect data regarding the prevention, spread, and treatment of malaria. Furthermore, we had a sample size of only 13 participants; therefore, it is difficult to make broad generalizations about the community from this information. We also had to utilize a translator due to the language barrier between the researchers and survey participants. However, there are some inherent issues with using a translator, because some information may be misinterpreted between languages and information could have been lost, which may have potentially skewed the data. In addition, there may be a stigma associated with malaria, which may have made people uncomfortable talking openly about the disease. For example, when asked if they knew anyone who had had malaria, one respondent looked very uncomfortable (according to the researchers) and answered that it was one of her neighbors, and that she was unwilling to give the individual’s name. For ethical reasons, researchers answered questions related to malaria at the end of each interview. However, we believe that there was not enough time for this provided information to have spread to other villagers during the conduct of our study. Future research may wish to analyze several other aspects of malaria awareness. For instance, they may the correlation between education level and preventative methods. The source of education could also be linked to knowledge of other areas, including treatment and preventative strategies, which would provide the basis for determining the sources or methods of malaria knowledge that would be most effective. Acknowledgments We would like to thank the village of Tshambuka for their willingness to participate in our research project. We express our gratitude to Vhosana Maphanda and her family for their hospitality in accomodations. We also wish to thank Elphas Hlungwani who was our translator throughout the research process. REFERENCES 1. Lundmark, R. (2010) European trade in forest products and fuels.Journal of Forest Economics16: 235-251. 8

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Blumberg, L and Frean, J (2007) Malaria control in South Africa-challenges and successes. South African Medical Journal, vol. 97, no. 11, pp. 1193-1197. Croll, L, Guidera, K, Kang, K and Simon, M (2011) Inadequacies of malaria knowledge in rural South Africa, OTS summer 2011, Dotha, Limpopo Province, South Africa. Gerritsen, A, Kruger, P, Schim van der Loeff, M, Grobusch, M (2008) Malaria incidence in Limpopo Province, South Africa, 1998-2007. Malaria Journal, vol. 7, no. 162. Govere, J, Durrheim, D, La Grange, K, Mabuza, A and Booman, M (2000) Community knowledge and perceptions about malaria and practices influencing malaria control in Mpumalanga province, South Africa. South African Medical Journal, vol. 90, no. 6, pp. 611616. Makuya Clinic pers. Comm Opiyo, P, Mukabana, W, Kiche, I, Mathenge, E, Killeen, G and Fillinger, U (2007) An exploratory study of community factors relevant for participatory malaria control on Rusinga Island, western Kenya. Malaria Journal, vol. 6, no. 48. World Health Organization (2011) World Malaria Report. World Health Organization, Geneva, Switzerland.

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