Practices of Malaria Prevention among School Adolescent within Calabar Metropolis, Southern Nigeria

This study examines the practices of Malaria prevention among school adolescent within Calabar Metropolis, Southern Nigeria. Stratified and systematic sampling technique was used to select four hundred (400) respondents used as the sample for the study. Questionnaire was administered to the respondents. Data collected were analyzed by the use of frequency tables, graphs, means, and standard deviation. Chi-square was used to compare proportions and associations between variables. It was discovered that respondents who have heard of malaria 400 (100%) are also aware of Insecticide Treated Nets (ITN), 394 (98.5%) but the use of ITN was substantially average among them. Stagnant water and over grown weeds were identified as breeding site for Anopheles mosquito. Health workers, followed by media were the major sources of information on malaria prevention. It is recommended that school teachers should be empowered with information about the causes of malaria and prevention strategies.


Introduction
Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infective female Anopheles mosquitoes. According to the latest estimates, there were about 219 million cases of malaria in 2010 (with an uncertainty range of 154 million to 289 million) and an estimated 660 000 deaths (with an uncertainty range of 490 000 to 836 000). Malaria mortality rates have fallen by more than 25% globally since 2000 and by 33% in the WHO African Region. Most deaths occur among children living in sub-saharan Africa where a child dies every minute from malaria. Country-level burden estimates available for 2010 show that an estimated 80% of malaria deaths occur in just 14 countries and about 80% of cases occur in 17 countries (WHO, 2013). Together, the Democratic Republic of the Congo and Nigeria account for over 40% of the estimated total of malaria deaths globally (WHO, 2013).
In Nigeria, malaria ranks among the five commonest cause of childhood deaths and also represent 25 to 30% of deaths of children under five (WHO, 1999). It is the commonest cause of outpatient visit in Nigeria and also the commonest cause of school and work absenteeism (Salako, 2001). Najera and Hempel (2006) reported that school absenteeism due to malaria was as high as 70%. Leigton and Foster (1993) reported that in Kenya, 11% primary school students and 4.3% secondary school students missed school days per year due to malaria. They also reported that Nigerian school children missed an estimated 3-12 school days per year (2.6%). Fernando et al. (2003) observed that there was significant adverse impact of repeated malaria attacks on school performance of children. Lallo (2004) stated that malaria is an important cause of adolescents' hospital admission in many sub-Saharan African countries.
Among school adolescents, malaria is responsible for school absenteeism, poor performance in school, examination failures, school dropouts and even death. The problem of malaria among adolescents has largely been overshadowed by the huge burden of HIV/AIDS among this younger age group (Lallo, Olukoya & Olliaro, 2006). The younger age group has been identified as bearing half of the burden of HIV worldwide (Arowojolu, Ilesanmi, Roberts & Okunola, 2002). As much as 60% of school children's learning may be impaired by malaria (Howard & kulie, 1994;Booth & Maclean, 2001;Ekanem et al, 1998;Chukuezi, 1995;WHO, 1998).
In Cross River State in south-eastern Nigeria, malaria is such a significant problem among school children that the state government decided to involve them fully in the implementation of the RBM programme (Ugot, 2003). According to (Ugot, 2003), this is because school children are known to easily imbibe and implement new knowledge and can, therefore easily act as change agents and as role models for their siblings and peers.

Objective of the Study
The general objective of this study is to determine the practices of malaria prevention among school adolescent in Calabar metropolis, southern Nigeria.
1. Calabar metropolis is divided into two strata i.e. Calabar south and Calabar municipal. 2. In each stratum, 3 government secondary schools were selected and employed in the study giving a total of 6 secondary schools. 3. In each school, systematic random sampling technique was employed in the selection of students. Class register was obtained from class teachers and students whose name appeared on the register with even numbers were selected for the study. The procedure continued until 400 students were selected to partake in the study (that is, 200 students from each stratum and 67 students from each school).

Data Collection Tool
A structured questionnaire was designed to generate quantitative data from respondents. The questionnaires were self-administered to respondents with both open and closed ended questions. The questionnaire comprised of 32 items and 4 sections with attention on socio-demographic characteristics, knowledge of malaria, attitude towards malaria and practices of malaria prevention among respondents.

Data Analysis
The questionnaires were manually sorted out and analyze using Statistical Package for Social Science (SPSS, version 15.0) and Microsoft excel 2007. Data was summarized using frequency tables, graphs, means and standard deviations. Chi-square test was used to compare proportions and associations between variables.

Ethical Consideration
Approval was obtained from principals of selected schools. Informed consent was also obtained from students who participated in the study. Confidentiality of information elicited was assured and participation was strictly voluntary.

Results:
All 400 administered questionnaires were returned, giving a response rate of 100%. Of the respondents, 190 (47.5%) were male while 210 (52.5%) were female. The ages of the respondents ranged from 11 to 20 years with a mean age of 14.8 + 4.2 standard deviation. Most respondents were predominantly Christians 393 (98.3%) and in senior secondary classes. About 310 (77.5%) of the respondents reported living with both parents while 75 (18.8%) reported staying with a single parent (Table 1).  In table 2, virtually all respondents reported that they have heard of malaria before 400 (100%) with health workers as their major source of information 152 (38.0%). About 332 (83%) of the respondents reported suffering from a malaria attack one time or the other with at least one bout within the last 12 months 131 (39.5%). In defining malaria, most respondents subscribed to the fact that malaria is a non-communicable disease 200 (50%) while about 137 (34.3%) defined malaria as a communicable disease. Most respondents were knowledgeable about the symptoms of malaria with fever 145 (32.0%), yellow urine 119 (26.3%) and Headache 98 (21.6%) recording highest. A Gargantuan proportion of the respondents held a belief that everyone is at risk of suffering from malaria 173 (43.3%) though children were also seen as high risk group for malaria infection 103 (25.8%). About 340 (85%) reported that mosquito bite is the cause of malaria infection but contrarily, most respondents felt malaria cannot be passed from one person to another 340 (85%). Fifty five (91.7%) say malaria is majorly transmitted via mosquito bite. Most respondents agreed that there are ways one can avoid getting malaria 396 (99%) with the usage of insecticide treated net being the most known method 160 (41.9%). About 392 (98%) of the respondents believed that malaria can be cured with high knowledge of Amalar 150 (38.3%) and Atermisinin Combination Therapy 103 (26.3%) as effective anti-malaria drugs.  While majority of the respondents strongly agreed to the fact that malaria is a disease that kills 140 (35.0%), adolescent should go to the nearest hospital in the event of malaria attack 205 (51.2%) and prevention of malaria is better than curing or treating malaria 310 (77.5%), majority of the respondents strongly disagreed that delay in malaria treated is good 200 (50%) and disagreed that only the use of Insecticide treated net can prevent one from getting malaria 120 (30.0%) ( Table 3).  In table 4, majority of the respondents say they will go to the hospital first if they suffer a malaria attack 320 (80.4%). However, a larger proportion of the respondents claimed to have heard of Insecticide treated net 394 (98.5%) with health workers as their major source of information 177 (45.2%). About 333 (84.7%) of the respondents reported to have used an Insecticide Treated net before but only 175 (54.7%) of the respondents are currently using it. Reasons for non-usage was largely due to the fact that Insecticide treated nets causes heat 102 (37.6%) whereas 52 (19.2%) say they don't have an Insecticide treated net. The hospital/clinic was largely recognized by the respondents as the place where one can get or buy an Insecticide treated net 340 (85.9%). A larger proportion of the respondents reported that removing stagnant water from the environment 124 (33.3%), using anti-malarial drugs 96 (25.8%) and bush clearing around houses 54 (14.5%) were the current method in use to avoid getting malaria.

Discussion
This study showed a high knowledge gap in malaria transmission. About half of the respondents 200 (50%) stated that malaria is a non-communicable disease whereas only 137 (34.3%) defined malaria as a communicable disease. This finding is consistent with others studies carried out within and outside Nigeria. For instance, a cross-sectional survey carried out in a coastal community in Calabar revealed that only nine (2.25%) respondents were able to give a fairly acceptable definition of malaria as an infectious disease caused by the parasitic infection of red blood cells by Plasmodium, which is transmitted by the bite of an infected female mosquito (Udonwa, Gyuse & Etokidem, 2010). This may be due to the fact that teachers in schools lack adequate knowledge of malaria infectious disease and it also indicates inadequacy in health education curriculum. Most respondents reported to have suffered malaria at least one bout within the last 12 months 131 (39.5%). This is evidence to the fact that malaria in highly endemic in Calabar and Nigeria in general.
The major source of information about malaria in this study is via health workers 152 (38.0%). This finding disagrees with other studies where the media (Radio & TV) was the major source of information about malaria (Dambhare, Nimgade & Dudhe, 2012). This is evidence to the fact that health workers in Calabar metropolis are consistently involved in the campaign against combating malaria in order to enhance the achievement of Mellunium Developing Goal target by 2015. Fever 145 (32%) followed by yellow urine 119 (26.3%) then headaches 98 (21.6%) were the response on symptoms on malaria infection. This finding is similar to a study carried out among school adolescent in Wardha district Central India where fever was the most highly recognized symptom of malaria (Dambhare, Nimgade & Dudhe, 2012, Okwa, Bello and Olundegun, 2011). Two-third of the respondents knew that mosquito bite was the major cause of malaria. This finding corroborates with a study carried out by Udonwa et al, 2010 andMuula &Chimalizeni, 2004. Only 60 (15%) of the respondents knew that malaria can pass from one person to another whereas a substantial proportion of the respondents 340 (85%) disagreed with the fact that malaria can pass from one person to another. This finding corroborates with a cross-sectional study carried out in Calabar where school adolescent exhibited poor knowledge level of malaria transmission (Udonwa et al, 2010). This may be due to low capacity of teachers and deficiency in health education curriculum. Most respondents subscribed to the fact that malaria can be avoided majorly by sleeping under Insecticide Treated net 160 (41.9%) and keeping surrounding clean 84 (22.0%). This is evidence to the effectiveness of malaria campaigns on keeping the surrounding clean and the use of insecticide treated net through the media and poster/billboards in the fight against malaria in Calabar Metropolis. About 392 (98.0%) believed that malaria can be cured and 150 (38.3%) felt Amalar was the drug that could be used to treat malaria. Reasons may be that Amalar is widely advertisement, affordable and effective.
A reasonable proportion of school adolescent had favourable attitude towards malaria. About 140 (35.0%) respondents strongly agreed that malaria is a disease that kills, adolescent should go to the nearest hospital in the event of malaria attack 205 (51.2%) and prevention of Virtually 320 (80.4%) of the respondents would decide to go to the nearest hospital in the event of a malaria attack. This may probably be due to easy accessibility to health facilities since Calabar metropolis is an urban setting. Free treatment of school adolescent cover under the National Health Insurance Scheme may be another reason for using the health facilities. A substantial proportion of the respondents claimed to have heard of Insecticide Treated Net (ITN) 394 (98.5%) with health workers as their major source of information 177 (45.2%). This shows that health workers in Calabar metropolis have been constantly involved in the distribution of Insecticide Treated Nets to households intermittently. The media can also be a second prolific means where school adolescent would be constantly reminded on the need to use ITN always to prevent malaria. Teachers were a source of information on malaria prevention for only about one-tenth of the adolescents. This low percentage corroborates with a cross-sectional study carried out in Calabar coastal community ( (Salako, 1993). A large proportion of respondents 340 (85.9%) knew that Insecticide Treated Net (ITN) can be sold or gotten from the hospital/clinics. This may be probably because Insecticide Treated nets are perceived to be given free of charge in divergent health facilities and most patients visit the hospital for malaria treatment. Malaria preventive measures adopted by school adolescent in this survey recorded removal of stagnant water from the environment 124 (33.3%), use of anti-malarial drugs 96 (25.8%) and bush clearing around houses 54 (14.5%). School adolescent knew that stagnant water and over grown weeds or grasses serve as breeding sites for mosquitoes to live and proliferates around where they domicile thereby increasing their susceptibility to malaria infection. Malaria prophylaxis is not recommended for the general population in Nigeria, except for vulnerable groups such as those with sickle cell anaemia and non-exposed expatriates (National Anti-malarial Treatment Guidelines, 2005). Hence, the public health system should intensify campaign on ITN use while discouraging the use of chemoprophylaxis among adolescent for malaria prevention.

Conclusion and Recommendations
Despite the high awareness level of malaria among school adolescent in Calabar metropolis, Nigeria, understanding of how malaria is transmitted, treated and prevented is relatively low. Health workers and the media constituted their major source of information on malaria prevention. On the contrary, source of malaria prevention information among teachers was low as compared to the two sources previously mentioned. Prevalence of ITN