|Year : 2013 | Volume
| Issue : 2 | Page : 91-95
Knowledge and pattern of malaria case management among primary health-care workers in Jos
Danjuma A Bello, Yetunde O Tagurum, Tolulope O Afolaranmi, Oluwabunmi O Chirdan, Ayuba I Zoakah
Department of Community Medicine, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
|Date of Web Publication||24-Dec-2013|
Danjuma A Bello
Department of Community Medicine, Jos University Teaching Hospital, Jos, Plateau State
Source of Support: None, Conflict of Interest: None
Background: In Plateau State as well as in most parts of Nigeria, malaria continues to exert a significant burden on the population in terms of morbidity and mortality. Case management of malaria is being used as a major tool in limiting the duration and reduction of mortality associated with the disease. The aim of this study was to assess the knowledge of malaria case management among primary health-care (PHC) workers in Jos, Plateau State.
Materials and Methods: A cross-sectional descriptive study design was employed in studying PHC workers involved in treatment of malaria in Jos, Plateau State. 105 PHC workers were selected using a multistage sampling technique and data was collected from them using a semi-structured interviewer administered questionnaire. Data processing and analysis was carried out using STATA 9 statistical software (Stata release 9, statcorp Texas, USA; 2005). Mean and standard deviation were done for quantitative variables while percentages were used to represent qualitative variables. A confidence level of 95% was used and level of statistical significance was set at P ≤ 0.05.
Results: Mean of age of the PHC workers was 40 ± 8.1 years and majority of them were females (89%). About 40% of them were senior community health extension workers. Majority of the workers (70%) had not had any recent training on malaria case management. In spite of this, knowledge of malaria was good among the respondents (95% were able to define malaria and 98.1% were able to list the symptoms of malaria respectively). More than half of the respondents (55%) were also able to correctly manage severe malaria. There was a statistically significant association between health worker cadre and correctness of the drug prescriptions (P = 0.001).
Conclusion: Despite gaps in malaria case management, primary health-care workers in Jos appeared to be fairly knowledgeable in malaria case management.
Keywords: Case management, knowledge, malaria, primary health-care workers
|How to cite this article:|
Bello DA, Tagurum YO, Afolaranmi TO, Chirdan OO, Zoakah AI. Knowledge and pattern of malaria case management among primary health-care workers in Jos. J Med Trop 2013;15:91-5
|How to cite this URL:|
Bello DA, Tagurum YO, Afolaranmi TO, Chirdan OO, Zoakah AI. Knowledge and pattern of malaria case management among primary health-care workers in Jos. J Med Trop [serial online] 2013 [cited 2019 Dec 8];15:91-5. Available from: http://www.jmedtropics.org/text.asp?2013/15/2/91/123578
| Introduction|| |
Malaria is a major public health problem in Nigeria. It exerts a significant burden on the health system in Nigeria as well as on the country's economy. Nigeria experiences high malaria transmission recording between 154 and 729 cases/1000 population.  Malaria is the most common cause of hospital attendance in Nigeria accounting for about 30% of all hospital admissions and about 60% of all out-patient attendance.  About 50% of the Nigerian population have at least one episode of malaria each year. , Malaria is one of the leading causes of under-five morbidity and mortality contributing 30% of under-five mortality and 25% of infant mortality.  In 2009, it accounted for 60% of under-five admissions as well as 54% of deaths in under-five.  Malaria is also responsible for an annual loss of 132 billion naira in treatment costs and loss of man hours. 
Case management is a major strategy of malaria prevention in Nigeria. Case management is one of the major thrusts of recent efforts to control the disease both at global and national levels. It plays a key role in meeting the objective of halving the burden of malaria by 2010 as articulated by the roll back malaria (RBM), program. The main objective of malaria case management is to limit the duration of the disease, prevent progression to severe forms and reduce deaths associated with the disease. ,
Primary health-care (PHC) workers constitute the frontline health workers charged with the responsibility of managing disease conditions at the community level. They see more cases of malaria than any other childhood disease condition, malaria being the most common out-patient consultation.
This study aimed to determine the knowledge and pattern of malaria case management among PHC workers in Jos.
| Materials and Methods|| |
Background of Study Area
The study was performed in Jos Metropolis. The metropolis consisted of Jos North and South local government areas (LGAs) of Plateau State. Jos North Local Government has a total of 24 government owned PHC health facilities and 21 privately owned health facilities.  The PHC facilities are organized into the ward system. Jos North LGA has 14 wards each hosting between 1 and 4 health facilities. Jos North LGA has an estimated population of 437,217. 
Jos South LGA has a total of 35 PHC facilities organized into 16 wards with an average of 1-2 PHC per ward. It has an estimated total population of 311,392. 
The survey involved all PHC workers responsible for the treatment of malaria in the selected PHC centers in Jos North and South LGAs. These included nurses/midwives, community health officers (CHO), community health extension workers (CHEWs), both junior and senior.
This was a facility-based cross-sectional survey. An assessment of the knowledge and pattern of malaria case management among health-care workers was made across selected PHC centers in Jos metropolis.
A multistage sampling technique was employed in this study.
Stage 1, selection of wards: In Jos North LGA, 5 wards were selected by balloting from the 14 wards. These were Tafawa Balewa, Jenta Apata, Jenta Adamu, Lamingo and Tudun Wada political wards.
In Jos South LGA, 8 wards were selected by balloting from the 16 wards and these were Du B, Giring, Hwolshe, Bukuru, Gyel A, Chugwi, Vwang and Turu A.
Stage 2, selection of PHC - one PHC center was selected for each political ward by balloting. In Jos North, these were PHCs township, Jenta Apata, Jenta Adamu, Lamingo and Tudun Wada respectively, while in Jos South they were PHCs Rayfield, Hwolshe, Bukuru Central, Bukuru Express, State Lowcost, Chugwi, Vwang and Vom Vet respectively.
Stage 3, selection of health workers - all PHC workers who were involved in malaria case management in the selected PHC centers in Jos North and South LGAs and were eligible to participate in the survey were selected. A total of 105 health workers were selected.
Data was collected using a semi-structured interviewer administered questionnaire and was administered to all eligible participants in the survey. Information on health workers knowledge of causes, transmission and treatment of malaria and severe malaria was generated. Health worker socio-demographic characteristics were also generated.
Data processing and analysis was performed using STATA 9 statistical software (Stata release 9, statcorp Texas, USA; 2005). Mean and standard deviation were done for quantitative variables like age while percentages were used to represent qualitative variables such as knowledge and treatment pattern. Knowledge of malaria was assessed as percentage of health workers who could answer specific questions on various aspects of malaria such as definition, causes, symptoms etc., Chi-square was used to test for associations between qualitative variables. A confidence level of 95% was used and level of statistical significance was set at P ≤ 0.05.
Ethical clearance for this study was obtained from the Ethics Committee of the Jos University Teaching Hospital. Approval was sought and gotten from the Chairmen and PHC directors Jos North and South LGAs prior to the commencement of the study.
| Results|| |
A total of 105 health workers were studied. The mean age of respondents was 40 ± 8.1 years. Majority of the PHC workers were female (89%). The professional cadres of the respondents included CHO (8.7%), junior CHEW (20%), senior CHEW (39.1%) and nurses/midwives (32.4%) [Table 1].
|Table 1: Socio-demographic characteristics of PHC workers in Jos Metropolis |
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Health Workers' Knowledge of Malaria
Respondents' knowledge of malaria was good with over 95% of them able to define malaria, and 99.1% able to identify mosquito as the vector. About 98% of respondents were able to list main symptoms of malaria.
Majority (60%) of respondents were not able to define severe malaria with respondents attributing severe malaria to any malaria caused by Plasmodium falciparum. Some respondents (6.7%) considered severe malaria to be that form of malaria, which occurs in neonates. Nearly, 80% of the respondents were however, able to identify symptoms of severe malaria. Differential diagnosis for malaria was considered to be typhoid fever (47.6%) and measles (16.2%), while about 24.8% of health workers listed various ailments ranging from diarrheal disease to seizure disorders.
Health Workers' Practice of Malaria Case Management
About 70% of respondents had not had any training on malaria case management while only about 4% of those who had been trained received such training within 6 months prior to the commencement of the study.
Health worker pattern of anti-malarial use was determined with 38% of respondents prescribing artemisinin combination treatment (ACT), while about 30% prescribed chloroquine (CQ). About 32% of respondents prescribed any available anti-malarial [Table 2]. Accuracy of the drug dosages were also evaluated using a 5-year-old child as standard. Respondents' drug dosages were wrong in 61% of cases.
|Table 2: Antimalarial prescription pattern among PHC workers in Jos Metropolis |
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Respondents were asked about how they will manage a child with severe malaria. About 55% of respondents will start treatment and refer while 26% will refer immediately and 16% will admit and treat. 3% of respondents will treat and send home [Figure 1].
|Figure 1: Management of severe malaria among primary health-care workers in Jos|
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There was a statistically significant association between health worker cadre and correctness of drug prescriptions (P = 0.001) [Table 3]. The higher the cadre, the more likely a correct prescription will be made.
|Table 3: Relationship between health worker cadre and drug dosages among PHC workers in Jos |
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There was also a statistically significant relationship between past training on malaria case management and making correct prescriptions with 59.4% of prescriptions among trained health workers being correct while only 30% of prescriptions among untrained health workers were correct (P = 0.005) [Table 4]. Those who had past training on malaria case management were more likely to make correct prescriptions.
|Table 4: Relationship between malaria training and drug dosages among PHC workers in Jos |
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No associations were found between age, sex and work experience with drug dosages. Similarly, no relationship was found between these variables and the ability to identify and correctly manage severe malaria as well as the choice of anti-malarial.
| Discussion|| |
PHC workers performed reasonably well in most of the parameters assessing knowledge. Health workers at the primary level of care have generally been described as having good knowledge as shown by the survey of knowledge and management of malaria in under-fives among PHC workers in Ibadan, where it was observed that general knowledge of malaria was good with workers demonstrating good knowledge of several of the key components assessed by the researchers.  Similarly, a cross-sectional study of malaria treatment practices and perceptions in South East Nigeria also observed good knowledge among PHC workers. 
Malaria diagnosis was based on a presenting symptom of fever in 69.1% of cases and based on laboratory test in 29.1% of cases. The diagnosis of malaria based on fever algorithms is the recommended mode of diagnosis in malaria case management of under-fives among PHC workers in Nigeria as advocated for in highly endemic countries with poor laboratory support. ,
While knowledge was observed to be good, there were shortcomings observed in the case management of malaria among PHC workers. This finding is consistent with other findings on health-care workers treatment patterns. , In the review of case management among PHC workers in Sokoto, 86.2% of respondents commonly prescribe CQ as the first line drug and 4.6% prescribe ACT's with wrong drug dosages in 63.6% of the time.  In this study, 30% of workers still use only CQ as first line drug, while 32% will use any available antimalarial. Drug dosages were wrong in 61% of cases in this study. Furthermore, in keeping with other findings,  years of work experience had no association with treatment patterns of PHC workers. However, in this study, health worker cadre had a statistically significant relationship with correct drug dosages. This might be related to the longer training times associated with the higher cadres. In addition, the more senior cadres are likely to be recommended for training ahead of the more junior cadres.
A malaria case management, which is effective has been described as that which institutes complete anti-malaria treatment and provision of required support to a person with malaria-like symptoms within 24 h of the symptoms.  It involves a timely decision to treat either based on clinical or on parasitological diagnosis, accessibility of appropriate drugs, correct use of drugs and follow-up to detect treatment failure or referral to appropriate care centers. Nigeria has a national policy on diagnosis and treatment of malaria, which is a necessary accompaniment to effective case management.  It adopted the RBM strategic framework on case management in 2006 and was updated in 2010. , The policy spells out the recommended guidelines for case management ranging from clinical and laboratory diagnosis, treatment and prevention.
Changes in policy have been known to affect health-care worker case management practices. In a review of malaria case management in Kenya, following the adoption of the World Health Organization recommendations on ACT's and parasitological diagnosis where possible, presumptive diagnosis still prevailed among health-care workers and testing rates were low.  There were however improvements in the use of ACT's and a decrease in the use of sulphadoxine-pyrimethamine following this change in policy.
While there is an up to date policy on malaria case management in the country accompanied by several efforts to ensure adequate supply of recommended anti-malarial, this has not guaranteed improved malaria case management among PHC workers. Efforts to improve malaria case management may need to be reviewed in light of the deficiencies highlighted in this study.
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[Table 1], [Table 2], [Table 3], [Table 4]