Malaria in West Cameroon: An Assessment of the Populations’ Knowledge, Attitudes and Practices

Background: Malaria remains one of the main causes of morbidity and mortality in Cameroon. Children under 5 years old and pregnant women are most burdened. A few studies have been carried out on the knowledge, attitudes and practices (KAP) of patients towards malaria in this country. Objective: We aimed at evaluating the level of knowledge, attitudes and practice towards malaria in Western Cameroon. Method: We conducted a cross-sectional survey, using a semiopened questionnaire in two Cameroonian’s hospitals in April 2018. We analyzed our collected data with Chi square test through SAS software (version 9.4). P-values lower than 0.05 were considered statistically significant. Result: Of 691 participants, 55.14% (381/691) defined malaria as a parasitic disease, 100% mentioned the mosquito as the transmission vector and 89.15% (616/691) mentioned blood stream as transmission route. The most preventive method used by the participants was mosquito nets. The use of malaria treatment was associated with the level of income and the fact of consultation of a health care practitioner the month preceding the survey. About 72.4% (501/691) of respondents took antimalarial treatment without consultation or medical prescription. Among patients who spent less than 8000XAF (12Euro) for treatment during their last episode of malaria, 70.1% (101/144) used a plant-based treatment. Conclusion: Participants had good knowledge and attitudes towards malaria. However, practices were not the best. These results highlight the problem of self-medication, which might lead to some resistance against antimalarial treatment in the future.


Introduction
Malaria is a public health concern around the world. It is one of the leading causes of mortality and morbidity in sub-Saharan Africa. In 2019, the World Health Organization (WHO) recorded about 229 million cases of malaria worldwide (94% of all cases recorded in Africa Region), of which there were 409,000 deaths (94% of deaths registered in Africa Region). [1] In the same year, the WHO reported 274,030 deaths of children under 5 years of age (about 67% Knowledge, Attitudes and Practices of deaths in all age groups). [1] Indeed, some groups have an increased risk of being infected with malaria; these include children under 5 years old and pregnant women. [2] Cameroon is a malaria endemic country. It is located in Central Africa between the end of the Sahara in the North and the beginning of the equatorial forest in the South. In Cameroon, Malaria is the leading cause of death and morbidity among pregnant women and children under 5 years old. [3] The Ministry of Public Health of Cameroon reported 8,294,473 individuals coming for consultation in healthcare facilities in 2018, 1,934,876 cases of malaria were recorded, representing an attributed morbidity rate of 25.8% [4] About 22,813 deaths recorded with 3263=malaria-related, representing a mortality rate of 14.3%. [4] Moreover, malaria alone is responsible for 26% of absences in the workplace and 40% of household health expenditure. [5] Many control strategies were put in place by WHO and Governments. Despite these innovative and cost-effective strategies, malaria persists, because the lack of knowledge, inappropriate attitudes and practices towards the disease increase the number of malaria cases. [6] Community participation and community knowledge, attitude, behavior and practices, play an important role in the successful implementation of malaria control programs. [6] In Cameroon, a few studies were carried out on the knowledge, attitudes and practices (KAP) of patients in relation with malaria. [7][8][9][10][11][12] None of them assessed the West region of Cameroon. Hence our goal is to assess the KAP towards malaria among patients of Western Cameroon.

Materials and Methods
We conducted a cross-sectional analytical study, through a semi-opened questionnaire, in two hospitals of the western region of Cameroon, Dschang District Hospital in Dschang and the Mbouo Protestant Hospital in Bandjoun. The questionnaire was structured to answer questions about participants' socio-demographic characteristics, knowledge, attitudes and practices towards malaria. Data collection took place in April 2018 and involved all patients seeking for consultation for malaria-related symptoms in each of the two above-mentioned hospitals. We included patients aged at least 18 years old, and who gave their informed consent. The calculation of the sample size according to Lwanga & Lemeshow, 1991, allowed us to obtain a minimum sample size of 588 people. Anticipating a 10% non-response rate, we set our target to 647participants [13].
Before the analysis, the data was encoded in Microsoft Excel software version 2007 and exported to the SAS software (version 9.4) for analyses. Chi square test were used. P-values lower than 0.05 were considered statistically significant.

Knowledge About Malaria
Regarding knowledge about malaria, all respondents had heard about malaria and 55.1% (381/691) defined malaria as a parasitic disease (

Attitudes and Practices Towards Malaria
The analysis of attitudes and practices revealed 45.4% (314/691) of participants using mosquito nets as a preventative measure (  (Table 3). The reason given for the use of plants was that, the plants remain accessible and cost less than the drugs sold in pharmacies. In the month prior to the survey, 27.6% (191/691) consulted at least once for malaria and all participants to the study used a malaria treatment at least once (Table 3). About 77.9% (538/691) said they spent between 8000 and 15,000 XAF (12 and 23 Euro) to get Knowledge, Attitudes and Practices treatment during their last episode of malaria (Table 3).

Factors Influencing Malaria Treatment Among the Study Population
The analysis of the use of treatment compared to the consultation during the month preceding the survey shows a significant correlation (P-value <0.05). And in the month preceding the survey, 72.4% (501/691) of respondents used treatment without prescription (Table 4). We analyzed the cost of treatment versus treatment used by respondents. There is a significant correlation (P-Value <0.05) between these two variables. The group of patients who spent less than 8000 XAF (12Euro) for treatment during their last episode of malaria, 70.1% (101/144) used a plant-based treatment. While in the group of patients who spent more than 15,000XAF (23 Euro), 88.9% (8/9) used drugs from pharmacies (Table 5). Finally, we analyzed the use of treatment in relation to income. It appears that income is significantly correlated (P-Value <0.05) with the use of treatment. Moreover, most of patients (74.1%, 513/691) with an income less than 50,000 XAF (76Euro), used treatment, at least once in the month preceding the survey.

Discussion
This study focused on the assessment of knowledge, attitudes and practices of western Cameroon's patients towards malaria. Our study shows a good knowledge of malaria among the patients surveyed. Malaria endemicity coupled with efforts of the National Malaria Control Program of Cameroon makes patients familiar and more educated about the disease. This result goes in line with findings of Kimbi et al. in their study conducted in 2014, 86% of participants had a good knowledge of malaria transmission route. [14] The respondents new about the most costeffective malaria prevention method, the use of mosquito nets. These results are similar to those obtained by Ndo et al. in 2011; where 69% reported the use of mosquito nets as malaria preventing method. [9] Malaria attitudes and practices were not the best among the respondents. Between 2011 and 2016, the Cameroonian Government, thanks to Roll Back Malaria funding, organized two long-lasting impregnated nets (LLINs) distribution campaigns, in order to fulfill the commitment to ensure "Universal coverage of populations of LLINs". Despite the increase of LLINs use between 2013 and 2017, going from 40.4% in 2013 to 58.3% in 2017 nationwide, efforts are required for a sustainable behavioral change. [15] Pharmacy drugs rather than herbal treatment high used could be explained by recent directives of the Ministry of Public Health of Cameroon regarding the pricing of the management of non-severe and severe malaria cases. According to these guidelines, the treatment of non-severe and severe cases of malaria is free of charge in children under 5 years old. [16] For patients over 5 years old and adults, the treatment of non-severe malaria costs between 105 and 250 XAF (0.16 and 0.38 Euro) while that of severe malaria costs 8000 XAF (12Euro) and 4000 XAF (6Euro) for pregnant women. [16,17] Thus, pharmacy drugs are affordable and reduce the solicitation of other therapeutic itineraries.
Despite these guidelines, plant-based treatments are still used because they are significantly cheaper than pharmacy drugs. The same reason was mentioned in studies carried out by Willcox et al., and Getachew et al. [18,19] A supportive argument to this cost-related issue is that the group of patients who spent less than 8000 XAF (12Euro) during their last episode of malaria, prioritized plant-based treatments, while those who spent more than 15,000 XAF (23 Euro) during their last episode of malaria preferred pharmacy drugs.
All patients reported at least one malaria treatment within the month prior to the survey, and most of them have low income. Interestingly, this result does not correlate unpublished results reporting 50% of patients from the Dschang District Hospital who did not take antimalarial drugs 6 months prior to the survey. This could imply that having a low income is a factor favoring malaria infection and hence the need for treatment. Still, we should consider the common confusion of fever as malaria, and antipyretics as antimalarial drugs.
Self-medication appeared as a recurrent issue. This was raised by Pouhé et al. in 2011. They highlighted selfmedication as the first reflex in illness in Cameroon and more than half of the population use antimalarial drugs systematically. [20] The justifications most often mentioned are the high cost of care for patients in healthcare facilities, the low purchasing power, the avidity of some pharmacists who do not respect the rules for dispensing medicines. [21] According to Chiribagula et al. (2015), the main risks associated with self-medication include microbial resistance to drugs, drug accidents, nonbeneficial drug interactions, drug dependence, and substance abuse. [21]

Conclusion
The main purpose of our study was to assess KAPs towards malaria of patients of the western Cameroon. We noted a good level of knowledge on malaria. Attitudes and practices were less good, especially self -medication which hides several consequences including drug resistance. Moreover, plant-based drugs usage was related to the purchase power of patients.
It is important to raise awareness about good attitudes and practices towards malaria, but also about self-medication and its consequences.

Limits
In this study, we noted as main limitation in the site which was hospital environments. The representativeness in relation to the general population is doubtful especially if we consider that people tend to come to the hospital when they face critical health situations. It was a convenient decision, given the limited resources. Another limitation could be a selection bias related the inclusion criteria, coming to consultation for malaria-related symptoms. Then we needed the help of the practitioners to select participants.

Conflict of Interests
The authors declare that they do not have any conflict of interest.

Funding
This work did not receive funding.