Knowledge and health seeking behavior for malaria among the local inhabitants in an endemic area of Ethiopia: implications for control

doi:10.4236/health.2010.26085

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Vol.2, No.6, 575-581 (2010) Health

doi:10.4236/health.2010.26085

Knowledge and health seeking behavior for malaria

among the local inhabitants in an endemic area of

Ethiopia: implications for control

Kaliyaperumal Karunamoorthi1,2*, Abdi Kumera1

1Unit of Vector Biology & Control, Department of Environmental Health Science, College of Public Health and Medical Sciences,

Jimma University, Jimma, Ethiopia

2University Research and Development Center, Bharathiar University, Coimbatore, Tamil Nadu, India;

*Corresponding Author: k_karunamoorthi@yahoo.com

Received 24 October 2009; revised 10 December 2009; accepted 14 December 2009.

ABSTRACT

This cross-sectional study was conducted to

assess the knowledge and health seeking be-

havior for malaria among the local inhabitants in

an endemic area of Ethiopia: Implications for

control. 98.6% and 80.7% of respondents had

awareness about malaria and the cause (‘mos-

quito bite’) of malaria, respectively. 186 (81.6%)

respondents seek treatment for a febrile disease

from health care facilities. Chi-square analysis

revealed a strong association between the edu-

cational status of respondents and the meas-

ures they take to prevent malaria (Х2 = 58.7; df =

16; p < 0.001). The findings clearly suggest that

the majority of the respondents had adequate

knowledge and enviable health seeking behav-

iour. However, still a sizable faction had mis-

conception and undesirable health seeking be-

haviour. It’s a major barrier to implement effec-

tive malaria control strategies in the resource-

limited settings particularly in country like

Ethiopia. In this context, appropriate communi-

cation strategies apparently inevitable. Therefore,

appropriate communication strategies should

be designed to promote the knowledge and

health seeking behaviour of vulnerable section

of the society in this vicinity.

Keywords: Malaria; Knowledge;

Health seeking behaviour; Ethiopia

1. INTRODUCTION

Malaria remains a major cause of morbidity and mortal-

ity in tropical and subtropical regions of the world, de-

spite decades of malaria control efforts. There are ap-

proximately 300-500 million clinical cases and about

one million deaths due to malaria globally, and Africa

south of the Sahara accounts for over 90% of the disease

burden [1]. Most of the infections and deaths in highly

endemic areas occur in children and pregnant women,

who have little access to health systems [2-4].

109 countries were endemic for malaria in 2008, 45

within the WHO African region. Ethiopia had approxi-

mately 6% of malaria cases in the African Region in

2006. Malaria is present everywhere except in the cen-

tral highlands. A total of 1.2 million cases were reported

in 2007, the lowest number in the period 2001-2007 [5].

Over the past years, the disease has been consistently

reported as the leading cause of outpatient visits, hospi-

talization and death in health facilities across the country.

The diverse eco-climatic condition in the country makes

the malaria transmission pattern seasonal and unstable

usually characterized by frequent focal and cyclic wide-

spread epidemics [6].

Except for southern Africa, many countries in the con-

tinent do not have successful malaria control pro-

grammes due to the magnitude of the problem com-

pounded by lack of adequate health infrastructure, as

well as financial and human resources [7]. Vector-borne

disease control programs mostly rely on controlling the

parasite and/or vector and have often overlooked the

importance of the target population’s knowledge, beliefs

and behavior in the transmission and control of disease

[8]. Malaria control programs must consider the broad,

complex and interrelated factors that influence human

behavior, especially now that malaria control is theo-

retically within reach of even the poorest countries

through the availability of insecticide treated bednets

and highly effective antimalarial drug combinations [9].

Malaria protective measures are related to knowledge

and beliefs of people; when they think malaria risk is

low, it is more difficult to implement protective meas-

K. Karunamoorthi et al. / HEALTH 2 (2010) 575-581

576

ures [10]. The poor and vulnerable populations are dis-

proportionately affected by malaria and the severe con-

sequences of malaria are borne more by the poorest [11].

Studies on knowledge, attitudes and practices are be-

coming more important to design and improve malaria

control activities, to establish epidemiological and be-

havioral baselines and to identify indicators for moni-

toring programs [12].

Poor knowledge about malaria was significant factor

for death from malaria among the household members in

Sudan [13]. Thus, there is an urgent call for updated in-

formation on key sociocultural, socio-economic indictors

and human understanding about malaria to apply appro-

priate control strategies. Therefore, the purpose of this

study was to assess the knowledge and health seeking

behavior for malaria among the local inhabitants in an

endemic area of Ethiopia: Implications for control. The

present study findings could provide baseline informa-

tion to design effective and sustainable malaria control

strategies suited to local conditions in the near future.

2. MATERIALS AND METHODS

2.1. Study Settings

The study was conducted in Serbo town, which is lo-

cated 345km south-west of the capital Addis Ababa in

Oromia Regional State, south-western Ethiopia. It’s lo-

cated between latitudes 7º35-8º00 N, and between lon-

gitudes 36º46-37º14 E, at altitudes between 1,740-2,660

m above sea level and has a mean annual temperature of

19°C. According to the 2005 census, the study area had a

total population of 6,115 and 511 households. Malaria is

the major health problem in the Serbo town. As the six

consecutive years data (2002-2007) from Serbo Health

Center showed, the number of malaria cases ranged be-

tween 3,925 and 22,938, with the peak being during

2004/5. The prevalence seems decreasing although the

number of cases per year is still high [14]. The main

socio-economic activities of the local communities are

small business, subsistence mixed farming involving the

cultivation of staple crops (maize, teff and sorghum),

and cattle and small stock raising.

2.2. Study Design

The study was a descriptive cross-sectional survey. A

structured questionnaire was designed and administered

by trained field workers. The first part of the question-

naire included sociodemographic characteristics, whereas

the second part had questions on, adult residents' know-

ledge and perceptions about malaria transmission, cause,

treatment seeking patterns, preventive measures and

practices. To improve the quality of the data, pre-testing

of the questionnaire was carried out prior to the actual

data collection. The questionnaire was tested on ten re-

spondents by the enumerators, in an area different from

the study area, but with a similar socio-demographic

pattern.

2.3. Data Collection

The questionnaire was administered to 228 randomly

selected households between January and March 2009.

The head of household or a responsible adult was inter-

viewed. Only one person per household was interviewed.

To minimize bias information and variables the ques-

tionnaire prepared in English language was translated

into native local language Amharic to make it easy to

understand and to administer by interviewers and inter-

viewees.

2.4. Ethical Considerations

The study was approved by the ethical clearance com-

mittee of the Jimma University, Jimma, Ethiopia. Before

the commencement of the survey, meetings with com-

munity health workers, community leaders and members

of the neighborhood associations were held in which the

objectives of the survey were clearly explained. Written

consent was obtained from each study participant. Every

participant was assured to withdraw the interview at any

phase if they wish to do so. However, all the informants

actively involved and no one declined to finish the inter-

view.

2.5. Statistical Analysis

Statistical analysis was carried out using SPSS, version

9.0. Range and mean were analysed and appropriate ta-

bles, graphs and percentage were displayed. Level of

significance also determined by using 95% of confi-

dence intervals and p-value.

3. RESULTS

3.1. Characteristics of Study Population

The socio-demographic characteristics of respondents are

presented in Table 1. The study participants consisted of

46.5% males and 53.5% females. Majority of the re-

spondents (44.3%) were in between 20-29 years old.

33.5% of the study population had no formal education.

About 34.7% of the participants monthly income was

20-30 USD (Table 1).

3.2. Knowledge and Perceptions of

Respondents about Malaria Cause,

Transmission and Mosquitoes

Breeding Sites

Tables 2 presents respondents awareness about malaria

K. Karunamoorthi et al. / HEALTH 2 (2010) 575-581

577

Table 1. Socio-demographic characteristics of study population.

Socio-demographic characteristicsn %

Sex

Male 106 46.5

Female 122 53.5

Age

15-19 37 16.2

20-29 101 44.3

30-39 54 23.7

40-49 21 9.2

>50 15 6.6

Ethnicity

Oromo 136 59.6

Amhara 34 14.9

Gurage 13 4.9

Tigray 8 3.5

Kaffa 16 7.1

Dawuro 23 10.0

Educational status

Illiterates 81 35.5

Can read & write 26 11.4

1-4th grade 32 13.6

5-8th grade 51 22.4

9-12th grade 23 10.1

>12th grade 16 7.0

Occupational status

Civil servants 32 14

Merchants 84 36.8

Housewives 41 18.0

Farmers 53 23.3

Private sector worker 12 5.3

NGO worker 6 2.6

Monthly income (Ethiopian Birr)*

< 100 31 13.6

101-200 53 23.3

201-300 79 34.7

301-400 33 14.5

401-500 20 8.8

> 500 12 5.1

Note*: 1$ = 12.4 Ethiopian Birr.

transmission, cause, and mosquito breeding sites. In

general, 98.6% of respondents had awareness about ma-

laria. Majority of respondents (80.7%) were aware about

the cause (‘mosquito bite’) of malaria irrespective of sex,

age, monthly income and occupation. During the survey,

80.7% of the respondents knew that mosquitoes are

transmitting the malaria. A total of 178 (78.1%) people

knew that stagnant water bodies are serving as mos-

quito’s breeding sites (Table 2). About 40.4% of re-

spondents had known about malaria through mass media

(Figure 1).

3.3. Knowledge and Perceptions of

Respondents Regarding Malaria

Prevention and Control

Table 2. Respondents knowledge and perception about malaria

causes, transmission and mosquito breeding sites.

Variables n %

Awareness about malaria

Yes 224 98.6

No 4 1.4

Causes of malaria*

Mosquito bites 184 80.7

Chill climate 167 73.2

Malnutrition 96 42.1

Eating raw vegetable 71 31.1

Drinking dirty water 123 54

I don’t know 46 20.2

Malaria transmission*

Cold weather 101 44.3

Mosquitoes bites 184 80.7

Heat/Sun shine 23 10.1

Dirty stagnant water /swamp 106 46.5

Due to poor personal hygiene 102 44.7

Starvation 46 20.2

Mosquitoes breeding sites*

Stagnant water 178 78.1

Tree holes 29 12.7

Waste/polluted water 43 18.9

Stream/River 26 11.4

Dirty places/Dustbin 97 42.5

I don’t know 22 9.6

Note*: Percentages do not add up to 100 due to multiple responses.

K. Karunamoorthi et al. / HEALTH 2 (2010) 575-581

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Figure 1. Sources of information about malaria related information as reported by respondents.

95.6% and 77.2% of respondents believe that regular

deployment of bednets and DDT indoor residual spray

(IRS) could prevent malaria, respectively (Table 3).

Chi-square analysis revealed a strong association be-

tween the educational status of individual households

and the measures they take to prevent malaria (Х2 =58.7;

df =16; p <0.001) (Table 4).

3.4. Febrile Disease Treatment Seeking

Behavior of Respondents

As shown in Figure 2, 186 (81.6%) respondents seek

treatment for a febrile disease from the health care facili-

ties. However, few respondents cited such as self medi-

cation, approaching traditional healers and eating health

foods.

4. DISCUSSIONS

This study sheds light on a group of adults in a malaria

endemic area of Ethiopia regarding the level of under

standing community knowledge about malaria and

health seeking behavior. It provides information for

Figure 2 Treatment-seeking behaviors for febrile disease as

reported by respondents.

educators and policy makers that are necessary for

guidance towards malaria preventive campaigns. In the

present survey, majority of the study participants (98.6)

demonstrated general awareness about malaria, which is

relatively higher than a recent study, which was con-

ducted in Swaziland showed that of 320 households sur-

veyed 298 (93.1%) of the respondents had heard about

malaria [15]. This discrepancy could be because of the

fact that usually the population in malaria endemic set-

tings has higher awareness than the residences of en-

Table 3. Respondents knowledge and perception about malaria

prevention and control.

Variables n %

Possible options to prevent/control malaria*

Residual house spraying with DDT 176 77.2

Environmental management 112 49.1

Regular deployment of bednets 218 95.6

Early diagnosis and treatment 22 9.6

Personal hygiene 79 34.6

Healthy food/Nutrition 92 40.3

Benefits of IRS

To prevent from malaria /mosquito bite 126 55.3

To avoid bites from other insects 84 36.8

I don’t know 18 7.9

Benefits of ITNs/Bednets*

To avoid insects bites 221 96.9

To prevent malaria and other diseases 213 93.4

I don’t know 3 1.4

To kill domestic insects 5 2.2

Note*: Percentages do not add up to 100 due to multiple responses.

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Table 4. Association between mosquito preventive measures and educational status of the respondents.

Educational level of the respondents

Types of prevention

measures Total respondents

IlliteratesCan read & write1-8th grade9-12th grade >12th grade

p-value

Mosquito net 57 16 9 13 10 9

DDT spraying 52 3 12 22 8 7 Х2 = 58.7

Draining stagnant water 93 41 19 28 5 0 df = 16

Don’t use 13 13 0 0 0 0 p < 0.001*

Burning repellent plants 13 8 4 1 0 0

Total 228 81 44 64 23 16

Note*: p<0.05 statistically significant

demic/nonendemic area. In addition this study was con-

ducted in urban area too.

80.7% of the respondents knew the role of mosquitoes

in malaria transmission (‘mosquito bite’). The respon-

dents’ level of awareness about mode of malaria trans-

mission was very low when compared to the findings in

previous studies carried out in Ethiopia which reported

awareness levels of up to 93% [16,17]. However, it’s

relatively higher than that reported in other studies 55%

of the surveyed population in a nationwide study in Ma-

lawi (Ziba et al., 1994) [18], 67% in Turkey [19], and

17.3% in Ethiopia [20,21].

However, many people had not known the real cause

of malaria. Such misconceptions have also been reported

from other studies in Ethiopia and other countries [22-24].

The present study findings were comparable with previ-

ous studies in India [25] and in Ethiopia [17] although

the association of malaria with mosquitoes is widespread

in these communities, other causal factors of malaria

such as traditional beliefs like eating maize stalks, con-

tact with malaria patients, exposure to rains and cold

weather, bad smell and dirty water were frequently sug-

gested. The correction of such misconceptions about the

relationship between mosquito bite and malaria through

health education messages is very critical for the success

of malaria prevention and control using ITNs [26].

78.1% of respondents indicated that stagnant water

bodies serving as potential mosquito breeding sites. Pre-

vious studies in Ethiopia have also confirmed similar

findings [17,27]. However, the level of awareness re-

garding mosquito breeding site was relatively lower than

earlier studies. Most of the respondents knew about ma-

laria related information through mass media and

friends/family members. Findings were consistent with a

study in Ethiopia [17]. The most common source of in-

formation about malaria was from relatives. Radio was

ranked third after medical personnel as a major informa-

tion source [28].

The great majority of the respondents believe that

regular deployment of bednets and DDT indoor residual

spray (IRS) could prevent insect’s bites and malaria. The

findings comparable with an earlier study in Mozam-

bique demonstrated that the majority of respondents as-

sociate malaria with mosquitoes and are aware of vari-

ous methods to prevent illness, including IRS and bed

nets [29]. Table 4 Chi-square analysis suggest an asso-

ciation between the educational status of individual

households and the measures they take to prevent ma-

laria (Х2 =58.7; df =16; p <0.001). Results consistent

with an earlier study, which was conducted in Swaziland,

found that most respondents believed that malaria is

preventable, and mentioned clinic, spraying and the use

of bed nets as key malaria preventive measures. Despite

these positive responses a substantial number of them

(43.4%) did not take any personal protective measures

against malaria infection [15]. Indeed, several studies

across the globe particularly in Africa evidently suggest

that Bednets/Insecticide-treated nets are regarded as one

of the most effective prevention methods and sleeping

under the protection of bednets could substantially re-

duce the malaria burden.

Another interesting finding was that the majority of

the respondents preferred to seek treatment in the health

facilities rather than approaching traditional healers and

self medication. This may be due to the fact that the

Serbo health center is located within the study area as

result accessibility is extremely high among the local

inhabitants. In addition, it’s providing services free of

charge. The present study findings are comparable with

few earlier studies. In Ethiopia, 98% respondents had

their first visit to health care facilities including public

and private health services as well as malaria control

laboratories, drug venders/pharmacy and CHWs seeking

treatment for malaria [17]. Another study in Swaziland

found that almost 90% of the respondents seek treatment

in the health facilities [15].

The scope of malaria control is changing worldwide.

With less emphasis being placed on insecticide use, in-

K. Karunamoorthi et al. / HEALTH 2 (2010) 575-581

580

creased community participation in malaria control and

prevention measures will be of higher importance. With

greater emphasis being placed on community control

and prevention, health education based on understanding

community and individual behaviors, attitudes and

knowledge pertaining to malaria is moving to the fore-

front as a measure necessary for malaria control [30].

The present study findings clearly suggest that the

majority of the study participants had adequate knowl-

edge and ample enviable health seeking behavior. How-

ever, still a sizable proportion had misconception and

undesirable health seeking behavior. Indeed, it’s a major

barrier to implement effective as well sustainable ma-

laria control strategies in the resource-limited and ethni-

cally-diverse settings particularly in country like Ethio-

pia. Therefore, appropriate communication strategies

should be designed and implemented in the study area to

bring the constructive outcome in the near future.

5. ACKNOWLEDGEMENTS

We would like to thank the study participants and their families for

their frankness in sharing their knowledge about malaria and

health-seeking behavior with us. Without their contribution, this study

would have been impossible. Our last but not least heartfelt thanks go

to our colleagues from the Department of Environmental Health Sci-

ence, College Public Health and Medical Sciences, Jimma University,

Jimma, Ethiopia, for their kind support and cooperation. We also thank

our anonymous reviewers for their constructive comments and valu-

able suggestions to improve this manuscript substantially.

REFERENCES

[1] Snow, R.W., Guerra, C.A., Noor, A.M., Myint, H.Y. and

Hay, S.I. (2005) The global distribution of clinical epi-

sodes of Plasmodium falciparum malaria. Nature, 434

(7030), 214-217.

[2] Luxemburger, C., Mc Gready, R., Kham, A., Morison, L.,

Cho, T., Chongsuphajaisiddi, T., White, N.J. and Nosten,

F. (2001) Effects of malaria during pregnancy on infant

mortality in an area of low malaria transmission. Ameri-

can Journal of Epidemiology, 154(5), 459-465.

[3] World Health Organization (1996) Fighting disease, fos-

tering development. Geneva.

[4] Snow, R.W., Craig, M., Diechmann, U. and Marsh, K.

(1999) Estimating mortality, morbidity and disability due

to malaria among Africa’s nonpregnant population. Bul-

letin of the World Health Organization, 77(8), 624-640.

[5] World Health Organization (2008) World malaria report.

Geneva.

[6] Federal Ministry of Health of Ethiopia (2006) National

five years strategic plan for malaria control in Ethiopia:

2006-2010. Malaria and Other Vector-borne Diseases

Prevention and Control Team, Diseases Prevention and

Control Department, Ministry of Health, Addis Ababa.

[7] Mabaso, M.L.H., Sharp, B. and Lengeler, C. (2004) His-

torical review of malarial control in Southern Africa with

emphasis on the use of indoor residual house-spraying.

Tropical Medicine and International Health, 9(8), 846-

856.

[8] Ruebush, T.K., Weller, S.C. and Klein, R.E. (1992)

Knowledge and beliefs about malaria on the pacific

coastal plain of Guatemala. American Journal of Tropical

Medicine and Hygiene, 46(4), 451-459.

[9] White, N.J., Nosten, F., Looareesuwan, S., et al. (1999)

Averting a malaria disaster. Lancet, 353(9168), 1965-

1967.

[10] Winch, P.J., Makemba, A.M., Kamazina, S.R., Lwihula,

G.K., Lubega, P., Minjas, J.N. and Shiff, C.J. (1994) Sea-

sonal variation in the perceived risk of malaria: Implica-

tion for the promotion of insecticide impregnated bednets.

Social Science Medicine, 39(1), 63-75.

[11] Barat, L.M., Palmer, N., Basu, S., Worrall, E., Hanson, K.

and Mills, A. (2004) Do malaria control interventions

reach the poor? A view through the equity lens. American

Journal of Tropical Medicine and Hygiene, 71 (Suppl 2),

174-178.

[12] Schultz, L.J., Ettling, M., Chitsulo, L., Steketee, R.W.,

Nyasulu, Y., Macheso, A. and Nwanyanmu, O.C. (1994)

A nation-wide malaria knowledge, attitudes and practices

survey in Malawi: Objectives and methodology. Tropical

Medicine and Parasitology, 45(1), 54-56.

[13] Saeed, I.E. and Ahmed, E.S. (2003) Determinants of

malaria mortality among displaced people in Khartoum

state, Sudan. Eastern Mediterranean Health Journal,

9(4), 593-599.

[14] Federal Ministry of Health of Ethiopia (2007) Entomo-

logical profile of malaria in Ethiopia. Addis Ababa.

[15] Hlongwana, K.W., Mabaso, M.L.H., Kunene, S., Goven-

der, D. and Maharaj, R. (2009) Community knowledge,

attitudes and practices (KAP) on malaria in Swaziland: A

country earmarked for malaria elimination. Malaria

Journal, 8(1), 29-37.

[16] Jima, D., Tesfaye, G., Deressa, W., Woyessa, A., Kebede,

D., Ali, A. and Enquoselassie, F. (2003) Knowledge, at-

titude and practice about malaria, the mosquito and anti-

malarial drugs in a rural community. Ethiopian Journal

of Health Development, 17(2), 99-104.

[17] Jima, D., Tesfaye, G., Deressa, W., Woyessa, A., Kebede,

D. and Alameraw, D. (2005) Baseline survey for the im-

plementation of insecticide–treated mosquito nets in ma-

laria control in Ethiopia. Ethiopian Journal of Health

Development, 19 (1), 16-23.

[18] Ziba, C., Slutsker, L., Chitsulo, L. and Steketee, R.W.

(1994) Use of malaria prevention measures in Malawian

households. Trop Med Parasitol, 45(1), 70-73.

[19] Simsek, Z. and Kurcer, M.A. (2005) Malaria: knowledge

and behaviour in an endemic rural area of Turkey. Public

Health, 119(3), 202-208.

[20] Yeneneh, H., Gyorkos, T.W., Joseph, L., Pickering, J. and

Tedla, S. (1993) Antimalarial drug utilization by women

in Ethiopia: a knowledge-attitudes-practice study. Bulle-

tin of the World Health Organization, 71(6), 763-772.

[21] Deressa, W., Ali, A. and Hailemariam, D. (2008) Ma-

laria-related health seeking behaviour and challenges for

care providers in rural Ethiopia: Implications for control.

Journal of Biosocial Science, 40(1), 115-135.

K. Karunamoorthi et al. / HEALTH 2 (2010) 575-581

581

[22] Hamel, M.J., Odhacha, A., Roberts, J.M. and Michael,

S.D. (2001) Malaria control in Bangoma district, Kenya:

A survey of home treatment of fever, bed net use and at-

tendance at antenatal clinics. Bulletin of the World Health

Organization, 79(11), 1014-1123.

[23] Legesse, Y., Tegegn, A., Belachew, T. and Tushune, K.

(2007) Knowledge, attitude and practice about malaria

transmission and its preventive measures among house-

holds in urban areas of Assosa Zone, western Ethiopia.

Ethiopian Journal of Health Development, 21(2), 157-

165.

[24] Adongo, P.B., Kirkwood, B. and Kendall, C. (2005) How

local community knowledge about malaria affects insec-

ticide treated net use in northern Ghana. Tropical Medi-

cine and International Health, 10(4), 366-78.

[25] Vijayakumar, K.N., Gunasekaran, K., Sahu, S.S. and

Jambulingam, P. (2009) Knowledge, attitude and practice

on malaria: a study in a tribal belt of Orissa State, India

with reference to use of long lasting treated mosquito

nets. Acta Tropica, 112(2), 149-155.

[26] Belay, M. and Deressa, W. (2008) Use of insecticide

treated nets by pregnant women and associated factors in

a pre-dominantly rural population in northern Ethiopia.

Tropical Medicine and International Health, 13(10),

1303-1313.

[27] Deressa, W., Ali, A. and Enquosellassie, F. (2003) Know-

ledge, attitude and practice about malaria, the mosquito

and antimalarial drugs in a rural community. Ethiopian

Journal of Health Development, 17(2), 99-104.

[28] Alilio, M.S., Eversole, H. and Bammek, J. (1998) A KAP

study on malaria in Zanzibar: implications for prevention

and control a study conducted for UNICEF Sub-office

Zanzibar. Evaluation and Program Planning, 21(4), 409-

413.

[29] Pool, R., Munguambe, K., Macete, E., Aide, P., Juma, G.,

Alonso, P. and Menendez, C. (2006) Community re-

sponse to intermittent preventive treatment delivered to

infants (IPTi) through the EPI system in Manhica, Mo-

zambique. Tropical Medicine and International Health,

11(11), 1670-1678.

[30] Cropley, L. (2004) The effect of health education inter-

ventions on child malaria treatment seeking practices

among mothers in rural refugee villages in Belize, Cen-

tral America. Health Promotion International, 19(4),

445-452.