ABSTRACT

In Ethiopia, regardless of working towards vector control and epidemic prevention as one of the core strategies still, a significant number of households have poor practices related to malaria prevention. Besides, substantial numbers of communities are still suffering from malaria morbidity. However, the level of malaria prevention practice and integrated community base malaria intervention is not well studied. Therefore, the study’s general objective is to assess the implementation of integrated community-based malaria intervention and identify the level of malaria prevention practices for policymakers and program managers to improve the strategies. Quantitative and qualitative approaches were undertaken in this study. For qualitative methods, in-depth interviews were conducted with health sector leaders and health extension workers. For the quantitative method, a community-based descriptive cross-sectional study design was implemented. The sample size for the quantitative study was 387, and A total of 21 in-depth interviews were conducted. The study enrolled 387 participants; the majority (92.8%) of the respondents are under the age category of 31-50 years. More than half (54.3%) of the participants are female, nearly 89% are married, and Approximately 58% are protestant Christians by religion. The majority of the participant, 338 (87.3), correctly identified fever, chills, and headache are the key sign and symptoms of malaria. The majority of the participants, 89.7%, knew that mosquitos bite at night and 369 (95%) believed mosquitos are breading at the water body. The study revealed that the most recognized method of malaria prevention is LLIN, this was confirmed by a total of 240(62%) participants,  in addition to this drainage (25.3%), covering stagnant water body (10.1%) and Smoke (1.3%) were also identified as a prevention method. Only half of the study participants, 194(50.1%), always slept in the mosquito nets; besides that, nearly half,  155 (40.1%) of the respondent’s house was never sprayed with IRS, indicating the practice of using the primary prevention of malaria tend to be very low. The principal actors responsible for influencing the policy decision, its implementation, and evaluation are only the health sectors. The findings of this study indicated that there was no specific policy, Strategy, guideline, and intervention for integrated community-based malaria intervention. The practice of the study community toward major malaria prevention methods is inadequate. In addition, this study’s findings indicated that there was no specific policy, Strategy, guideline, and intervention for integrated community-based malaria intervention. In conclusion, the implementation of integrated community-based malaria intervention is at its infant stage. The policy implication of this study is to develop a specific procedure and Strategy for integrated community-based malaria intervention at the International, regional and national levels. Besides reinforcing inter-sectorial collaboration among stack holders, developing an explicit annual plan, performance indicator, and evaluation framework for the program is very important. In addition to this, wider partnerships between health and non-health sectors, enhancing community mobilization, and ensuring community participation in malaria prevention programs are inevitable.

 

1.     INTRODUCTION

1.1.   Historical Background- The Disease Malaria

In ancient times, people described malaria in vivid enough terms for historians to confirm their identity. Ancient Greeks understood malaria as a seasonal scourge that arrived during harvest time. The physician Hippocrates described it as a disease common around marshlands, while the poet homer referred to malaria when he decried Sirius as an “evil star” that was the harbinger of fevers. The ancient Chinese called malaria the “mother of fevers,” while in India, thirty-five hundred years ago, it became known as the king of diseases.¹ In the literature, it was discussed how slavery introduced Plasmodium falciparum into the Americans; the following statements expressed this; “Despite these conditions, between 1700 and 1800, European slavers brought some six million bound and shackled Africans to the Americas. With falciparum parasites roosting in their veins, they changed the face of the Americas forever.”¹

According to the Centers for Disease Control and Prevention (CDC) document, during the United States military occupation of Cuba, and the construction of the Panama Canal at the turn of the 20th century, U.S. officials made great strides in the control of malaria and yellow fever.² The major milestone in the history of malaria was malaria parasite resistance to malaria drugs, the first signs that malaria parasites could resist synthetic drugs cropped throughout the finale of World War II, as the Allies dosed their troops with the hated quinacrine.¹ The scientist rounded up hundreds of volunteer Jewish refugees and injured soldiers among them to be purposely infected with malaria and then rigorously dosed with quinacrine to show how well the drug worked to prevent illness. After world war II, a body to oversee global public health, the World Health Organization, equivocated over reports of malaria that resisted chloroquine, too. The first hints of malaria retaliation against chloroquine emerged from Colombia and along the Thai-Cambodia border in 1957, just twelve years after the drug was introduced.¹

Malaria is a disease caused by plasmodium parasites; Plasmodium species of human malaria disease are plasmodium, falciparum, vivax, ovale and malariae. The literature reviewed indicates, that malaria parasites are highly species-specific no-animal reservoirs for human malaria parasites.³ The typical malaria paroxysms have three stages; cold, chilly feeling followed by rising body temperature (headache, nausea, and vomit), hot, high temperature 39 to 40.5 sweating, the falling temperature is accompanied by sweating (fatigue and weakness). Malaria relapse and recrudescence can happen with a patient treated for malaria. Malaria relapse is the presence of dormant hypnozoites in the liver of a patient caused by P. vivax and P. ovale. Malaria recrudescence is the reappearance of blood forms of parasites and drug resistance caused by all four species.³

Malaria transmission can be determined by different factors, and the following are the major factors; spreading and profusion of the mosquito vector, temperature and extent of water for larval breeding, seasonal fluctuation of mosquito populations, vectorial capacity of the common vector species, and duration of conditions suitable for mosquito survival. ⁴According to the literature, malaria endemicity can be classified as holoendemic: transmission occurs all year long, hyperendemic: intense but with periods of no transmission during the dry season, meso endemic: regular seasonal transmission, and hypoendemic: very intermittent transmission.³

Humans are the only reservoir for malaria. Malaria is entirely vectored by mosquitoes in the genus anopheles. There are 422 species of anopheles mosquitoes worldwide, most common in the tropics and subtropics but also dispersed in temperate climates and may extend to summer arctic distributions phylogenetically distinct from the culicines.⁵

The burden of malaria is high in sub-Saharan Africa; according to the reviewed literature, 100 courtiers in the world are malaria-endemic; among those, half are in sub-Saharan Africa. 2.4 billion populations are at risk, and 300 to 500 million cases of malaria are recorded each year. The death toll is high in children (1.0 to 2.7 million). 25% of the death among children is in Africa. In general, 90% of all malaria mortality in under-five children, and the major cause of death among children are; Low birth weight, preterm delivery, cerebral malaria, and severe malarial anemia. Sequelae from severe clinical complications of malaria include cognitive impairment, behavioral disturbances, spasticity, and epilepsy, as well as vision, hearing, and speech impairments.⁶

1.2.  Integrated Malaria Intervention

New strategies for malaria prevention and control emphasize integrated vector management. This style reinforces connections between health, and the environment, optimizing benefits to both. Integrated vector management is a vibrant and still-evolving field. IVM strategies are intended to achieve the greatest disease-control advantage in the most cost-effective manner while reducing negative impacts on ecosystems and adverse side effects on public health. Possible health risks vary from acute exposures to pesticides and their residues to bio-accumulation of toxic chemicals, as well as the progression of vector resistance to some widely-used pesticides and drugs.⁷

A new WHO Global Strategic Framework for assimilated vector management is defined as an approach to advance the efficacy, cost-effectiveness, ecological soundness, and continuity of disease vector control. IVM encourages a multi-disease control method, integration with other disease prevention measures, and the systematic and careful application of a range of interventions, often in combination and synergistically.⁷

The Inter-Organization Programme for the Sound Management of Chemicals (IOMC), supported by the Food and Agriculture sector of the United Nations, the International Labour Organization, the Organization for Economic Co-operation and Development, UNEP, the United Nations Industrial Development Organization, the United Nations Institute for Training and Research, and WHO, have distributed guidance on alternative strategies for sustainable pest and vector management to help decrease the use of persistent organic pollutants. A menu of options for the best-practice Strategy of dams and agricultural irrigation projects to control vector breeding sites while minimizing the interruption to ecosystem services has been detailed in the joint WHO/FAO/UNEP/UNCHS Panel of Experts on Environmental Management for Vector Control series.⁸

With simple, accessible measures appropriate in any endemic malaria region, it is possible to adequately control the disease. According to the study conducted in Colombia, The Integrated Malaria Control Program was established to be effective in the field in 23 communities on the Choco Pacific Coast of Colombia. An important component of the IMCP was that it included man, the only one of the three actors in the malaria drama who could be educated. The educational program was carried out through courses, community meetings, and workshops in the communities and municipalities in which leaders and authorities participated.⁹

As in other existing malaria control programs in Colombia and the rest of the world, the parasite and vector were kept in mind, executing measures for the immediate diagnosis and timely, complete treatment, in addition to actions to decrease vector density. Through the IMCP, deaths were avoided, the incidence of cerebral malaria (the most serious complication) was reduced by 46%, and the average sick leave due to malaria decreased from 7.6 to 3.6 days. Fewer cases and the absence of complications and hospitalizations meant enormous economic savings for the communities.⁹

The program managers in Colombia explained that they believe the program should be implemented in other endemic areas of the country and continent, with the essential adaptations for each region. The success and stability of an integrated control program for a disease such as malaria is created on the true integration of ecological, cultural, biological, administrative, and political aspects. It is important that community leaders and health officials participate in the program’s design and implementation. Therefore, they should be involved from the beginning and participate actively in the whole process. There should be no discrimination based on race, sex, religion, or age.¹⁰

2.     PROBLEM CONTEXT AND STATMENT

2.1. Malaria as a Global Public Health Challenge

Bayu Mulatu, 14, came to Addis Ababa from Dire Dawa, where malaria freshly created havoc on the people, to join thousands of street children living on the roads of Addis Ababa along with some 70,000 stray dogs. Bayu is not distressed from rabies but malaria. “I wish I could die quickly,” he says, shaking from malaria fever. In Ethiopia, more than three-quarters of the 1.1 million square kilometers of land is malarious, and 40 million of the 5 million Ethiopians are at risk of malaria, and the disease occurs in epidemic form.¹¹

Malaria transmission in Ethiopia is mostly seasonal and unsteady in character. However, there are places where malaria is transmitted throughout the year. The highest transmission seasons are from September to October, and in minor cases, from April to May.¹¹ These periods are very important to agricultural work. It is through these months that farmers convey out their farming and harvesting activities. Malaria hampers the function of the population resulting in low productivity and low growth. It hampers the economy of the families and the country. Annually, an average of 600,000 cases with positive blood film for malaria is treated.¹¹ However, the real number of malaria cases that occur annually in Ethiopia is estimated at five million. In Ethiopia, the major courses for the spread of malaria include displacement, change in climate, migration, and drought. According to the latest report, malaria is the leading cause of illness together with HIC/AIDS and other communicable diseases.¹¹

Ethiopia’s fight against malaria started many years ago, and transmission of this infectious disease has significantly decreased since 1959. However, malaria still residues a major public health problem.¹² The estimated total population of Ethiopia is 100 million, and it is estimated that 68% of the population is at risk of malaria.¹³ Plasmodium falciparum and P. vivax co-exist as major parasite species in Ethiopia.¹² This epidemiologic story makes malaria control more complicated than in most African countries where P. vivax has low or nil endemicity. The distribution of malaria varies from place to place depending on climate, rainfall patterns, and altitude.¹⁴ It is a major apprehension in the country, and it is one of the leading causes of morbidity and mortality. The key epidemics occur cyclically every 5–to 8 years in Ethiopia, but focal epidemics occur every year.¹⁵ About 2.9 million cases of malaria and 4,782,000 related deaths have been reported yearly, and the rate of morbidity and mortality dramatically increases during epidemics.¹⁶

Beyond the enormous health consequence, malaria imposes a substantial economic burden on individuals, households, and the entire economy.¹⁷ Malaria disease has been found to decrease the potential economic growth rate by 1.3% per year in some African kingdoms as a single disease. According to Gallup and Sachs’ study, malaria and poverty are closely linked at the macro-level, in which malaria is the leading contributor to poverty.¹⁸

2.2. Community Involvement in Malaria Prevention and Control

Studies indicated that despite the enormous health and economic consequence of malaria, communities in Ethiopia are not well oriented on the impact of malaria in all social and economic aspects. The community’s knowledge of malaria is far from perfect, and misunderstandings are extensive.¹⁹ There have been a significant number of records about the practice relating to malaria and its control from different parts of Africa. This information determined that misunderstandings concerning malaria still exist and that practices for the control of malaria have been unsatisfactory.²⁰ Early finding and prompt treatment of malaria cases, selective vector control (indoor residual spray, use of insecticide-treated mosquito nets, and source reduction), and epidemic prevention and control are the major strategies adopted in the country. Vector control strategies are the major area that requires community involvement.²¹

The transmission of disease by the vector to humans was first elucidated in the late 19^th and early 20th centuries. Since operative vaccines or drugs were not always existing for the prevention or cure of these diseases, control of transmission often had to trust principally on the control of the vector. Early control activities comprised house screening, the use of insecticide-treated bed nets, filling and drainage of swamps and other water bodies used by insects for breeding, and the application of oil or Paris green to breeding places. After the finding of the insecticidal properties of DDT in the 1940s and the subsequent discovery of other insecticides to kill both larval and adult stages of the mosquito vector, the vector control focus was shifted to the deployment of insecticides.²² Vector transmitted diseases remain a severe public health burden in the world. Currently, the most acceptable methods of vector control are IRS, and long-lasting insecticidal nets, with Larval Source Management valid in certain settings where mosquito breeding sites are limited, fixed, and findable.²³ ITNs and IRS have been extensively used as front-line tools against malaria vectors in endemic African regions. These preventive actions are highly effective against malaria vectors, which prefer to bite and rest inside the rooms. The use of ITNs and IRS over the last decade has led to a significant decrease in malaria transmission in many areas of sub-Saharan Africa.²⁴

A malaria prevention strategy must engage the community. Unless individuals in communities see the advantages of preventing the illness, even the best-intended prevention strategies might not be used. It is necessary to recognize how a community perceives malaria, the significance placed on it in community belief systems regarding illness in general, and what prevailing behaviors are practiced that can either match or hamper preventive measures.²⁵

The implementation of any type of prevention method will be affected by two things: how affected communities define their significance regarding health and illness and the degree to which individuals think they can personally control or prevent illness. No matter how sound a preventive method might be, if individuals do not see the advantages of a specific method or if competing needs are prioritized higher, the preventive methods will fail to some degree.²⁵

Perceptions about malaria illness, particularly household’s perceived susceptibility and beliefs about the seriousness of malaria, are important preceding factors for decisions to take preventive and curative actions against malaria.²¹ The knowledge of the possible causes, modes of transmission, individual preference, and decisions about the implementation of preventive and control measures vary from community to community and among individual households.²⁶

According to the study title “Malaria prevention practices and associated factors among households of Hawassa City Administration, Southern Ethiopia.”²⁷ Conducted by, Fikir et al., the overall malaria prevention practice of the study participants is found to be 54.3%. Though the practice of malaria prevention measures attained in this study was comparable to prior studies, it is lower than the stipulated strategic objective of the Ethiopian operational plan for malaria. The study participants who were sleeping under an ITN showed slightly lower than the targets of the national operational plan for malaria, which was planned to have levels above 80%. More than a quarter, 76.7% of study participants are protected by IRS. More than three-fourths of the study participants actively participated in the drainage of stagnant water and cleaning bushes surrounding their houses.²⁷ Different strategies and methods have been tried and implemented to control malaria at the community level in different parts of the world. A lack of education, information, and access to effective intervention restricts the success of malaria control initiatives in many countries.²⁸ Most research done elsewhere focuses on the community’s knowledge, attitude, and practice towards malaria and its control and identifies the gap in community involvement in the control program.²⁹

So far, the study conducted on the status of integrated community-based malaria intervention was limited. According to research, this type of study was conducted in a very limited region of the country, and no evidence was found, which indicates the study was conducted in the selected zone of the region. The researcher trusts that the contribution of the finding from this study is highly significant in the fight against malaria and its elimination.

3.     PURPOSE AND OBJECTIVE OF RESEARCH

3.1. Purpose of the Study

Vector transmitted diseases residues a serious public health burden in the world. Malaria is a parasitic disease caused by mosquitoes. People with a disease often experience fever, chills, and flu-like illnesses.³⁰ Malaria is a widespread communicable disease caused by a parasite called plasmodium. It is transmitted by mosquitos, which feed on humans. The symptoms of malaria include fever, headache, shaking, and chill. Even though malaria is a fatal disease, it can also be prevented.³¹ Worldwide, malaria is considered to be one of the serious public health problems. In 2019, malaria caused nearly 229 million clinical episodes and 409,000 deaths. In 2019, 94% of the total estimated death was from Africa.³²

The global burden of malaria is higher in the African continent, affecting the entire development of the countries. “Malaria is so common you can get it anywhere, anyhow, any time,” Jessica, a malaria sufferer in Liberia; this is because Africa’s mosquitoes are “supremely efficient vectors of malaria disease,” says the World Health Organization’s David Schellenberg.³³

Ethiopia is among the few countries with uneven malaria transmission. Malaria is mostly seasonal in the highland fringe areas and of comparatively longer transmission period in lowland areas, river basins, and valleys. Nearly 60% population lives in malaria-endemic areas in Ethiopia, chiefly at elevations below 2,000 meters.

World Health Organization recommends the use of ITN and IRS for preventing mosquito bites. By 2018, 72% of households in sub-Saharan Africa had at least one ITN, and about 57% of the population had access to an ITN, while 40% of the population lived in households with enough  ITNs for all inhabitants.³⁴ In Ethiopia, regardless of working towards vector control and epidemic prevention as one of the core strategies still, a significant number of households have poor practices related to malaria prevention.³⁵ The possible explanations for these poor practices could be due to poor or no awareness and misuse of malaria prevention practices. Besides, significant numbers of communities are still suffering from malaria morbidity.³⁶ However, factors affecting malaria prevention practice and the level of integrated community base malaria intervention are not well studied, particularly in the study zone of the country. Moreover, the current Ethiopian national malaria strategic objective stated that: by the year 2020, all households living in malaria-endemic areas will have the Knowledge, Attitude, and Practice used to adopt appropriate health-seeking behavior for malaria prevention and control³⁷. Therefore, this study will assess the level of integrated community base malaria intervention and also identify the factors affecting malaria prevention practices for policymakers and program managers to improve the strategies.

3.2.   Objective of the Research

General Objective

Review and evaluate the integrated community-based malaria intervention in East Africa, focusing on Ethiopia and its national, regional international public health policy implications.

Specific Objectives

• To review the implementation of an integrated community-based strategy for malaria prevention
• To assess the level of community practice toward malaria prevention and control
• To recommend for the policymakers and managers an evidence-based strategy of malaria prevention and control methods at the community level

4.     RESEARCH STATEMENTS  AND QUESTIONS

4.1.  Primary Statement

Study results overwhelmingly suggest that integrated community-based malaria intervention is the best strategy to eliminate malaria. For a high level of community involvement, the program must be an interactive process that relies on early involvement, frequent feedback, and active community participation.

According to the Ethiopian malaria indicator survey of 2015, the coverage of the two major malaria prevention services, LLIN and IRS, is below 50%.³⁸ The author of the Ph.D. dissertation believes that involving districts and communities in planning and executing community-based interventions is essential.

4.2.  Secondary Statement

To prevent and ultimately eliminate malaria, community and district participation in all strategies is mandatory. Henceforth the researcher believes that understanding the level of malaria prevention practice and implementation of integrated community-based malaria intervention at the community level will contribute to identifying the gap in policy and Strategy for better community support. The researcher also believes that qualitative and quantitative methods will explore all the necessary information, which is vital for the implementer to make an informed decision. Besides, the researcher believes that the absence of a similar study, especially in the study area, will contribute to the review of the existing policy and Strategy to maximally utilize the power of community and none health sector entities.

The researcher postulates that the level of community practices and the integrated community-based intervention toward malaria prevention is low. By conducting a global, regional, and nationwide desk review and interviewing the selected community members using structured questionnaires, the study will come up with a decision to determine the level of integrated community-based malaria intervention and community practice in malaria prevention. The result will further inform the decision-makers and program managers on how to improve malaria prevention methods at the community level.

The guiding research question of the Ph.D. dissertation is:

What is the level of integrated community-based malaria intervention and community practice in the prevention and control of malaria?

4.3.   Research questions

• What is the level of integrated community-based malaria prevention in Ethiopia?
• What is the level of community practice toward malaria prevention and control in Ethiopia?
• What are the recommendations for the policymakers and managers in implementing an evidence-based strategy of malaria prevention and control methods at the community level in Ethiopia?

To answer the research question of this Ph.D. Dissertation mixed methodology: qualitative and quantitative methods were used, exploring detailed information, including:

• Examination of concepts and perceptions about malaria
• Assessment of practice on prevention of malaria at the community Level
• Evaluation of knowledge and implementation of community-based malaria intervention
• Investigation of availability of Policy/Strategy and intervention packages from the qualitative study

For the qualitative method, in-depth interviews with health sector leaders and HEW were conducted. For quantitative methods, a community-based descriptive cross-sectional study design was implemented to assess the practice and engagement of the community toward malaria prevention. The result of the qualitative and quantitative methodology combined to come up with the final conclusion of the study findings.

5.     LITERATURE REVIEW

5.1.   Search Strategy

Keywords/ search terms used to identify the literature for review, which represent the main concepts of my research topic, are Integrated, community, intervention, malaria, and engagements.

The inclusion and exclusion criteria of the literature review

Inclusion criteria

• Articles/ research with an appropriate study design for the research question
• The study conducted on malaria prevention, control, and elimination
• Articles with measurable outcomes and defined target population
• The study is original and has not been reviewed
• Studies must be both qualitative and quantitative

Exclusion criteria  

• Study with no measurable outcomes and biased
• The study was in a language other than English or translated

• Study with design issues
• The study only qualitative or quantitative

5.2.   Introduction

This literature review aims to gain an understanding of the existing research and debates relevant to my study area and to present that knowledge in the form of a written report.³⁹ The literature review of this Ph.D. study consisted of assessments of books, Scientific and other peer-reviewed journals, newspaper articles, WHO and National malaria guidelines, annual reports, and situation report. As part of the secondary data analysis, online background checks were conducted on relevant documents to verify the sources and ensure the data sources’ credibility. Besides, the researcher surveyed primary or secondary data sources focusing on primary data sources. Most of the literature is accessible online.

A handful of the literature review was done on malaria prevention methods; one of those includes the systematic review of knowledge, attitudes, and beliefs about malaria among the South Asian population, the indication from 32 articles (26 quantitative, four qualitative, and two mixed methods). Based on the finding of this review, overall awareness and knowledge of malaria, preventative measures, its transmission, and control were generally found to be poor amongst both the general public and healthcare professionals. Moreover, the study shows that poor socio-economic aspects, including inadequate access to services due to limited availability, and issues of affordability, are considered major risk factors.⁴⁰ Six studies reported numerous measures to prevent malaria, which exist in different parts of Southern Asia, and that the achievement of these measures depends on the knowledge of, access to, and utilization of services, as well as a combination of users’ behaviors and healthcare access and quality issues.⁴¹ The other studies also emphasized that in spite of people’s knowledge and awareness about the use of long-lasting impregnated nets, some of the community members are not using them due to the high price, the discomfort of the chemicals, and lack of availability.⁴² There has been a lot of research about KAP relating to malaria and its control from different parts of Africa. The outer reviewed most of the relevant studies related to community practice in the prevention of malaria; however, studies related to malaria drug adherence at the community level are very limited.

The following sub-sections will deliver readers with an overview of the health, economic and social impact of malaria in general and integrated community intervention of malaria in particular. Moreover, the author believes this study will help to improve the malaria control program in Ethiopia.

1) Health Economics and Social Impact of Malaria

According to the latest world malaria report released on 30 November 2020, there were 229 million cases of malaria in 2019 compared to 228 million cases in 2018. The estimated number of malaria deaths stood at 409 000 in 2019, compared with 411 000 deaths in 2018.⁴³ Malaria takes its toll not only on lives lost but also on medical costs, lost income, and reduced economic output. The annual direct and indirect costs of malaria in Africa are estimated to be more than US$2 billion, according to the WHO. Once seen as a significance of poverty, malaria is now regarded as one of its causes. Experts say malaria slows economic growth in Africa by up to 1.3 percent per year.⁴⁴

Malaria and poverty are intimately connected. As T. H. Weller, a Nobel laureate in medicine, noted, “It has long been documented that a malarious community is a disadvantaged community.”⁴⁵ Weller could have said the same for malarious countries.

Malaria is most intractable for countries in the poorest continent, Africa. The only parts of Africa free of malaria are the northern and southern extremes, which have the richest countries on the continent. India, the country with the greatest number of poor people in the world, has a serious malaria problem. Haiti has the worst malaria in the Western Hemisphere, and it is the poorest country in the hemisphere.⁴⁶

The economic impact of malaria is estimated to cost Africa $12 billion every year. This figure factors in costs of health care, nonappearance, days lost in education, decreased productivity due to brain damage from cerebral malaria, and loss of investment and tourism.⁴⁶

There are at least two broad categories of mechanisms through which malaria can impose economic costs well beyond direct medical costs and foregone incomes. The first is the effect of the disease to change the household behavior in response to the disease, which can affect wide-ranging social costs. These include such factors as schooling, demography, migration, and saving. The second is macroeconomic costs that arise precisely in response to the pandemic nature of the disease, and that cannot be measured at a household level. These include the influence of malaria on trade, tourism, and foreign direct investment.⁴⁷ According to the literature, poverty has widened from a narrow focus on salary and consumption to a multidimensional notion of education, health: social and political participation, rights, personal security and freedom, and environmental quality. Thus poverty includes not just low income but lack of access to services, resources, and skills, helplessness, uncertainty, noiselessness, and hopelessness. Multidimensional poverty is a determinant of health risks, health-seeking behavior, health care access, and health outcomes.⁴⁸

2) Malaria Prevention Control and Elimination Through Community Engagement

The goal of the control program is to decrease the number of death and cases related to malaria, while elimination is zero reports of indigenous malaria. In addition to this control, the program aims for malaria, not more to be a public health problem.⁴⁹ Malaria elimination is an interruption of local transmission (reduction to zero incidences of indigenous cases) of a defined malaria parasite in a specific geographical area as a result of deliberate activities. Sustained actions to prevent the re-establishment of transmission are required.⁵⁰ No single intervention or package of interventions will achieve malaria elimination in all countries. Preferably a set of interventions should be acknowledged and used correctly for the malaria transmission intensity and dynamics in each country to achieve and maintain elimination.⁵¹ National malaria elimination is defined as a countrywide interruption of local mosquito-borne transmission of specific malaria parasite species and zero incidences of indigenous cases.⁵¹

A global technical strategy for malaria is a framework for the development of tailored programs to accelerate progress toward malaria elimination. The Strategy is made on three pillars with two supporting elements that guide global efforts to move closer to malaria elimination.⁵² In Ethiopia, as a result of major investment, access to preventive intervention has been intensely expanded to at-risk communities along with the extension of access to treatment interventions in public health facilities. Due to continued high coverage of these interventions, the country detected a 50 percent decrease in hospital malaria morbidity and a 60 percent reduction in mortality between 2006 and 2011.⁵³ Launching the malaria elimination endeavor on a national scale at once is not feasible for epidemiological and operational reasons. It is, however, likely to create malaria-free zones within selected geographical areas in the country. Therefore, According to the national malaria elimination plan, Ethiopia is following a step-wise approach by targeting adjacent areas to attain malaria-free districts.⁵⁴; currently, the country is moving to the malaria pre-elimination phase as many malaria districts have reduced annual malaria incidence exceeding WHO criteria of being under the pre-elimination phase.⁵⁵

The process by which communities participate to influence the decisions and resources that directly affect them is called community engagement.⁵⁶ The introduction of interventions into communities should take into account all actors, their roles, competence, and experience, as well as their environment. Communities should participate in the inception and planning of new interventions whenever possible, although community participation can be introduced at any stage of ongoing intervention. Continuous monitoring and evaluation of community activities are serious since regulations and progression to interventions can only be happened by identifying strengths and weaknesses in their implementation.⁵⁷ The findings of the study seek to expand on community engagement approaches for malaria by looking to a diversity of health and development programs for lessons that can be applied to malaria elimination; the result revealed that C.E. must be an iterative process that relies on early participation, frequent feedback and active community involvement to be successful. Empowering districts and communities in planning and executing community-based interventions is necessary. Communities affected by the disease will eventually attain malaria elimination. For this to happen, the community itself must describe, believe in, and commit to strategies to interrupt transmission.⁵⁸

5.3.  Summary and conclusion

A total of more than 35 pieces of literature have been reviewed in relation to the research topic of the current study. Almost all the reviewed literature revealed integrated community-based malaria intervention is the best strategy for malaria prevention control and elimination as well. In some of the countries where malaria prevention intervention vertically implemented failed to achieve the desired outcomes, the integrated community-based intervention approach to malaria prevention, which advocates the use of several malaria prevention methods, is being explored to reduce the burden of the disease. Such multi-interventional approaches have been used in the control of other diseases such as HIV/AIDS and those affecting the cardiovascular system. In addition to this, almost all internationally and nationally reviewed literature proved that community engagement had been accepted as one of the key components for successful health interventions for malaria control. Despite this, in practice, community engagement has often played a marginal role within malaria control and elimination programs in the last several decades.

My current study focuses on the review and evaluates the integrated community-based malaria intervention; the author conducted a desk review of all the relevant internal and external data sources, such as government policy, strategy, annual reports, and research outcomes. All the review results were discussed and evaluated comparatively with the literature analysis as primary information. In addition to this, to come up with a concrete and evidence-based conclusion to advocate for the policymakers, the relevant literature reviewed here can be used as a baseline to determine the outcome of the study’s national, regional, and international policy implications.

6) RESEARCH DESIGN/METHODOLOGY

In this section of the research, the author describes the research methodology:

6.1.  Research Design

The research design involved both primary and secondary data.

Secondary Data

Desk review research was conducted, and during the desk review, both internal and external data were reviewed; the internal data includes departmental records, annual reports, minutes, and performance review records. The external data includes media sources, data compiled by Government statistics, data accumulated by commercial market research organizations, websites, data published in trade Publications and trade associations, and information published in newspapers, magazines, and other such general media. During the desk review, data were gathered for all relevant sources, data were compared from different sources and normalized, and data were analyzed to come up with a conclusion.

Primary Data

Both qualitative and quantitative methods were used. For the qualitative method;

• Twelve in-depth interviews with health sector  leaders
• Nine  in-depth interviews with health extension workers

For quantitative methods;

A community-based descriptive cross-sectional study design was implemented to assess the practice and engagement of the community toward malaria prevention.

6.2.  Study Area and Study Period

The study was conducted in SNNPR of Ethiopia, Bolosos Sore Woreda, three intervention kebele. Quantitative data was collected from the southern part of Ethiopia, where malaria prevalence is high. SNNPR is one of the largest regions in Ethiopia, accounting for more than 10 percent of the country’s land area and an estimated population of 20,768,000, almost a fifth of the country’s population. Less than one in a tenth of its population (8.9%) lived in urban areas in 2008. The region is overwhelmingly rural. The SNNPR region is divided into 13 administrative zones, 133 Districts, and 3512 Kebeles, and its capital is Awassa.⁵⁹ This study was conducted from January 20 to February 30, 2022.

6.3.  Source Population

The source population is the population from which the sample was taken, and therefore all members of the population in SNNPR have a chance of being selected for inclusion in the study.  The source population for this study is all households in the intervention region.

6.4.  Study Population

The study population is a subset of the source population from which the sample is actually selected. The study population of this research is people from the selected kebeles.

6.5.  Sampling Units

A sampling unit is the building block of a data set; an individual member of the population, a cluster of members, or some other predefined unit. In surveys and market research, the units might be households or targeted individuals. The sampling unit of this study is selected households for the quantitative study and focus groups, experts, and selected documents for qualitative methods.

6.6.  Sample Size Calculation

The Federal Democratic Republic of Ethiopia is located in the north-eastern part of Africa, commonly known as the Horn of Africa. It is strategically proximate to the Middle East and Europe, with its easy access to the region’s major ports, enhancing its international trade. Sudan borders it in the west, Somalia and Djibouti in the east, Eritrea in the north, and Kenya in the south. The country covers 1,112,000 square kilometers (472,000 sq. miles), making it roughly as large as France and Spain combined and is five times the size of the UK.

With a population of about 110.14 million, Ethiopia represents a melting pot of ancient cultures with Middle Eastern and African cultures evident in the religious, ethnic, and language composition of its Semitic, Cushitic, Omotic, and Nilotic peoples. The Ethiopian people comprise about eighty nationalities, of which the Amhara and the Oromo constitute the majority, with about 60 percent of the total population. Approximately 85 percent of the population lives in rural areas. The annual population growth rate is about 3.09 percent, and the economically active segment, between ages 14 and 60, is about 50 percent of the total population. Ethiopia is a Federal Democratic Republic composed of 9 National Regional States (NRS) – Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern Nations, Nationalities, and Peoples Region, Gambella, and Harari and two administrative councils – Addis Ababa and Dire Dawa. The NRS and the Administrative councils are further divided into 62 zones and 523 woredas.⁶⁰

Sample Size

The sample size for the quantitative data was calculated based on the prevalence of knowledge, attitude, and practice based on the next assumptions: 50% prevalence of knowledge, attitude, and practice (p) to get maximum sample size, 95% confidence level, maximum tolerable error of 5% (d), the sample size was then calculated using the online calculator;

 

Where:

n= sample size

Z= value corresponds to a 95 percent level of significant=1.96

d= absolute precision =5%

None respondent rate =10%

p=expected proportion of people who practice malaria prevention and adherence to malaria treatment 35.5 %

q= (1-p)= (1-0.355)=0.645

The sample size calculation was  387 with a 10% none respondent rate.

The Sample size for the qualitative method was determined based on the saturation level.

(A total of 21 in-depth interviews) ZHD: 3, WRHO: 3, From two HC: 6 from 3 HP: 9.

A multistage stratified sampling technique was applied to get study subjects.

6.7  Inclusion And Exclusion Criteria

Community members who lived six months and above are included in the study. The head of the household was interviewed.  In some cases, if the head of the house old is not able to do the interview for a different reason, the next person, his wife, or his elder children who are above 18 years old, was interviewed.

6.8.  Study Variables

All studies analyze a variable that can define a person, place, thing, or idea. A variable’s value can change between groups or over time.  In this research, we have both dependent and independent variables. The dependent variables for the qualitative study are the level of integrated community-based strategy toward malaria prevention; for quantitative study are knowledge, attitude, and the practice of the community on malaria prevention.

6.9. Sampling Procedure and Sampling Technique

Quantitative method: the calculated sample size was proportionally allocated to the random clusters and selected kebeles, the study household were selected by systematic random sampling method, and the head of the household or his wife were interviewed. In some of the cases, both are absent for any reason, and the elder member of the household was interviewed.

Qualitative method: purposive method of selection was used to conduct the in-depth interview..

6.10. Data Collection Procedures

Standard structured questionnaires were used. The questionnaire was translated into Amharic and then translated back to English to check for their consistency. The questionnaires were pre-tested on 5% of the total sample size in non-selected kebeles.

6.11.  Data Collection Method

In the first phase, quantitative data was collected, analyzed, and interpreted, and then accordingly, qualitative data followed.

Qualitative data: in-depth interviews carried out at each level of the health system. The information was recorded to support the field notes and an in-depth interview to get adequate information on the study population.

Quantitative data: For the standard structured questionnaire, health professionals with degree levels who have experience in malaria prevention and fluently speak the local language were recruited to collect the data. The training was given for two days, including one day for pre-testing to overview the objective, relevance of the study, confidentiality of information, respondent’s right, informed consent, and techniques of interview. A senior supervisor with a master’s degree in public health were assigned to supervise the data collection along with the investigator.

6.12. Statistical Analysis

The data were entered, cleaned, and analyzed with SPSS version 28.

6.13. Ethical Considerations

Ethical clearance and permission were obtained from SNNP zonal Health Bureau, and permission letters were collected from the respective levels of administrative offices from all levels. The nature of the study was entirely explained to the study participants to attain their oral informed consent before involvement in the study, and data were kept confidential. Informed consent was gained from each respondent before an interview.

7) RESULT OF THE STUDY

7.1. Quantitative Results

Background Characteristics of the Participants

The study enrolled 387 participants; the Majority (92.8%) of the respondents are under the age category of 31-50 years. More than half (54.3%) of the participants are female, nearly 89% of the participants are married, Approximately 58% of the participants are protestant Christians by religion, followed by Orthodox Christians (34.4%), almost 41% of the study participants are illiterate, and high school educational attainment is only 10.1%. Nearly half (48.1%) of the study participants are farmers.

Knowledge And Awareness About Malaria

The study revealed that 333 (86%) heard about malaria; among them, 210(54.3%) were females. A total of 298 (77%) of the participant identified parasites as a cause of malaria; only 19 (4.9%) reported the virus as a cause of malaria. Most of the participants, 338 (87.3), knew that the sign and symptoms of malaria are; fever, chills, and headache.

Variable	Variable category	Number	Percent
Information about malaria	No	54	14.0
	Yes	333	86
Couse of malaria	Parasite	298	77.0
	Bacteria	67	17.3
	Viruses	19	4.9
	I don’t know	3	0.8
Sign/symptom of malaria	Fever	140	36.1
	Chills	97	25.1
	Headache	101	26
	Joint pain	18	4.7
	Vomiting	31	8.0

Table 1. Respondent’s Information on, causes, sign, and symptoms

The majority of the participants, 89.7%, knew that mosquitos bite at night and 369 (95%) believed mosquitos are breading at the water body; this result was significantly associated with educational level (P=0.019). All diploma graduates and 97% of high school graduates knew the breeding sites of mosquitoes; nearly one-third (64%) of the participant knew that mosquitos are resting outside the house.

Table 2. Respondents knowledge of mosquito biting time, breading, and resting site (N=387)

Variable	Variable category	Number	Percent
Mosquito biting time	Day	31	8.0
	Night	347	89.7
	I don’t know	9	2.3
Mosquito Breading site	Dry Area	18	4.7
	Waterbody	369	95.3
Mosquito resting site	House	139	35.9
	Outside houses	248	64

Most participants believed mosquito bites transmit malaria (85.3%), while fewer participants (12.9) also believed fly bites could transmit mosquitoes; no statistically significant association was observed between educational level and knowledge of the mode of transmission. The study revealed that the most recognized method of malaria prevention is LLIN, this was confirmed by a total of 240(62%) participants,  in addition to this drainage (25.3%), covering stagnant water body (10.1%) and Smoke (1.3%) were also identified as a prevention method. A total of 236(68.2%) of the participant knew that LLIN could be used to prevent mosquito bites; only 8.3% of the participant believed that LLIN could prevent high-risk groups in society.

Association of knowledge of malaria with socio-demographic parameters

Variables like knowledge of the mode of malaria transmission and cause of malaria were significantly associated with the educational level of respondents, with a p-value less than o.o2 and o.o3, respectively. All of the diplomas graduated, and 98% of high school-educated respondents know about malaria mode of transmission. Further, 95% of respondents with an educational level above high school correctly identified the cause of malaria. Occupation of respondents was found to be significantly associated with the information about malaria respondents who are housewives are 75% less likely to be informed about malaria than their government employ counterparts, with a p-value of 0.01.

Considering the use of ITN and drainage system as a core indicator of malaria prevention methods, the knowledge of respondents on malaria prevention was found to be highly associated with the occupation of participants. Farmers are 65% less likely to be knowledgeable on malaria prevention methods compared with government and private employees, with a p-value less than 0.002.

Concepts and Perceptions About Malaria

Of a total of 387 participants, 320 (82.6%) strongly believed malaria is a life-threatening disease, and only 18(4.7%) perceived malaria as not a serious disease.  Nearly 74% of the study participants accepted malaria as a communicable disease only 6.2% disagreed that malaria can be transmitted from one person to another. 64.1% of participants agreed that malaria could be transmitted through contact; of 387 participants, only 111(28.7%) strongly agreed that avoiding mosquito bites is the best way to prevent malaria; eight (2.1%) of the participants disagreed with the idea. The majority of the participants (88%) believe that sleeping under a mosquito net during the night can prevent malaria.

Association of educational level and belief of participant’s on severity and transmission of the disease 

There was no statistically significant association observed between educational level and the belief of participants about the seriousness of the disease (P=0.116). In addition to this, the study revealed no statically significant association between educational level and belief of participants on the transmission, consequence of mosquito bites, and benefits of sleeping under mosquito nets.

Of the 387 participants, 266 (68.7%) strongly agree that there is a greater risk of getting malaria if they work and sleep overnight outside. Only 9 (2.3%) strongly disagreed with this belief; this result was significantly associated with educational level (P=0.001). Only 38.5% of the participants strongly believe that anyone can get malaria; however, the majority, 317(81.9%) of the participants strongly agreed and agreed that children and pregnant women are at higher risk of malaria. Nearly one-third of the participants believe in seeking advice when they get malaria; there was no statistically significant association observed between educational levels and seeking advice for the treatment of malaria.

From a total of 387 participants, 292(75.4%) believed that they should have a blood test if they have a fever; only 12 (3.1%) strongly disagreed with testing for malaria when they have a fever. More than half of the participants believe that they can buy anti-Malaria drugs from the drug shop/pharmacy to treat themselves when they get malaria; only 18.1% of the participant strongly disagree with the idea. Only 63.9% of the participant strongly agreed and agreed that it is very important to check for the expiry date of the drug before taking it, 28.5% of the participants disagreed with the importance of checking the expiry date before taking the drugs

The belief of the participant buying anti-Malaria drugs from the drug shop/pharmacy to treat themselves when they get malaria was significantly associated with educational level with a P-value of 0.002. The participants with a higher level of education, like high school and above, are 70% less likely to buy malaria medicine without a doctor’s prescription than illiterates.   Near to 50% of participants disagreed with the importance of checking the expiry date before taking the drugs, which is 40% higher than their literate counterparts, which indicates the result was significantly associated with educational level with a P- value0.015.

Association of case management beliefs and educational status of the respondents    

Educational level             Std. Error            P-value 95%  C.I

Belief on blood test        Illiterate              .791       .002       .182       7.465

Read & write      1.074     .001       .075       3.557

Elementary         .927       .003       .154       6.767

High school        .999       .003       .061       5.218

Diploma or above           .000       .001       .              .

Self-treatment of malaria            Illiterate              .601       .177       .200       2.336

Read & write      .627       .544       .199       2.501

Elementary         .646       .588       .239       2.974

High school        .643       .790       .202       3.064

Diploma or  above          .694       .729       .200       2.336

Checking expiry date of  drugs   Illiterate              .540       .015       .123       3.988

Read & write      .615       .003       .062       2.815

Elementary         .758       .000       .027       2.319

High school        .692       .000       .087       5.127

Diploma or above           .000       .000       .123       3.988

Practice on Prevention of Malaria at the Community Level

The study revealed that from a total of 387 participants, only 194 (50.1%) always slept in mosquito nets, and 94 (24.3%) of the participant never slept in mosquito nets. In addition to this, only 42.1% of the household members slip into the mosquito net, and 24.5% of the household members never slip into the mosquito nets. Only a few (16%) of the respondents always use mosquito repellants in their houses, and 35.9% of the participant never used mosquito repellants. This study also revealed that 155(40.1%) of the respondent’s house was never sprayed with IRS; in addition to this, from a total of 387, only 50(12.9%) always used the anti-mosquito spray in their houses;

Table 3. Respondent’s practice on LLINs IRS and mosquito repellants (N=387)

Variable	Variable category	Number	Percent
Frequency of  sleeping in a mosquito net	Never	94	24.3
	Sometimes	99	25.6
	Always	194	50.1
Other members of the household sleep in mosquito nets	Never	95	24.5
	Sometimes	127	32.8
	Always	163	42.1
Use mosquito repellents in the house	Never	139	35.9
	Sometimes	186	48.1
	Always	62	16.0
House sprayed with IRS by CHW	Never	155	40.1
	Sometimes	157	40.6
	Always	71	18.3
use the anti-mosquito spray in your house	Never	167	43.2
	Sometimes	170	43.9
	Always	50	12.9

 

Association of core malaria prevention practices with the educational level of participants

	Educational level	Std. Error	P-value
Attendance of malaria prevention campaign	Illiterate	1.506	0.001
	Read & write	0.221	0.003
	Elementary	0.614	0.001
	High school	0.710	0.002
	Diploma or above	1.174	0.001

Sleeping under a mosquito net is one of the core prevention practices of malaria; the study revealed there was a significant association between educational level and practice of sleeping under a mosquito net with a p- a value of o.o4. More than 75% of the diploma and high school educated respondents sleep under the mosquito nets, whereas less than 65% of the illiterate counterparts sleep under the mosquito nets. In addition to this, among all the educational levels, the highest proportion of illiterates (28%) never slept under the mosquito nets. This study also indicated that there was no statistically significant association observed between educational levels and frequency of use of the antimosquito spray in the houses and IRS spray status of the houses.

This study identified that only 41.8% of the participants always clean and cut bushes around their house, and 9.8% never clean or cut bushes around the house. Of a total of 387 participants, only 211(54.5%) always cleaned stagnant water near their house, and 18(4.7%) never cleaned stagnant water near their houses. Only about one-fourth (25.5%) of the respondents participate in malaria prevention campaigns, 47.5% of participants sometimes, and the rest (26.9) never participated in malaria prevention campaigns. Only 23.2% of the participants revealed that community-level discussions on malaria prevention are always conducted in the village; 27.9% said this type of discussion never occurred in the village. Nearly 40% of the participant declared that they attend community-level malaria prevention planning with stakeholders; in contrast, 38.8 % of the respondents indicated they never attended the meeting.  The study revealed that 44.8% of the respondents always visit the health center when they fall sick; only 7.3% will never visit the health center even though they feel sick.

 

 

Variable	Variable category	Number	Percent
Frequency of clean/cut bushes around the house	Never	38	9.8
	Sometimes	187	48.3
	Always	162	41.86
Frequency of cleaning  stagnant water near the house	Never	18	4.7
	Sometimes	158	40.8
	Always	211	54.5
Frequency to participate in malaria prevention campaigns	Never	104	26.9
	Sometimes	184	47.5
	Always	99	25.5
Frequency of community-level discussion on malaria prevention	Never	108	27.9
	Sometimes	189	48.8
	Always	90	23.2
Frequency to attend community-level malaria prevention planning with stakeholders	Never	150	38.8
	Sometimes	149	38.5
	Always	88	22.7

 

The supplementary prevention methods of malaria include environmental management, like cleaning of stagnant water and bush, use of long sleeves, and mosquito repellants. Furthermore, participation in malaria prevention campaigns and early treatment-seeking behaviors play an important role in the prevention of malaria. This study revealed a significant association between educational level and practice of participating in malaria prevention campaigns with a p-value less than o.o2. Moreover, the participants educated with a diploma or above are 92.3% more likely to participate in malaria prevention campaigns compared with their illiterate counterparts. The study indicated that there was a significant association between health-seeking behavior and the educational level of participants, with a P-value of 0.018.  More than 80% of respondents with a diploma or above level always visit a health facility when they feel sick from malaria; in contrast, only 42% of the illiterate participants will always seek treatment when they are sick. In addition to this, 7% of participants with no formal educational background never went to the health facilities when they were ill. None of the educated counterparts ever fail sick treatment while they are sick

7.2. Qualitative Result

The findings are presented according to the four themes that have emerged: (1) Knowledge and implementation of community-based malaria intervention, (2) Participation and performance of stakeholders, (3) Availability of policy/strategy and intervention packages, (4) Community Engagement.

Knowledge and Implementation of Community-Based Malaria Intervention

The existence of abandoned mosquito breeding sites, low access to LLINs, and IRS are recognized as the major contributing factors to the high burden of malaria in the region. Other contributing factors mentioned by the study group include poor utilization of IRS and lack of integration among different sectors on malaria prevention and control. The majority of the study participants recognized that health, agriculture, transport, construction, water and sanitation, education, and administrative sectors are responsible for malaria control and prevention intervention. Almost all the study participants agreed that community involvement is crucial for the successful implementation of malaria prevention, control, and elimination programs. The representative of the Wolayta zone health department director narrated how community involvement is important;

“We are living and working in the community; from our previous experience, we learned a lesson, a program started without engagement and recognition of the community end up with failure, especially for a health program to be successful, community engagement is mandatory. We need to engage the community from planning to program evaluation.”

In addition to this, the participants of the study explained the role of the community in malaria prevention and control includes, including the destruction of larvae by environmental management, clearing of bushes and stagnant water, sharing information in the community on how to prevent malaria, using of bed nets and other personal protection methods like mosquito repellants and wearing long sleeves at night.

The majority (85%) of the participant has knowledge of integrated community-based malaria intervention; according to the participants, malaria prevention and control activities are not the responsibility of only one sector because destroying and controlling the vector is not possible without the involvement and integration of different sectors and the community as well, the major sectors which are part of integrated community base malaria intervention are health, agriculture, transport, construction, water and sanitation, education, and admin. All participants explained that they don’t have a separate annual plan for the activities of community-based integrated malaria intervention, but some indicators are included in the general malaria annual work plan. Most of the participants didn’t explain the major activities of integrated community-based malaria intervention; only a few (10%) said planning and budgeting, sharing responsibility, community mobilization, and program performance evaluation are some of the major activities of integrated community-based malaria intervention.   Despite the well-known advantage of community-based malaria intervention, the participant disclosed that the intervention was not well organized, lacked leadership, coordination, poor participation, especially from ministries other than the health sector, no measurable performance indicators and evaluation.

Participation and Performance of Stakeholders

Health sectors and UN, and other NGOs are the main sectors participating in the development of strategic malaria plans, policy formulation, and development of guidelines.  Most of the participants agreed that the engagement of other governmental sectors is very minimal. An inter-sectorial task force is not available for integrated community-based malaria intervention. Some participants believe that an inter-sectorial task force is very important for programs based at the community level; as one of the participants elaborated:

“Usually, the programs at the community level are not stand alone; it requires the engagement of different sectors, the community, civic society, and NGO; due to this nature, organizing, leading, and evaluating the task force is a critical point for the success of community-based programs.”

The principal actors responsible for influencing the policy decision, its implementation, and evaluation is mostly the health sector; community representatives are not part of the activity. Most of the participants noted that malaria prevention is considered as an agenda only by the ministry of health and other NGOs working for the health sector. In addition to this, earmarked resources to prevent malaria are assigned only by the ministry of health. One of the participants from the District health officials explained that:

The socioeconomic burden resulting from malaria is immense: the high morbidity and mortality rate in the adult population significantly reduces production activities; the high transmission of malaria is usually during the farming season, affecting the farming activity, this will entirely affect the economic development in spite of all the negative socio-economic impact of malaria, the prevention and control task was left only for one sector, if we want to eliminate malaria truly, we need to integrate and collaborate with the relevant sectors and community.

Availability of Policy/Strategy and Intervention Packages

Integrated community-based malaria intervention aims to work closely with the public health system in place, improving both the use and effectiveness of community-based health services for malaria prevention; in addition to this, it helps to enhance the involvement of governmental and NGOs to improve the performance of malaria prevention and control services. All of the study participants recognized that there was no specific policy, strategy, guideline, and intervention for integrated community-based malaria intervention. But under the malaria prevention and control strategy, there is a chapter that elaborates on integrated community-based malaria intervention. Many participants explained that the annual work plan and evaluation mechanism on the general performance of malaria prevention and controls is done once per year, but it was not specified for integrated community-based malaria intervention. The majority of the participant recognized that there was no intervention package for malaria control that specifically addresses inter-sectorial collaboration, as elaborated by the participant from the zonal health department;

Harmonized, inter-sectoral action to improve health, including between ministries, between diverse levels of government, and with shareholders outside government, is important in order to address complex and persistent health problems. Legal and regulatory reform can support inter-sectorial action in health in a variety of ways, including by establishing new governance structures and processes for advancing shared goals, establishing an accountability framework that sets out the responsibilities of participants, and providing a clear mandate for inter-sectorial actions by relevant government agencies and authorities. But the certainty on the ground is very far from the standard; the government official at all levels need to work hard to improve the current situation.

Community representatives are not involved during the development of strategy/policy; the majority of the participant discussed there were no annual evaluations and report documents on the performance of community-based malaria intervention.

Community Engagement

Most of the participants explained that the planning of malaria interventions is conducted only by the health sector; in principle, most of the interventions, especially the vector control part and environmental management, will not be successful without the involvement of the community members. We need to involve the community representative during the palming section, but this is done on regular bases; we involve the community members only during the epidemic seasons.

According to the majority of the respondents, the role of community members in integrated community-based malaria intervention are, attending the steering comity meeting, active participation during environmental management, like feeling holes, removing stagnant water bodies, clearing bushes, and following the rules of self-protection methods to prevent mosquito bites. Most of the participants reported that women and male development groups and one to 30 development groups are the leading community-based platform for participation in malaria intervention. But based on the report of the participants, there was no financial or in-kind contribution from the community members for malaria intervention. The majority of the participant recognized the importance of community mobilization, but there were no plans, regularity, or standards to mobilize the community. As elaborated by the health extension worker from Achura kebele ;

As we all know, most of our community members are not literate; they don’t know what is good and bad for their own health; therefore, we need to teach our community regularly and in a planned manner; community mobilization is the engine for change and bring a positive perception for malaria prevention and control, but in practice, we are not utilizing this engine properly, and missing the golden opportunity to get the maximum participation and engagement of the community members.

A vast majority of the participant explained that the opportunities for inter-sectoral collaboration are the existence of steering comity at all levels, led by government officials. Some of the significant challenges described by the participants are lack of appropriate planning, no specific strategic planning and policy, lack of knowledge by the health workers and other organizations, no consideration of malaria by other stockholders other than the health sector, and lack of earmarked budget for the program.

8. DISCUSSION OF SURVEY RESULTS

Malaria is a life-threatening disease; information about malaria, early treatment, and seeking health behaviors can save a life. The presented study showed that some of the study participants did not ’t have information about malaria; this finding is somewhat consistent with the KAP study done in Tripal community of Baigachaek area.⁶¹ A vast majority of the participants (82.6%) believed that malaria is a life-threatening disease; this certainty is considered positive for preventing and early treatment of malaria.  The majority of the participant correctly identified fever, chills, and headache are the key sign and symptoms of malaria. The fact that people in an endemic malaria area know the sign and symptoms of malaria was also reported in a study conducted to understand the levels of knowledge regarding malaria causes, symptoms, and prevention measures among Malawian women of reproductive age.⁶²

Usually, people get malaria by being bitten by an infective female Anopheles mosquito. Only Anopheles mosquitoes can transmit malaria, and they must have been infected through a previous blood meal taken from an infected person. When a mosquito bites an infected person, a small amount of blood is taken in, which contains microscopic malaria parasites. About one week later, when the mosquito takes its next blood meal, these parasites mix with the mosquito’s saliva and are injected into the person being bitten.⁴³ Knowing malaria transmission is proven to be the most important factor in preventing malaria. The study indicated that most participants understood that mosquito bites transmit malaria; however, few (14.7%) participants believed fly and other insect bites could also transmit malaria.

The study in Assosa Zone, Western Ethiopia, showed that Mosquitoes’ ability to transmit malaria was mentioned by 174 (29.9%) of the respondents. Five hundred fifty-five (95%) of respondents identified that mosquitoes bite during the night.²¹ The result of the current study indicated a higher knowledge of people about the transmission of malaria by mosquito bite than in a study conducted in Assosa, Western Ethiopia.

As revealed in the multinomial logistic regression analysis, knowledge of the mode of malaria transmission and cause of malaria were found to be significantly associated with the educational level of respondents, with a p-value less than o.o2 and o.o3, respectively. All of the diplomas graduated, and 98% of high school-educated respondents have knowledge of malaria mode of transmission. Further, 95% of respondents with an educational level above high school correctly identified the cause of malaria. This result was similar findings with the study conducted in Rufiji, Tanzania.⁶³ Therefore malaria health education and awareness creation programs at the community level are essential in the fight against malaria.

The finding of the current study highlighted that even though near to one-third of the participant strongly agreed on the risk of malaria while sleeping and working at night, 31.1% of the participants were neutral, disagreed, or strongly disagreed with the ideas, which is similar with the study conducted in Rural Zambia.⁶⁴ This barrier may be due to a lack of knowledge on the risk of malaria transmission. On the other hand, 68.7% of the participants strongly agree that there is a greater risk of getting malaria if they work and sleep overnight outside. The result was significantly associated with an educational level of P- value0.001. This study finding was also supported by a study conducted in Southern Tanzania.⁶⁵  According to the current study findings, the knowledge and perception of outdoor malaria transmission are inadequate; therefore, outdoor sleeping and other night-time activities were extensive and could significantly increase malaria risk. Furthermore, indoor-oriented control measures such as ITNs and IRS are insufficient to control malaria in this setting, especially given the low net use observed. Development and evaluation of complementary outdoor control strategies should be prioritized. A research agenda is proposed to quantify the relative risk of outdoor night-time activities and test potential vector control interventions that might reduce that risk.⁶⁶

Evidence suggests that children and pregnant women are at higher risk of malaria.¹²  This study also revealed that despite less Zane half of the participants correctly understanding anyone can get malaria, the majority know that children and pregnant women are the venerable groups of society. This finding is similar to the study conducted in Ethiopia on Knowledge, Attitude, and Practice of the Community towards Malaria Prevention and Control Options in Anti-Malaria Association Intervention Zones of Amahara National Regional State, Ethiopia.²⁰

Mosquitoes breed in standing water; the first, most vital step in controlling them is finding all places where water can accumulate. Adequate knowledge of mosquito breeding sites is most important in the prevention of malaria. Most (95%) of the present study participants acknowledged mosquitos are breeding at the water body; however, some participants believed mosquitoes are breeding in dry areas. The current study result is consistent with the study conducted in Amahara National Regional State, Ethiopia, which indicated that 627 (72.6%) respondents mentioned stagnant water as a breeding site for malaria.²⁰

It was known that proper understanding and awareness of malaria are considered essential components before taking any informed action. Knowledge of vector management tools such as insecticides, environmental modification, and bed nets has contributed significantly to successful malaria control efforts historically.⁶⁷ The study also revealed that most of the study participants are knowledgeable about malaria prevention methods; some of the recognized malaria prevention methods are LLIN, covering stagnant water bodies, drainage, and the use of repellants. The finding of this study is consistent with the study among residents of Arba minch town and Arba minch zuria district, southern Ethiopia.⁶⁸ According to the WHO guidelines for malaria vector control, Universal coverage with effective vector control using a core intervention (ITNs or IRS) is recommended for all populations at risk of malaria in most epidemiological and ecological settings.⁶⁹ The result identified that only one-third of the participants have knowledge of the use of mosquito nets to prevent malaria, and very few (8.3%) of the participant has knowledge of the advantage of mosquito nets in preventing high-risk groups of the societies like pregnant women’s and under-five children’s. The result of the current study is different from the study on the use of insecticide-treated mosquito nets among pregnant women and children in rural Southwestern Uganda, which revealed that almost all participants knew that ITN use could help prevent malaria. ⁷⁰ However, this result is similar to the study findings of Insecticide-Treated Bed Net Utilization and Associated Factors among Households in Ilu Galan District, Oromia Region, Ethiopia.⁷¹

On the other hand, the knowledge of respondents on malaria prevention methods was found to be highly associated with the occupation of participants; farmers are 75% less likely to be knowledgeable on malaria prevention methods compared with government and private employees, with a p-value less than 0.002. This association was expected to occur due to the workplace information flow and knowledge sharing among educated co-workers. Henceforth availing of malaria prevention information is vital to hasten malaria control and elimination.

According to WHO, vector control is a vital component of malaria control and elimination strategies as it is highly effective in preventing infection and reducing disease transmission. The two core interventions are insecticide-treated nets (ITNs) and indoor residual spraying (IRS).⁷² This study revealed that only half of the study participants always slept in the mosquito nets, and one-fourth of the participants never slept in the mosquito nets; a study conducted in Uganda reported that the prevalence of malaria cases is significantly lower in households with ITNs compared to non-users (9% vs. 14%) (73).⁷³ It is, therefore, important to educate the community on the advantage of using ITNs. Besides that, nearly half of the respondent’s house was never sprayed with IRS, and the pattern of using anti-mosquito spray among the household was revealed to be very low, indicating the practice of using the primary prevention of malaria tend to be very low, with a similar finding in rural Tigray Ethiopia.⁷⁴

The finding of this study identified a significant association between educational level and practice of sleeping under a mosquito net with a p-value of o.o4. More than 75% of the diploma and high school educated respondents to sleep under the mosquito nets, whereas less than 65% of the illiterate counterparts sleep under the mosquito nets. In addition to this, according to the study conducted in villages outside of Kinshasa, Democratic Republic of the Congo, Education was the most crucial factor affecting bed net use. Developing an educational program, particularly one directed toward parents, is necessary to reduce misconceptions and increase the prevalence of bed net use among all age groups.⁷⁵ This study finding complements the current study result. Therefore the outer suggests educating the community on the advantage of core malaria vector control strategy is vital to control malaria transmission.

Evidence suggests that environmental modification and environmental manipulation, like the drainage of swampy areas, land reclamation, clearing of bushes around the house, and other permanent methods, have played an essential role in eliminating or reducing the number of vector-borne diseases.⁷⁶ This study clearly identified that most of the community members are not cleaning and cutting bush’s around their houses on a regular base; only some of the community members are habitually cleaning and draining stagnant water near their houses. The current study was similar findings with a study conducted in Mvomero, Tanzania, by which only 18% of the participant clean vegetables around their home and 32% drained stagnant water.

Community participation is vital for malaria prevention, control, and ultimately elimination.⁷⁷ The finding of the present study indicated that the expected level of participation of the community in malaria prevention is poor; only 25.5% of the respondents participate in malaria prevention campaigns, and a majority of the participants declared that community-level discussions on malaria prevention never occurred in the community and some participant reported they ever attended community-level malaria prevention planning’s.

On the other hand, the current study’s finding revealed a significant association between educational level and practice of participating in malaria prevention campaigns with a p-value less than o.o2. Moreover, the participants educated with a diploma or above are 92.3% more likely to participate in malaria prevention campaigns compared with their illiterate counterparts. Henceforth as stated in the study conducted in Aneityum Island, Vanuatu, mobilizing social networks; intersectoral collaboration; integration of malaria interventions with activities addressing other community health and disease priorities; and targeted implementation of locally appropriate, multi-level media campaigns that sustain motivation for community participation is crucial.⁷⁸

Evidence suggests that community mobilization can help meet the challenges of societies in transition by changing attitudes, norms, practices, and behaviors of individuals as well as groups. As a result, communities are able to better assess their needs, identify options for addressing them, prioritize, leverage resources and create solutions.⁷⁹ The study revealed that community mobilization was not conducted on regular bases. Despite there being no in-kind or financial contribution from the community for malaria prevention activities which indicates the engagement of the community is poor.

Time of treatment-seeking plays a vital role in supporting the effectiveness of malaria management. WHO recommends that treatment for malaria should occur within 24 hours of the onset of malaria symptoms to prevent the advancement of infection.⁸⁰ This study examined that only some participants strongly believe in sick advice when they feel seek of malaria. This finding is similar to results that revealed 356 (52.4%) participants sought treatment within 24 hours of fever in the study conducted on early treatment-seeking behavior for malaria in febrile patients in northwest Ethiopia.⁸¹ The finding of this study highlighted that more than half of the study participants did not understand the problem of self-malaria treatment and its connection with the safety of their health. This study is similar to the study findings conducted in the Democratic Republic of Congo. The result indicated seven hundred eighty-five patients were consulted, among them 57.8% (average age 38.7 ± eight years; average income: 95 ± 12 USD; gender male / female ratio: 0.47) practice self-medication with antimalarial.⁸² In addition to this, nearly one-third of the participants disagreed with checking the expiry date of the drugs before use. This practice will entirely risk the life of the patient.

According to WHO, consideration of all options for collaboration within and between public and private sectors; strengthening communication channels among policymakers, vector-borne disease control program managers, and other IVM partners are vital for malaria prevention, control, and elimination.⁸³ The current study’s findings revealed that most of the study participants acknowledged the importance of inter-sectorial collaboration and community participation and fully understood the role of the community in the successful implementation of malaria prevention. However, the intervention was not implemented due to the following factors; lack of leadership, coordination, poor participation, especially from ministries other than the health sector, and no measurable performance indicators and evaluation. A study in Tanzania showed that there was a lack of inter-sectorial approaches in malaria control programs, including the fact that the health sector does not involve other sectors during the planning and development of policy guidelines, differences in sectorial mandates and management culture, lack a national coordinating framework and lack of budget for inter-sectorial activities.⁸⁴ This study’s result is similar to the current research.

Planning and evaluation are vital for programs. Planning is a process of determining in advance where we want to get t and how we will get there. Evaluation allows us to assess how well we are doing and to learn from this. Integrated community-based malaria intervention was well known by most of the participants and explained its purpose and importance in detail to some of the health officers; despite the officer’s knowledge about the program, there was no identified annual plan, performance indicator, or evaluation of the program.

The cross-sectorial approach to disease control has been described to ensure better preparedness and contingency planning, cost-sharing between sectors,  increased health equity, and improved sharing of costs for service provision. The fact that there are linkages between environment,  livelihoods, and malaria poses an opportunity for the various sectors to work together to help solve each other’s problems.⁸⁴ On the contrary, the findings of this study indicated that the principal actors responsible for influencing the policy decision, its implementation, and evaluation are mostly the health sector; moreover, the engagement of other government sectors and the community representatives are very minimal.

According to WHO policy and strategic planning help the malaria program to think strategically and clarify future direction; to make evidence-based decisions in light of their future consequences; to solve major organizational problems; to contribute to solving health system problems; improve performance; to adapt to rapidly changing environment and epidemiology; to build partnerships, teamwork, and expertise; to provide a framework for collaboration with other programs.⁸⁵ The findings of this study showed that there was no specific policy, strategy, guideline, and intervention for integrated community-based malaria intervention. Even though limited information on the integration of malaria intervention and the responsibility of stakeholders was documented in the National malaria guideline, it lakes a full range of strategies and guidelines on how the implementation needs to be performed at all levels.

9. CONCLUSION

Evidence suggested a positive correlation between knowledge attitude and practice; the current study’s findings proved a similar result. The primary preventive practice expected from the community to prevent malaria are; the use of insecticide-treated mosquito nets and indoor residual spraying. Other complementary measures include suitable housing structures, an environmental control that reduces the breeding of malaria vectors, and community participation in forums and campaigns for malaria prevention discussions. The study revealed that from a total of 387 participants, only 194 (50.1%) always slept in mosquito nets, and 94 (24.3%) of the participant never slept in mosquito nets. Moreover, the finding of this study identified a significant association between educational level and practice of sleeping under a mosquito net with a p-value of o.o4.  More than 75% of the diploma and high school educated respondents sleep under the mosquito nets, whereas less than 65% of the illiterate counterparts sleep under the mosquito nets. In addition to this, according to the study conducted in villages outside of Kinshasa, Democratic Republic of the Congo, it was emphasized that education was the most critical factor affecting bed net use.

Besides that, this study also revealed that 155 (40.1%) of the respondent’s house was never sprayed with IRS.  Of a total of 387, only 50(12.9%) always used the anti-mosquito spray in their houses, and the pattern of using anti-mosquito spray among the household was revealed to be very low, indicating the practice of using the primary prevention of malaria tends to be very low. The study also identified that only 41.8% of the participants always clean and cut bushes, and 9.8% never clean or cut bushes around the house. Of a total of 387 participants, only 211 (54.5%) always cleaned stagnant water near their homes, and 18 (4.7%) never cleaned stagnant water near their houses.

On the other hand, the expected level of participation of the community in malaria prevention is poor. Only 25.5% of the respondents participate in malaria prevention campaigns. The majority of the participants declared that community-level discussions on malaria prevention never occurred in the community, and some participants reported they ever attended community-level malaria prevention planning. Furthermore, the current study’s findings revealed a significant association between educational level and practice of participating in malaria prevention campaigns with a p-value less than 0.02. Similarly, the participants educated with a diploma or above are 92.3% more likely to participate in malaria prevention campaigns compared with their illiterate counterparts.

Henceforth as stated in the study conducted in Aneityum Island, Vanuatu, mobilizing social networks; intersectoral collaboration; integration of malaria interventions with activities addressing other community health and disease priorities; and targeted implementation of  locally appropriate, multi-level media campaigns that sustain motivation for community participation is crucial.  In conclusion, the practice of the study community toward major malaria prevention methods is inadequate.

Integrated community-based malaria intervention is essential to bridge the gaps between the community and health institutions. Community mobilization is an important component of attaining a maximum level of community participation. Nevertheless, this study revealed community mobilization was not conducted on regular bases. There was no inter-sectorial collaboration among stakeholders. Despite the knowledge of key informant interviewees on integrated community-based malaria intervention, there was no identified annual plan, performance indicator, or evaluation of the program. The principal actors responsible for influencing the policy decision, its implementation, and evaluation are only the health sector; there was no evidence indicating the engagement of other government sectors and the community representatives. In addition to this, the findings of this study indicated that there was no specific policy, strategy, guideline, and intervention for integrated community-based malaria intervention. In conclusion, the implementation of integrated community-based malaria intervention is at its infant stage.

10. RECOMMENDATIONS

10.1. Recommendation at the National level

Provision of the necessary information and community awareness is essential for maintaining public or community support; creating community awareness is the best strategy to enhance the utilization of health services. The MOH of Ethiopia needs to establish sustainable community awareness programs using primary malaria prevention methods, LLIN and IRS. In Ethiopia, for the utilization of primary prevention methods of malaria, scarcity of chemicals and bed nets are the main challenges. The government of Ethiopia needs to ensure the availability of LLIN and IRS, as well as all the necessary financial and logistic support for the timely implementation of indoor residual spray. Moreover, conducting operational research for continuous understanding and level of LLIN utilization and fixing the gaps based on the findings is also recommended. It is essential to encourage the community through community health workers to improve the utilization of LLIN and comply with the indoor residual spray.

It is vital to strengthen the HEW programs to address larva source management issues and environmental alteration to prevent mosquito breeding sites. Regional governments need to develop rules and regulations on properly utilizing LLIN and compliance with indoor residual spray at the community level. It is also mandatory to develop strong disease surveillance, including monitoring and evaluation, as well as early diagnosis and proper treatment of malaria at all levels. The researcher further recommends focusing on the need to develop appropriate strategies to improve individual and community practices to prevent and control malaria through engaging the community and conducting formative research as a basis for behavior-change communications in various socio-cultural situations and address other determinants to progress access to malaria interventions. Finally, the government of Ethiopia needs to develop rules and regulations to encourage the community to attend and maximize participation in malaria prevention exercises, set a policy for inter-sectoral collaboration, and integrate malaria interventions with activities addressing other community health and disease priorities are  essential.

10.2.  Recommendation at the international level

Partnerships increase the lease of knowledge, expertise, and resources available to make better products and reach a greater audience. In line with this, improving international collaboration to resolve the financial and logistic scarcity special in developing countries, is necessary for a better performance of the integrated community-based malaria program.     Research plays an important role in learning how to enhance the performance of health care services and has the potential to help improve care for people around the world, harnessing innovation and supporting novel research on how to improve the malaria prevention campaign at all levels and behavioral change strategies, developing guidelines and policy direction on community-based malaria intervention will play an important role in malaria prevention, control and elimination at the community level. Moreover, conducting a worldwide forum, especially from the WHO side, on how to develop a policy and its implementation on the integration of malaria intervention at the country level will support the nations to strengthen the program performance.

10.3.  Intergovernmental Recommendations

According to the 2021 World Malaria Report, nearly half the world’s population lives in areas at risk of malaria transmission in 87 countries and territories. In 2020, malaria caused an estimated 241 million clinical episodes and 627,000 deaths. An estimated 95% of deaths in 2020 were in the WHO African Region. The burden of malaria is high in sub-Saharan Africa; according to the literature review, 100 courtiers in the world are malaria-endemic; among those, half are in sub-Saharan Africa. 2.4 billion Populations are at risk, and 300 to 500 million cases of malaria are recorded each year.

The death toll is high in children (1.0 to 2.7 million). 25% of the death among children is in Africa. In general, 90% of all malaria mortality in under-five children, and the primary cause of death among children are; Low birth weight, preterm delivery, cerebral malaria, and severe malarial anemia. A squeal from severe clinical complications of malaria includes cognitive impairment, behavioral disturbances, spasticity, and epilepsy, as well as vision, hearing, and speech impairments.⁶

Beyond the enormous health consequence, malaria imposes a substantial economic burden on individuals, households, and the entire economy.¹⁷ Malaria disease has been found to decrease the potential economic growth rate by 1.3% per year in some African kingdoms as a single disease. According to Gallup and Sachs’ study, malaria and poverty are closely linked at the macro-level, in which malaria is the leading contributor to poverty.¹⁸

Various literatures revealed integrated community-based malaria intervention is the best strategy for malaria prevention control and elimination as well. In some of the countries where malaria prevention intervention vertically implemented failed to achieve the desired outcomes, the integrated community-based intervention approach to malaria prevention, which advocates the use of several malaria prevention methods, is being explored to reduce the burden of the disease. Such multi-interventional approaches have been used in the control of other diseases such as HIV/AIDS and those affecting the cardiovascular system. In addition to this, almost all internationally and nationally reviewed literature proved that community engagement had been accepted as one of the key components for successful health interventions for malaria control. Despite this, in practice, community engagement has often played a marginal role within malaria control and elimination programs in the last several decades.

Besides the recognition of the importance of integrated community based malaria intervention in this study, the implementation is at its infant stage. The policy implication of this study is to develop a specific procedure and strategy for integrated community-based malaria intervention at the International, regional and national levels. In conclusion reinforcing inter-sectorial collaboration among stack holders, developing an explicit annual plan, performance indicator, and evaluation framework for the program is very important. In addition to this, wider partnerships between health and non-health sectors, enhancing community mobilization, and ensuring community participation in malaria prevention programs are inevitable.

Therefore to enhance integrated community based malaria intervention step forward, the support of intergovernmental organization are crucial, the major area of support includes, Strengthen regional and worldwide forums and partnerships to share experiences and resolve issues of resource scarcity, support and encourage countries financially in implementing novel research on how to improve the malaria prevention campaigns and behavioral change strategies, and Ensure financial support for policy development and implementation of integrated community-based malaria intervention.

10.4.  Final Words

Many aspects account for the existing malaria burden in emerging countries, including climate change, infrastructure, emerging drug and insecticide resistance, enormous population and demographic shifts, and costs of containment and therapy. In Sub-Saharan Africa, community-based malaria intervention has been one of the main strategies to reduce malaria morbidity and mortality. Integrated partnerships between governments, communities and donors to form healthier environments for malaria prevention could play a vital role in building an ultimate platform for malaria-specific interventions. Such programs could be articulated in joint partnerships between the government, community, and various industrial, waste management, education, and public health institutions.

This review suggests the importance of improving awareness and applicability of the community on malaria prevention methods, utilization of core vector control strategies, application of environmental management, and personal protection methods. For the achievement of a program goals existence of a clearly specified policy and strategy is important; based on the review, the policy implication of this study suggests the development of a specific policy and strategy for integrated community-based malaria intervention at International, regional and national level, reinforce inter-sectorial collaboration among stack holders, develop a specific annual plan, performance indicator, and evaluation framework of the program, wider partnerships between health and non-health sectors, enhance community mobilization and ensure community participation in malaria prevention programs is inevitable.

11.  CONTRIBUTION/LIMITATIONS

In addition to the academic exercise, this Ph.D. dissertation aims to contribute to more evidence on the level of community practice in malaria prevention and integrated community base malaria intervention. Understanding the potential causes, modes of transmission, and resolution of an agreement of preventive and control measures differ from community to community and among individual households. According to the study satisfactory knowledge of mothers of under-fives about malaria has a pronounced correlation with reduced morbidity and mortality among the vulnerable groups: pregnant women and children less than five years. However, a lot of misunderstandings concerning malaria still exist. Thus, local knowledge and practices in relation to malaria are vital for the implementation of culturally appropriate, sustainable, and effective interventions.  In addition to this, an integrated approach at the community level will contribute a lot to malaria prevention and control in the community. Therefore this study will contribute to developing a sustainable strategy for malaria prevention and control through community involvement.

Due to the COVID-19 pandemic, there can be many non-respondents for an interview both for the qualitative and quantitative methods, and a respondent may also feel that surveys are a waste of time or may express anti-government feelings. It is the interviewer’s job to determine the reason for the refusal of the interview and attempt to overcome it. Due to those reasons, none-respondent can be considered as a limitation of the study. Non-compliant government strategy can be regarded as dishonorable by the Ethiopian community. Due to this, disclosure of non-compliance can be challenging and a significant limitation of the study. The interviewer needs to be trained on how to convince the community to disclose the status of compliance with the prevention methods and need to explain the purpose of the study to the interviewee.

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