association between maternal level of education and the...
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Association between maternal level of education and the
treatment with antimalarial drugs in children under the
age of 5 in Nigeria A cross-sectional study
Julia Cederlund
____________________________________________ Master Degree Project in Global Heath, 30 credits. Spring 2020
International Maternal and Child Health (IMCH)
Department of Women’s and Children’s Health
Supervisor: Shirin Ziaei
Word Count: 10,386
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Abstract Background
Malaria is a major threat to global public health, with adverse health effects. Nigeria alone
accounts for 25% of the global burden of malaria. Children are especially vulnerable to
malaria, and if the disease is not treated it could have fatal consequences. Mothers have an
important role in ensuring that adequate and timely treatment is given to the child.
Aim
The aim of this study was to investigate whether there was an association between maternal
level of education and the treatment with antimalarial drugs in malaria positive children
under-5 in Nigeria.
Methods
This study was a cross-sectional study that utilized Demographic and Health Surveys (DHS)
data from the 2015 Nigeria Malaria Indicator Survey. Data on 2’622 malaria positive children
were used, and a logistic regression analysis was conducted to determine the association with
maternal level of education.
Results
The mothers with a higher level of education had two times higher odds (OR 2.31, CI 1.62-
3.32) of making sure their child received treatment with antimalarial drugs, compared to the
mothers with no education. With an increase of 38% (OR 1.38, CI 1.11-1.71) in the odds for
the child receiving treatment with antimalarial drugs if the mother has primary education and
an increase of 51% (OR 1.51, CI 1.24-1.84) if the mother has secondary education compared
to mothers with no education.
Conclusion
Mothers with a higher level of education waere more likely to make sure that their child
received treatment with antimalarial drugs, compared to the mothers with no education.
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Table of contents Abstract ...................................................................................................................................... 2
1. Introduction ............................................................................................................................ 5
1.1 Transmission of malaria ................................................................................................... 5
1.1.1 Determinants of transmission .................................................................................... 5
1.1.2 Preventing transmission ............................................................................................ 7
1.2 Malaria symptoms ............................................................................................................ 7
1.3 Malaria diagnosis ............................................................................................................. 8
1.4 Malaria treatment ............................................................................................................. 9
1.5 Factors that influence the malaria treatment .................................................................. 10
1.6 Malaria burden in Nigeria .............................................................................................. 11
1.6.1 Malaria in children under-5 in Nigeria .................................................................. 12
1.6.2 Education and knowledge about malaria in Nigeria .............................................. 13
1.7 Justification and research aim ........................................................................................ 14
2. Methods ................................................................................................................................ 15
2.1 Study design ................................................................................................................... 15
2.2 Study population ............................................................................................................ 15
2.3 Study setting ................................................................................................................... 15
2.4 Sample size/selection ..................................................................................................... 17
2.5 Data collection ................................................................................................................ 17
2.6 Methods and variables .................................................................................................... 18
2.7 Statistical analysis .......................................................................................................... 19
2.7.1 Descriptive analysis ................................................................................................ 19
2.7.2 Bivariate analysis .................................................................................................... 19
2.7.3 Multivariate analysis ............................................................................................... 19
2.8 Ethical consideration ...................................................................................................... 20
3. Results .................................................................................................................................. 21
3.1 Characteristics of the study population .......................................................................... 21
3.2 Bivariate analyses to evaluate association between the outcome and exposure variables
and the background characteristics ...................................................................................... 23
3.3 Regression analyses evaluating the association between maternal level of education and
antimalarial treatment in their children under-5 in Nigeria .................................................. 25
4. Discussion ............................................................................................................................ 28
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4.1 Main findings ................................................................................................................. 28
4.2 Impact of maternal level of education on the treatment with antimalarial drugs in
children under-5 ................................................................................................................... 28
4.3 Background characteristics role in the treatment with antimalarial drugs in children
under-5 ................................................................................................................................. 31
4.4 Strengths and limitations ................................................................................................ 33
4.4.1 Strengths .................................................................................................................. 33
4.4.2 Limitations ............................................................................................................... 33
5. Conclusion ............................................................................................................................ 35
6. Acknowledgement ................................................................................................................ 36
References ................................................................................................................................ 37
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1. Introduction Since 2000 the malaria incidence has declined globally. Despite that almost half of the
world’s population is currently at risk of being infected with malaria (1), and there is an
estimate of malaria related deaths between 0.7 and 2.7 million deaths per year (2). The highest
burden of malaria is in sub-Saharan Africa, which accounts for nearly 89 percent of the global
malaria cases (1). Children under the age of 5 are the most vulnerable group, and in 2018
children accounted for 67 percent of all malaria related deaths (3). Although malaria can be
fatal it is largely preventable and a highly treatable disease, and early diagnosis and adequate
treatment is key (4). The formal education plays a role in the knowledge about malaria and
ensures timely and adequate treatment. Therefore education of the caregivers helps decrease
the morbidity and mortality related to malaria in children under-5 (5–7).
1.1 Transmission of malaria
Malaria is caused by Plasmodium parasites, and is transmitted to humans by mosquito bites
from female Anopheles mosquitoes infected with Plasmodium parasites. There are over 100
different species of the Plasmodium parasites, but only 5 protozoa species that transmit
malaria, P. vivax, P. falciparum, P. ovale, P. Knowlesi and P. malariae. Of these species of
the Plasmodium parasites, P. falciparum accounts for most cases of malaria in the African
region (3,4,8).
A female Anopheles mosquito ingests the Plasmodium parasites during blood feeding, the
parasites then mates in the gut of the mosquito and starts to multiply. After 10 to 18 days the
parasite migrates to the mosquito’s salivary glands. When the mosquito then acquires a new
blood meal from another human the bite from the infected female Anopheles mosquito injects
saliva along with the Plasmodium parasites to the human. Within the human the Plasmodium
parasites first grow and multiply inside the liver and then inside the red cells of the blood.
Once in the blood, successive broods of parasites grow inside the red cells and destroy them,
also releasing daughter parasites (merozoites) that continue the cycle by invading other red
cells. The parasites destroying the red blood cells is what causes the symptoms of malaria (9).
1.1.1 Determinants of transmission
There are a few different factors that make it easier for the mosquitoes to survive or find
humans for blood meals. But also factors that affect the life span of the Plasmodium parasites,
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and thus increasing the transmission of malaria. For instance, climate is a key determinant for
the geographical distribution and abundance of mosquitoes, and therefore affects the
transmission (10). The temperature is critical for development of the mosquitoes in each
stage, and also affects the longevity of the mosquitoes (10,11). Higher temperatures also
affect the ability of the Plasmodium parasite to survive inside the mosquito. Since a longer
life span of the mosquito gives the parasite time to complete its development inside the
mosquito (3). The mosquitoes lay their eggs in water and therefore precipitation also becomes
an important determinant for mosquito abundance (10,11).
Behavioural factors of the humans can also affect the transmission of malaria. These
behavioural factors are often related to social and economic factors. For instance, human
activities can lead to breeding sites for the mosquitoes, people living in poor rural areas
usually cannot afford protective measures against mosquito bites and migration may expose
people to malaria transmission. Having domestic animals near the household can serve as a
protective factor, since it provides alternative sources for blood meals for the Anopheles
mosquitoes (9).
Additionally, there are biological determinants that can protect humans from transmission of
malaria. There are two genetic factors, both involving the red blood cells, which can serve as
a protective factor against malaria transmission. For instance one of the factors is the sickle
cell trait some people have, giving them protection against P. falciparum malaria (9).
Some people may also have acquired immunity to malaria over time. This happens after a
person has had repeated malaria infections, and requires continued exposure or the acquired
immunity is gradually lost. The person may still be able to get infected with malaria, but the
symptoms will not be as severe. The acquired immunity is important to how malaria affects a
person and the community (9).
In conclusion, warmer and humid climates give the mosquitoes better possibilities to survive
and increase the abundance. It also increases the chance of the Plasmodium parasite to
survive. People are also more likely to sleep unprotected outdoors in the warmer climates, and
quite possibly without any protection from the mosquitoes. Which increases the malaria
infections in those warmer areas. Behavioural factors of the humans can serve as both a factor
for increasing and decreasing the risk of malaria transmission. There are also people who
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biologically are protected from malaria transmission and people who have acquired immunity
to malaria, thus giving them a biological advantage (9,10).
1.1.2 Preventing transmission
There are several ways to prevent transmission and reduce the number of malaria cases and
malaria related deaths. For instance insecticide-treated nets (ITN), intermittent preventative
treatment in pregnant women and indoor residual spraying are some of the more common
measures globally (10). Due to the nocturnal habits of the Anopheles mosquitoes most bites
happens at night, and the most common prevention measure is sleeping under a ITN (4).
ITNs give not only a physical barrier to protect humans from mosquito bites, but also an
insecticide barrier since they are treated with an insecticide (3,10). The nets treated with
insecticide are much more efficient for protection than the untreated nets as the insecticide in
the ITNs kills and repels mosquitoes and other insects. There are only 2 insecticides that are
approved for usage on ITNs, pyrroles and pyrethroids. These 2 insecticides poses low risk to
humans and other mammals while being deadly to insects. The ITNs used to need to be
retreated with the insecticide every 6 to 12 months, depending on how often they are washed.
But Long-Lasting Insecticide Nets (LLIN) has been developed and maintains the insecticide
for 3 years even if being washed. LLINs provide good protection and have been associated
with a decrease in malaria cases worldwide as many LLINs have been distributed during
campaigns and programmes worldwide (10).
Sometimes vector-controlling measures are used to try and control the mosquito abundance,
and thereby limiting the transmission of malaria. Vector-controlling measures includes
chemical larviciding, sterilisation of male mosquitoes and removing breeding sites for the
mosquitoes. In some extreme cases mass drug administration of antimalarial drugs is used,
this is when every person living in a defined area receives treatment at the same time (10).
1.2 Malaria symptoms
Malaria is a febrile illness that causes flu-like symptoms such as fever, headache and chills,
and the symptoms usually start within 7 to 15 days after being infected (3,4). The incubation
period is usually shorter with malaria cause by P. falciparum (9). First symptoms might be
mild and the combination with a sometimes longer incubation period might make it difficult
to recognize the symptoms as malaria at first (3,10).
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There are uncomplicated and severe malaria infections. With the uncomplicated malaria the
patients usually present symptoms such as fever, chills, sweats, headache, nausea and body
aches (10). If the uncomplicated malaria infection is not detected and treated it can lead to
severe illness (3). Severe malaria occurs when there is organ failure or abnormalities in the
patient’s blood or metabolism. It presents itself with symptoms such as seizures, loss of
conscience, severe anaemia, acute respiratory distress, low blood pressure, acute kidney
injury or metabolic acidosis (10).
Children who develop a severe malaria infection often get symptoms such as severe anaemia,
respiratory distress, confusion and coma. Recurrent malaria infections in children under the
age of 5 caused by P. falciparum could lead to severe anaemia (9). Additionally, if the
infection is not treated it could lead to death. This is why early detection and diagnostic of
malaria is crucial, so that adequate treatment can be initiated (3).
1.3 Malaria diagnosis
All suspected cases of malaria should be confirmed using either microscopic diagnostic tests
or rapid parasite-based diagnostic tests (3). A malaria infection should be confirmed before
any type of treatment is initiated (10). Microscopy examination is the “gold standard” for
detecting malaria. The test is performed by collecting a blood specimen from the patient and
spreading it on a microscope slide. Visual criteria is then used to detect the Plasmodium
parasite infecting the patients red blood cells (12). Microscopic diagnosis makes it possible to
count each parasite and is therefore more effective for monitoring the effectiveness of malaria
treatment than Rapid diagnostic tests (RDT). But even if it is a method well known to
laboratorians worldwide, the microscopy requires a level of skills that usually is not available
in health care facilities in malaria-endemic areas. The transmission usually occurs in remote
rural areas. Additionally, the electricity to run the microscopes and high workload may affect
the quality of the results from the test in malaria-endemic areas (10).
In recent years, the usage of RDT has expanded around the world. RDT are useful in settings
or situations where reliable microscopic diagnostic tests are not available; this is the case for
most malaria-endemic places (3,4,10). The usage of RDT in malaria endemic places has
greatly increased the quality and management of malaria infections. RDT are simple to
perform, and require limited training of the staff performing the tests. A blood specimen is
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collected from the patient and is applied to the sample pad on the test card. The RDT for
malaria detect specific antigens produced by the Plasmodium parasites, which are present in
the infected individuals blood (13). Using RDT, malaria confirmation can be available in 30
minutes or less and treatment can be started early (3).
1.4 Malaria treatment
There are many different anti-malarial drugs available for use, such as chloroquine,
amodiaquine, quinine and artemisin derivatives which are often used in combination
treatment (4). The World Health Organization (WHO) recommends artemisinin-based
combination therapies (ACTs) as the first-line treatment for treating uncomplicated malaria
caused by the Plasmodium parasites. Severe malaria should according to WHO be treated
with intramuscular or intravenous injectable artesunate and that treatment should be followed
by a treatment with ACTs. Access to ACTs has increased over the years and is the first-line
treatment against malaria in 80 countries worldwide (14).
To ensure all patients have an equal chance of being cured from the malaria infection, the
antimalarial drugs given must be of quality and be given at correct dosages. The quality of the
antimalarial drugs should be ensured by national drug and regulatory authorities, and should
be assured in both private and public sectors. The dosage of the treatment with antimalarial
drugs is based on the patient’s weight and the duration of the treatment varies. ACTs should
for example be given during 3 days and intramuscular or intravenous injectable artesunate for
at least 24 hours. Additionally, in low-transmission areas a single dose of ACTs could be
given to patients in order to reduce transmission (14).
A major and recurring problem is the resistance to antimalarial drugs. Plasmodium parasites
developed resistance to several antimalarial drugs such as fansidar and chloroquine during the
1950s and 1960s (3). With few new antimalarial drugs being developed there are concerns
since resistance to the first-line treatment ACTs has been reported. This could have major
consequences to public health and fatality due to malaria (15). Antimalarial resistance is
defined by the ability of the Plasmodium parasites to survive or multiply even though an
antimalarial drug has been administered (16).
In order to prevent the Plasmodium parasites to develop resistance to the first-line treatment
timely diagnosis, correct treatment and also patient adherence is of key value. With main
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emphasis on the patient adherence (15,17). And in children under-5 the caregivers mainly
influence patient adherence. Since it is the caregivers job to ensure to early detect a malaria
infection in the children and make sure the correct treatment is given (18).
1.5 Factors that influence the malaria treatment
To be able to make sure that adequate treatment is given for malaria proper knowledge about
the disease is important. Education, as well as other factors such as socioeconomic status and
place of residence play an important role in promoting health overall but also to prevent
diseases like malaria (6). These factors does not only affect the knowledge about malaria but
they also affect each other (7).
For instance there are differences in the knowledge about malaria and the education
depending on if the person reside in a rural or urban area. With people in rural areas having
less knowledge about malaria (7). Due to the lack of access to health care facilities in rural
areas, home management of malaria has become an important strategy for targeting malaria
elimination in rural areas. As previously stated early diagnosis is important, and diagnosis of
malaria at home is done by caregivers. They do so by recognizing symptoms such as cough,
fever, headache and loss of appetite. Therefore, knowledge about malaria is important in order
to ensure symptoms are recognised and the children receive the correct treatment (19). But
with people in rural areas generally having less knowledge about malaria, less education and
having longer distances to health care facilities, they turn to drug vendors, self-medication
and herbalists for treatment if the child is sick (7). Most children who die of malaria at home
do so without receiving adequate treatment although symptoms are recognised by caregivers
(5).
The choice of treatment is affected by the knowledge of the caregiver, the access to health
care services and cost of treatment, but also the attitude towards the health care. The socio-
economic status is a major factor associated with delay in treatment with antimalarial drugs in
children under-5, and the delay in treatment causes an increased morbidity and mortality due
to malaria. The socio-economic status affects the access to health care by functioning as a
barrier. The people with low socio-economic status might be unable to pay for direct and
indirect costs of the treatment. With the antimalarial drugs being a direct cost and the
transportation to and from the health care clinics being a indirect cost (5). The people with
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low socio-economic status also have a lower formal education, and the formal education is
also a barrier to adequate and timely treatment of malaria in children (6,20).
Formal education is a good tool to gain knowledge about malaria. In a malaria endemic area,
with between 70 to 80 percent of the residents having formal education, most people report
having knowledge about malaria, the symptoms to look for and what antimalarial drugs are
available. But even if antimalarial drugs were given they were often not given in the correct
dosage, especially to children under-5 (21). Formal education is a good way of removing
some of the misconceptions surrounding malaria that affects the prevention and treatment of
malaria (6). But understanding who already has knowledge about malaria, malaria prevention
and the treatment is also important, in order to target interventions and education about
malaria correctly (22).
1.6 Malaria burden in Nigeria
Nigeria has a climate suitable for malaria transmission with a tropical climate of dry and wet
seasons. Approximately 30 percent of the population resides in an area of high to very high
transmission rates, and 67 percent resides in an area of moderate transmission rates. The
duration and intensity of the malaria transmission season depends on the weather and the
duration of wet and dry seasons. The northern parts of Nigeria has a shorter malaria
transmission season in general (20).
Efforts have been made to reduce the prevalence of malaria, but it remains endemic in Nigeria
and poses a major threat to public health (20). Nigeria contributes to 25 percent of the global
burden of malaria (3). With children under 5 years of age and pregnant women being the most
vulnerable and affected. Malaria puts stress on Nigeria’s already weakened health system and
poses a huge economic burden for the country (20,23).
Over the years Nigeria has implemented different policies and strategies to deal with the
burden malaria puts on the country. The Malaria Control Programme was established in 1948
for research purposes and was incorporated into the Department of Public Health. In 2013,
The Malaria Control Programme was renamed the National Malaria Elimination Programme
(NMEP). The NMEP has over the years implemented three National Malaria Strategic Plans
(NMSPs) to build and nurture partnerships to gain political will, and also targeting vulnerable
populations for interventions. The fourth NMSP was being developed in 2014, and have
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seven objectives to work towards a malaria-free Nigeria. These seven objectives address the
issues around preventing malaria with LLINs, the use of RDTs and providing information and
adequate treatment. The 2014 NMSP has objectives that ensure that timely diagnosis and
treatment should be provided, and everyone should have access to appropriate treatment. By
2020 the NMSPs aims to provide 80 percent of the population with preventive measures
against malaria and to treat all individuals with a diagnosed malaria with effective anti-
malarial drugs (20).
Additionally, the National Malaria Policy was launched in February 2015, and aims to
eliminate malaria in Nigeria. The policy expressed a desire for the Nigerian government to
commit on all levels to ensure the elimination of malaria. The policy addresses issues
regarding malaria prevention, diagnosis, treatment and regulations regarding antimalarial
drugs (20).
The most used preventive measures against malaria in Nigeria are ITNs, LLINs and indoors
residual spraying. The use of ITNs is also one of the most effective measures of protection
from malaria transmission. ITN and LLIN are mostly used in the rural areas of Nigeria. With
more people sleeping outdoors in these areas compared to the urban areas, there is a greater
need for the ITNs and LLINs in the rural areas. Many prevention programmes in the country
emphasises the importance of awareness to the public in order to increase the usage of
mosquito nets, which has led to an increased demand for the mosquito nets. The Nigerian
government have distributed almost 52 million mosquito nets across the country, and during
replacement campaigns almost 46 million mosquito nets were distributed (20).
1.6.1 Malaria in children under-5 in Nigeria
Incidence of malaria in children under-5 in Nigeria is 27 percent, and malaria contributes to
30 percent of the under-5 mortality in Nigeria. The percentage of children using preventive
measures in form of LLINs is 29 percent. With almost half of the mothers knowing that
children are in fact a vulnerable group to malaria. Also the percentages of malaria incidence
in children are much higher in rural areas in Nigeria than in urban areas. Which ties into what
has already been discussed about the importance of education to achieve knowledge about
malaria and the access to health care (20).
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In 2015, out of all the children who displayed symptoms of malaria in the form of fever,
treatment was sought the same or next day for 35 percent of the children. With the least of the
children being brought in for treatment living in the rural areas of Nigeria (20). But overall
the treatment is not timely in children, despite living in rural or urban areas (5,20).
1.6.2 Education and knowledge about malaria in Nigeria
In Nigeria knowledge about malaria is high, with 87 percent of the women interviewed for the
Nigeria Malaria Indicator Survey (NMIS) 2015 having heard of the illness and 97 percent of
those women knowing one or more symptoms of malaria. And 23 percent of women in
Nigeria know malaria can be treated with ACTs. A majority of the women knew mosquitoes
caused malaria, but that knowledge varied depending on the woman’s level of education.
With a higher level of education of the women came more knowledge about malaria (20).
Showing that formal education contributes to a higher knowledge about malaria. Also formal
education could lead to earlier detection and better treatment of malaria infections (5,19).
Knowledge about treatment of malaria varied and increased with the level of education and
level of household wealth. The wealthier the household is the more educated the women
generally are (20). Although, studies have shown that most begin treatment at home with anti-
malarial drugs that were purchased at drug vendors without any prescription. And these drugs
are often the given at the wrong dosage and are not the recommended first-line treatment for
malaria (18).
A caretaker training programme was carried out in a south-east rural area in Nigeria in 2002,
and aimed at providing caretakers with education. The education provided the information
needed to detect and provide adequate treatment for malaria in their children but highlight the
importance of taking their sick child to a health care facility. The overall result of this
programme was an increased knowledge in the caregivers and a decreased number of severe
cases of malaria in children under-5 and decreased the number of children who received
treatment (20).
But there are still problems to tackle regarding the issue of malaria incidence in children
under-5 in Nigeria (18). And the 2014 NMSPs do not have an objective that directly addresses
the issue with education and how that is linked to increased treatment with antimalarial drugs.
The formal education has been shown by this caretaker programme and by previous studies to
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be an effective way to educate the caretakers and hence decrease the malaria incidence in
children under-5. But education is also necessary for adequate treatment to be given (5,19,20).
1.7 Justification and research aim
Malaria is a major problem in Nigeria today, and a threat to the public health of the residents
(20). Children are an especially vulnerable group, and they are dependent on their caregivers
to receive timely diagnosis and adequate treatment (3,5,18). The mothers, and their
knowledge, play an important role in whether or not the child receives treatment with
antimalarial drugs (5,18,23). Knowledge can be acquired from formal education (21).
Previous studies have not looked at education and how that is associated to treatment with
antimalarial drugs in children under the age of 5. The overall aim of this study is to explore
whether the level of maternal education is associated with the treatment for malaria in
children under-5, who have been tested positive with malaria, in Nigeria and if the level of
maternal education plays a role in the child receiving treatment or not.
Research Question: Is there an association between maternal level of education and the
treatment with antimalarial drugs in malaria positive children under the age of 5 in Nigeria?
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2. Methods 2.1 Study design
This study has a cross-sectional design and utilizes secondary data from the NMIS 2015 (20).
The Demographic and Health Surveys (DHS) programme conducted the NMIS 2015. The
DHS programme collects data nationally that provides a more in-depth understanding of
health issues. They provide decision makers with this information making it possible for them
to plan, monitor and evaluate population health and nutrition programmes (24).
2.2 Study population
The 2015 NMIS was conducted on a national level in Nigeria, and 8’148 households were
selected as eligible to be included in the survey, out of those 7’745 households were
interviewed for the survey. Making the household response rate 98.8 percent. All women in
these households aged 15 to 49 were eligible for individual interviews. Out of the 8’106
eligible women, 8’034 women were interviewed for the survey. Making the eligible women’s
response rate 99.1 percent. Respondents were asked about malaria prevention and treatment
of fever among their children during these interviews. Children aged 6 to 59 months were
offered testing for anaemia and malaria using finger- or heel-prick blood samples (20).
2.3 Study setting
Nigeria is a country located in sub-Saharan Africa, and has the largest population in Africa
and the seventh largest in the world, with an estimated population of 177.1 million people and
with an estimated annual growth of 3.2 percent. The fertility rate in the country has declined
from 6.0 in 1990, to 5.5 in 2013. Nigeria has a young population, with people between the age
of 0 and 24 accounting for more than 60 percent of the country’s residents and children under
the age of 5 alone contributes to 16 percent of the country’s residents (20).
It is bordered to Niger republic in the north, the Republic of Chad in the northeast, Republic
of Cameroon in the east, and the Republic of Benin to the West. The country is divided into 6
geopolitical zones: North Central, North East, North West, South East, South South and South
West and is also divided into 36 states and a Federal Capital Territory. Politically Nigeria is a
democratic country that has had a stable government since 1999. There are approximately 374
ethic groups, of which the 3 major ones are Igbo, Hausa and Yoruba (20).
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Nigeria is considered a lower middle-income country and since 2015 Nigeria’s economic
growth is muted. Nigeria is Africa’s biggest oil exporter, and the oil price collapse in 2014-
2016 hit the country’s economy hard. Before the oil price collapse the country had an average
gross domestic product (GDP) increase of 7 percent per year (25). The three southern zones
have a greater proportion of their population in the higher wealth quintiles than the northern
zones. The southern zones are more urbanised than the northern zones (20).
Nigeria has a diverse climate with dry and wet seasons. The dry season usually occurs from
October to March, and the wet season occurs from April to September. The temperature
usually lies between 25°C and 40°C, and the rainfall ranges from 2’650 millimetres in the
south-eastern parts of Nigeria to less than 600 millimetres in the northern parts. Nigeria has a
wide range of climatic-, vegetation- and soil conditions that allows for the possibility of a
wide range of agricultural production (20).
The physical characteristics of a household are an important determinant for the health of the
people living there, especially for children. For instance, about half of the Nigerian
households do not have electricity and use non-improved latrine facilities. Poor water quality
and inadequate sanitation have a negative impact on health, food security and livelihood. And
every year people die due to the lack of access to clean water and proper sanitation, most
vulnerable are children. The urban population are more likely than the rural population to
have access to these determinants for health (20).
Nigeria’s health system includes private and public health sectors. The private health sector
includes not-for-profit and for-profit organizations, traditional medicine providers, medicine
vendors, drug shops and alternative practitioners. The public health sector includes large
referral hospitals, tertiary health facilities and primary health facilities. The primary health
centres provide basic preventive, promotive, rehabilitative and curative health care services
for most of the rural population. Included in the primary health care system are also the
community-oriented resource persons (CORPS), who treat children under-5 for diseases such
as malaria, pneumonia and diarrhoea at a community level (20).
The first National Health Policy was implemented in 1988, and its target is to achieve health
for all Nigerians. The National Health Policy aims to support implementations of health-
related programmes and interventions, and support regulations of the health care system. It
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has since been revised due to issues, trends and realities, and the revised version was launched
in 2004. The long-term goal of the revised policy is to provide adequate access to primary,
secondary and tertiary care services to the Nigerian population (20).
Between 2003 and 2013 the under-5 mortality rates decreased from 201 deaths per 1’000 live
births to 128 deaths per 1’000 live births. The maternal mortality ratio was 545 deaths per
100’00 live births in 2008, and in 2013 it had increased to 576 deaths per 100’000 live births.
There has been a decline in the fertility rates in Nigeria, from 6.0 in 1990 to 5.5 in 2013. The
Integrated Maternal, Newborn and Child Health Strategy was developed by the Federal
Ministry of Health in 2007 to achieve the Millennium Development Goals that aimed to
reduce the child mortality and improve maternal health (20).
2.4 Sample size/selection
The women’s questionnaire and the household questionnaires were used to find the data
necessary for this study. In the women’s questionnaire a total of 6’524 of children aged 6 to
59 months were documented from the 8’034 women who participated in the survey. Only the
last-born child of the woman was included in the survey. Out of the total 6’524 children aged
6 to 59 months, 3’902 were excluded on the basis that they were not malaria positive or that
there was no information on the child receiving treatment with antimalarial drugs (See Figure
1). The remaining 2’622 malaria positive children aged 6 to 59 months that were included in
this study for analysis. 1’100 children were treated with antimalarial drugs and 1’522 children
did not receive any treatment with antimalarial drugs.
2.5 Data collection
For the sampling method, the NMIS 2015 used a two-stage stratified cluster sampling based
on Enumeration areas (EAs) and households. In the first stage 333 EAs were selected, 138 in
urban areas and 195 in rural areas. A household listing operation was carried out in all
selected EAs, with the resulting lists of households serving as the sampling frame for
selecting households in the second stage. In the second stage, a fixed number of 25
households were selected on each cluster by an equal probability systematic sampling method
(20).
For this study the NMIS 2015 was obtained from the DHS website after access to it had been
granted. A team from the DHS collected the data for this survey between September 2015 and
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November 2015. Three questionnaires were used for this survey: the household questionnaire,
the woman’s questionnaire and the biomarker questionnaire. The Survey Implementation
Committee was responsible for implementation of the 2015 NMIS and ICF International
provided the technical support team consisting of survey coordinator, sampling specialist,
survey manager, data processing specialist and biomarker laboratory science specialist. There
were 37 interviewing teams each consisting of one supervisor, two interviewers, a laboratory
scientist and one driver. In addition to English the questionnaires were translated into three
major Nigerian languages: Hausa, Igbo and Yoruba (20).
2.6 Methods and variables
The exposure variable for this study was the maternal level of education level and the
outcome variable was if the child aged 6 to 59 months positive for malaria received any
treatment with antimalarial drugs or not.
Exposure variable
Maternal level of education was divided into six categories in the survey: No education,
incomplete primary education, complete primary education, incomplete secondary education,
complete secondary education and higher education. For this study the categories incomplete
primary education and complete primary education were merged into the category primary
education. The categories incomplete secondary education and complete secondary education
were merged into the category secondary education. The final categories used for this study
were: No education, primary education, secondary education and higher education of the
mothers. With no education being the reference category.
Outcome of interest
In the survey mothers responded yes or no to the question if the child aged 6 to 59 months
received any treatment with any of the following antimalarial drugs if they had tested positive
for malaria: SP/Fansidar, Chloroquine, Amodiaquine, Quinine, combination with artemisinin,
country specific antimalarial or other antimalarial drug. For this question about treatment it
was preselected in the DHS MIS survey as the youngest child of the mothers. So this study
will be looking at only one of the children in a family, even if the mothers have more
children. For this study children who received any treatment with 1 antimalarial drug or more
were coded as 1, and children who did not receive any treatment was coded as 0.
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Confounding variables
Variables used in this study are based of previous studies (26–28). Confounding factors
included are the household wealth index, place of residence being rural or urban, maternal age
and number of children of the mother. For the wealth index the five categories were: poorest,
poorer, middle, richer and richest, and the category poorest was chosen as reference category.
For place of residence urban was chosen as the reference category. Maternal age and number
of children of the mother were used as continuous variables.
2.7 Statistical analysis
2.7.1 Descriptive analysis
A descriptive analysis was conducted to be able to present the frequency distribution and
percentages of the categorical variables, and mean and standard deviation of the continuous
variables included in this study.
2.7.2 Bivariate analysis
All variables were tested against both the exposure variable and outcome variable. For the
analysis R version 3.6.3 was used.
Chi-squared tests were carried out on all categorical variables to look for associations. The
variables wealth index of the household and place of residence were tested against both the
exposure and outcome. Independent t-tests were carried out when looking for associations
between the numerical variables mother’s age and number of children against both the
exposure and outcome. If the variables were associated with both the exposure and outcome,
with a p-value of <0.2, they were included as confounders in the logistic regression.
2.7.3 Multivariate analysis
For the multivariate analysis logistic regression was carried out in three different models. The
first model was the unadjusted logistic regression containing the exposure variable and
outcome variable alone. The second model included the exposure, outcome and confounders
wealth index of the household and place of residence. Wealth index and place of residence
were the two variables with an association in the bivariate analysis and therefore included as
confounders in the logistic regression. The third model included all variables in this study.
Maternal age and number of children did not show an association with the outcome in the
bivariate analysis. But since they have been shown from previous studies to have an impact
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on both the maternal level of education and odds of the child to receive treatment, they were
included in a third separate model to see the impact they had on the outcome. The level of
significance was set at p-value <0.05 and with a confidence interval of 95% in the logistic
regression. .
2.8 Ethical consideration
The Nigeria Health Research Ethics Committee of the Federal Ministry of Health (NHREC)
approved the 2015 NMIS survey protocol. Confidentiality for each of the participants was
ensured. Participation in the survey was completely voluntary and written consent was
collected from each participant beforehand. Children were asked to take a malaria diagnostics
test. If the malaria test was positive the child was offered treatment with antimalarial drugs
(20).
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3. Results A total of 8’034 women participated in the 2015 DHS NMIS Survey. There was information
that these women had 6’624 children combined. After excluding the children who were
malaria negative and the children there were no information on whether they received
treatment or not, a total of 2’622 children were used for this analysis (figure 1).
Figure 1 – Flowchart of the participants’ chosen for this study based on the DHS MIS Survey
in Nigeria 2015.
3.1 Characteristics of the study population
With most of the mothers having no education (49.8%) and the fewest mothers had a higher
level of education (5.4%), the distribution of the maternal level of education being shown in
table 1.
The variables place of residence showed that 62.3% (n=1’634) of the children resided in a
rural area in Nigeria, and 37.7% (n=988) resided in an urban area. The wealth index of the
household in which the children resided in were evenly distributed, and divided into the
groups poorest, poorer, middle, richer and richest (Table 1). The mean age of the mothers was
27.88 ± 8.72 years. The mean number of children in the household was 3.72 ± 2.13 (Table 1).
All children aged 0-69m
(n=6’524)
All children positive for malaria with information
on treatment (n=2’622)
Children that were malaria negative or no information
on treatment with antimalarial drugs
(n=3’902)
Children not treated with antimalarial drugs
(n=1’522)
Children treated with antimalarial drugs
(n=1’100)
Women included in the study (n=8’034)
Women with no information on any
children (n=1’510)
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The different antimalarial drugs and the distribution of the treatment with them are shown in
Table 1, with most children receiving combination treatment with artemisinin (14.9%). The
overall treatment with antimalarial drugs in children under-5 that were malaria positive was
42%.
Table 1 – Descriptive table showing the characteristics of the study population included in
this study, including frequency distribution, mean and standard deviation for the variables
(total n=2’622). Variables Frequency (%)/Mean ± SD
Maternal level of education
No education 1’305 (49.8)
Primary 484 (18.5)
Secondary 690 (26.3)
Higher 143 (5.4)
Place of residence
Rural 1’634 (62.3)
Urban 988 (37.7)
Wealth index
Poorest 516 (19.7)
Poorer 529 (20.2)
Middle 579 (22.1)
Richer 551 (21.0)
Richest 447 (17.0)
Number of children 3.72 ± 2.13
Maternal age 27.88 ± 8.72
Treatment with antimalarial drugs
SP/Fansidar 168 (6.4)
Chloroquine 302 (11.5)
Amodiaquine 68 (2.6)
Quinine 74 (2.9)
Combination with artemisinin 392 (14.9)
Country specific antimalarial 55 (2.1)
Country specific antimalarial 66 (2.5)
Other antimalarial 115 (4.4)
Overall treatment with antimalarial drugs
Yes 1’100 (42)
No 1’522 (58)
SD – Standard deviation
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3.2 Bivariate analyses to evaluate association between the outcome and exposure
variables and the background characteristics
Table 2 displays the bivariate analysis between the treatment with antimalarial drugs in
children under-5 positive for malaria and the background characteristics. As seen in Table 2,
maternal level of education showed significant association with the treatment with
antimalarial drugs in children under-5 (p-value <0.001). For the children who received
treatment with antimalarial drugs 44% had mothers who had no education, compared to the
children who did not receive treatment 53.9% had mothers with no education. Out of the
children who received treatment with antimalarial drugs 7.4% had mothers with a higher level
of education, compared to children who did not receive any treatment with antimalarial drugs
4.1% had mothers with a higher level of education.
Additionally in Table 2, looking at the percentages for all of the children who received
treatment, the percentages are higher for the children where the mothers have primary
education (19.5%) and secondary education (29.1%). Compared to the group of children who
did not receive any treatment with mothers who have primary education (17.7%) and
secondary education (24.3%).
Even though the wealth index was not significant associated to the treatment with antimalarial
drugs in children under-5 (p-value 0.1077), Table 2 shows that the children who received
treatment the majority (22.8%) belonged to the richer category of the wealth index. Compared
to the children who did not receive any treatment with the majority (22.5%) belonging to the
middle category of the wealth index.
The place of residence was not significant either (p-value 0.0661), but the children were more
likely to receive treatment if they resided in an urban area in Nigeria. Maternal age and
number of children showed no significant association (p-value 0.4612 and 0.5243
respectively) to the treatment with antimalarial drugs in children under-5 that were malaria
positive (Table 2).
Table 2 – A bivariate analysis of the background characteristics and the treatment of children
under-5 with antimalarial drugs using the Chi-squared test and the independent t-test (total
n=2’622).
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Factors Treatment No treatment P-value
Maternal level of education (Frequency (%)) (Frequency (%)) <0.001
No education 484 (44.0) 821 (53.9)
Primary 215 (19.5) 269 (17.7)
Secondary 320 (29.1) 370 (24.3)
Higher 81 (7.4) 62 (4.1)
Wealth index 0.1077
Poorest 200 (18.2) 316 (20.8)
Poorer 235 (21.4) 294 (19.3)
Middle 236 (21.5) 343 (22.5)
Richer 251 (22.8) 300 (19.7)
Richest 178 (16.2) 269 (17.7)
Place of residence 0.0661
Rural 663 (60.3) 971 (63.8)
Urban 437 (39.7) 551 (36.2)
Maternal age
(Mean ± SD)
28.03 ± 8.77 27.77 ± 8.72 0.4612
Number of children (Mean ± SD) 3.76 ± 2.14 3.70 ± 2.11 0.5243
SD = Standard deviation
Table 3 displays the bivariate analysis between the maternal level of education and the
background characteristics. There was a significant association between the maternal level of
education and the wealth index of the household (p-value <0.001). As shown in Table 3, the
majority (29.3%) of the women who had no education belonged to the poorest category of the
wealth index and the least (11.3%) of the women who had no education belonged to the
richest category. In comparison out of the women whom had a higher level of education the
majority (29.4%) belonged to the richer category of the wealth index, and the least (6.3%) of
the women who had a higher level of education belonged to the poorest category.
The place of residence showed significant association with the maternal level of education (p-
value <0.001). Out of the women whom had no education 71.4% resided in the rural areas of
Nigeria, compared to the women with a higher level of education out of which 44.8% resided
in the rural areas. Out of the women with no education 28.6% resided in the urban areas,
compared to the women with a higher level of education out of which 55.2% resided in the
urban areas.
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The mean age of the mothers did not show any significant association. But Table 3 shows that
the mean age of the mothers increased as the education level did although it was not
significant. As mothers with no education had a mean age of 27,57 compared to mothers with
a higher level of education that had a mean age of 28.97.
The number of children of the women showed significant association to the maternal level of
education. The number of children of the women decreased as the education level increased.
Mothers with no education had a mean number of children of 4.04 compared to the mothers
with a higher level of education who had a mean number of children of 2.97 (Table 3).
Table 3 – A bivariate analysis of the background characteristics and the maternal level of
education using the Chi-squared test and the independent t-test (total n=2’622). Factors No education Primary Secondary Higher P-value
Wealth index (Frequency (%)) (Frequency (%)) (Frequency (%)) (Frequency (%)) <0.001
Poorest 383 (29.3) 70 (14.5) 54 (7.8) 9 (6.3)
Poorer 334 (25.6) 94 (19.4) 88 (12.8) 13 (9.1)
Middle 252 (19.3) 110 (22.7) 179 (25.9) 38 (26.6)
Richer 189 (14.5) 109 (22.5) 211 (30.6) 42 (29.4)
Richest 147 (11.3) 101 (20.9) 158 (22.9) 41 (28.7)
Place of residence <0.001
Rural 932 (71.4) 281 (58.1) 357 (51.7) 64 (44.8)
Urban 373 (28.6) 203 (41.9) 333 (48.3) 79 (55.2)
Mother age
(Mean ± SD)
27.57 ± 8.76 27.46 ± 8.82 28.52 ± 8.72 28.97 ± 8.05 0.0342
Number of
children (Mean ±
SD)
4.04 ± 2.19 3.96 ± 2.22 3.12 ± 1.84 2.97 ± 1.69 <0.001
SD = Standard deviation
3.3 Regression analyses evaluating the association between maternal level of education
and antimalarial treatment in their children under-5 in Nigeria
From the unadjusted logistic regression analysis in Model 1 conclusions can be drawn that
compared to the mothers with no education, mothers who have primary education have an
increased odds of 35% (OR 1.35, CI 1.09-1.67) of making sure their child receive treatment
with antimalarial drugs. Mothers with secondary education have increased odds of 46% (OR
1.46, CI 1.21-1.76) of making sure their child receives treatment with antimalarial drugs,
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compared to mothers with no education. Additionally, mothers with a higher level of
education have more than two times higher odds (OR 2.21, CI 1.56-3.15) compared to
mothers with no education of making sure their child receives treatment with antimalarial
drugs (Table 4).
When adjusting for the variables wealth index and place of residence in model 2 all categories
of maternal level of education stayed associated with the outcome. With an increase to 38%
(OR 1.38, CI 1.11-1.71) in the odds for the child receiving treatment with antimalarial drugs
if the mother has primary education and an increase to 51% (OR 1.51, CI 1.24-1.84) if the
mother has secondary education compared to mothers with no education. The mothers with a
higher level of education still have two times higher odds of making sure their child receives
treatment with antimalarial drugs compared to the mothers with no education, but with an
increase in the odds ratio from 2.21 (CI 1.56-3.15) to 2.31 (CI 1.62-3.32).
In the adjusted regression in model 2 the category richest in the wealth index was show to be
associated with the treatment of the child. Showing that children belonging to a household in
the richest category, compared to the poorest category, had decreased odds of 27% (OR 0.73,
CI 0.53-0.99) of the child receiving treatment with antimalarial drugs (Table 4). Additional
findings in model 2 show that place of residence was associated with treatment of the child.
Living in a rural area in Nigeria decreases the odds of the child receiving treatment with
antimalarial drugs with 19% (OR 0.81, CI 0.66-0.99), compared to living in an urban area.
In the adjusted logistic regression in model 3 the variables maternal age and number of
children of the mothers were added. There was a small change in the odds ratio for the
maternal level of education categories, and they remained associated to the outcome. For
wealth index richest remained the only category that showed association with small changes
in the odds ratio (add odds ratio). Living in a rural area still showed a 19% (OR 0.81, CI 0.66-
0.99) decrease in odds in treatment with antimalarial drugs in children compared to living in
an urban area. Maternal age and number of children was not associated with the treatment
with antimalarial drugs in children under 5 (Table 4).
Table 4 – Evaluating the association between maternal level of education and the treatment
with antimalarial drugs in children under-5 that were malaria positive in Nigeria (total
n=2’622).
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Model 1 Model 2 Model 3
Factors OR (95% CI) P-value OR (95% CI) P-value OR (95% CI) P-value
Maternal
level of
education
No education (Ref) (Ref) (Ref)
Primary 1.35 (1.09-1.67) 0.004 1.38 (1.11-1.71) 0.003 1.38 (1.11-1.72) 0.002
Secondary 1.46 (1.21-1.76) <0.001 1.51 (1.24-1.84) <0.001 1.55 (1.27-1.90) <0.001
Higher 2.21 (1.56-3.15) <0.001 2.31 (1.62-3.32) <0.001 2.38 (1.66-3.43) <0.001
Wealth index
Poorest (Ref) (Ref)
Poorer 1.20 (0.93-1.53) 0.150 1.19 (0.93-1.53) 0.162
Middle 0.89 (0.69-1.15) 0.399 0.89 (0.69-1.15) 0.397
Richer 0.98 (0.74-1.30) 0.926 0.98 (0.74-1.29) 0.901
Richest 0.73 (0.53-0.99) 0.049 0.72 (0.52-0.99) 0.046
Place of
residence
Urban (Ref) (Ref)
Rural 0.81 (0.66-0.99) 0.046 0.81 (0.66-0.99) 0.048
Maternal age 1.00 (0.99-1.01) 0.604
Number of
children
1.03 (0.99-1.07) 0.114
OR = Odds ratio, CI = Confidence interval, Ref = the reference group
Model 1 = the unadjusted logistic regression.
Model 2 = the adjusted logistic regression using the variables wealth index and place of residence.
Model 3 = the adjusted logistic regression using the variables wealth index, place of residence, maternal age and
number of children.
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4. Discussion 4.1 Main findings
The aim of this study was to investigate whether maternal level of education had an impact on
the treatment of children under-5 with antimalarial drugs in Nigeria. The main finding of this
study concludes that maternal level of education plays a role in whether a child receives any
treatment with antimalarial drugs or not. There is also a difference in treatment depending on
the level of education of the mother. For example, mothers who had a higher level of
education compared to mothers who have no education are more than two times more likely
to make sure their child receives treatment with antimalarial drugs.
4.2 Impact of maternal level of education on the treatment with antimalarial drugs in
children under-5
Knowledge has previously been established as an important tool in the prevention of malaria.
The knowledge plays a role in people’s perception of the problem and their practices in order
to control malaria infections (6). The knowledge about malaria and how to treat it has been
shown to increase with formal education (21). In this study the higher level of education the
mothers had, in comparison to the mothers who did not have any education, the more likely
the mothers were to make sure their child received treatment with antimalarial drugs. The
mothers with a higher level of education were more than two times more likely to give their
child treatment with antimalarial drugs compared to the mothers without any education. The
mothers with secondary education were 51 percent more likely to give their child treatment
with antimalarial drugs compared to the mothers without education. And the mothers with
primary education were 38 percent more likely to give their child treatment with antimalarial
drugs compared to the mothers with no education. This indicates that higher level of maternal
education might be associated with higher knowledge about malaria and malaria treatment.
Thus, the mother’s formal education helps ensure treatment with antimalarial drugs is given to
children under-5, and might reduce the possibility of under-5 morbidity and mortality due to
malaria.
Another study conducted in Nigeria in 2014 also concluded that the education of the mothers
was a factor for adequate and timely treatment with antimalarial drugs in children under-5.
With a higher level of education in the mothers being associated with more timely and
adequate treatment for the children under-5 (5).
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Additionally, a study conducted in India in 2017 concluded that the higher level of formal
education the better knowledge on malaria diagnosis and preventive measures the people had.
The study from India was investigating the determinants for seeking treatment for malaria.
But it also showed that the higher level of education the less delay there was in seeking
treatment and self-medication or less preference for using traditional healers compared to the
less educated people (29). This is conclusive with the main result of this study, which also
showed an association between level of maternal education and the likelihood of their
children who were malaria positive receiving treatment in Nigeria. Indicating that the formal
education provides the mothers with some kind of knowledge that leads to them to the
decision to seek treatment for their sick child.
While the knowledge about malaria has been shown to be associated with the level of
education in some studies, a previous study conducted in South-Eastern Nigeria in 2005
concluded that formal education is an important tool to acquire information about malaria and
how it should be treated, but it is not the only tool since higher level of education is not
always associated with better knowledge about malaria. Therefore interventions targeting
malaria treatment cannot solely focus on formal education. Although it is an important tool
for people to gain knowledge about the malaria treatment (6).
A study conducted in Uganda also indicates that the formal education of the mothers is an
important tool, but also that the content of the formal education is important. This study was
conducted in an urban setting during the malaria season, and 88 percent of the mothers had
formal education. Despite having formal education the mothers did not make the association
between fever in their children and that it could be malaria. It was concluded that the mothers
had an overall poor knowledge about malaria. Their failure to recognize a malaria infection in
their children could have adverse health consequences. Since the treatment could be delayed
or not given if care is not sought. Indicating that the content in the formal education matters as
well (30). What kind of knowledge the mothers had gained from their formal education that
lead to the decision to give their children treatment was not looked at in this study. That topic
requires further research as it has been shown to be an important topic.
It is important to look at how knowledge is acquired. Education interventions could for
instance be hard to assimilate for mothers without any formal education. Formal education
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could provide the mothers with the skills necessary to obtain knowledge and process
information. But it is not necessarily from formal education the knowledge about malaria is
provided.
For instance, a study was carried out in rural refugee villages in Belize with the objective to
increase the mother’s health seeking behaviour for their children under-5 with malaria. To
achieve the study’s objective, health education interventions were used with the interventions
targeting the mothers. There was only a small increase in the health seeking behaviours of the
mothers regarding their children following this intervention. The increase in health seeking
behaviour was mostly due to the inter-personal communication between the mothers. With a
majority of the mothers having no formal education, the results indicating that formal
education provides the mothers with knowledge to understand health messages overall (31).
Overall, the people in Nigeria have a good knowledge about the cause of malaria and the most
common symptoms of a malaria infection (28). The biggest knowledge gap is prevention and
treatment of malaria. With most mothers actually giving their children treatment with
antimalarial drugs, but the problem being that they do not know which drugs to give or what
dosages to give. Or they do not ensure the child completes the full course of the treatment
with the adequate antimalarial drug (21).
This study did not explore the question of compliance or the timeliness of the antimalarial
treatment given to the children. In the children under the age of 5, it is the mothers or
caregivers task to ensure the child receives the adequate treatment and complies with it. Thus,
further studies are needed to explore the topic of maternal level of education and the
association with timeliness and compliance with treatment with antimalarial drugs in children
under-5.
Knowledge is not the only aspect of formal education of the mothers, previous studies
indicate that the education also provides the mothers with higher autonomy. A study
conducted in Ethiopia concluded that the maternal education was associated with more
autonomy of the mothers. The mothers who had a higher education were more likely to make
their own decisions regarding not only their own health, but also their children’s health (32).
In addition, a study conducted in Kenya that investigated the association between maternal
education and the immunization of their children concluded that maternal education is
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important for acquiring health knowledge. That the mothers were able to make better
decisions regarding their children’s health, which ultimately leads to improvements in child
health (33).
To conclude this study is conclusive with previous studies (21,29,31), that formal education
was associated with treatment with antimalarial drugs in children under-5. Since this study
concludes that the higher level of education of the mother, compared to no education at all,
the higher the odds of the child receiving treatment with antimalarial drugs. The previous
studies explore the reasons for why formal education is a great tool for improving child health
(5,21,29,32,33). But it is also important to remember that formal education is not the only
factor to take into consideration when looking at the reasons for treatment with antimalarial
drugs in children under-5.
4.3 Background characteristics role in the treatment with antimalarial drugs in children
under-5
The result from this study indicates that the richest households had a 27 percent decreased
odds, compared to the poorest households, of the children under-5 receiving treatment with
antimalarial drugs. This result does not conclude with some previous studies (5,27). A
previous study, which was conducted in rural areas of Tanzania, concluding that the overall
coverage of treatment with antimalarial drugs was low. But particularly disadvantaged was
the population living in the poorer households. And that the poorest population were less
likely to benefit and gain access to antimalarial drugs for treating malaria, in comparison to
the richer population. Notable from this study was also that people living in wealthier
households were not only more likely to gain access to antimalarial drugs, but also to obtain
effective and safe antimalarial drugs than those living in poorer households (27).
Another study conducted in Nigeria in 2014, which looked at the determinants for delay in
treatment in children under-5, concluded that the economic status of the household served as a
barrier for timely and appropriate antimalarial treatment in children under-5. With poorer
households having less access to adequate treatment, and thus the children from richer
households were more likely to receive treatment (5). Not conclusive with the findings from
this study.
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Furthermore, preventive measures such as whether the child slept under an ITN is different
depending on the household wealth and the place of residence. The wealthier households
usually have more access to ITNs, but the poorest household are more likely to use them. This
can be due to the fact that the poorest households often are considered a vulnerable group that
is targeted with interventions regarding ITN usage (34). In Nigeria the ITN and LLIN usage
was 29 percent in children under-5, with most of those using them belonging to the wealthier
households (20). Another study shows that less fever in children under-5 is reported from
households with ITN usage (35). Which could explain why the incidence of malaria is higher
in children under-5 belonging to the poorest households. But does not explain why children in
richer households are less likely to receive treatment compared to children in poorer
households in this study.
In this study, results showed that living in a rural area in Nigeria decreases the odds of the
child under-5 receiving treatment with antimalarial drugs with 19 percent, compared to
children living in an urban area. Which is cohesive with the study conducted in India in 2017,
which indicates that there was a delay in treatment with antimalarial drugs for people living in
rural areas. This might be due to of the distance to health care facilities (29). In line with the
findings of this study, a study conducted in Tanzania reported the results that the children
from the urban areas are less likely to contract a malaria infection overall, and additionally
they are also more likely to receive proper and adequate treatment with antimalarial drugs
(27).
This study indicates that when investigating the topic of treatment with antimalarial drugs in
children under the age of 5, determinants such as place of residence and the wealth of the
household the child lives are two important background characteristics that were associated
with the treatment with antimalarial drugs in children under-5 in Nigeria. When adjusted for
these background characteristics of the children in this study, the formal level of education of
the mothers still showed a significant association with the treatment with antimalarial drugs in
the children. With mothers with a higher level of education, compared to no education, had
increased odds of making sure their child received treatment.
This study showed no association between the maternal age and the treatment with
antimalarial drugs in children under-5, which is not conclusive with some previous studies. A
study conducted in Nigeria in 2014 concluded that the age of the mothers was associated with
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the treatment with antimalarial drugs in children under-5. The mothers who were older did not
wait for the father’s approval to seek care and sought care for their child sooner than the
younger mothers. The older mothers were also less prone to economic related issues which
could possibly affect the access to treatment (5).
The study conducted in Nigeria in 2014, also concluded that the number of children of the
mothers served as a delaying factor for seeking care for their children. The mothers with a
higher number of children did not take the symptoms in their children as serious as mothers
with fewer children did. Resulting in children who’s mothers had more children were less
likely to receive adequate or timely treatment with antimalarial drugs than children who’s
mothers had fewer children (5). This was not conclusive with the results of this study, as this
study concluded no association between the number of children and the treatment with
antimalarial drugs in children under-5.
4.4 Strengths and limitations
4.4.1 Strengths
The main strength of this study was using data from the DHS, which is an internationally
recognized and population-based dataset. The DHS datasets offers a nationally representative
sample with high quality. It obtains the high quality by the fact that trained and experienced
field workers collected and analysed the data provided in the datasets. By using DHS data this
study was conducted at a low cost. The large sample size used in this study serves as an
additional strength. It helps provide reliability and ensures a more precise and accurate dataset
and values.
An additional strength is that studying the topic of malaria makes this study generalizable
other sub-Saharan African countries, or possibly other countries, with malaria transmission at
the same level as Nigeria and similar access to treatment and health care.
4.4.2 Limitations
Studying malaria and the many reasons why treatment with antimalarial drugs is provided or
not can be complex. Looking at those reasons on a national level could possibly mask some of
the reasons for treatment on an individual level. But since this study is taking advantage of the
DHS data, which is large and nationally representative, it will bring to light the overall trends
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on decisions for treatment, which could not have been brought to light by looking at a smaller
sample size on an individual level.
This study relies on the use of RDTs and microscopy for malaria diagnosis in the children
under-5. So there is always a chance with diagnoses that some patients were missed, and
therefore making it likely that the malaria prevalence figures is an underestimate in the DHS
dataset used for this study.
Since a complex cluster sample design was used in the DHS data collection, a limitation of
this study is that it is not adjusted for that. This makes it a possibility that reported p-values
are at risk of a type 1 error. Meaning that some of the associations could have been reported
as significant while it was in fact not significant.
Additionally, as this study was of cross-sectional design it did not allow an assumption on
causality to be drawn from the findings. Rather just analysing the association of the outcome
and exposure variables.
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5. Conclusion In conclusion, the results of this study indicate that the maternal level of education was
associated with the likelihood of the child positive for malaria being treated with antimalarial
drugs or not. The mothers with a higher level of education was more than 2 times more likely
to ensure their child receives treatment with antimalarial drugs, compared to the mothers with
no education. The wealth of the household and the place of residence are background
characteristics that need to be taken into consideration when exploring this issue. And future
interventions targeting the treatment in children under-5 with antimalarial drugs need to be
aware of the impact of maternal level of education and also the background characteristics
and target the interventions accordingly.
Most interventions in Nigeria seemed to have focused on the prevention of malaria using
ITNs (20). And most previous studies focused on treatment with antimalarial drugs in relation
to factors such as knowledge of the caregivers and place of residence, but also the infection
rate of malaria in children under-5 and the association to maternal level of education
(21,22,28,36,37). But the interventions and studies have not focused on the association
between treatment with antimalarial drugs in children-5 and the educational level of the
mothers.
Following this study, more research is needed to look at how the maternal level of education
affects the compliance and timeliness of the treatment with antimalarial drugs in children
under the age of 5. But also what type of knowledge the formal education provides the mother
with in order to make the decision regarding treatment with antimalarial drugs for their
children.
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6. Acknowledgement I wish to acknowledge the Demographic and Health Surveys Program for providing free
access to the data needed for this study.
A special thanks to my supervisor Shirin Ziaei for all the help and support throughout this
study. The feedback provided was essential and deeply appreciated, and without it and your
guidance this study would not have been made.
Lastly, I would like to thank my family and my partner, for always believing in me and
supporting me no matter what.
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