Background

To date, malaria remains the most prevalent vector-borne parasitic disease in the world and a major public health problem in sub-Saharan Africa. Among the 241 million malaria cases and 627,000 deaths worldwide in 2020, sub-Saharan Africa accounted for more than 96% of cases [1]. Malaria is both a disease of poverty and a cause of poverty [2]. Delayed urbanization, poor quality of life, underfunded and poorly managed health services with long consultation times, all make malaria eradication difficult. Despite the high intensity of malaria infection in the African region, the use of control measures is still often insufficient in developing countries. Furthermore, people only consult health services when their practice of self-medication has failed despite the availability of early diagnosis and treatment for malaria in health facilities [3,4,5].

According to the World Health Organization (WHO), the majority of these reported cases in sub-Saharan Africa are children under 5 years of age which account for 67% of cases [1]. Moreover, in the Central African region, malaria is one of the main causes of morbidity and mortality for vulnerable groups such as pregnant women and young children [6,7,8]. In children, malaria can cause several organ malfunctions, which can lead to complicated forms of the disease. Severe anaemia is one of the main manifestations of severe malaria in children aged under five, followed by cerebral malaria and respiratory distress [9,10,11].

In Gabon, a central African country, malaria transmission is stable and intense throughout the year. According to the National Malaria Control Programme (NMCP), Gabon has recorded nearly 799,000 cases of malaria with over 500 deaths. Yet, in 2010, the country had 50% coverage of insecticide-treated nets (ITNs) and 99% coverage of artemisinin-based combination therapy (ACT). However, in recent years, the absence of the NMCP in the field and, therefore, the absence of awareness campaigns, education on malaria epidemiology and the distribution or sale of ITNs are becoming increasingly rarer each year [12].

The city of Franceville, located in southeastern Gabon, is the capital of the Haut-Ogooué province and the third largest city in the country. This city has a high population but mostly with a low economic status. Franceville is an urban area but additional urbanization efforts are needed as anarchic constructions favor the presence of mosquito breeding grounds and, therefore, their proliferation. The prevalence rate of malaria in Franceville is approximately 20% and the most frequently encountered plasmodial species is Plasmodium falciparum.

Despite the accessibility of health facilities, the community-based management of childhood fever remains a very common practice in Gabon and leads to a delay in proper care by health facilities. The objective of this study was to evaluate the level of knowledge of the various symptoms of childhood malaria among mothers, as well as their attitudes and care practices.

Methods

Type of study and location

This study is a descriptive cross-sectional survey. It was conducted in six districts (Ongouégné, Sable, Alélé, Ombelé, Ongali, Yéné) of the city of Franceville, in southeastern Gabon. The study was conducted during the month of June 2021. The different households were selected by the simple random sampling method. The city of Franceville is an administrative city whose neighborhoods are mostly under-integrated. According to the latest population census, dating from 2013, the city of Franceville had 129,694 inhabitants [13].

Data collection

Mothers from each selected household were included in the study after obtaining their informed consent. A survey with closed-ended questions was administered through an interview. The structured interviews were conducted by a team of two examiners. The information collected from the mothers in each household included socio-demographic data; knowledge, attitudes, and practices about malaria and its different forms; use of preventive or control means for malaria; possession of ITNs; practice of self-medication and type of medication used. The survey of mothers was conducted in French for those who spoke French and in the vernacular language of the region (Teke-Obamba) for those who did not speak French well.

Data analysis

The different answers of all interviewed mothers were recorded in Excel 2013 spreadsheets. Statistical analyses were performed with Epi-info version 3.3.2 (2005, CDC, Atlanta, USA) and RStudio version software (version 1.1.419). Categorical variables were described by proportions. These proportions were compared using the Chi2 test. For all analyses, the significance level was set at α = 5%.

Ethical clearance and approval was obtained from the National Research Ethics Committee in Gabon (No. 001/PR/SG/CNER/2018). Informed written consents were obtained from all levels of local government prior to data collection, and verbal consents were obtained from participants during data collection. Respondents were given the right to refuse or participate in the study and to withdraw from the study at any time. Privacy and confidentiality were maintained throughout the study.

Results

Socio-demographic characteristics of mothers

A total of 146 mothers from different households were interviewed in the city of Franceville. All of the households visited were from under-integrated neighbourhoods (100%). The Ongouégné neighbourhood had the highest proportion of mothers interviewed (30.3%), followed by the Alélé neighbourhood (29.4%). The majority of the study population had a middle school education (55.5%), followed by primary (Table 1) education (34.2%). Approximately 75.3% of the households surveyed had a low monthly income (below the minimum monthly income of about 272 dollars). The majority of mothers were unemployed (54.8%), and 15.7% were students. The study population was predominantly composed of young mothers, as 54.8% of women were aged 18 to 30 years.

Description of the mothers’ knowledge of malaria

The analysis of the mothers’ knowledge showed that 98.6% had at least heard of malaria and 55.5% of them knew about severe malaria. Among the 146 mothers, 93.2% cited mosquito as the vector of malaria and 83.6% of them used ITNs as a means of protection. Other information is shown in Table 2.

Table 1 Socio-demographic characteristics of the mothers in the study
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Table 2 Mothers’ knowledge of malaria in Franceville, Gabon
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Table 3 Determinants of the mothers’ self-medication practices
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Assessment of the mothers’ attitudes and practices

The results show that 68.5% (100/146) of mothers chose to self-medicate when their child had malaria and only 24.7% (36/146) of women went to a health centre as is proper. The use of health facilities was motivated by better (Table 3) care, the decision of the head of the family and, to a lesser extent, the severity of the disease. During the onset of fever in children, the practice of self-medication consisted of buying medicines in pharmacies and administering mainly Artefan (41.1%, 60/137), followed by Coartem (37.0%, 54/137). All the information is recorded in Fig. 1.

Fig. 1
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Malaria pratices of mothers in Franceville, Gabon

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Comparison of self-medication by socio-demographic data

The analysis of these data showed that the practice of self-medication was not related to age, level of education, marital status and standard of living of the mother’s household in relation to the occurrence of malaria in children (p > 0.05).

Discussion

This study highlights the unfavorable socio-economic conditions to which the majority of mothers (75.3%) are subjected in their households in Franceville. Given that malaria is a disease which affects impoverished areas [14], the study was conducted to focus on sub-integrated neighbourhoods of Franceville to conduct this study.

All of the mothers who participated in the study had attended school (100%) and 98.6% of them had knowledge of the epidemiology of malaria and its mode of transmission (93.2%). The proportion of women with a knowledge of the mode of transmission was higher than that in other studies, 17.3% and 63% in Ethiopia [15, 16]. In this study population, 93.2% of women had good knowledge of the malaria vector, and 85.6% named fever as the main symptom of malaria. Other studies showed that mothers in Togo and Senegal also identify fever as the main symptom of malaria, with proportions of 72% and 81%, respectively [17, 18]. Knowledge of fever as the main symptom of malaria among mothers is beneficial for a rapid and effective management of the disease in children. However, the findings suggest that educational campaigns should also insist on the manifestations of severe forms of malaria. In fact, only 55.5% of the population surveyed in our study had knowledge of severe malaria and its different clinical signs.

The main sources of information for the surveyed population were community relays (50.0%), followed by health agents (30.8%) and malaria awareness campaigns (8.9%). These results are partially similar to those of Seck et al. in Senegal [18], where the dominant source of information were community health workers (62.9%).

These findings show that mothers react quickly to fever in their children. However, several external factors lead them to self-medicate as a first resort. This practice has also been widely reported in other studies focused on mothers with febrile children, such as in Tunisia with a frequency of 88.2%. In a study conducted in Gabon, 24.1% of mothers practiced self-medication [19,20,21]. This practice of self-medication could be a major problem by leading to the emergence of strains resistant to the different anti-malarial drugs. In this study population, the practice of self-medication did not depend on social status, marital status, level of education, on the young age or inexperience of mothers. This result could be explained by the fact that mothers are very responsive when their child has a fever, and even better, they always have antipyretics in reserve at home to bring down the child’s temperature in case of fever.

Conclusion

This descriptive cross-sectional study was conducted to support education campaigns and health measures to control malaria in Franceville, Gabon. The data revealed that mothers may underestimate severe malaria and delay medical care by self-medicating, which can have detrimental effects for children and hinder the regression of the disease. These results show that there is a need for the Ministry of Health through the NMCP to increase awareness campaigns on severe malaria in Gabon so that the population can improve their knowledge of the disease and seek medical care.