Survey on knowledge, attitudes and practices (KAP) of malaria prevention and control among Chinese expatriates in South Sudan

Abstract

Background

Malaria is a major health risk faced by Chinese expatriates working in South Sudan. The purpose of this study is to investigate the knowledge, attitudes and practices (KAP) of Chinese expatriates in South Sudan towards malaria prevention and control, analyze the influencing factors, and provide a basis for reducing the morbidity and mortality of malaria.

Methods

By distributing questionnaires, data on socio-demographic characteristics of Chinese expatriates in South Sudan, and information on their knowledge, attitudes, and behaviors towards malaria prevention and control were collected from April 5th to 12th, 2023.

Results

The recognition degree of malaria prevention and control was better, and the accuracy of each choice in knowledge, attitude and pracice was 19.4–99.75%, 85.57–99.25% and 82.59–99.00%, respectively. Of the 402 respondents, none had a history of malaria before coming to South Sudan, the malaria infection rate was 41.29% (166/402). The results of multiple linear regression analysis suggest “Knowledge Scores” will have a significant positive impact on “Practices Scores” (B = 0.206, 95% CI: 0.045 ~ 0.367, P = 0.013). However, the remaining five independent variables do not have an impact on “Practices Scores”.

Conclusions

The KAP of Chinese expatriates in South Sudan towards malaria prevention and control is good, but needs to be further strengthened. Improving knowledge about malaria prevention and control can reduce the incidence of malaria.

Background

Malaria is one of the parasitic diseases that severely endanger human health. To this day, more than 3 billion people worldwide still face the risk of contracting malaria. In 2021, it is estimated that there were 247 million cases of malaria in 84 endemic countries worldwide, resulting in 619,000 deaths [1]. The African region currently accounts for 95% of global malaria cases and 96% of deaths from malaria, with approximately 3 million cases in South Sudan [1]. The increased resistance of Plasmodium to current antimalarial drugs, the emergence of side effects such as vomiting and dizziness, and the high cost of these drugs have led to the failure of malaria treatment and control [2]. South Sudan has amongst the poorest health indicators owing to poor access to essential services and severe disruption of health service delivery during the decades of civil war [3]. Malaria poses a significant public health challenge in South Sudan, with year-round transmission observed across most regions of the country. Malaria transmission in northwest South Sudan has a marked seasonality, with a relatively long peak season that occurs between June and December, following the rainy season. In 2020, there were an estimated 3,211,331cases and 7431 malaria deaths in South Sudan [4]. Misunderstandings about malaria have led to adverse attitudes and practices, further increasing the burden on malaria-endemic countries. The lack of antimalarial drugs, the use of herbal remedies, increased conflicts, the scarcity of health workers, and poor road conditions are important factors increasing the incidence of malaria and premature death in South Sudan [5].

Currently, China is South Sudan’s largest source of investment, most important trading partner, and one of its key aid providers. According to the statistics of the Embassy of the People’s Republic of China in South Sudan, there are about 2000 Chinese expatriates in South Sudan, including about 1030 peacekeepers. Chinese enterprises in South Sudan live in certain areas as companies and are mainly engaged in oil exploration and development. Non-oil investment is mainly for infrastructure, hotel catering services, retail stores, clinics and small-scale agricultural projects [6]. The peacekeepers and staff of many Chinese enterprises and institutions will change shifts regularly and stay in South Sudan for no more than one year, so there are many new Chinese people in South Sudan every year. China has eliminated malaria by 2021, and Chinese people generally lack protective immunity against malaria. Many Chinese expatriates who are going to work in South Sudan have a fear of malaria due to poor local medical conditions and no effective vaccine. Hence, Malaria is a major health risk faced by Chinese expatriates working in South Sudan, malaria prevention is important to avoid further contagion in the population [7]. This survey is specifically conducted to understand the knowledge, attitudes, and practices (KAP) of Chinese expatriates towards malaria prevention and control. The aim is to reduce their excessive fear of malaria and promote scientific methods for preventing malaria.

Methods

Study design

Referencing the standard malaria KAP questionnaire content of the European Malaria Health Advisory Committee, reviewing historical data, related research papers, and combining the clinical work experience of the 10th Batch of China Medical Team to South Sudan and local realities, this cross-sectional study of malaria prevention and control KAP was designed (Figs. 1, 2).

Figs. 1, 2

South Sudan map. Study location map

Sampling

All the respondents aged 18 years old and above were eligible to participate in the study. Inclusion criteria are: (1) Chinese expatriates working in South Sudan; (2) Familiar with the operation process of the WeChat “Questionnaire Star” App; (3) Willing to participate in this study. Peacekeeping troops and other Chinese in South Sudan live in different areas as companies or departments. The sectors exhibit variations in terms of their living environment, habits, and frequency of pesticide utilization. We selected 20% of Chinese individuals from each unit as survey participants to represent the characteristics of Chinese expatriates in South Sudan.

Study procedures

Before the survey began, 10 Chinese respondents in South Sudan were selected for investigation. We invited two experts, YG and JL, from the Department of Infectious Diseases and Epidemiology at Anhui Medical University to assess and provide guidance on the questionnaire. After expert review and modification, the final version of the survey questionnaire was reliable and effective. This group of 10 was not included in the statistics. Through a App in WeChat, we input the questions and options that need to be investigated into the questionnaire. After the questionnaire is set up, a QR code will be generated, and the respondents can scan the QR code through their mobile phones to enter the questionnaire page and complete the survey. After the survey is completed, the researchers can obtain all the information of the respondents through this App. The respondents’ IP addresses and questionnaire contents were included, and then statistical analysis was performed. Specialized personnel conducted online review, and 50% of the respondents from each unit were selected for return visits to ascertain whether the completion of the questionnaire was influenced.

Instruments and variables

The content includes: (1) basic information of the survey subjects (age, gender, education level, average daily outdoor working hours, cumulative length of stay in South Sudan, etc.); (2) KAP questionnaire, including three dimensions, a total of 13 items: knowledge of malaria prevention and control (K): including 6 items such as malaria transmission routes, symptoms, epidemic seasons, etc.; attitude towards malaria prevention and control (A): includes 4 items such as willingness to actively learn about malaria prevention and control knowledge, whether to take measures to prevent mosquito bites, etc.; practices of malaria prevention and control (P): includes 3 items such as whether to participate in malaria prevention and control training, measures to prevent malaria, etc.

Each question item is worth 10 points, the total score is 130. If one of the answers to each question is incorrect, this question item will not be scored. The total score of knowledge, attitudes and practices were 60, 40 and 30 points respectively. In the questionnaire, all the questions are multiple answer/choice except age, which is fill-in-the-blank.

Statistical analysis

Data were double entered into the SPSS 23.0 (IBM, Armonk, NY) electronic spreadsheet by two different researchers. Then, a third researcher cross-checked the accuracy of the two datasets and created a data set for analysis. Respondents’ demographic data were presented as mean ± standard deviations ($\overline{x}$ ± s) and median (IQR: 1st and 3rd quartiles) for continuous data with and without normal distribution, categorical data were represented by frequency and percentage. Independent sample t-test is used for data conforming to normal distribution between two groups, Mann Whitney U test is used for non-normally distributed measurement data, and Pearson χ² test or Fisher's exact test is used. Multiple linear regression analysis was used to assess the impact of exposure factors on the risk of malaria in 166 respondents who had been infected with malaria. P < 0.05 is considered statistically significant.

Results

From April 5th to 12th, 2023, a total of 402 people participated in this survey, and 402 valid questionnaires were obtained. The majority of the respondents were male (382, 95.02%), the mean age was 33.90 years (18–65 years). 287 (71.39%) of the respondents had received university education. The vast majority of respondents (376, 93.53%) worked outdoors, including 149 (37.06%) for more than 8 h a day, 122 (30.35%) for 4–8 h, and 105 (26.12%) for less than 4 h. Half of the respondents (199, 49.50%) had been in South Sudan for less than 6 months, and another 161 (40.05%) for more than a year. The characteristics of the participants are displayed in Table 1.

Table 1 Socio-demographic characteristics of participants (n = 402)

Knowledge

Almost all respondents (398, 99.00%) know that female Anopheles mosquito bites can transmit malaria, while only half of the respondents know that blood transfusion (224, 55.72%) and mother-to-child/placental transmission (171, 42.54%) can spread malaria. Some respondents (87, 21.64%) erroneously believe that contaminated food and water sources can also transmit malaria. 328 (81.59%) respondents believed that malaria was most likely to occur in the rainy season, and 73 (18.16%) believed that malaria was most likely to occur in both the rainy and dry seasons. 400 (99.50%) respondents knew that malaria could be reinfected. The symptoms of malaria were as follows: intermittent chills in 368 (91.54%) respondents; 384 respondents (95.52%) had fever; 318 (79.10%) respondents had great sweating and dry mouth; 252 (62.69%) respondents suffered from vomiting and diarrhea; There were 386 (96.02%) respondents with headache, muscle soreness and fatigue. 324 (80.60%) respondents erroneously believe that there is currently no effective vaccine for the prevention and control of malaria. The knowledge of malaria prevention measures was as follows: radical treatment of patients and plasmodium carriers (283, 70.40%); to maintain environmental hygiene and prevent mosquito bites (401, 99.75%); took antimalarial drugs (337, 83.83%); used the vaccine (110, 27.36%); 214 (53.23%) respondents mistakenly believed that attention to food and drinking water hygiene could prevent malaria (Table 2).

Table 2 Participants’ knowledge of management and prevention of malaria (n = 402)

Attitudes

Almost all respondents (399, 99.25%) expressed willingness to actively learn about malaria prevention and control. 382 (95.02%) respondents were willing to take the initiative to participate in malaria screening in hospitals after returning to China. 344 (85.57%) respondents believed that malaria was very harmful. The vast majority of respondents (395, 98.26%) would take anti-mosquito measures when visiting areas with many mosquitoes (Table 3).

Table 3 Participants’ attitudes on malaria management and prevention (n = 402)

Practices

332 (82.59%) respondents had participated in malaria prevention and control knowledge training. Most respondents take one or more anti-mosquito measures, including: wore long clothes and trousers in outdoor work (392, 97.51%), applied mosquito repellent on exposed skin (360, 89.55%), used mosquito nets and window screens (398, 99.00%), promptly cleaned up water and filled puddles (342,85.07%), used mosquito repellent incense before going to bed (382, 95.02%), and emergency malaria kits (containing thermometers and antimalarial drugs, etc.) were available to 360 (89.55%) respondents. If they suspected that they had malaria, 375 (93.28%) respondents would choose to go to the hospital for diagnosis and treatment, and only 27 (6.72%) respondents chose to take anti-malaria drugs on their own (Table 4).

Table 4 Participants’ practices on management and prevention of malaria (n = 402)

Univariate analysis of factors influencing the onset of Malaria

Among the 402 respondents, none had a history of malaria before coming to South Sudan. After coming to South Sudan, 166 (41.29%) respondents had malaria (diagnosed by microscopic examination), while 236 (58.71%) respondents did not. Univariate analysis (Pearson χ² test, t-test or Mann Whitney U test) of exposure factors found that variables with statistically significant differences include: age, education, average outdoor working hours, cumulative length of stay in South Sudan, knowledge scores, and practices scores (Table 5).

Table 5 Univariate analysis of factors influencing the onset of malaria [n(%)]

Multivariate analysis of factors influencing the onset of Malaria

Multiple linear regression analysis was used to assess the effects of age, education, average outdoor working hours, cumulative length of stay in South Sudan, knowledge scores, and behavior scores on the risk of malaria in 166 people who had been infected with malaria. Taking age, education,average outdoor working hours per day, cumulative length of stay in South Sudan, knowledge scores as the independent variable and practices scores as the dependent variable for linear regression analysis, the R-square value of the model is 0.067, which means that five independent variables can explain 6.7% of the variation of practices scores as the dependent variable. It was found that the model passed the F test (F = 2.286, P = 0.049 < 0.05), which means that at least one of the five independent variables will have an impact on practices scores. In addition, the multicollinearity test of the model shows that all the VIF values in the model are less than 5, which means that there is no collinearity problem. Moreover, the D-W value is near the number 2, which indicates that there is no autocorrelation in the model, and there is no correlation between the sample data, and the model is good. The regression coefficient of “Knowledge Scores” is 0.206 (t = 2.508, P = 0.013 < 0.05), which means that “Knowledge Scores” has a significant positive influence on “Practices Scores”. Summary analysis shows that “Knowledge Scores” will have a significant positive impact on “Practices Scores”. However, the remaining five independent variables do not have an impact on “Practices Scores”. (Table 6).

Table 6 Multivariate analysis of factors influencing the onset of malaria (n = 166)

Discussion

This study surveyed the KAP of Chinese expatriates in South Sudan on malaria prevention and control through questionnaires. A total of 402 people participated in the survey, with the majority of respondents being male (95.02%), aged 18–29 (47.76%), holding a junior college or above (71.39%), working outdoors for more than 8 h a day (37.06%), and having been in South Sudan for less than a year (59.95%). According to statistics from the Embassy of the People’s Republic of China in South Sudan, most Chinese people in South Sudan were engaged in labor, aid construction, business, etc., during the research period, and the socio-demographic characteristics of these groups align with this study, suggesting that the included population has good representativeness. The recognition degree of malaria prevention and control was better, and the accuracy of each choice in knowledge, attitude and practice was 19.4–99.75%, 85.57–99.25% and 82.59–99.00%, respectively. Some respondents have low knowledge scores, and there is still a need to strengthen the learning and training of malaria prevention and control knowledge. Additionally, by grouping respondents based on whether they had been infected with malaria in the past, it was found that factors such as age, education, average outdoor working hours, cumulative length of stay in South Sudan, knowledge scores, and practices scores are correlated with the occurrence of malaria.

In terms of knowledge related to malaria prevention and control, respondents demonstrated a high level of awareness regarding the transmission of malaria through female Anopheles mosquito bites, peak seasons, potential for recurrent infection, malaria symptoms, and the importance of maintaining environmental hygiene to preventing mosquito bites, and using antimalarial drugs for prevention (81.59–99.75%). This result indirectly reflects that Chinese people in South Sudan have received good training on malaria prevention and control. Respondents demonstrated a low level of awareness regarding the transmission of malaria through mother-to-child/placental transmission, the existence of malaria vaccines (19.40–42.54%), and the fact that vaccination can prevent malaria, suggesting that understanding of knowledge related to malaria prevention and control is incomplete and further training is still needed. The RTS, S/AS01 (RTS, S) malaria vaccine is the first vaccine against human parasites recommended for use by WHO after long-term clinical trials [7] and is widely used in children in sub-Saharan Africa and other moderate to high malaria transmission areas, potentially saving tens of thousands of young lives annually [8]. Moreover, vaccination can prevent malaria. Studies by Chandramohan et al. [9] showed that the RTS, S/AS01_E vaccine combined with sulfadoxine-pyrimethamine (SP) + amodiaquine treatment reduced malaria by 62.8% and deaths by 72.9%. The low level of awareness among respondents about the existence of a malaria vaccine is possibly because there is currently no effective vaccine for use in adults, leading to the general public belief that there is still no malaria vaccine and/or that the vaccine's efficacy is low. 21.64% of respondents mistakenly believed that contaminated food and water sources can transmit malaria, and 53.23% of respondents erroneously believed that paying attention to food and drinking water hygiene can prevent malaria. These results reflect an overgeneralization of malaria transmission routes, reflecting a sense of panic about malaria among most Chinese people when living in high malaria incidence areas.

The vast majority (99.25%) of respondents are willing to actively learn about malaria prevention and control and actively take measures to prevent mosquito bites (95.02%), and 85.57% of respondents still believe that malaria poses a significant threat, demonstrating a certain level of panic, which is consistent with the aforementioned overgeneralization of malaria transmission routes. The WHO officially announced on June 30, 2021, that China had eliminated malaria [10], thus most Chinese citizens have a relatively positive attitude towards malaria prevention and control after going abroad. Most respondents reported taking a number of anti-mosquito measures. According to the frequency of use, mosquito nets were used when sleeping (99.00%), long clothes were used when working outside (97.51%), mosquito repellent incense was used (95.02%), mosquito repellent liquid/paste was applied to skin (89.55%), malaria emergency kit was equipped (89.55%), and water was cleared and puddles were filled in time (85.07%). Since 2012, with the increase in the number of Chinese workers going abroad and returning home, the proportion of transnational companies has increased, and the number of imported malignant malaria cases has shown an increasing trend [11]. Thousands of imported malaria cases each year still remain the focus of China's malaria elimination and post-elimination phase [12, 13]. From 2017 to 2021, a total of 10,085 imported malaria cases were reported in China, mainly from Africa (86.7%) and Asia (12.4%), with cases from Africa mainly infected with Plasmodium falciparum (74.0%) [14]. In this survey, 95.02% of respondents would actively go to the hospital for malaria screening after returning home, indicating that the Chinese government's publicity and education work on imported malaria prevention and control in recent years has achieved certain results.

For thousands of years, malaria has plagued the African region, leading to the emergence of protective genes and acquired immunity in the local population. In the absence of effective vaccines, Chinese expatriates in Africa have not yet formed this protective immunity. Furthermore, they often work on projects outside buildings, posing a serious intrinsic threat of malaria exposure [15]. Among the 402 respondents, none had a history of malaria before coming to South Sudan, and 166 (41.29%) had been infected with malaria after coming to South Sudan. The results of multiple linear regression analysis suggest “Knowledge Scores” will have a significant positive impact on “Practices Scores” (B = 0.206, 95% CI: 0.045 ~ 0.367, P = 0.013). However, the remaining five independent variables do not have an impact on “Practices Scores”. However, considering the varying age and educational backgrounds of the respondents, it is important to acknowledge that their knowledge levels may also differ. Additionally, other independent variables such as age could potentially influence the behavior score.

In fact, preventative behavior is related to the overall measures of their respective units/groups, and individual behavior has little impact. But the individual's grasp of knowledge can impact the incidence of malaria: improving the score of malaria knowledge significantly reduces the risk of contracting malaria (12.7%). The WHO recommends that workers planning to travel or reside in potential malaria risk areas should receive standardized educational materials and guidance before leaving their home country [16]. Most Chinese companies, especially oil companies located in Africa, have already formulated malaria prevention and treatment strategies for non-immune travelers and foreign workers in accordance with the OGP/IPIECA Malaria Management Program [17]. However, based on the results of this survey, more comprehensive training on knowledge of malaria prevention and control is still needed for Chinese expatriates in South Sudan.

Malaria prevention and control are a daunting task, and although some progress has been made so far, the economic and morbidity burden caused by malaria is still huge, based on global incidence data [18]. Further reductions in the incidence and mortality of malaria should be achieved through the popularization of malaria prevention and control knowledge, controlling transmission vectors, and improving levels of malaria diagnosis and treatment. These measures are necessary to achieve the WHO's goal of reducing global malaria incidence and mortality by at least 90% by 2030 [19].

Limitations

The limitations are mainly reflected in: this study is a retrospective cross-sectional study, the diagnosis of whether the respondents have contracted malaria is based on self-recollection, and there may be some deviation in the diagnosis. Respondents’ recall bias is one factor that could threaten the internal validity of this study.

Conclusions

The KAP of Chinese expatriates in South Sudan towards malaria prevention and control is good, but needs to be further strengthened. Improving knowledge about malaria can reduce the incidence of malaria.