Studies have shown that social and cultural factors affect how people perceive diseases. Thus, the area of perception about malaria has been the focus of several scholarly interventions. However there has been limited investigation of the perception of people and their understanding of malaria prevention information in Nigeria. This study, anchored on the Health Belief Model, investigated the perception of selected rural dwellers in Oyo and Osun states, Nigeria, about malaria and their understanding of available malaria prevention information provided by Roll Back Malaria (RBM) in the two states. The study used Survey, Focus Group Discussion and analysis of secondary data. There were 2120 survey respondents selected through multi-stage sampling across 10 local government areas of Oyo and Osun states and 96 participants in 16 focus groups involving men, women and expectant mothers. The result of this study indicates that although respondents had a good understanding of the symptoms of malaria, a significant percentage still had a wrong perception about its cause, respondents had low level of exposure to the malaria prevention information and therefore a low recall of the messages on malaria prevention. Pearson Chi-Square test indicated significant relations between perception of the rural dwellers and their utilization of malaria prevention information (p.value = 37.947, DF = 16, Asymp.Sig. (2-sided) = .002 while a test of correlation of Knowledge, Attitude and Practice of information about malaria prevention indicated positive and statistically significant relationship between the perception about malaria and knowledge of people of respondents on information on malaria prevention (r = 0.212 p < 0.01). The study recommends state governments should direct their broadcast stations to air malaria prevention jingles regularly as a part of social service among other efforts at devoting more resources to communication activities on the disease.

Like many other health conditions, social-cultural factors affect the perception about the causes of malaria and subsequently attitude to its control (Oaks, Mitchell, Pearson &Carpenter, 1991, Aberese‑Ako, Magnussen, Ampofo, and Tagbor, 2019). It is therefore imperative that people’s perception and some of their cultural associations must not only be well understood in tackling the incidence of malaria, the whole context of lives that give shape to these perceptions and behaviours must be clearly identified and accepted for a successful (behaviour) change to take place (Heggenhougen et al. 2003; Kywat-Kywat-Swe & Pearson, 2004; Minja, Schellenberg, Mukasa, Nathan, et al., 2008). In south eastern and south-western Nigeria, excessive heat, over–work, sunlight, excessive sex, too much sun, mosquitoes, fried food, cold weather, dirty environment, weakness, alcohol, noise as well as witchcraft are perceived as possible causes of malaria (Morenikeji, 2009; Brieger, Nwankwo, Ezike, Sexton, Breman, Parkes, 1997; Nebe, Adeoye, Agomo, Mosanya, 2000; Okeke &Okafor, 2008).

While Okeke &Okafor (2008) found a correlation between education and correct knowledge of mosquitoes as cause of malaria, they also report other respondents as claiming that the disease can be transmitted through breast milk, bodily contact, drinking dirty water, inhalation and sharing the same cup. Some of the respondents felt it is inborn. Majority of respondents in the study above mentioned high fever as a symptom suggestive of a severe illness and while convulsion was recognised as a symptom of severe illness that kills children easily, most of the respondents did not connect it with malaria. To them, it is not malaria that causes convulsion but the high fever associated with malaria. Some of the mothers attributed the cause of convulsion to cold weather saying that “if rainy season or cold weather comes, it causes fever which results in convulsion” (Okeke & Okafor, 2008: 218).

And in a study of the perception of causes and treatment of malaria in a Nigerian university, 7.3% of the study population who were Christians expressed confidence that prayer is the best cure for malaria while others, predominantly Muslims from Awori tribe, believed that local remedies were the best cure (Okwa &Ibidapo, 2010). This indicates how belief is a factor of access and utilisation of malaria prevention information. Such beliefs which contradict scientific explanation for the cause and treatment of malaria may lead to inaction, delay in seeking appropriate treatment or ineffective action, and may even inhibit community participation in intervention programmes (Heggenhougen, 2003: 38). Thus, it is evident that people in different societies hold a variety of beliefs about the cause and transmission of malaria that vary according to cultural, educational, and economic factors, and which have direct consequences for both preventive and treatment-seeking behaviour as well as for activities to control malaria (Aunger & Curtis, 2007, p38). This is why there is need to understand people's perceptions of malaria, and the social, political, cultural factors in which the disease occur as a critical element in mounting successful interventions (communication) programmes (Jones and Williams, 2004).

Statement of the Problem

Available literature point to the reality that people in different societies still hold a variety of beliefs about the cause and transmission of malaria which have negative impacts on activities to control the disease (Aunger & Curtis, 2007). Therefore, perception about various aspects of malaria has been the focus of scholarly investigations (Okwa and Ibidapo, 2010, Omole, Ogboi, Agu, Jarikre, Audu and Nmadu, 2018, Andrada, Herrera, Inyang, Mohammed, Uhomoibhi and Yé, 2019, Muhammad, Oyewole and Dipeolu, 2021, Duodu, Dzomeku, Emerole, Agbadi, Arthur-Holmes and Nutor, 2022), Abiodun and Ilori, 2022). To tackle the challenge the Nigerian government adopted the Global Strategic Plan on Roll Back Malaria (2005–2015) and domesticated its recommendations into her National Malaria Strategic Plan (2014–2020). The Strategic Plan included the creation of awareness, demand and appropriate use of malaria prevention products and the development of country-level advocacy and communication. It is therefore apt to examine the current state of perception about malaria, especially among rural people who have been exposed to the communication materials, vis a vis the goals of the Strategic Framework. In doing this, this study sought to know how the Strategic Framework for Malaria Communication address wrong perception about malaria among the rural population, investigated prevailing perception of rural dwellers in Oyo and Osun states about malaria and examined how the prevailing perception affect their attitude to the available prevention information. None of the available studies on malaria perception examined the preventive information against which they investigated the perception and attitude of their respondents. This study is therefore able to fill that gap in the scholarly investigations about malaria and perception of selected populations. A positive perception about malaria will enhance the acceptance and utilisation of preventive measures and the achievement of the SDG Goal 3 of ensuring healthy lives and promoting well-being for all at all ages, among others.

Literature Review

Many scholars have investigated various aspects of perception abut malaria among diverse populations in Nigeria with varied findings. Okwa and Ibidapo (2010) studied the perception of cause and treatment of malaria among 600 undergraduate students of Lagos State University. In that study, only 53.3% of the respondents understood the cause of malaria while 25% attributed the disease to exposure to sunlight. Only 35.5% understood the use of insecticide treated nets as prevention against malaria, 30% of the students believed local remedies are the best treatment for malaria while 7.33

there are two ways to treat malaria in my own understanding because those of us in the village, the old men will ask us to first try herbs and when we have done that for some days without result that is when we come here (clinic) and they will treat us.

These findings indicate that while respondents knew about the use of ITN to prevent malaria and the use of ACT for the treatment of the disease, a significant number still believed however that local herbs could be effective in treating the disease. This type of misconception could hinder the adoption of safe treatment behaviour among such respondents.

Perception about malaria among Respondents and FGD participants

Respondents were asked to indicate their level of agreement or disagreement with 12 statements that covered perceived causes and treatments of malaria. Findings presented in Fig 4 indicated that a majority of the respondents (83.8%) agreed that malaria is caused by bites from mosquitoes while 73.2% also agreed there is a close association between mosquito and malaria. However, there was an almost polarity of opinion on one of the variables; the role of the sun as a cause of malaria, among the respondents. While 41.6% agreed that exposure to sun is a cause of malaria, only 43.4 % disagreed with the statement, representing less than two percentage point difference. Also of interest was the number of respondents that agreed that malaria can be easily treated with local herbs (44.6%) and those who agreed that it could be cured with prayers (42.7%). This means that although a greater number of respondents believed that malaria is caused by mosquito bites and that there is therefore a close association between malaria and mosquito, almost half of the same population nevertheless believed that non-orthodox means are effective in treating the disease.

Friedman nonparametric test of the responses to the 12 statements on respondents’ perception about the causes and possible treatment of malaria indicated significant differences in the perception of survey respondents (Chi-Square =5402, p-value =.000). The results showed that perception that malaria is caused by mosquito bites had the highest mean rank (10.64) among subjects, followed by the perception that there is close association between mosquitoes and malaria (9.70), and that prayers can cure malaria (7.80), that malaria can be easily treated with herbs (7.58) and that malaria is caused by too much exposure to sun (7.53). The perception that malaria is caused by not eating enough palm oil in the soup had the lowest rank (mean rank =4.74) among the causative variables tested in the study.

Responses from the FGD also indicated that while many rural dwellers understood the close link between mosquito bites and malaria, the majority nevertheless still attributed the disease to other non-orthodox factors particularly “staying under the sun for long”, just like the 41.6% of the survey respondents. Other ‘causes’ identified by the FGD participants were, “insufficient palm oil intake”, “attack by witches”, “dirty environment”, “exposure to evil air”, “working too long in the farm” and “bed bugs”. For instance, according to an FGD participant (Akinmorin 1) in Afijio Local government area of Oyo state, someone can have malaria by inhaling a lot of dust during the dry season or while travelling on rural roads that are mostly untarred. Akinmorin 1, a commercial motorcyclist said,

if you look at the present season, we have a lot of dust and it causes malaria. When women are sweeping and dust enters their noses or when you travel on an untarred road and you inhale dust, it causes malaria.

Such line of thinking was supported by other participants such as a female trader (Iresaadu 5) from Surulere local government area of Oyo state and two farmers, (IdoOsun3), from Egbedore local government area of Osun state and (Araromi1) from Oyo East local government area of Oyo state. Iresaadu 5 said:

one can also have malaria if you are cooking and children defecate and you don’t clean them up well and flies perch on it and come and land on your food.

On his part, Ido Osun 3 said:

what I believe is that when someone stays for long under the sun, he may get home in the evening and complain about headache; that is what I know

In the same vein, (Araromi1) said:

if you have someone who works mostly under the sun and he does not take good care of himself, it can also cause malaria

Arowomole 4, a retired teacher also from Oyo East local government area of Oyo state, added another dimension to the misconception when he said:

although mosquito is the prime cause of malaria, I still believe that malaria is also present in the air; may God no allow us to collide with evil.

However, there were participants, such as Arowomole 1; also, a retired school teacher, who countered some of the misconceptions thus:

i don’t believe that (exposure to sun causes malaria) because if it is true, then all the Okada riders should be having malaria because they work under the sun. I believe it is only when mosquito bites you that you have malaria.

These results therefore indicate that a significant percentage of rural dwellers in South-west Nigeria still have a wrong perception about the cause of malaria which would naturally affect the adoption of preventive measures. It can be concluded therefore, that a significant percentage of rural dwellers in Oyo and Osun states, Nigeria still had wrong perception about the cause of malaria, particularly by attributing the disease to exposure to sun. The results indicate a need for more effective communication that will address the misconceptions if the battle against malaria would be won in the mind of rural dwellers. This is because the wrong perception about the disease also influences the attitude to appropriate prevention and control measures and therefore the continued spread of the disease which is reflected in the percentage of respondents who believed that local herbs can easily treat malaria (44.6%) or that prayer can cure the disease (42.7%).

The misconception about the cause of malaria was included in the Inter-Personal Communication Flip Chart for Malaria Control in the Community used by Community Volunteers engaged by MAPS, and in RBM IPC GUIDE used by volunteers of ACCOMIN and AFRICARE in the conduct of Advocacy, Communication and Social Mobilization (ACSM) activities. Specifically, the RBM IPC GUIDE used by ACCOMIN and AFRICARE in Osun state has a page on “Myths and Misconceptions” and lists the following misconceptions that were meant to be corrected during the ACSM activities: that malaria is caused by witchcraft, working under the sun/rain, eating too much oil, drinking palm wine/alcohol and stress. The Inter-Personal Communication Flip Chart for Malaria Control in the Community used by MAPS in Oyo state also has a page dedicated to addressing misconceptions about malaria. The following misconceptions are highlighted in the document: working under the sun, excessive work, witchcraft, eating too much oil, bad weather and bad air and sleeping in the afternoon (PMI&fhi360, nd: Card 2). It is significant to note that none of the radio jingles accessed for the current study dealt with any of the misconceptions above, thus creating the impression that the producers worked from the background of an assumption that the respondents had the right understanding about malaria and only needed to understand and accept the use of Long-Lasting Insecticidal nets (LLINs) for protection against mosquito. While they might have succeeded on this given the percentage of respondents who linked malaria with bites from mosquitoes (83.8%) and those who identified a positive link between mosquito and malaria (73.2%), the existence of a significant percentage that still linked the disease with exposure to sun and those who still considered non-orthodox method of treatment as valid should be of concern to developers of prevention messages.

Perception about malaria and the religion matrix

Given the influence of religion in shaping opinions and perception and the finding that many respondents still believed that prayer, a religious exercise, is a major way of preventing malaria, four possible but medically wrong perceptions; “witches can cast spell of malaria on people”, “malaria can be caused by exposure to evil air”, “prayer can cure malaria” and “malaria can be easily treated with herbs” were statistically tested against the religious background of respondents. This became all the more important given the preponderance of FGD participants who also indicated that they believed witches could still cast spell of malaria on people and that prayers is a major weapon for treating malaria. During the FGD sessions, the researcher asked participants to close their eyes and raise their hands (as if in a voting process) whenever the question about witches and prayers were asked. This was done to safeguard their identity and ensure freedom of expression. During the sessions, 45 (47.0%) participants indicated with a raise of hands that they believed witches could cast a spell of malaria on people. Also 74 (77.1%) of the participants indicated they believe that prayers can cure malaria.

The result of the t-test on the perception that “witches can cast spell of malaria on people” and religion of respondents indicated a significant difference among survey respondents based on their religious background (Chi-square=17.889, DF=8, p=0.022) with Christians (mean score=2.31), Muslims (mean score=2.37) and Others (mean score=2.53). The t-test comparing the means confirmed that the differences are significant at F (2, 2070) =3.264, DF=2, p=.038), thus indicating that there is a strong association between religion of respondents and the perception that links malaria and witchcraft. However, this association is stronger among those who subscribe to ‘Other Religions’ (mean score=2.53) than those who reported to be Christians (2.31) or Muslims (2.37). The category, ‘Other Religions’ could refer to atheists, traditional worshipers, or adherents of other religious movements.

The study also tested the association between the religious background of respondents and the wrong perception that, ‘malaria can be caused by exposure to evil air’. The result indicated that there was no statistically significant difference among the religious beliefs and the wrong perception (Chi-square=6.557, DF=8, p=0.585). A test of possible association between the religious background of respondents and the perception of prayer as cure for malaria indicated that there was no significant difference among the religious beliefs (Chi-square=6.557, DF=8, p=0.585). The study also tested the statistical association between the religious background of respondents and the use of herbs as cure for malaria. The result indicated that there was no significant difference among the religious beliefs tested in the study (Chi-square=5.685, DF=8, p=0.685).

The major inference from these results is the existence of a wrong perception that promotes malaria as a disease that could be cast upon people by ‘witches. This is the only variable with significant differences among the respondents. The continued existence of this perception, despite the availability of information on malaria that denies any link between the disease and witches is an indication of the strength of the belief among the Yoruba people of South-west Nigeria despite their education, civilisation and exposure to technology. This attitude has been of concern to scholars such as Prince (1961), Awolalu (1979), Ogungbemi (1992) and Jayeola-Omoyeni, Oyetade and Omoyeni (2015) among others. Prince (1961) noted that witchcraft has remained an active and vital universal image in the consciousness of the Yoruba people of South-west Nigeria irrespective of their social level, religion or education while Awolalu (1979) was of the view that there is no belief ‘more profoundly ingrained’ in the mental and social attitudes of the Yoruba than that of the existence of witches. Sickness, misfortunes and even death are often attributed to witches in Yoruba culture.

Unfortunately, both Christianity and Islam, the two prominent religions in the zone, have inadvertently promoted witchcraft by their respective acknowledgement of its existence and the offering of prayers as a potent weapon against the activities of witches. Today several churches attribute some sicknesses to the activities of ‘demonic powers’, among them witches, and offer various deliverance prayers as a way out for their ‘victims’. This was perhaps why Ogungbemi (1992) argued that most of the charismatic churches are increasing in the south-west zone ‘because their converts want an abode of refuge from the fear and power of witchcraft.’ This position is similar to what Bohannan (1964) had earlier posited, that witchcraft has remained relevant in modern religion because ‘it answers many of the same questions about misfortune that religious dogma sets out to answer.’

Currently, religious leaders appear to play insignificant roles in the communication of malaria prevention initiatives in the South-west zone. It appears that those who designed the available malaria information for rural dwellers of South-west Nigeria have not understood the religious views that shape the perception of the people about the disease or incorporated such adequately into the development of prevention information. Religion is part of the culture of a community and must be taken into consideration while preparing communication activities/messages that are meant to change their world view about a behavioural disease like malaria. There is therefore great need to involve religious leaders more in the fight against malaria but this must be first by educating them on their own inadvertent role in promoting the false belief that witches cast malaria on people.

The results of the various statistical tests have indicated that two major issues still need much greater attention in the fight against malaria. These are the wrong perceptions that the disease can be caused by exposure to sun as well as activities of witches. This need becomes more germane when it is noted that both the RBM Guide on Malaria Control and the Inter-Personal Communication Flip Chart for Malaria Control in the Community paid attention to addressing these issues in their respective publications. The result is an indication that firstly, there is need for more education to tackle the perceived relationship between exposure to sun and malaria and secondly, religious leaders have not been properly educated and empowered to educate their own followers, in turn, on the causative factors for malaria by which the wrong perception which arose from an over spiritualising of issues as highlighted earlier would be dealt with appropriately.

Conclusion

Perception is a key element in achieving successful malaria preventive measures. Therefore, in the design of malaria prevention information attention must be given to the perception of the people about malaria, particularly its causes and treatment with specific reference to the wrong perception that exposure to sun can cause the disease and that witches can cast it on their victims. This will help in accelerating the achievement of the SDG Goal 3 of ensuring healthy lives and promoting well-being for all at all ages, among others. This study has indicated the existent of some wrong perception about malaria despite the availability of preventive information to the rural communities in Oyo and Osun states of Nigeria.

Recommendations

Based on the outcome of this study, the following suggestions are made as recommendations for policy makers and practitioners:

Stakeholders in the fight against malaria should devote more resources to communication activities on the disease. State governments should direct their broadcast stations to air malaria prevention jingles regularly as a part of social service.

Producers of malaria prevention information should focus more on correcting the misconceptions about the disease that is common among the rural populace more aggressively and systematically.

Producers of malaria prevention information should be conscious about the attitude of rural audience to the language, models and illustrations used in the production of communication materials for use among rural people.

RBM and other Partners should endeavour to produce enough copies of their respective interpersonal communication flip charts on malaria prevention and more importantly, such materials should be translated into local languages to enhance better access among rural people.

Table 1: Correlation of Knowledge, Attitude and Practice of respondents on information about malaria prevention

Table 1 shows the relationship between all variables. There is positive and statistically significant relationship between the perception about malaria and knowledge of people of South-west people on information on Malaria prevention (r=0.212 p<0 r=0.143 r=-0.090>

Table 2 Test of H0: There is no significant relationship between the perception of rural dwellers in Oyo and Osun states, Nigeria, about malaria and their utilisation of malaria prevention information.

Pearson Chi-Square (p.value=37.947, DF=16, Asymp.Sig. (2-sided) =.002

Decision Rule: Reject H0 if p-value is less than α- value (.05), otherwise do not reject H0.

Conclusion: Since the p-value (0.02) is less than the standard α- value (.05), then we reject the null hypothesis that says the variables are independent of each other meaning that the perception of rural dwellers in Oyo and Osun states, Nigeria, is significantly associated with their utilization of malaria prevention information.

Declarations

Ethics approval and consent to participate

Ethical approval for the study was received from the Osun State Health Research Ethics Committee, Osogbo, Osun state (OSHREC/PRS/569T/42) and Oyo State Research Ethical Review Committee, Ibadan, (AD/13/479/871)

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The author declares no competing interest relative to this study.

Funding

The author received no funding for this research