Evaluation of knowledge, perception, and attitude of malaria burden in the Upper River region of The Gambia

Abstract

Background

Despite increased malaria interventions, the Upper River Region of The Gambia still faces a higher malaria burden compared to other parts of the country. This issue may be related to the population’s knowledge of malaria, as well as environmental and socioeconomic factors that influence their prevention and treatment choices. Therefore, this study focused on assessing the level of malaria knowledge, perceptions, and attitudes among the residents of the Upper River Region, as limited studies have been conducted across the region’s seven districts.

Methods

To achieve the study’s objectives, a descriptive research survey using a parallel mixed method was adopted, with a robust multistage sampling approach for selecting 381 household heads involved in the quantitative study, 31 key informants, and 7 focus group discussions for the qualitative study. Descriptive statistics were performed on the assessed variables using StataSE18, and the association of socio-demographic factors with malaria prevalence was analyzed using Chi-square (Χ2). Thematic analysis was conducted for the qualitative part using NVivo.

Results

The results indicate a very high level of knowledge of basic malaria concepts, with a percentage index of 81. There is a statistically significant influence from factors such as district, number of health centers in the region, gender, distance to the health centre, and occupation, all at < 5%. Using a treated bed net was the most effective prevention tool, while hospital visits and herbs remain the main treatment options among the population. The trend of malaria infection shows a general decrease across most communities, although a few still experience an increase over the year. Malaria profile data reveal an 87% reduction in cases for individuals above 5 years old and a 45% reduction for those under five. Additionally, mortality rates have decreased by 98% and 89%, respectively, over the 12 years (2011–2023).

Discussion and conclusion

This study examined knowledge, perception, and attitudes toward malaria prevention and treatment. Results showed a high level of understanding of basic malaria concepts among the population, which influenced their perceptions and fostered a positive attitude toward managing and preventing the infection. However, differences in knowledge levels exist across districts, along with some contradictions in perceptions and attitudes. An overall decline in malaria cases has been observed across the districts and communities in the region, with a few exceptions. These findings are expected to inform the national malaria prevention efforts and assist policymakers in planning the next steps for the malaria elimination campaign.

Background

The malaria vector is one of the deadliest animals globally because of its ability to multiply rapidly under slight environmental changes. Malaria is a major cause of morbidity and mortality worldwide, posing a threat to the poorest and most vulnerable populations. Resurgence can occur when efforts to achieve and maintain elimination weaken [1, 2]. Malaria has become a significant public health concern, prompting governments and non-governmental organizations to plan strategically for its elimination. Five major strategies include using insecticide-treated nets, residual house spray, artemisinin, chemopreventive therapy, and environmental hygiene. Due to strong intervention efforts and political commitment, malaria cases and deaths declined from 2000 to 2019 [1, 3, 4], but issues like climate change and the COVID-19 pandemic disrupted these interventions. As a result, malaria cases and deaths increased from 2019, with sub-Saharan Africa bearing 94% of the burden [5].

The Gambia has been identified by the World Health Organization (WHO) and Roll Back Malaria partners as one of seven countries in the West Africa sub-region working towards accelerated malaria elimination in 2017 [6, 7]. They have been recognized for reaching their 2020 milestone of reducing malaria cases and deaths by 40% compared to 2015, and they have set a goal to eliminate malaria by 2050 [8]. Thanks to government efforts, the overall malaria parasite rate has fallen to 0.2% from 4% in 2011, a significant decline of over 90% across all health centers in the region [9]. However, malaria transmission has not stopped; the population of The Gambia remains at risk of ongoing transmission, with the Upper River Region being more vulnerable than other areas in The Gambia [9–11].

The goal of malaria elimination may seem difficult to reach in rural areas if there is limited awareness and negative perceptions among the population regarding the disease, poverty, and inadequate health facilities [12]. This indicates that malaria control and prevention largely depend on the overall effectiveness of the health system. A successful malaria response relies on investing in health systems that are efficient, equitable, resilient, and rooted in primary health care [5]. This is also a key goal of The Gambia’s National Health Sector Strategic Plan [13] to reduce inequality in health care services. By improving the management and administration of health services, enhancing the infrastructure of referral hospitals and health facilities, revitalizing and expanding primary health care services for all communities, and employing highly motivated and trained staff in disease management and awareness, establishing an effective procurement agreement is crucial to ensure that everyone receives quality health care and to reverse the declining trend in health outcome indicators [14].

Therefore, the best starting point when organizing public health interventions is to understand the knowledge and perceptions of the people, paying closer attention to factors that could influence their understanding of the disease and their strategies for adapting. This is crucial because the population's knowledge and perceptions about the causes of illness, symptoms, and infection risks are key drivers of positive attitude changes toward prevention and treatment [15]. The health belief model (HBM) uses people’s perceptions as a basis for their actions. The model suggests that perceptions of disease severity and susceptibility, or perceived benefits and barriers, motivate action. When there is a perceived threat to health, the likelihood of adopting positive behaviors increases, and the perceived costs or barriers of the action do not outweigh its benefits. It predicts that individuals will act to protect their health if they feel susceptible to the condition (perceived susceptibility); if the condition has a significant impact (perceived severity); if taking action can reduce their vulnerability (perceived benefits); and if the benefits outweigh the costs (perceived barriers) [16]. In this model, perceived severity and susceptibility are called perceived risks, while perceived benefits reflect people’s knowledge or opinions on whether the proposed activity will lower the risk [17]. Therefore, HBM is a valuable framework for modelling the population’s knowledge, perceptions, and attitudes toward malaria infection to identify districts or communities that need more proactive intervention, as limited work has been done in this area (see Fig. 1).

Fig. 1.

Health Belief Model (Source: [18])

Methods

Study area

The study was conducted in the Upper River Region of The Gambia (URR) among the household heads randomly selected in all seven districts in the region: Kantora, Tumana, Basse Fuladu East, Jimara, Wuli West, West East, and Sandu. The region is the second largest city in The Gambia, with a land mass of about 2000 sq km and a population density of 116/Km² [19]. Its geographical coordinates are 13° 19 0ʺ N and 14° 13 0ʺ N.

Study population

The Upper River region has a total population of 239,916, distributed across 15,975 households. The population for the quantitative survey was randomly selected from the heads of households in each district. The number of individuals chosen in each district was based on the proportion of the total population, derived from a sample size of 381 calculated using the formula developed by Raosoft (2024), as shown in Eq. 1. The calculation was conducted with a 5% margin of error, 95% confidence level, and 50% response distribution. Additionally, five (5) more individuals were included to account for potential unforeseen errors and because of the expectation of uniformity, resulting in a total sample size of 381. For the qualitative study, 91 individuals were selected, including 31 community heads (Alkalo) who served as Key Informants. The remaining participants were chosen for their heterogeneity and divided into seven groups for focus group discussions.

$$n=\frac{Z^{2}P\times \left(1-P\right)}{e^2}$$ 1

n is the required sample size; P is the estimated proportion of the population; E is the margin error; Z is the z-score corresponding to confidence.

Study design/sampling method

A cross-sectional, parallel mixed-method approach was selected for the study. The research design, which combines both qualitative and quantitative methods, aims to strengthen each approach, improve the validity and quality of the data, and provide a more effective way to answer questions that cannot be addressed using only one method. A multistage sampling method, combining purposive and simple random sampling techniques, was considered most appropriate for obtaining a representative sample of respondents. The sampling process involved several stages, where at each stage, Probability Proportional to Size (PPS) and random procedures were applied to determine the final sample size of 381 as outlined in the sample design.

1. Selection of study area: The URR of The Gambia was purposively chosen due to its higher average temperature and frequent CC-related challenges such as floods and extreme temperatures, compared to other regions.

2. District selection: All seven districts within URR were purposively included in the study to capture the impact of CC across the region.

3. Sample size calculation: A sample size of 381 household heads was determined using a formula adopted by Raosoft, distributed proportionately across the seven districts based on population size.

4. Settlement selection: Thirty settlements meeting specific criteria (more than 50 households, similar characteristics) out of 365 settlements across the seven districts were purposively selected.

5. Inclusion criteria: Participants included household heads aged over 18 years, providing informed consent, and residing in their community for at least 10 years.

6. Settlement sampling: From the eligible settlements, specific settlements were randomly chosen using XLSTAT data analysis software.

7. Household sampling: The number of households visited in each selected settlement was determined based on the proportion of total households, with household heads serving as the primary sampling units.

This multistage sampling strategy ensured a robust representation of the population’s awareness and perception of CC in the URR of The Gambia.

For qualitative sampling, focus group discussions were conducted with purposively selected individuals over 23 years old, primarily within the 40–70 age range. Key informant interviews were carried out with Alkalos or community representatives in all the designated settlements. The chosen participants are individuals who are fully aware and mentally stable, capable of recalling past events and relating them to present issues, since climate change discussions require referencing both past and present events. Most of the discussions took place in the community square or at the Alkalo residence, and all key informant interviews were conducted at the Alkalo residence.

Written consents were obtained from the selected participants after a brief explanation of the study's aim, objectives, and procedures. Participation was voluntary, and participants could choose not to answer any interview questions or withdraw at any time without penalty. The individual responses were anonymized and referenced instead.

The official language used for data collection was English, but it was interpreted and communicated in the local languages.

Types and sources of data collection

Primary data was used in the study, encompassing both qualitative and quantitative data. The demographic of the respondents, their knowledge and perception of malaria, their attitude towards prevention and treatment, and the trend of malaria infection in the region, were the primary data collected for the study. Secondary monthly malaria cases and deaths from 2011–2022 for under and above 5 years extracted from the Department of the National Malaria Control Programme were also analysed for trends across the year.

Data collection and piloting of the data instrument

The data was collected using a closed-ended questionnaire. The questionnaire was piloted, revised, and translated back into English and checked for clarity. Trained surveyors (enumerators) administered the questionnaire at the respondent’s household using Survey Solution software for primary qualitative data.

The official language used for data collection was English, but it was interpreted and communicated in local languages to benefit those who do not understand English. Written and verbal consent were obtained from respondents before administering the questions. The questionnaire was further revised after piloting, translated back into English, and checked for clarity. Additionally, the reliability of the questionnaire data was tested using Cronbach's alpha, which resulted in a coefficient of 0.77, indicating that it is reliable and valid.

Data processing

Descriptive analyses, such as frequency, mean, and percentage, were used to explore the socio-demographics of household heads and to evaluate their knowledge of basic malaria concepts. Their percentage index was further calculated to measure knowledge of malaria levels across districts. For the knowledge index, numerical scores based on responses to questions about causes, symptoms, and prevention of malaria were totaled for each respondent, with scores ranging from 0 to 27 across six sub-questions. The resulting score was divided by 27 to normalize the index. Furthermore, to assess the perception of the population regarding malaria infection, a 5-point Likert scale was employed (Strongly Agree = 5, Agree = 4, Neutral = 3, Disagree = 2, Strongly Disagree = 1). The true strength and rate of either agreement or disagreement were measured using the mean score of all respondents to evaluate response certainty. The true strength was assessed by the degree of respondents’ agreement or disagreement with the concept. The perception rate, in this context, is given by the frequency of responses in each scale divided by the total number of responses, multiplied by the scale value.

The rate of perception is measured by the additional value above or below the attributed scale value from the mean score. Any value at the midpoint of 3.0 is considered neutral and is not measured. Stata 18 was employed to carry out the descriptive analysis of the quantitative data.

NVivo 14 was used for qualitative analysis to facilitate coding, organization, and searching for meaning units within the English transcripts, and to systematically compare the emergence of inductively identified themes and sub-themes. First, the interview was read and reread to immerse oneself in the data and grasp the meaning of the text, and the subject themes were extracted based on the objective. The participants’ text was compiled into a single document, serving as an analytical unit. This text was further segmented into meaning units, which were condensed into descriptions close to the original text. These condensed meaning units were then abstracted and assigned codes. The codes were reviewed and revised throughout the coding process. When inconsistencies appeared, the codes were refined through discussion with co-authors until consensus was reached. Similarities and differences among the codes were compared and categorized into themes in line with the objective.

Ethical consideration

The research was conducted based on the principles of Climate Change and Education at the University of the Gambia. The study received approval from the University of the Gambia Ethics Committee on August 28, 2023. Written consent was obtained from participants after a brief explanation of the study’s purpose, goals, and procedures. Participation was voluntary, and participants could choose not to answer any interview questions or withdraw from the study at any time without penalty. Individual responses were anonymized and referenced instead.

Results

Knowledge, perception, and attitude of the population to malaria infection

The study assessed the knowledge, perception, and attitude of the respondents using both qualitative and quantitative methods. Their knowledge of malaria was assessed using basic concepts: causes, symptoms, prevention of malaria, mosquito biting and breeding space, and prevention of mosquito breeding ground, and then the knowledge level was evaluated using the mean percentage proportion. Their perceptions, attitudes on prevention and treatment, and finally, the trend of malaria infection across the region were further looked at for proactive and holistic adaptive and adaptation measures.

Knowledge of causes, symptoms, and prevention of malaria among the population

The results in Table 1 reveal that the majority percentage (99.7%) indicate mosquitoes as the cause of malaria infection. The symptoms of malaria include fever with shivering, vomiting, weakness, and loss of appetite, as indicated by a higher percentage population. However, fever with interval was also included by 67.7% of respondents as symptoms and effects of malaria infection vary across individuals. The majority of the respondents noted that malaria transmission can be prevented using insecticide-treated bed nets (98.9%), cleaning mosquitoes' breeding/resting places (88.5%), and window nets (66.1%). However, a minority of the respondents mentioned other methods.

Table 1.

Frequency and percentage assessment of the knowledge of malaria among the population

Variable	Freq	%
Causes of malaria
Mosquito bite	380	99.7
Unhealthy food intake	0	0
Drinking contaminated water	1	0.26
Lack of physical exercise	0	0
Symptoms of malaria
Fever with shivering	372	97.6
Fever with an interval	258	67.7
Vomiting	363	95.3
Weakness	348	91.3
Loss of appetite	329	86.4
Prevention of malaria
Insecticide-treated bed nets	377	98.9
Window nets	252	66.1
Using an insecticide spray	125	32.8
Cleaning mosquitoes' breeding and resting places	337	88.5
Using mosquito coils/repellents	140	36.8
Treatment (prophylaxis)	168	44.1

The result of Fig. 2c (since there are no Fig. 2, this one should be renumbered as Fig. 2) shows that the majority of the population believed that nighttime is most suitable biting time for malaria (95.8%); however, a few others perceived otherwise. The majority (95.8%) further reported that bushes/grasses are the main breeding space among the options provided (Fig. 2b), in addition to the latrine toilets, cattle shed, and freshwater, in that order of hierarchy. Their knowledge of mosquito breeding space, based on the percentage responses for each question, can be considered limited because of the breeding capacity of mosquitoes in cleaner water compared with dirty water. Mosquito breeding space can be prevented by clearing bushes around the environment, draining stagnated water, and cleaning house surroundings, as indicated by more than 95% (Fig. 2a) of respondents in each question. This also demonstrates good mosquito control and preventive measures.

Fig. 2.

Knowledge of the mosquito’s suitable biting time, breeding conditions, and prevention of breeding space of mosquitoes

The results presented in Fig. 3 show that the percentage knowledge index across the districts slightly varies; however, it ranges between 60 and 91%, indicating high and very high levels of malaria knowledge across the districts. Kantora, Tumana, and Wuli East have percentage indices between 65–79, indicating a high level, while Basse, Jimara, Wuli West, and Sandu have indices between 80–91, reflecting a very high knowledge level of malaria. Wuli West and Sandu have the highest knowledge level indices of 91% each, while Kantora has the lowest with a 65% index. Importantly, the overall average percentage index for the region is 80, indicating high malaria knowledge in the Upper River Region of The Gambia.

Fig. 3.

Percentage index on knowledge of malaria. 10–19% very low knowledge, 20–39% low knowledge, 40–59% moderate knowledge, 60–79% high knowledge, 80–100% very high knowledge

Socio-demographic influence on the level of knowledge of malaria

Socio-demographic influence on the level of knowledge of malaria was tested using Pearson’s Chi-squared test, and the results are presented in Table 2. It shows that five out of seven tested socio-demographic factors are associated with the level of knowledge of malaria among the population of the URR district. These factors include the number of health centers in the community, gender, distance to the hospital, and occupation, with the p-value remaining at 0.05.

Table 2.

Socio demography association on the level of knowledge of malaria

Variable	Definition	Percentage	Pearson Chi2	P value
District	–	–	131.405	0.005
Number of health centers in the settlement	Varies	–	75.486	< 0.001
Gender	Male/female	84.8/15.2	10.891	0.012
Age bracket	31–80	95.7	196.173	0.154
Educational status	No formal education	80.6	11.210	0.262
Distance to the hospital	< 30 min	82.7	25.674	0.012
Occupation	Farming	70.6	51.023	< 0.001

Perception of the malaria concept among the population

The findings presented in Table 3 indicate that the majority of respondents strongly agree that malaria is a serious disease and that all populations are vulnerable to infection, as evidenced by a mean score of 4.7. They also concur that children under 5 years of age are more susceptible (4.2). Still, they disagree with the notion that only individuals over five and the elderly are at risk for malaria. Furthermore, they reject the idea that pregnant women are not vulnerable to infection and that malaria cannot result in death. These points suggest that pregnant women are indeed at risk of malaria infection, and that untreated malaria can lead to fatal outcomes. Respondents also disagree with statements claiming that there is no effective drug for malaria treatment and that herbal remedies are a superior treatment option, as shown by mean scores indicating disagreement (approximately 2). Additionally, 51.2% believe that malaria is a spiritual issue, while 50.7% think it does not require medical treatment.

Table 3.

Mean score distribution on the perception of malaria among the population

Concept	Strongly agree %	Agree %	Neutral %	Disagree %	Strongly disagree %	Mean score
Malaria is a serious disease	3.8 (76)	0.9 (23%)	0.008 (0.3)	0.005 (0.3)	0 (0)	4.7
Only children under 5 get malaria	0.1 (2)	0.1 (3)	0.023 (0.8)	1.32 (66)	0.3 (30)	1.8
Only the elderly can get malaria	0.07 (1.4)	0.07 (1.8)	0.008 (0.3)	1.1 (55)	0.42 (42)	1.7
The entire population is vulnerable	3.64 (73)	0.99 (25)	0.008 (0.3)	0.01 (5)	0.013 (1.3)	4.7
Those under 5 years are more vulnerable	1.63 (33)	2.3 (58)	0.07 (2.3)	0.15 (8)	0.01 (1)	4.2
Pregnant women are not more vulnerable	0.41 (8.2)	0.35 (9)	0.15 (5)	0.77 (39)	0.4 (40)	2.1
Malaria cannot lead to death	0.58 (12)	0.18 (5)	0.024 (0.8)	1.04 (52)	0.49 (49)	2.3
Malaria is better treated with traditional herbs	0.1 (2)	0.47 (12)	0.13 (4.3)	0.99 (49.5)	0.32 (32)	1.94
There is no effective medical drug for malaria treatment	0.066 (1.3)	0.36 (8.9)	0.28 (9.5)	0.85 (41.3)	0.38 (38)	1.9
Malaria does not require medical treatment	0.05 (1.1)	0.01 (0.3)	0.03 (1.1)	1 (50.7)	0.47 (46.9)	1.6
Malaria is a spiritual problem	0.04 (0.8)	0 (0)	0.13 (4.5)	1 (51.2)	0.44 (43.6)	1.6
Malaria can only be treated spiritually	0.01 (0.3)	0.01 (0.3)	0.09 (2.9)	0.89 (44.4)	0.52 (52.2)	1.5

Strongly agree = 5, Agree = 4, Neutral = 3, Disagree = 2, Strongly disagree = 1

The perception of malaria was further examined using a qualitative approach (Table 3) to identify new concepts and diverse opinions from the community. The results in Table 4 reveal five emerging sub-themes, with causes, symptoms, and risk of infection being most emphasized by participants. The findings showed that most respondents believed malaria is caused by mosquito bites (32 references in 28 coded files), and symptoms such as joint pain, fever, cold, headache, and vomiting were mentioned in 13 coded files with 16 references. They also believed that malaria can be fatal, especially for children and pregnant women, if not properly treated, as documented in 12 coded files with 20 references. The qualitative results support the conclusions of the quantitative study.

Table 4.

Qualitative findings on the perception of malaria

Sub-theme	NCFs	NCRs	Respondent’s statements
A disease caused by a mosquito	28	32	It is a disease caused by mosquito bites that makes people sick
Malaria can lead to death	12	20	Malaria is a very serious disease that can lead to the death of under-five or pregnant women if not rushed to the hospital
Symptoms of malaria	13	16	The effect of malaria differs from person to person, but mostly is joint pain, fever, cold, shivering, and vomiting
Malaria is communicable from person to person	2	5	Malaria can be transferred, e.g., when someone lies in the position where I was lying, malaria will be transferred to the person
Malaria bites more at night	3	3	At night, mosquito are many. So, people need to spread their house

NCFs stands for number of coded references, NCFs denotes number of coded files

Interestingly, very few in the population assume malaria is communicable and can be contracted through human contact, as illustrated in the result table. This indicates that only a few people in the population have a low level of understanding of the subject.

Attitude toward malaria prevention and treatment among the population of the region

The attitudes of the population towards mosquito prevention, malaria, and treatment were thoroughly evaluated using both quantitative and qualitative methods. Regarding preventive attitudes (Table 5), the results showed that most of the URR population consistently sleeps under treated mosquito bed nets, as reported by 88.9% of respondents. A small number sleep under the bed nets occasionally, and 9.5% never sleep under them, while 1.6% never sleep at all. Some respondents also reported occasionally using anti-mosquito spray in their homes, as indicated by 53.3%. The findings further revealed that most of the population regularly participates in cleaning activities such as cutting bushes and draining stagnated water, with 66.9% and 68.8% of respondents doing so, respectively. However, a significant portion also engages in these cleaning activities occasionally, as shown by 32.6% and 30.9% of respondents, respectively.

Table 5.

Attitude toward malaria prevention

Variable	Always Freq (%)	Sometimes Freq (%)	Never Freq (%)
How often do you and other members of the household sleep in mosquito insecticide-treated nets?	339 (88.9)	36 (9.5)	6 (1.6)
How often do you use anti-mosquito spray in your house?	62 (16.3)	203 (53.3)	116 (30.5)
How often do you clean/cut bushes around your house?	255 (66.9)	124 (32.6)	2 (0.5)
How often do you drain stagnant water near your house?	262 (68.8)	118 (30.9)	1 (.3)

The qualitative finding further aligns with the quantitative, highlighting that environmental cleaning (45.0%) and sleeping (26.6%) are the most effective attitudes adopted by a majority of the population. For example, during some of the FGDs, respondents stated that:

The entire community comes out every Friday for a general cleanup, clearing bushes around, and filling potholes where stagnant waters collect (KII Diabugu Bisillah Tumana).

We used a mosquito bed net inside and outside the room (FCG Kantora).

Other measures of malaria prevention mentioned by the population include the use of mosquito insecticide coils or repellents, adherence to health workers’ advice, ensuring the administration of Seasonal Malaria Chemoprevention (SMCs) to children under five, routine check-ups, attending awareness programs organized by health professionals on malaria infection, limiting outdoor time, drinking herbs, wearing long dresses, and lighting fires.

When we are outside, we apply mosquito repellent, and sometimes we spray our house (KII Boro Wuli East).

We heed the advice of health workers. Relying solely on what our ancestors say will not benefit us (FGD Bassa).

We have educated people, increasing awareness among the population about the importance of medication and the risks of improper herb use (FCG Jimara).

Their attitude towards malaria treatment, as captured in Fig. 4, shows that the majority (89.9%) of the population visits hospitals for malaria treatment, while a few others (10.1%) engage in self-medication, use herbs (7.6%), visit drug shops (2.1%), and visit traditional healers (1.0%).

Fig. 4.

Quantitative findings on the attitude toward malaria treatment

In addition, qualitative findings highlighted only two alternative means of malaria treatment among the population: visits to hospitals or clinics and the use of herbs, as illustrated in Table 4.

Progression of malaria infection in the region

A trend of malaria infection across the region shows a decline, as evidenced by 38 references in 30 coded files. However, 13 references indicate an increase in malaria infection over the years within 8 coded files, as shown in Fig. 5. For example, during the discussion, respondents stated that:

Malaria is decreasing here due to extensive follow-up, research, and other efforts. Previously, malaria was very common among the population. People fall ill randomly, but since the government protects imported food and provides mosquito nets, malaria cases are declining (FGD Bassa).

Malaria is increasing in the community due to reported cases at the clinic. This has led the community to build their own health center instead of going to the old Demba Kunda Koto clinic built by the government (KII Demba Kunda Jimara).

Fig. 5.

Perception of progression of malaria among the population of URR

Figure 6 shows variation in the number of malaria cases and deaths in both age groups over the studied years, with a decreasing trend in malaria cases from 9546 to 1228 in the recent 5 years, and 26,787–14,647 in the under-five age group. Additionally, malaria deaths declined from 55 in 2011 to 1 in 2022 in the overall population, and from 45 in 2011 to 5 in 2022 among children under five. The results indicate that children under five are at higher risk of malaria infection.

Fig. 6.

Trend in malaria cases and deaths for under and above 5 years

Figure 7 highlights government efforts and support for malaria reduction by providing various preventive measures to the population. Specifically, it includes the distribution of LLITNs, IRS, SMCs, and ACT, as detailed in 33 coded files with 47 references. Additionally, it involves the construction of healthcare facilities across the region, raising awareness about malaria prevention and treatment, and training health workers.

Fig. 7.

Government efforts toward malaria reduction

Discussion

This study explored knowledge, perceptions, and attitudes toward malaria prevention and treatment. Results showed a strong understanding of basic malaria concepts among the population, which influenced their perceptions and fostered a positive attitude toward prevention and treatment of the infection. However, there are differences in knowledge levels across districts, along with some contradictions in perceptions and attitudes. An overall decline in malaria cases has been observed across districts and communities in the region, with few exceptions.

Malaria is a well-known household name and a major public health concern, as people from different districts show a high level of knowledge about its causes, symptoms, breeding sites, and prevention strategies (Table 1 and Fig. 2). This awareness likely results from campaigns aimed at increasing awareness and eliminating malaria, conducted across the country by the federal Ministry of Health in partnership with the WHO [6, 7]. It may also reflect their proximity to health centers and the increased number of clinics in various communities, which often serve as points for health worker education (statistically significant at p-value < 0.001). This finding aligns with [20], who reported that most (54.4%) of the studied population learned about malaria from health workers at health centres. The respondents’ district and occupation also significantly influence their level of knowledge, suggesting that their experiences and exposure to infection risks during farming activities (70.6%) contribute, especially since malaria prevalence tends to be higher during this time.

The calculated knowledge index for the region is 81%, indicating a very high level of knowledge about malaria. This suggests that the URR population is well-informed about malaria infection; however, there is still room for improvement, particularly in the district with the lowest awareness percentage of 65.0% (Kantora district). The findings somewhat align with [21]’s findings on moderate to good knowledge of malaria transmission, signs, and symptoms among populations in Morogoro and Dodoma regions in Tanzania, but fully agree with [22], who reported high knowledge of malaria among the studied population in Bubaque Island, Guinea-Bissau [15, 20, 23].

Knowledge of mosquitoes as the vector of malaria is quite high (99.7%), similar to findings from [15, 21, 24], where 83.7%, 85%, and 65.5%, respectively, of the population were aware of the cause of malaria. The quantitative results also match the qualitative findings, as shown by 32 references out of 65 in 28 coded files. Reported malaria symptoms differ among respondents, indicating that symptoms in those who are symptomatic mainly depend on their biological makeup and immune system. However, the primary symptoms identified in both quantitative and qualitative data include fever, vomiting, weakness, headache, chills, and loss of appetite. This aligns with earlier research [15, 23], which reported one or more of these symptoms in the studied population. Fever with shivering was identified by 97.6% of respondents in the quantitative data as the main symptom of malaria.

Using treated mosquito nets is a better option for preventing mosquito bites and malaria; it is recommended by the WHO [24–27]. Along with environmental cleaning, effective strategies for preventing mosquito breeding and multiplication align with the WHO's recommended mosquito control and prevention strategies, as well as findings from [20, 28]. However, the understanding of the preferred breeding sites for mosquitoes is somewhat limited, as both clean and polluted water bodies can promote the breeding of most Anopheles mosquitoes, but not very smelly or highly polluted water [29]. This also suggests that their knowledge may be limited to their experience, considering that 88% of respondents have only a basic education.

Overall, the population showed a high level of knowledge about basic malaria concepts, which is largely influenced by their socio-demographic factors. This aligns with a study by Kouamé et al. [30], which found that education and socio-economic status affect the use of insecticides and malaria knowledge among rural farmers in Southern Côte d’Ivoire. This indicates that the region is mentally prepared to adopt a better attitude toward mosquito control, prevention, and treatment options for malaria.

Furthermore, the population’s perception of malaria infection is largely shaped by their knowledge, although some contradictions exist. Malaria is viewed as a serious disease and a public health concern that affects all genders, ages, educational levels, occupations, and socioeconomic backgrounds [5, 32–34]. The entire population appears vulnerable to infection; however, children and pregnant women are seen as being at higher risk, consistent with other findings [23, 36–39] that identify children and pregnant women as high-risk groups, especially those in malaria-endemic areas. If not properly treated, malaria is believed to cause anemia, complications, and even death, as reported by the population.

They believe that malaria can be more effectively treated with modern drugs, reflecting their awareness and response to both herbal remedies and contemporary medicine. This aligns with Madne et al. [23], where 72.8% of study participants believe that malaria can be treated with drugs. The social anthropological belief held by some respondents that malaria is better treated with herbs may originate from traditions rooted in African culture, where many illnesses are attributed to evil spirits. In this context, the use of natural treatment methods, similar to those of ancient practices, seems ideal [15]. A small percentage of the population (Table 3) also believes that malaria is contagious and can be transmitted through human contact. This indicates a lack of education and insufficient awareness of the full facts about malaria. Therefore, there is a significant opportunity for improvement.

Given the population’s awareness and perception of malaria, a recommended attitude toward malaria prevention and treatment has been adopted. The primary preventive measure employed by the population, as demonstrated in both quantitative and qualitative studies, involves the use of bed nets, consistent with previous research [20, 22, 31]. This indicates a good understanding of basic malaria concepts, awareness of the risks from mosquito bites gained through experience, and the availability and accessibility of long-lasting insecticidal nets (LLITNs) among people in URR [9]. The irregular use of anti-mosquito spray suggests a lack of awareness of its proper use, as it’s not intended for daily application. It also reflects sensitivity in its use, either by the household head or another household member. Low-income status may also contribute to inconsistent use. The government is encouraged to provide financial support, if possible, to help ease economic constraints, as the study suggests. This finding aligns with Kurmi et al. [27], where only 20% of the population reported using insecticides.

Effective engagement in cleaning activities, such as cutting bushes and draining stagnant water, adopted by the population, is a suitable measure because a clean environment reduces and controls mosquito activity since mosquitoes breed and multiply excessively in dirty, damp grasses and stagnant water. The findings support [22, 32] that environmental cleanliness is one of the key malaria prevention strategies among the studied population. Some other measures, as revealed in qualitative findings, include burning firewood to diminish mosquito activity, limiting time spent outside the house, burning cow feces, routine checkups, using mosquito coils or repellents, and wearing long dresses in line with Hutchins et al. [22] and Madne et al. [23] among the study population on some of these measures.

While a positive preventive attitude toward malaria is becoming routine among the population, a good attitude toward treatment has also been instilled. More than half of the population (Fig. 4 and Table 6) visits the hospital for malaria treatment, demonstrating the availability of health centers and healthcare in the region. However, despite the presence of health centres in various communities and advances in modern medicine, some people still practice self-medication, especially the elderly, choosing herbs over modern drugs. Their preference for herbs mainly arises from incompetence among health personnel and care providers, particularly due to limited malaria drugs in many health centres. The cost of hospital bills is also a factor, given their low financial status, leading to self-medication and visits to spiritual healers. This research aligns with [27, 32, 33], where self-medication has been adopted by the studied population as an alternative or better substitute for malaria treatment.

Table 6.

Qualitative findings on the population’s attitude towards treatment

Themes	NCFs	NCRs	Quotes from respondents
Use of the herb	16	27	We use an herb (jambakasala) here; if you take it 3 times a day, malaria will go. We go for herbal treatment, cooking with moringa leaf, boiling and drinking neem leaf Each time we go to the hospital, they will say is malaria without checking, and after they will give us only paracetamol, so we treat ourselves using herbs instead of going to the clinic
Visit to the hospital	30	40	We go to the hospital and take our children to the hospital when they fall sick. We also advise pregnant women to visit clinics to get treated if they are sick and get nets from the government, and drugs to prevent malaria

The results further revealed a continuous decline in malaria infections over the years (Figs. 5 and 6). This decrease was mainly due to government efforts in providing seasonal malaria chemoprevention (SMCs) drugs to children under five, intermittent malaria preventive therapy for pregnant women, indoor residual spraying (IRS), and the distribution of treated mosquito nets (LLITN) to the population (Fig. 7), in line with WHO malaria prevention measures [4, 30]. Additionally, the 2017 malaria indicator survey report indicated that 62% of children and 69% of women received insecticide-treated nets, and 40% of pregnant women received three doses of intermittent preventive therapy.

There is an 87% reduction in malaria cases among those over five (> 5) years old and a 45% reduction among those under five (< 5) years old (Fig. 6). The mortality rate also shows a decrease of 98% and 89% for those above and under five, respectively. This is a significant milestone, thanks to the efforts of the Gambia government. This finding supports other studies [9, 34–39] that reported a decline in malaria incidence across the studied regions.

Unfortunately, there is still a notable progressive increase in malaria in some study areas despite government intervention; Demba Kunda-Jimara, Fatoto-Kantora, Koina-Kantora, Giroba-Bassa, Peria Tenda-Tumana, Sandy Kunda–Jimara, Sare Alpha-Tumana. The increase was attributed to their proximity to the swamp and proximity to the border, where the infected immigrants contribute to malaria risk in the region.

In conclusion, malaria continues to be a significant public health issue, especially in African countries where poverty and malaria are interconnected. Vulnerability is higher among populations with limited knowledge or poor perception of the infection, as their attitudes toward prevention and treatment are often influenced. Research findings showed very high awareness of basic malaria concepts among people in the Upper River of the Gambia, which is reflected in their prevention and treatment choices, as well as their perceived susceptibility and severity of the disease. Their level of knowledge demonstrates strong support from the government to eliminate malaria. The government’s dedicated efforts are nearing success, as the region has experienced a notable decline in both malaria mortality and morbidity across all age groups over the past few decades. However, a perception gap remains, and some communities in the region continue to see steady progress of the disease (Fig. 5).

Therefore, government intervention remains crucial in raising awareness and upgrading community health clinics to meet current hospital standards—both in diagnostic tools and operational techniques—so that modern malaria medications are mainly accessible to discourage the use of unregulated herbal medicines. Increasing the recruitment of healthcare personnel to clinics to accommodate the growing population's demands, along with enhancing annual indoor residual spraying across the region, are also necessary. The provision of chemotherapeutic drugs for the elderly is requested, as they often feel neglected in broader malaria control efforts in the area. More importantly, strict environmental cleaning practices should be adopted and prioritized among the population for sustainable malaria elimination.

The ability to use both qualitative and quantitative methods to evaluate the perception and attitudes of the population towards malaria infection is a strength of the work, not overlooking the limitations faced in communicating in the indigenous language of the citizens, especially in the qualitative approach. However, this limitation was later overcome by recruiting indigenous research enumerators for effective interaction and discussion.

Appendices

Appendix A: Objective: Determination of knowledge, perception, and attitude of the population towards malaria infection

Section A: General Knowledge of Malaria

What do you think is the cause of malaria?

1. Mosquito bites

2. Drinking contaminated water

3. Drinking contaminated water

4. Lack of physical exercise

What are the symptoms of malaria?

1. Fever with shivering

2. Fever with interval

3. Vomiting

4. Weakness

5. Loss of appetite

Can you mention where mosquitoes breed?

1. Stagnant water

2. Bushes

3. Freshwater

4. Latrine

5. Cattle shed

How do you think malaria can be prevented?

1. Insecticide-treated bed nets

2. Window nets

3. Using an insecticide spray

4. Cleaning mosquitoes' breeding and resting places

5. Using mosquito coils/repellents

6. Treatment(prophylaxis)

When do we normally get bitten by mosquitoes?

1. During nighttime

2. During the daytime

3. Any time

4. I don’t know

What steps do you think, if taken, can prevent mosquito breeding? Specify all that apply.

1. Cleaning of the house surroundings

2. Draining of stagnant water

3. Clearing of bushes around the house

Section B: Perception of Malaria Disease:

For each of the following statements, please select the most applicable one.

Perception	S	A	N	D	SD
Malaria is a serious disease
Only children under age 5 can get malaria disease
Only the elderly can get malaria disease
All the population are vulnerable
Children under 5 of age are more vulnerable than other population
pregnant women are not more vulnerable than the rest of the population
Malaria cannot lead to death
Malaria is better treated with traditional herbs
There is no effective medical drug for Malaria treatment
Malaria does not require medical treatment
Malaria is a spiritual problem
Malaria can only be treated spiritually

Section C: Attitude towards malaria prevention.

Please tick the most appropriate

No	Questions	Always [√]	Sometimes [√]	Never [√]
1	How often do you and your family members sleep in mosquito insecticide-treated nets?
4	How often do you use anti-mosquito spray in your house?
5	How often do you clean/cut bushes around your house?
6	How often do you drain stagnant water near your house?

What was your first line of action if you had a fever?

1. Go to the hospital

2. Go to a drug shop

3. Go to the traditional healer

4. Go to a spiritual healer

THANK YOU FOR YOUR TIME

Appendix B

Themes and codes generated from Focus Discussion and Key Informant Interview.

Themes in orange color, Codes in blue color.

Author contributions

Ugochinyere Agatha Okafor conceptualized the idea, reviewed the literature, collected data, analyzed data, and wrote the paper. Sidat Yaffa, Umberto D’Alessandro, Vincent Nduka Ojeh, and Walter Leal Filho supervised and proofread the work.

Funding

No external funding was provided for this paper.

Data availability

The data will be made available on request.

Declarations

Ethics approval and consent to participate

The University of The Gambia Research Ethics Committee approved the study. All the respondents were informed about the confidentiality of the data.

Competing interests

The authors declare no competing interests.