Project – Knowledge, Attitudes and Practices Regarding Malaria Prevention among Pregnant Women: A Study of Selected Primary Healthcare Centres in Ikorodu Local Government Area, Lagos State

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Malaria remains one of the most important public health challenges in malaria-endemic countries, particularly in sub-Saharan Africa, where pregnant women constitute one of the population groups at increased risk of malaria infection and its associated complications. Pregnancy alters maternal immunity and can increase susceptibility to malaria, with possible consequences including maternal anaemia, severe illness, pregnancy loss, premature delivery and low birth weight. The consequences of malaria during pregnancy therefore extend beyond the mother to the developing fetus and newborn. The World Health Organization (WHO) recognises malaria prevention during pregnancy as an essential component of maternal and reproductive health services in endemic settings. Major preventive interventions include the use of insecticide-treated or long-lasting insecticidal nets, intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP), appropriate antenatal care and prompt diagnosis and treatment of suspected malaria. These interventions are particularly important because malaria infection may occur without obvious symptoms, making prevention an important aspect of protecting maternal and fetal health (World Health Organization [WHO], 2022, 2025). The continued importance of these interventions provides a strong justification for examining how well pregnant women understand malaria prevention and how such knowledge is reflected in their attitudes and everyday practices.

The prevention of malaria during pregnancy depends not only on the availability of effective interventions but also on women’s knowledge and understanding of those interventions. Knowledge involves awareness and understanding of the causes, mode of transmission, signs and symptoms, complications and preventive measures associated with malaria. Pregnant women who understand that malaria is transmitted primarily through the bites of infected female Anopheles mosquitoes may be more likely to appreciate the importance of reducing mosquito exposure. Similarly, understanding the purpose and timing of IPTp-SP can help women appreciate why preventive medication is recommended during pregnancy even when they do not feel sick. WHO recommends that in malaria-endemic areas, IPTp-SP should begin as early as possible in the second trimester, with doses administered at least one month apart and the objective of ensuring that pregnant women receive at least three doses under the applicable national programme guidance (WHO, 2022, 2025). However, knowledge of malaria in general does not necessarily mean that a woman understands all aspects of malaria prevention. Kalu et al. (2022), in a study among pregnant women in Nigeria, found that although many respondents were aware of malaria transmission and the increased risk during pregnancy, important gaps remained concerning the complications of malaria, the benefits of long-lasting insecticidal nets and the purpose of IPTp-SP.

Attitude is another important component of malaria prevention because what pregnant women believe about preventive measures can influence whether they are willing to adopt and consistently use them. A positive attitude may be reflected in the belief that malaria prevention is necessary, that sleeping under a long-lasting insecticidal net is beneficial, that attending antenatal care is important and that recommended preventive medication should be taken according to health-provider instructions. Conversely, negative perceptions, misconceptions about medication, fear of side effects, discomfort associated with mosquito nets or doubts concerning the seriousness of malaria can discourage preventive behaviour. In Nigeria, evidence indicates that awareness of malaria does not always translate into appropriate attitudes and preventive practices. Kalu et al. (2022) reported that pregnant women in their Nigerian study had relatively good awareness of basic malaria concepts but demonstrated inadequate knowledge and attitudes concerning some important prevention measures. Similarly, Peters and Naidoo (2022) found that many pregnant women attending antenatal care in Bwari Area Council had inadequate knowledge concerning who should receive IPTp-SP and when and how frequently it should be taken, despite generally positive attitudes toward its use. These findings suggest that understanding the attitudes of pregnant women is essential for determining whether health education messages are likely to translate into effective malaria-prevention behaviour.

The practice component of malaria prevention concerns what pregnant women actually do to protect themselves and their unborn children from malaria. Appropriate practices may include sleeping under a long-lasting insecticidal net every night, attending antenatal care regularly, receiving recommended IPTp-SP doses at appropriate intervals, seeking professional care when malaria symptoms occur and following prescribed treatment instructions. The effectiveness of malaria-control programmes can be weakened when there is a gap between awareness and actual behaviour. For example, a woman may possess a long-lasting insecticidal net but fail to sleep under it consistently, or she may attend antenatal care but fail to receive the recommended preventive treatment. Kalu et al. (2022) reported that although approximately 80% of women in their Nigerian study had long-lasting insecticidal nets, only 41.5% reported sleeping under one the previous night, while only 31% had received IPTp-SP under direct observation. Earlier evidence from Badagry, Lagos State, also demonstrated substantial gaps between awareness and actual preventive practices, with Chukwurah et al. (2016) reporting that many pregnant women knew about malaria prevention but continued to rely on measures such as herbs, insecticide sprays and other practices that did not necessarily correspond with recommended malaria-prevention guidelines. These findings demonstrate why assessing practice is necessary alongside knowledge and attitudes.

Nigeria continues to carry a substantial malaria burden, making malaria prevention during pregnancy an important public health priority. The Nigeria Malaria Indicator Survey (NMIS) 2021 provides evidence of differences in the uptake of intermittent preventive treatment across states. In Lagos State, 69.1% of women who had a live birth in the two years preceding the survey reported receiving at least one dose of sulfadoxine-pyrimethamine during the relevant pregnancy, while 58.7% received at least two doses and only 30.7% received three or more doses (National Malaria Elimination Programme [NMEP], National Population Commission [NPC], & ICF, 2022). These figures demonstrate that access to at least one preventive dose does not necessarily translate into completion of the recommended preventive schedule. Since antenatal care provides an important opportunity for health education, malaria prevention counselling, distribution of insecticide-treated nets and delivery of IPTp-SP, the knowledge and practices of women attending primary healthcare facilities are particularly relevant. The WHO also emphasises that antenatal care contacts remain an important platform for delivering malaria-prevention interventions during pregnancy (WHO, 2024, 2025). Consequently, examining KAP among pregnant women attending primary healthcare centres can provide information about possible gaps that may affect the effectiveness of malaria-prevention efforts.

Evidence from previous Nigerian studies further shows that malaria-prevention behaviour among pregnant women is influenced by several individual, social and health-system factors. In Badagry, Lagos State, Chukwurah et al. (2016) studied 450 pregnant women attending antenatal clinics and found substantial misconceptions concerning the use of sulfadoxine-pyrimethamine, with many women believing that the drug was primarily for malaria treatment rather than prevention. The study also identified reliance on alternative practices and inadequate use of recommended preventive measures. In another Nigerian study, Peters and Naidoo (2022) reported that poor knowledge of IPTp-SP, cost, inadequate availability of preventive commodities and weaknesses in the implementation of directly observed treatment affected the uptake of preventive treatment. Kalu et al. (2022) similarly demonstrated that possessing basic knowledge about malaria did not automatically result in appropriate preventive practices. These findings indicate that KAP should be assessed as related but distinct dimensions: a woman may possess considerable knowledge but have an unfavourable attitude or inadequate practice. Understanding these dimensions is therefore necessary for designing health education and maternal-health interventions that address not only awareness but also behavioural barriers.

The need to investigate malaria-prevention knowledge, attitudes and practices among pregnant women is particularly relevant at the primary healthcare level because primary healthcare centres constitute an important point of contact between pregnant women and the formal health system. Ikorodu Local Government Area of Lagos State contains communities where primary healthcare centres serve pregnant women through antenatal care, health education, preventive services and referral. However, evidence obtained from studies conducted in other parts of Nigeria cannot automatically be assumed to represent the situation among pregnant women attending selected primary healthcare centres in Ikorodu. The Badagry study provides useful Lagos State evidence, but its setting and population differ from those of Ikorodu (Chukwurah et al., 2016). Similarly, studies conducted in Nnewi and Bwari Area Council demonstrate important national patterns but do not provide specific evidence concerning pregnant women in Ikorodu (Kalu et al., 2022; Peters & Naidoo, 2022). Therefore, there is a need for a context-specific assessment of what pregnant women in selected primary healthcare centres in Ikorodu know about malaria prevention, how they perceive recommended preventive measures and what they actually practice. Such evidence can assist healthcare providers and public-health stakeholders in identifying gaps in malaria-prevention education and strengthening interventions aimed at improving maternal and fetal health outcomes.

1.2 Statement of the Problem

Malaria in pregnancy remains a significant maternal and public-health concern because pregnant women are particularly vulnerable to the consequences of malaria infection. Despite the availability of effective preventive interventions, malaria continues to threaten maternal health and pregnancy outcomes in endemic settings. The WHO recommends the use of long-lasting insecticidal nets, IPTp-SP, appropriate antenatal care and prompt diagnosis and treatment as important components of malaria control during pregnancy (WHO, 2022, 2025). Nevertheless, evidence from Nigeria indicates that the uptake and consistent practice of these interventions remain inadequate. The Nigeria Malaria Indicator Survey 2021 reported that only 30.7% of women in Lagos State who had a recent live birth received three or more doses of sulfadoxine-pyrimethamine during the relevant pregnancy (NMEP, NPC, & ICF, 2022). This situation raises concerns about whether pregnant women have adequate knowledge of malaria prevention and whether existing health education interventions are sufficiently effective in promoting appropriate preventive practices.

A major problem is that awareness of malaria does not necessarily translate into adequate knowledge of all recommended preventive measures. Some pregnant women may know that mosquitoes transmit malaria but may not understand the seriousness of malaria during pregnancy, the complications that can arise, or the preventive purpose of IPTp-SP. Evidence from Nigeria supports this concern. Kalu et al. (2022) found that although many pregnant women were familiar with malaria and its transmission, important gaps existed in their knowledge of malaria complications, the benefits of long-lasting insecticidal nets and the use of preventive medication. Peters and Naidoo (2022) also found considerable knowledge deficiencies concerning eligibility, timing and frequency of IPTp-SP among pregnant women attending primary healthcare facilities in Bwari Area Council. Such knowledge deficiencies may reduce the ability of pregnant women to make informed decisions concerning malaria prevention. If these gaps remain unidentified at the local healthcare level, health education provided during antenatal care may fail to adequately address the specific misconceptions and information needs of pregnant women.

Another problem concerns the attitudes of pregnant women toward recommended malaria-prevention measures. Positive attitudes are important because women may not consistently practise a preventive behaviour that they consider unnecessary, uncomfortable, unsafe or ineffective. Some women may be concerned about taking medication during pregnancy, while others may perceive malaria as a routine illness that does not require preventive attention in the absence of symptoms. Evidence from Nigerian communities has demonstrated that misconceptions and perceptions can influence acceptance and utilisation of malaria-prevention measures. Chukwurah et al. (2016), in Badagry, Lagos State, found that although many pregnant women had heard of malaria prevention and sulfadoxine-pyrimethamine, considerable misconceptions existed regarding the purpose of the medication, while some respondents relied on non-recommended preventive practices. Kalu et al. (2022) similarly observed that adequate awareness of malaria did not consistently translate into appropriate attitudes and practices. Therefore, without examining attitudes among pregnant women in Ikorodu, it may be difficult to understand why awareness of malaria prevention may or may not result in appropriate behaviour.

The final problem concerns the gap between recommended malaria-prevention practices and what pregnant women actually do in their daily lives. A woman may receive health education during antenatal care and possess an insecticide-treated net but may not use it consistently. Similarly, she may know about IPTp-SP but fail to receive the recommended doses at the appropriate intervals. The findings of Kalu et al. (2022) demonstrate this knowledge-practice gap, as a substantial proportion of women possessed long-lasting insecticidal nets but did not use them consistently, while IPTp-SP uptake was also incomplete. Peters and Naidoo (2022) identified additional structural challenges, including availability of preventive commodities, cost and weaknesses in directly observed administration. These issues demonstrate that effective malaria prevention requires more than simply providing information; it requires understanding the interaction between knowledge, attitudes, access and actual practices. However, there is limited specific evidence describing these dimensions among pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State. This study therefore seeks to assess the knowledge, attitudes and practices regarding malaria prevention among pregnant women in selected primary healthcare centres in Ikorodu Local Government Area.

1.3 Aim and Objectives of the Study

The main aim of this study is to assess the knowledge, attitudes and practices regarding malaria prevention among pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State.

The specific objectives are to:

1. assess the level of knowledge of malaria prevention among pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State;
2. examine the attitudes of pregnant women toward recommended malaria-prevention measures in selected primary healthcare centres in Ikorodu Local Government Area, Lagos State;
3. determine the malaria-prevention practices adopted by pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State; and
4. examine the relationship between knowledge and the malaria-prevention practices of pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State.

1.4 Research Questions

The following research questions will guide the study:

1. What is the level of knowledge of malaria prevention among pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State?
2. What are the attitudes of pregnant women toward recommended malaria-prevention measures in selected primary healthcare centres in Ikorodu Local Government Area, Lagos State?
3. What malaria-prevention practices are adopted by pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State?
4. What relationship exists between knowledge and malaria-prevention practices among pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State?

1.5 Research Hypothesis

The following null hypothesis will be tested at the 0.05 level of significance:

H₀: There is no significant relationship between knowledge of malaria prevention and malaria-prevention practices among pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State.

1.6 Significance of the Study

The findings of this study will be significant to pregnant women because it will identify gaps in their understanding of malaria prevention, attitudes toward preventive interventions and actual preventive practices. Information obtained from the study may help pregnant women recognise the importance of consistent malaria-prevention behaviours, including appropriate use of insecticide-treated nets, regular antenatal attendance and compliance with recommended preventive medication. Improved understanding may contribute to more informed health decisions during pregnancy.

The study will also be useful to nurses, midwives, community health officers and other healthcare providers working in primary healthcare centres. The findings may enable health workers to identify specific misconceptions and behavioural barriers among pregnant women and design more targeted health education during antenatal sessions. Rather than relying only on general malaria messages, healthcare providers may use the findings to focus attention on areas where women demonstrate inadequate knowledge or inappropriate practices.

The study will be useful to public-health authorities and malaria-control programme managers in Lagos State. The findings may provide local evidence that can support the strengthening of malaria-prevention activities at the primary healthcare level. Information about knowledge, attitudes and practices may help programme planners identify areas requiring additional health education, counselling, commodity availability or monitoring.

The study will also be beneficial to researchers and students in public health, nursing, community health, medicine and related disciplines. It will contribute to the body of literature on malaria prevention among pregnant women in Nigeria and provide a basis for further studies. Researchers may also use the findings to compare malaria-prevention behaviour across different local government areas, healthcare settings and population groups.

Finally, the study may be useful to policymakers and maternal-health stakeholders by providing context-specific evidence from Ikorodu Local Government Area. Since malaria prevention is closely linked to maternal and fetal health, evidence from primary healthcare facilities can support efforts aimed at improving the quality and utilisation of preventive maternal-health services.

1.7 Scope of the Study

This study focuses on the knowledge, attitudes and practices regarding malaria prevention among pregnant women attending selected primary healthcare centres in Ikorodu Local Government Area, Lagos State.

The study will specifically examine pregnant women’s knowledge of malaria, including its causes, mode of transmission, symptoms, complications and prevention. It will also assess their knowledge of important preventive measures such as long-lasting insecticidal nets, antenatal care and intermittent preventive treatment during pregnancy.

The study will examine the attitudes of pregnant women toward malaria-prevention measures, including their perceptions of the seriousness of malaria during pregnancy, willingness to use insecticide-treated nets, acceptance of recommended preventive medication and perceptions of antenatal malaria-prevention services.

The study will further examine malaria-prevention practices, including sleeping under insecticide-treated nets, attending antenatal care, receiving recommended IPTp-SP doses, environmental measures for reducing mosquito exposure and appropriate health-seeking behaviour when malaria symptoms occur.

Geographically, the study is limited to selected primary healthcare centres in Ikorodu Local Government Area of Lagos State. The study will focus on pregnant women attending the selected facilities and will not cover pregnant women who do not attend the selected facilities. The study is also limited to malaria prevention and does not seek to investigate the laboratory diagnosis, treatment outcomes or clinical management of malaria beyond issues directly related to prevention.

1.8 Operational Definition of Terms

Attitude: The beliefs, perceptions, feelings and dispositions of pregnant women toward malaria and recommended malaria-prevention measures.

Insecticide-Treated Net (ITN): A mosquito net treated with insecticide and used as a personal protection measure against mosquito bites and malaria transmission.

Intermittent Preventive Treatment in Pregnancy (IPTp): The administration of recommended antimalarial preventive medication to pregnant women at predetermined intervals during pregnancy, irrespective of whether malaria infection is clinically apparent.

Knowledge: The level of awareness and understanding possessed by pregnant women concerning malaria, its transmission, symptoms, complications and recommended preventive measures.

Malaria: A mosquito-borne infectious disease caused by Plasmodium parasites and transmitted mainly through the bites of infected female Anopheles mosquitoes.

Malaria Prevention: Measures taken to reduce the risk of malaria infection among pregnant women, including the use of insecticide-treated nets, IPTp, appropriate antenatal care, environmental protection and prompt healthcare seeking.

Pregnant Women: Women who are carrying a developing fetus and who attend the selected primary healthcare centres for antenatal or related maternal-health services.

Practice: The actual actions and behaviours undertaken by pregnant women to prevent malaria, including use of insecticide-treated nets, attendance at antenatal care and uptake of recommended preventive treatment.

Primary Healthcare Centre: A health facility providing basic and essential healthcare services, including antenatal and maternal-health services, at the primary level of the healthcare system.

1.9 Organisation of the Study

The study will be organised into five chapters. Chapter One presents the introduction, including the background to the study, statement of the problem, aim and objectives, research questions, hypothesis, significance, scope and operational definitions. Chapter Two will review relevant conceptual, theoretical and empirical literature related to malaria, malaria in pregnancy, malaria-prevention measures, and knowledge, attitudes and practices among pregnant women. Chapter Three will present the research methodology, including the research design, study population, sample size, sampling procedure, research instrument, validity and reliability of the instrument, data collection procedure and methods of data analysis. Chapter Four will present and analyse the data obtained from the respondents and discuss the findings in relation to the research questions and hypothesis. Chapter Five will provide the summary of findings, conclusion, recommendations and suggestions for further studies.

Project – Knowledge, Attitudes and Practices Regarding Malaria Prevention among Pregnant Women: A Study of Selected Primary Healthcare Centres in Ikorodu Local Government Area, Lagos State