Socioeconomic and cultural factors associated with mortality in Malaria induced anaemia among under-five children in Benin city, Nigeria

Introduction Malaria remains a major public health problem worldwide. About two billion people are at risk of having malaria and 90% of such people live in the sub-Saharan Africa where malaria transmission is most intense. Globally, an estimated 300-500 million clinical malaria episodes occur annually with more than two million deaths yearly; most of these occurring in children under the age of five years.1 These children exhibit inadequate immunity against malaria and are thus prone to the severe forms of the disease including life threatening complications.2,3 Severe malaria is a major cause of childhood morbidity and mortality in developing countries.2,4,5 and can present with one or more life threatening complications such as severe anaemia, cerebral malaria, hypoglycaemia and hyperparasitaemia among others. In holoendemic regions like Nigeria, malaria induced anaemia (MIA) is the most prevalent presentation of severe malaria in children accounting for as high as 3055% of cases.5-7 The high prevalence of MIA worsens the problem of anaemia in children thus increasing the morbidity and mortality in under-fives.8 Malaria induced anaemia contributes 37% to malaria mortality.9 The burden of malaria-associated anaemia has been estimated at 190 000–974 000 deaths per year in children under five years of age.9 Even with blood


Introduction
Malaria remains a major public health problem worldwide.About two billion people are at risk of having malaria and 90% of such people live in the sub-Saharan Africa where malaria transmission is most intense.Globally, an estimated 300-500 million clinical malaria episodes occur annually with more than two million deaths yearly; most of these occurring in children under the age of five years. 1 These children exhibit inadequate immunity against malaria and are thus prone to the severe forms of the disease including life threatening complications.2,3 Severe malaria is a major cause of childhood morbidity and mortality in developing countries.2,4,5 and can present with one or more life threatening complications such as severe anaemia, cerebral malaria, hypoglycaemia and hyperparasitaemia among others.In holoendemic regions like Nigeria, malaria induced anaemia (MIA) is the most prevalent presentation of severe malaria in children accounting for as high as 30-55% of cases.5-7 The high prevalence of MIA worsens the problem of anaemia in children thus increasing the morbidity and mortality in under-fives.8 Malaria induced anaemia contributes 37% to malaria mortality.9 The burden of malaria-associated anaemia has been estimated at 190 000-974 000 deaths per year in children under five years of age.9 Even with blood transfusion, case fatality rate for MIA is between 6-18%.10 The pathogenesis of malarial anaemia is often multifactorial, complex and incompletely understood.Postulated mechanisms fall broadly under haemolysis and dyserythropoiesis.Malaria-associated anaemia may present either as an acute episode or as a chronic process following repeated, often, asymptomatic infection.11 A number of studies have described the risk factors for malaria induced anaemia in Africa.10, 12-14 These factors, however, have been mainly clinical, laboratory, environmental, host-genetic factors and principally include the infecting malaria parasite species, intensity of transmission, patient age and presence of other concomitant, non-malarial causes of anaemia.Socio-economic and cultural factors associated with MIA have, however not been evaluated.Socioeconomic and cultural factors are important in disease transmission and outcome.This is more so in the case of malaria where the disease occur largely in certain geographical regions and pronounced in certain age groups compared to others.15-17 An understanding of these factors is necessary for the design of preventive interventions.We therefore, evaluated the socio-economic and cultural factors associated with mortality in under-five children with MIA requiring blood transfusion, who were admitted into the Children's Emergency Room of the University of Benin Teaching Hospital, Benin City, in southern Nigeria.

Subjects and Methods
The study was a cross-sectional one carried out at the Children Emergency Room (CHER) of the University of Benin Teaching Hospital (UBTH), Benin City, Nigeria from March to December 2009.Benin City is in the Southern part of Nigeria, lies in the rainforest belt as well as the malaria belt and has stable malaria transmission all through the year.Subjects included under-five children with severe malaria anaemia requiring blood transfusion.Recruitment did not depend on absolute packed cell volume (PCV) or haemoglobin concentration of the patients but on the fact that they were anaemic and clinically decompensating.They were transfused with human immunodeficiency (HIV) and hepatitis surface antigen (HBsAg)-negative blood.Excluded from the study were children with suspected malaria without Plasmodium falciparum parasitaemia.Diagnosis of malaria was confirmed on the basis of the presence of asexual forms (trophozoites/ring forms) of malaria parasites.18

Characteristics of study subjects
One hundred and sixty under-five children were studied made up of 93 (58.1%) males and 67 (41.9%) females giving a M: F ratio of 1.39: 1. Half of the under-fives 80 (50.0%) was in the age range 12 -35 months with a median age of 26.5 (3 -59) months [Table I].

Parents' socioeconomic and demographic characteristics and MIA occurrence
The majority of the mothers were married 124  II].

Mothers' health-seeking behaviour, beliefs, practices and recognition of symptoms of Malaria Induced Anaemia.
A higher proportion of the parents 113 (70.6%) do not believe in alternative medicine, cannot recognize pallor 99 (61.9%) and took their under-fives to the chemist 124 (77.5%) for pre-hospital treatment.While 130 (81.3%) gave self medications before coming to the hospital, 29 (18.1%) of the children were given native concoctions.Only 46 (28.7%) of the mothers brought their children directly to the hospital for treatment.(Table III).
Most of the mothers 121 (75.6%) recognised at least one symptom of malaria.Ninety eight (61.3%)mothers were aware that malaria could cause anaemia while 62 (38.7%) were not.

Patient Outcome and Socioeconomic/ Cultural Factors.
A hundred and fifty five (96.9%) of the children with MIA were discharged home while five died giving a case fatality rate of 3.1% (Table I).The under-fives  IV].
All the children that died had parents who were married and were unskilled workers.These findings were not statistically significant (p = 0.999).The majority had parents with low socioeconomic status 4 (80.0%), and fathers with secondary level of education 3 (60.0%).However, none of the findings was statistically significant (Table V).Worthy of note is the fact that majority 4 (80.0%) of the children that died were those of mothers with primary level of education (p = 0.035) (Table V), who were not aware that malaria could cause anaemia and did not recognise pallor in their children.

Discussion
Malaria brings to bear a huge burden and a devastating impact on morbidity and mortality in childhood.
Anaemia is an almost mandatory symptom of malaria, and severe anaemia constitutes the most frequent defining symptom of severe malaria 17 Socioeconomic and cultural factors affect the presentation and outcome of diseases.16 Although the interaction between malaria, anaemia, and socioeconomic status is multifaceted, its knowledge is however fundamental for our understanding of childhood morbidity and mortality and for the development of effective intervention strategies.The current study revealed that very few parents with tertiary level of education had children who developed MIA.This is not surprising as high maternal educational status positively influences the health-seeking behaviour, socioeconomic status and economic power of the family.20,21 Furthermore, most of the parents were unskilled workers.This is possibly related to the educational status of the parents.A poorly educated parent will likely be employed as an unskilled worker.
The Most of the parents had maximum of secondary level of education and were unskilled workers, thus reducing their SEC.Also, people from low SEC are likely to live in poor accommodation and environment which tend to encourage breeding of mosquitoes.They are also more likely to live in houses without mosquito nets.Knowledge about the symptoms of a disease by a caregiver can encourage early detection at home and presentation to the health facility for appropriate treatment.Over 75% of the mothers could recognise at least one symptom of malaria and 61% were aware that malaria could cause anaemia; however, only 38% could recognise pallor.Even though majority of the mothers knew the symptoms of malaria, if they could not recognise pallor, early presentation to the hospital may be hindered.Parental cultural beliefs and practices can influence their health-seeking behaviour, place of pre-hospital management and consequently influence the progression of disease.In the current study, majority of the mothers had visited chemists to get medicines for their children before presenting to the hospital and most of the children had taken some forms of med-ication before presentation, while fewer numbers visited places like the herbalists and prayer houses.A lower rate of use of orthodox medications (22%) and herbs (20%) in children with malaria was documented by Olasehinde et al 22 in Ota, Ogun State, in Southwestern Nigeria.The high use of medications prior to presentation is perhaps predicated on the assumption that it is seemingly easier, cheaper and less time consuming for parents to buy drugs over the counter than to see a doctor in the hospital.Patronage of chemists prior to presentation may also be related to the parents' educational status (particularly maternal education) and SEC.An educated woman is more likely to seek health care from a competent source ab-initio than an uneducated one.22 Delay in accessing appropriate treatment for malaria can enhance progression of uncomplicated malaria to severe forms of malaria.Child health in addition to being a development indicator itself, is closely associated with other development indicators, such as adult health, educational attainment, productivity, and income.23 Among the potential determinants of child health, the mother's education has been the focus of economists.More educated mothers may have healthier children because they have better knowledge about health care and nutrition, have healthier behaviour, and provide more sanitary and safer environments for their children.24 An understanding of how the mother's education affects child health will help us to evaluate a very important development policy in the world today: the improvement of women's education.25 In fact, two additional goals of the MDGs are to directly target the education of women.26 Raising the education of girls is also the priority of the World Bank.27 According to the World Bank, one primary All the mothers of the children with mortality were unskilled workers and had given drugs before presentation to the hospital.Although cases of mortality were few, parental low socioeconomic class, parents with unskilled labour, maternal lack of recognition of pallor, prior intake of drugs were common factors found in the mortality cases.Thus, modification of these factors will go a long way in reducing mortality associated with MIA.
In conclusion, we dare say that malaria-control programmes alone may not suffice in the reduction of childhood mortality associated with MIA.We identified poor maternal education as a factor associated with MIA mortality.Therefore, in addition to malaria-control programmes, we have to recognize and consequently target the underlying socioeconomic factors which modify the disease outcome.There is need to emphasize improvement in socioeconomic status especially female education and empowerment as this will equip mothers with the ability to take appropriate decisions relating to the child's needs.The aforementioned and other socioeconomic boost may reduce morbidity and mortality associated with MIA.Parental enlightenment on recognition of symptoms of malaria and anaemia will encourage early detection of the disease at home as well as early presentation in competent health facilities and thus promote early diagnosis and prompt institution of effective antimalarial therapy.

Table VI : Socio-demographic characteristics of parents and outcome following MIA Characteristics
This they explained to be due to the case mix of the children they sampled which did not distinguish children at high risk of mortality.Contrary to findings in the present study, Mockenhaupt et al 5 in their study conducted among hospitalized children with severe malaria in northern Ghana did not record any mortality due to severe malaria anaemia though it was the leading manifestation of severe malaria in the region; instead, malnutrition and circulatory collapse were the important predictors of fatal malaria.