A Cross-Sectional Survey on the Malaria Control and Prevention Knowledge, Attitudes, and Practices of Caregivers of Children Under-5 in the Western Area of Sierra Leone

(1) Background: Children under 5 years of age are the most vulnerable to malaria infection, and they suffer serious complications. Sierra Leone is one of the countries with the highest malaria burden in the world. This study aimed to assess the knowledge, attitudes, and practices (KAPs) toward malaria control and prevention among caregivers of children under 5 in the Western Area of Sierra Leone. (2) Methods: A cross-sectional survey was conducted among caregivers of children under-5 visiting the out-patient department of six selected hospitals/community health centers. Data were collected via questionnaire interviews with 350 caregivers. (3) Results: A total of 97.1% of the respondents were women and the majority of them were young mothers; 46.3% of respondents were unemployed; and 27.1% received no education. Only 1.4% accessed malaria related information from the internet/social media. This KAPs survey indicated that a misconception of the cause, transmission, and clinical symptoms of malaria; unawareness of its lethality and its severity; and inappropriate prevention and treatment behaviors, such as self-medicating, were still in existence among some caregivers. However, a positive correlation in knowledge–attitudes (rs = 0.13, p < 0.05) and in attitudes–practices (rs = 0.45, p < 0.001) was revealed. The caregivers, being mothers and having at least a secondary education, demonstrated positive attitudes and practices. Meanwhile, more urban caregivers (79.8%) followed a complete malaria treatment course of artemisinin-based combination therapies than the rural (63.3%), but in view of insecticide treated net use, more rural caregivers presented positive attitudes (85.3%) and practices (70.1%) than the urban (69.9%, 52.0%). (4) Conclusions: For better protection of children under-5 against lethal malaria, it is essential to provide better guidance at the community level for their caregivers, especially young mothers, in order to reduce some misconceptions and inappropriate behaviors. An increase in education and employment opportunities for women, establishment of an accessible community-based malaria counselling service, and construction of an effective communication channel are also needed.


Introduction
Malaria remains globally endemic in 85 countries, and it is mostly concentrated in the underdeveloped tropical and subtropical regions even though its occurrences vary with geographic-climatic environmental conditions and cultural-hygienic social factors [1,2].

Study Population and Eligibility Criteria
Caregivers with one or more child(ren) under-5 residing in WAR and WAU who visited the out-patient departments of the selected health care facilities were included.

Sample Size
The sample size was calculated using Cochran's formula (1977) (pp. 72-76) [16]. Where: n = sample size; z = z value 1.96 for 95% confidence level; p = proportion of malaria prevalence in children under-5 in Sierra Leone [17]; d = absolute error allowance/precision. Hence, the sample size was calculated as follow: 1.96 2 [0.205 × (1 − 0.205)]/0.05 2 = 250. Meanwhile, 40% of the calculated sample size was added to the study population to account for missing vital data. The final sample size was 350.

Survey Questionnaire
Based on the conceptual framework of this study, we developed a questionnaire that included items mainly referred from previous studies, validated and supplemented according to the biological characteristics of malaria epidemics [18,19]. The questionnaire Trop. Med. Infect. Dis. 2022, 7, 120 4 of 17 was written in English, confirmed by pretesting to ensure respondents understood, and thus used for a face-to-face interview. Trained investigators read each question to the participants and explained it in the local language if the participants did not understand English.
The final survey questionnaire contained open and closed-ended questions, and it was divided into four sections (Supplementary file S1). Section A focused on the sociodemographic characteristics of the caregivers. Section B assessed the caregiver's knowledge of the cause of malaria and its mode of transmission; signs and symptoms of malaria; and prevention. Section C assessed the caregiver's attitudes toward malaria such as how serious of a health problem they considered malaria to be, if they slept under a bed net with their child(ren), what time of day they thought mosquitoes bite most, and what they thought was the best treatment for malaria. Meanwhile, Section D assessed the caregiver's practices toward malaria prevention, such as the kind of measures they took to protect their children from mosquito bites, what they did when their child(ren) had a fever or was prescribed an antimalaria medication, what influenced their action and how long they waited before seeking medical care for their febrile child(ren).

Data Collection
After gaining ethical clearance and permission from the Sierra Leone Ethics and Scientific Review Committee, a face-to-face interview with participating caregivers and trained investigators was performed on workdays from mid-August to late-September 2019 using the questionnaire in six selected health care facilities in WAU and WAR.

Statistical Analysis
Socio-demographic characteristics and KAPs data were collected via the face-to face interview questionnaire from 350 caregivers. Descriptive statistics was used to analyze the socio-demographic characteristics of the respondents, and the results were expressed in frequencies and percentages. A scoring system was utilized in the evaluation of the KAPs data (Supplementary file S2) [10,20,21]. KAPs levels acted as dependent variables of the univariate analysis, and they were defined by the 60% cut-off value of the total score. The responses to the KAPs variables between the respondents from WAU and WAR were compared using Chi-square analysis. Fisher's exact test was used when more than 20% of cell counts were less than five. Spearman's rank test was used to determine the extent of correlation between KAPs scores since data was not normally distributed as per the outcome of the Kolmogorov-Smirnov test. Based on the rule of thumb of Cohen [22], the strength of correlation was interpreted as 0 = no relationship, 0.10-0.29 = small/low correlation, 0.30-0.49 = medium/moderate correlation, and 0.50-1.00 = large/high correlation.
The association between KAPs and the socio-demographic characteristics of the respondents was evaluated by univariate analyses. All variables significant in the univariate analysis with a p ≤ 0.25 were included in the multivariate logistic regression model. Reduced subset models were developed using elimination based on the AIC (Akaike information criteria) score. The level of statistical significance was set at 0.05. All of the data analyses and figure drawing were conducted in R software (Version: 3.6.1).

Socio-Demographic Characteristics of the Caregivers
As shown in Table 1, all 350 caregivers interviewed completed the survey with a nearly equal number of respondents from WAU and WAR. Most of them were less than 30 year-old mothers. A total of 70.0% of the caregivers were married, while 19.4% were single, and most caregivers were unemployed younger mothers. The total unemployed reached 46.3%, including 33 younger students. In total, 27.1% of them had no educational experience and only 64.3% had at least a secondary level of education. However, all of them had at least one child under-5 living with them and 54.6% had at least one more child above-5.

Knowledge
Up to 99.1% of the caregivers had heard of malaria, and no significant difference in malaria related information sources (p = 0.858) was found between the caregivers from WAR and WAU (Supplementary file S3: Table S1). Most of them received malaria related knowledge from health workers/facilities (88.3%), followed by radio (60.3%), television (17.4%), and printed materials, such as billboards/handbills (8.0%). Besides, 26.6% received information from other sources, such as community sensitization and announcements about malaria, their friends/peers, and also neighbors; and, only 1.4% were informed through the internet/social media, including only 1.7% of those residing in WAU, where the use of internet/social media was expected to be high-just a little higher than those living in WAR (1.1%) ( Figure 2). ceived information from other sources, such as community sensitization and announcements about malaria, their friends/peers, and also neighbors; and, only 1.4% were informed through the internet/social media, including only 1.7% of those residing in WAU where the use of internet/social media was expected to be high-just a little higher than those living in WAR (1.1%) ( Figure 2). As displayed in Figure 3 and Additional file S3: Table S1, the percentage of respondents that did not know malaria could be prevented and cured or that it could lead to death were 18.0%, 3.4%, and 8.8%, respectively. Among them, only 1.2% of urban caregivers were unaware of the lethality of malaria, whereas the number for rural caregivers was over four times higher (5.6%) (p = 0.05). When asked about the symptoms of malaria, the most common responses were fever (71.1%), followed by vomiting (42.9%), loss of appetite (30.9%), and body and joint pains (26.9%), with only a few responses for headaches (9.1%). Approximately 58.6% of them stated other signs and symptoms they knew such as weakness and dizziness, dark colored urine, yellow/pale/white eyes, etc. Approximately 10.0% did not know that malaria parasites can be transmitted through mosquito bites. This study revealed that misconceptions about the causes and the mode of transmission of malaria still prevailed among the caregivers, as 0.3% of them stated that eating too much and having close contacts with a person who has malaria can cause malaria. Furthermore, 4.0% of them stated other misconceptions about the cause of malaria, such as eating too many oranges, not washing hands regularly, cold and flu, dirty hands and feet flies, drinking too many sweet/soft drinks, etc. While 86.6% of the caregivers stated that bushes/dirty places were convenient resting/breeding places for mosquitoes, followed by stagnant water (51.1%), and dark places/sheds (11.7%). As displayed in Figure 3 and Supplementary file S3: Table S1, the percentage of respondents that did not know malaria could be prevented and cured or that it could lead to death were 18.0%, 3.4%, and 8.8%, respectively. Among them, only 1.2% of urban caregivers were unaware of the lethality of malaria, whereas the number for rural caregivers was over four times higher (5.6%) (p = 0.05). When asked about the symptoms of malaria, the most common responses were fever (71.1%), followed by vomiting (42.9%), loss of appetite (30.9%), and body and joint pains (26.9%), with only a few responses for headaches (9.1%). Approximately 58.6% of them stated other signs and symptoms they knew such as weakness and dizziness, dark colored urine, yellow/pale/white eyes, etc. Approximately 10.0% did not know that malaria parasites can be transmitted through mosquito bites. This study revealed that misconceptions about the causes and the mode of transmission of malaria still prevailed among the caregivers, as 0.3% of them stated that eating too much and having close contacts with a person who has malaria can cause malaria. Furthermore, 4.0% of them stated other misconceptions about the cause of malaria, such as eating too many oranges, not washing hands regularly, cold and flu, dirty hands and feet, flies, drinking too many sweet/soft drinks, etc. While 86.6% of the caregivers stated that bushes/dirty places were convenient resting/breeding places for mosquitoes, followed by stagnant water (51.1%), and dark places/sheds (11.7%).

Attitudes
As summarized in Figure 3 and Supplementary file S4: Table S2, although 90.0% of respondents believed that malaria was a very serious health problem, 3.1% still said, "No", 5.4% said, "Not sure", and 1.4% said, "Don't know". A total of 77.7% said that they and their children slept under bed nets, while the rural caregivers (85.3%) had a significantly more positive attitude than the urban (69.9%) (p < 0.001). Explaining their children's lack of bed nets, 46.2% caregivers mentioned that they could not afford them, 32.1% said they were not readily available, 6.4% did not like sleeping under bed nets, 3.8% thought it was not important, and 11.5% stated other reasons such as the statements that they and their children would have allergic reactions or sweat a lot whenever sleeping under bed nets (Supplementary file S4: Table S2, Figure 4). Moreover, when asked about how often their children used the bed net, 85.7% stated always and 14.3% sometimes, but 21.7% did not think the bed net was treated with insecticide. Meanwhile, 88.0% of the respondents thought that malaria-transmitted mosquitoes bite mostly at night. ACTs were considered as the best treatment for malaria by 65.1% caregivers, but 32.0% said, "Don't know", and 1.4% also shared other opinions such as injections, intravenous solutions, etc.

Practices
As shown in Figure 3 and Additional file S5: Table S3, although 77.1% of respondents would go to a hospital or a clinic if their child had a fever, 19.4% still preferred to first selfmedicate at home, and 3.4% would go to a pharmacy first. As stated by 93.4% of the caregivers, the most important factor influencing their action to seek medical help was the condition of the child, followed by perceived cost involved (3.7%), and time availability (1.7%). Furthermore, only 54.6% of the caregivers would seek medical attention for their febrile children within 24 h, whilst 45.1% usually waited for 2-5 days. Meanwhile, when an antimalarial medication had been prescribed, only 71.4% of caregivers mentioned administration of a complete treatment course, but 12.9% stop administration as soon as the child began to show improvement. There was a significantly higher rate among the urban caregivers (79.8%) who performed a complete treatment course than among the rural (63.3%) (p < 0.001).
Regarding the use of protective measures against malaria-transmitted mosquitoes, the most common practices employed by 61.1% of respondents was sleeping under ITNs, the rural caregivers had a significantly higher rate of ITNs use than the urban (70.1% vs. 52.0%, p < 0.01) (Figure 4). However, we observed that misuse of bed nets, such as using them for doing pond fishing and covering backyard gardens, is still common-especially in rural and provincial areas of Sierra Leone (Additional file S6: Figure S1). Other common selections for protection included using mosquito repellant (40.9%), regularly cleaning the surroundings of the house (31.7%), wearing protective clothing (25.1%), and using insecticide spray (24.9%). Only a few caregivers said that they got rid of stagnant water (8.3%) and cleared bushes around the house (3.4%), with 11 (6.4%) of them residing in WAU and only 1 from WAR (0.6%). Additionally, 6.0% of caregivers mentioned other protective measures, such as closing the windows and the doors early before dark, fixing a mesh on

Practices
As shown in Figure 3 and Supplementary file S5: Table S3, although 77.1% of respondents would go to a hospital or a clinic if their child had a fever, 19.4% still preferred to first self-medicate at home, and 3.4% would go to a pharmacy first. As stated by 93.4% of the caregivers, the most important factor influencing their action to seek medical help was the condition of the child, followed by perceived cost involved (3.7%), and time availability (1.7%). Furthermore, only 54.6% of the caregivers would seek medical attention for their febrile children within 24 h, whilst 45.1% usually waited for 2-5 days. Meanwhile, when an antimalarial medication had been prescribed, only 71.4% of caregivers mentioned administration of a complete treatment course, but 12.9% stop administration as soon as the child began to show improvement. There was a significantly higher rate among the urban caregivers (79.8%) who performed a complete treatment course than among the rural (63.3%) (p < 0.001).
Regarding the use of protective measures against malaria-transmitted mosquitoes, the most common practices employed by 61.1% of respondents was sleeping under ITNs, the rural caregivers had a significantly higher rate of ITNs use than the urban (70.1% vs. 52.0%, p < 0.01) (Figure 4). However, we observed that misuse of bed nets, such as using them for doing pond fishing and covering backyard gardens, is still common-especially in rural and provincial areas of Sierra Leone (Supplementary file S6: Figure S1). Other common selections for protection included using mosquito repellant (40.9%), regularly cleaning the surroundings of the house (31.7%), wearing protective clothing (25.1%), and using insecticide spray (24.9%). Only a few caregivers said that they got rid of stagnant water (8.3%) and cleared bushes around the house (3.4%), with 11 (6.4%) of them residing in WAU and only 1 from WAR (0.6%). Additionally, 6.0% of caregivers mentioned other protective measures, such as closing the windows and the doors early before dark, fixing a mesh on window and door frames to keep mosquitoes out, etc., (Figures 3 and 4, Supplementary file S5: Table S3).

Effects of Socio-Demographic Characteristics on KAPs
Through univariate analysis, the association of socio-demographic and malaria-related KAPs were demonstrated by comparing with referred groups (Table 3). The dependent variable of the univariate analysis is the levels of KAPs, which was scored and categorized into two levels according to the designed scoring system (Supplementary file S7: Table S4). The age, religion, educational background, and occupation were found to correlate with knowledge. The caregivers in the >30 year-old group tended to have higher knowledge than the 15-20 year-old group (OR = 3.03, 95% CI = 1. 35-7.28). In comparison to the Muslim caregivers, Christian faith was positively associated with knowledge (OR = 2.20, 95% CI = 1.29-3.86). The caregivers with a secondary education had higher knowledge than the group with no education (OR = 1.94, 95% CI = 1.15-3.28). Meanwhile, compared with the unemployed caregivers, students knew more malaria-related information (OR = 3.04, 95% CI = 1.20-9.33) but represented a negative practice (OR = 0.22, 95% CI = 0.07-0.56). As for attitudes, age, educational background, and district (urban or rural) were inferred to be associated. A positive association with attitudes was found in the respondents with a university education (OR = 4.46, 95% CI = 1. 42-19.73) and the rural caregivers (OR = 1.83, 95% CI = 1.14-2.96), but a negative association was found in the caregivers of the 21-25 year-old group (OR = 0.39, 95% CI = 0.19-0.76).  Furthermore, independent predictors of KAPs were inferred by a multivariate logistic regression analysis comparing referred groups (Table 4). Age, religion, education, and occupation were found to be independent predictors for malaria-related knowledge. The following groups were more likely to have a higher knowledge of malaria: 26-30 year olds (OR = 2.14, 95% CI = 1.02-4.55), >30 year olds (OR = 4.83, 95% CI = 1.95-12.69), caregivers with a secondary education (OR = 2.34, 95% CI = 1.32-4. 19), Christians (OR = 2.28, 95% CI = 1.30-4.14), and students (OR = 2.98, 95% CI = 1.12-9.48). Meanwhile, district, education, age, and relationship were found to be independent predictors of malaria-related attitudes. Rural caregivers (OR = 1.97, 95% CI = 1.20-3.28) and the group with a higher education (university level, OR = 5.53, 95% CI = 1.67-25.54; secondary level, OR = 1.86, 95% CI = 1.05-3.30), were more likely to have a positive attitude toward malaria, while caregivers in the 21-25 year-old group (OR = 0.40, 95% CI = 0.19-0.79) and fathers (OR = 0.19, 95% CI = 0.04-0.80) were more likely to have negative malaria-related attitudes. Meanwhile the relationship, occupation, and marital status were taken as independent predictors for malaria-related practices. The mothers seemed more likely to have better practices toward malaria control and prevention as compared to the fathers (OR = 0.19, 95% CI = 0.04-0.80). The caregivers who were students (OR = 0.11, 95% CI = 0.01-0.55), married (OR = 0.53, 95% CI = 0.29-0.97), or in a consensual union (OR = 0.30, 95% CI = 0.12-0.74) were more likely to have bad malaria-related practices.

Knowledge
In our study, the respondents in the Western Area in Sierra Leone received malaria related information mainly from health workers/facilities followed by radio as similar to previous studies [11,18], while 26.6% of respondents named other sources of information, such as community sensitization, meetings, and announcements, in accordance with the study conducted in Swaziland [11]. Only a few caregivers mentioned TV and printed materials (billboards/handbills, etc.) as sources, even fewer received the information from the internet or from social media, which might be due to limited accessibility to, and the high cost of, internet technologies in Sierra Leone. However, in Saudi Arabia, the main source of malaria related information was recorded from the internet and social media [12]. Additionally, even when confronted with very limited financial and human resources for healthcare in the 1950s in China, the cooperation among different sectors and paramedics, such as barefoot doctors at the village level, played a very important role in schistosomiasis control programs [23]. As for our references, therefore, more effort in Sierra Leone should be given to enhance caregivers' knowledge by continuously improving the content, type, and media of malaria related messages so as to facilitate the establishment of an effective community-coordinated health-education network and thereby achieve proper health education coverage for various groups in the urban and the rural regions. A highly effective mean could be developed by training paramedics at the community level using audio-visual messages in simple local languages for the caregivers to facilitate communication, especially for those not, or under, educated. In addition, the media infrastructure of the communities such as the radio, TV, and internet, or social media platforms, also need to be gradually improved upon in the course of local socio-economic development.
With regard to malaria, fever is the highest known symptom followed by other symptoms, such as weakness, dizziness, dark colored urine, etc., which were mostly mentioned by the respondents. Fever was recorded as the most known and common symptom of malaria in children under-5 in Cabo Verde and Zambia [2,13]. Other symptoms such as anemia were most associated with malaria in children under-5 according to reports in Tanzania [24,25]. Similar to other surveys [26,27], our study revealed that approximately 90% of the respondents knew malaria was transmitted through the bite of an infected mosquito. However, some misconceptions about the cause and the transmission of malaria was mentioned by some caregivers, such as eating too many oranges, not washing hands regularly, catching a cold and flu, dirty hands and feet, flies, drinking too many sweet/soft drinks, etc. The other misconceptions of malaria transmission, including prolonged sun exposure and drinking dirty water, were also reported in Tanzania and Uganda [24,28]. Regarding the resting and the breeding places of mosquitoes, bushes/dirty places and stagnant water were the most frequently mentioned by the respondents, which is consistent with previous study in Tanzania [29].

Attitudes
In the present study, malaria was known as a very serious health problem by 90% of the caregivers, similar to previous surveys in south-western Saudi Arabia and in Rwanda [30,31]. That malaria-related mosquitoes bite mostly at night time was recognized by 88% of the respondents. This kind of attitude is expected to influence the caregivers to be more vigilant, especially at night, in protecting their children from mosquito bites, but the most important thing was to get rid of mosquito breeding sites and to sleep under an ITN. Recent studies [32,33] agree the idea about the time-of-day of blood-feeding and malaria transmission by mosquitoes being mostly at night time. Compared with an earlier report of the Sierra Leone Demographic Health Survey (SLDHS) in 2013 that only 49.5% of children under-5 slept under a bed net at night [34], our findings showed that 77.7% of the respondents together with their children slept under bed nets. Yet, 78 caregivers still claimed that they did not use the bed net, 46 among them stating that they could not afford it. These are most likely individuals who are socioeconomically disadvantaged, and they are probably waiting for donation campaigns of the usual mass mosquito nets, as some even mentioned that they were not supplied with bed nets at their community health centers or claimed that mosquito nets were not readily available, which means they could probably afford it but could not easily find one to purchase. In essence, some of these common barriers to the use of bed nets have also been discovered by other studies [35,36]. Moreover, 21.7% of the caregivers still do not know anything about ITNs. Meanwhile, ACTs are recommended by the WHO, provided by the health facilities of governments, and even sold in pharmacies and drug stores nationwide as a part of the first-line anti-malaria treatment policy in Sierra Leone [9,37]. Yet, 32% of the caregivers said that they did not know ACTs are the best treatment for the disease.

Practices
Every respondent in this study stated that they employed at least one method of prevention against mosquito bites, with the highest being sleeping under an ITN, followed by using mosquito repellants, and regularly doing clean-up around the house, in accordance with the records in Kenya [38] and Zimbabwe [39]. The other preventive measures, such as wearing protective clothing, using insecticide sprays, getting rid of stagnant water, clearing bushes around the houses, and using mosquito barrier nets on windows and doors, etc., mentioned by the caregivers as good and effective strategies for vector control, are in line with previous study [40].
A good anti-malaria practice is also supported by previous studies [41,42], which have shown that 77% of caregivers come to the hospital first when the child has a fever. From the epidemiological and clinical perspective, fever is not only a crucial indicator of malaria, especially in children, but it may even be the most important warning indicator for administering treatment as recommended by WHO and the Sierra Leone NMCP, especially for the government to offer free health care services for children under-5 [43]. However, as a priority, some caregivers preferred self-medicating or going to a pharmacy when their child presented a fever, which is a dangerous practice that predisposes the sick child to a possibly worse situation. Other studies in Uganda [41] and Myanmar [44] have also found poor care-seeking behaviors for fever cases in children under-5. In our study, furthermore, more than 93% of the caregivers were influenced to seek appropriate medical care upon the conditions of their children, and some of the caregivers also mentioned during further explanations that they would decide to go with their child(ren) to the hospital only if they saw no improvement after self-medicating and observation for a few days. A similar finding was observed in a study done in Sudan, where some parents postponed seeking medical care for their child(ren) for a few days causing the child(ren)'s conditions to deteriorate by the time of going to a medical facility [45]. Nevertheless, our findings showed that approximately 54.6% of the caregivers did seek appropriate medical care within 24 h for their feverish child(ren). As follow-up therapeutic care, 71.4% of the caregivers completed a full course of antimalarial medications as well as the follow-ups, which is very important in maximizing antimalarial efficacy with respect to dosing regimens and preventing relapse. However, 12.9% suspended the administration of antimalarials as soon as their child(ren) showed a little improvement in their clinical symptoms and signs and, surprisingly, some even said they administered the medication to other siblings, all of which are considered harmful practices. Another critical point worth our attention is that previous studies [46] have confirmed the resistance to ACTs in some parts of the world such as South-East Asia, and they have also pointed out that the reduced efficacy has raised major concerns about malaria treatment and control. For this reason, it is essential to follow correct dosing regimens as prescribed in order to limit the spread of antimalarial resistance.

Correlation among Malaria Related KAPs
Although some studies have found that high knowledge about prevention is poorly reflected in practice [11,47], some other studies [48,49] have found that a high or an increased knowledge of malaria and its mode of transmission and infection could promote and improve preventative practices in communities where malaria is highly prevalent. Our findings indicated that good knowledge on malaria might lead to positive attitudes, and better attitudes might facilitate good practices against the disease.

Correlation between Caregivers' Socio-Demographic Characteristics and KAPs
The majority of the caregivers of children under-5 in this study were young mothers (<30 year-old), including 33 younger students, and 27.1% of them lacked any educational experience. Financially, most of them were unemployed and underprivileged: even among the 44.3% employed caregivers, some were self-employed, mostly engaged in petty trading and low income businesses from which they could hardly earn enough to meet their basic daily needs. For a relatively immature parent that is socioeconomically handicapped, having the right malaria related KAPs might make up for their deficiency in maturity and their socioeconomic disadvantages [50]. However, being a mother did result in more positive attitudes and practices toward malaria prevention and control than being a father, which supports why only women were engaged in most previously conducted studies on malaria perception or prevention and attitudes [51,52]. Meanwhile, having at least a secondary level of education was found to be associated with a positive influence on malaria related attitudes and knowledge, which is consistent with previous studies [10,53]. Yet, in Zambia, Nzooma et al. [14] reported that higher levels of education were not related to higher knowledge levels and good practices toward malaria control. Our findings indicated that the student mothers might know more but do less.
Moreover, only 1.2% of urban caregivers expressed their unawareness of the lethality of the disease, whereas the number for rural caregivers was over four times higher (5.6%). It is interesting to note that significantly more urban caregivers (79.8%) followed a complete malaria treatment course of ACTs than the rural (63.3%). However, in view of using ITNs for malaria prevention, the rural caregivers (85.3%) presented significantly more positive attitudes than the urban (69.9%), and the rural (70.1%) therefore represented better practices than the urban (52.0%).

Conclusions
The present KAPs survey toward malaria prevention and control indicates, to some extent, that misconception of the cause, transmission, and clinical symptoms, unawareness of the lethality and severity, and inappropriate behaviors in prevention and treatment, including self-medicating, are still in existence among caregivers of children under-5 in the Western Area of Sierra Leone. The KAPs toward malaria are affected by caregivers' educational background, occupational status, parenthood, living region, and religion. Positive correlations in knowledge-attitudes and attitudes-practices are evidently demonstrated. Therefore, in order to better protect children under-5 against severe and deadly malaria, their caregivers, especially young mothers, need such prior supports as increased education and employment opportunities. Meanwhile, there is also a need to set up an accessible community-based counselling service toward malaria and to construct an effective community-based communication channel, especially for caregivers of children under-5. The present study may facilitate the implementation of integrated malaria control strategies, especially dealing with malaria infections in children under-5.

Limitations of this Study
Despite its efficacy in enhancing the understanding of KAPs toward malaria, the present cross-sectional survey did not investigate the cause and the effect of malaria in children under-5. Meanwhile, the survey was conducted by self-reporting, which may cause discrepancies between the reported behaviors, participants' responses, and actual behaviors due to interviewer bias, participant bias, or response bias. Finally, another possible bias may be derived from the selection of the chosen hospitals or health centers.

Supplementary Materials:
The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/tropicalmed7070120/s1, Supplementary file S1: KAPs questionnaire designed for the caregivers of children under-5; Supplementary file S2: Scoring system; Supplementary file S3: Table S1: Comparison of knowledge toward malaria between caregivers living in rural and urban districts; Supplementary file S4: Table S2: Comparison of attitudes toward malaria between caregivers living in rural and in urban districts; Supplementary file S5: Table S3: Comparison of practices toward malaria between caregivers living in rural and in urban districts; Supplementary file S6: Figure S1: Images of mosquito bed net misuse in Sierra Leone; Supplementary file S7: Table S4: KAPs levels of caregivers toward malaria control/prevention based on the scoring system. Institutional Review Board Statement: The sealed Ethics Committee or Institutional Review Board approval of this study was obtained from the Sierra Leone Ethics and Scientific Review Committee, and the Approval Date was 16 August 2019.

Informed Consent Statement:
The approval and the permission of the medical director, superintendent, or hospital manager of the various selected hospitals were also sought and obtained for this study. Data collection was done using the study questionnaire and through a face-to-face interview method organized by Joan Mabinty Koroma. After gaining ethical clearance and permission from the respective authorities, caregivers who visited the out-patient department of the selected hospitals and met the inclusion criteria were approached and asked for their consent to partake in the study. The purpose of the study was explained to them and those who gave their consent to take part did so by signing or thumbprinting the informed consent, and they were assured of confidentiality before proceeding.

Data Availability Statement:
The datasets used and analyzed in the study are available from the corresponding author on reasonable request.