Knowledge, Attitudes and Practices Among Adult Malaria Patients Co-Infected with Opportunistic Intestinal Coccidian Parasites in Fundong Health District, Northwest, Cameroon: A Cross Section Study Design

: Introduction :


Introduction
Malaria still remains a public health concern globally with Sub-Sahara Africa (SSA), bearing the greatest burden of the disease. Globally, in 2021, there were 249 million cases reported and 619,000 million deaths were registered, with 234 million cases and 593,000 deaths reported in the Africa region alone (World Health Organization, 2022). Cameroon lies within the endemic area of high malaria transmission, whereby everyone is at risk of malaria infection (Antonio-Nkondjio et al., 2019). In 2021 over 6.6 million cases of malaria were reported with a slight increase in incidence, with 13,839 deaths, a decrease from the 2020.
Malaria and intestinal parasites affects the poorest and impoverished communities in low and middle income countries. Nearly 50% of hospitalization and 22% of annual deaths in Cameroon are due to malaria .
Today intestinal parasites (IPs) are considered one of the most prevalent infectious diseases affecting mankind (Harhay, Horton, & Olliaro, 2010). The World Health Organization (WHO), reports that there are over 3 billion people worldwide who are infected with one or more intestinal parasitic diseases (WHO, 2022).
The overlapping infections have been reported , and the risk of death is higher in patients with multiple infections of malaria and intestinal infections (CDC, 2021). There is evidence to support the integration of diseases (Standley et al., 2018) control and prevention in different settings. In Cameroon the national programme for the control of malaria and the national deworming programmes both committed to eradicate malaria and intestinal diseases however, this does not include intestinal diseases related to coccidian infection. Although runned parallel to each other, these efforts have kept malaria and www.ejtas.com EJTAS 2023 | Volume 1 | Number 4 1123 prevalence of intestinal parasites (PIPs) on a gradual decline. Malaria has witnessed a drop in prevalence over the past decade, largely due to the nationwide distribution of the long-lasting insecticides treated mosquitoes bed nets (LLITNs) (World Health Organization, 2022). The prevalence of PIPs also dropped from 33% to 27.8%, from 2006 to 2012 (Vouking et al., 2014) with lower rates in urban areas than rural. Recent studies on malaria co-infection with PIPs prevalence in Cameroon revealed 11.9% in rural setting and 3% in urban setting, clearly demonstrating the impact of knowledge on malaria and PIPs prevention and control. This shows behaviours are gradually changing as communities and individuals acquire more knowledge through health education that have continued to help them to adhere to control and prevention measures (Mekachie Sandie et al., 2021;Njunda et al., 2020).
Knowledge of the causes, modes of transmission and prevention of diseases such as malaria and pathogenic intestinal parasites have a key role in the modelling people's behaviours towards their prevention and control practices (Alharazi et al., 2020). Their understanding of knowledge, attitudes and practices towards malaria and PIPs control have improved over the years (Ming, & Huan, 2018). Some findings have revealed that poor knowledge, bad attitudes and poor practices towards a certain disease may be reluctant to implement some preventive measures and share information on the positive effects on the control of the diseases (Sazmand et al., 2020). The negative impact on individuals and communities are enormous, often resulting in the prevalence of bad practices such as selfmedication, use of street drugs, low ability to seek medical care and high tendency to use traditional medicine, improper use and low frequency of sleeping under the insecticide treated bed-nets (ITNs). In some settings, environmental hygiene, faecal contamination of food, and drinking water, have been reported Assob et al., 2012;Zvinorova et al., 2016;Same-Ekobe, 1997).
Knowledge of malaria co-infection with new emerging intestinal diseases such as those caused by coccidian parasites (Warren, 2009) is still very low in many communities in Cameroon. This requires that health educational campaign need to be evidence based and adapted to address new emerging public health threats. This study aimed to investigate the knowledge, attitudes, and practices of adult malaria patients suffering from multiple co-infections with intestinal coccidian parasites in the Fundong Health District (FHD) in Northwest region of Cameroon. The data generated will support evidence for innovative development of malaria-PIPs control strategies in Cameroon.

Study Site
The FHD is located between latitude 6° 4'and 6°23' to the North of the equator and longitude 10° and 10° 33' to the East of the Greenwich Meridian and its attitude ranges from (800-2500m) above sea level (Kamga et al., 2011). The FHD is located 80km to the North West Regional Capital city of Bamenda. Most of the settlements are rural (80%) with over 250,000 inhabitants who are mainly peasant farmers. Both men and women are involved in plantation and agricultural activities along the fertile slopes characteristic of the area. The Fulani men are involved are herdsmen involved mainly in cattle raising in the occupying the hilly terrains that surrounds most of the area. It is found within the malaria high risk zones in Cameroon with moderate levels of transmission during and just after the rainy season which begins in March and ends in early October. Malaria prevalence in the region is 10% (MOH, 2018;National Institute of Statistic, Cameroon, 2022). The tropical climate makes it a favourable environment for the malaria vector to thrive. A vast majority of the population are poor, creating a favourable condition for intestinal diseases to thrive (World Bank, 2019). The prevailing poor hygiene and sanitation, as well as the low socio-economic status of the inhabitants, that exist in the region and Cameroon as whole, exposes the population to the risk of water borne infections and opportunistic parasitic diseases in particular (Nsoh et al., 2016).

Study Population
Only adult malaria patients who signed the informed consent and willingly accepted to be www.ejtas.com EJTAS 2023 | Volume 1 | Number 4 1124 tested for opportunistic intestinal parasites were recruited as participants for the study. Those who had been on antibiotics and anti-parasitic drugs two weeks prior to consultation were excluded from the study.

The Survey Questionnaire
A questionnaire designed for this study was used. The interviews were conducted by trained investigators using a uniform protocol which was set up to minimize error and bias. Baseline demographic information which consisted of sex, age, marital status, education level, location. Information about knowledge, attitudes and practices related to malaria and intestinal coccidian parasites was collected. Information was also collected on travel history of participants.
The questions on knowledge included; if the participants were aware of malaria, the signs and symptoms, its causes, mosquito behaviour such as breeding and resting sites, frequent biting time, its transmission and prevention.
Questions on attitude included health seeking behaviours and on prevention. Questions on practice including practices related to prevention. Similarly, questions on knowledge of coccidian parasites, attitudes and practices related to intestinal coccidian prevention were included.
For the qualitative component of the study, questions included on the awareness of malaria and coccidian parasites, transmissions, treatments and their prevention. In-depth interviews were conducted using a semistructured interview guide. Using face to face interviews and in the English language, Kom, and Fulfulde, data was collected from participants. After interviewing 9 participants, data saturation was achieved.

Specimen Collection and Processing
Upon signing the consent form to participate in the study, participants were instructed on the procedure to follow to collect their stool samples. Each participant collected a teaspoon full of stool sample into a labelled sterile stool container. In addition about 4 mL of whole blood was collected into an EDTA anti-coagulated tube to perform to complete blood count (CBC). Thick and thin films were prepared for malaria microscopy. The HIV test was also performed on the blood samples to determine the HIV status for participants who voluntarily accepted to do so.

Parasitological analysis
Detection of malaria parasites were obtained by preparing a thick and thin film on glass slides. Both films were allowed to air dry for approximately 30 minutes. Methanol was used to fix the thin blood films, followed by staining with 10% Giemsa for 45 mins according to established standards (Berzosa et al., 2018) and carefully examined under a microscope by trained laboratory scientists. If parasite was observed, the density was determine using the procedure described (Njunda et al., 2020).
Stool was analysed using the normal saline wet mount and formol-ether concentration techniques as described by Cheersbrough (2006).

Data Analysis
Data collected were entered into Microsoft excel, 2016 (Microsoft Corporation Inc. USA), and transported to the Statistical Package for Social Sciences version 26.0 (IBM-SPSS, Inc., Illinois, USA). Descriptive statistics were used to summarise the data in tables. Categorical data, was presented using frequencies, counts, and percentages. Continuous variables such as attitudes were summarized using means and standard deviations. Association between categorical variables were tested using Chisquare (χ 2 ) and Fisher's exact tests. Comparison of proportions was done using cross-tabulations Pearson product-moment correlations were performed to observe associations between attitudes and practices. Computed mean scores were also compared to the score range on the Likert-scale table to make inferences on the overall attitudes of participants. Univariate and multivariate logistic regression models were used to identify predictors of knowledge and practices towards malaria and intestinal coccidian parasite prevention. A p-value of 0.05 or less was considered statistically significant.

Ethical Consideration
The study was approved by the Institutional Review Board of the Faculty of health Sciences, University of Buea, Cameroon. Administrative clearance was obtained from the regional delegation of public health for the Northwest Region of Cameroon. All study procedures were conducted according to good clinical practice. All eligible participants were asked to provide their consent by signing an informed consent form before enrolment in this study.

Participants' Knowledge of Malaria, Causes and Modes of Transmission and Prevention and Health Seeking Behaviours
A total of three hundred and sixty-seven ( On participants' health seeking behaviours, a majority 288/330 (87%) indicated that they will visit a health facility to consult only depending on the severity of the illness and 21/330 (6%), were concerned about the cost of treatment before visiting a health facility to seek healthcare services. Questioned on where malaria can be best managed, 1% indicated traditional medicines, 121(37%) indicated health facility and (7%) stated self-medication. On the knowledge of clinical symptoms, fever was the most widely known clinical symptom mentioned by participants 286(87%), followed by diarrhoea 127/330 (38%), vomiting 98/330 (30%), and body weakness 35/330(11%).
A statistically significant difference in knowledge score was observed among those who knew the causative agent for malaria was Plasmodium species, (P-value=0.011) and among those who knew mosquito resting places for malaria vector were the dark corners (P-value=0.019). There was a statistically significant difference observed in the knowledge score among those who knew that ways to prevent the mosquito from multiplying in their breeding sites was to a) clean the surroundings of the house b) clear the bushes around human dwelling environments. (P-value=0.003).

Participants' Socio-Demographic Factors Associated with Knowledge and Practices Towards Malaria and Coccidian Parasite Prevention
Sex and occupation were not associated with knowledge score of participants on environmental risk factors associated with opportunistic intestinal coccidian parasite transmission ( 1128 knowledge of environmental risk factors as transmission routes for intestinal coccidian parasites significantly increased with age. The younger age groups were more knowledgeable than adults. The area of residence, marital status and the level of education were significantly associated with participants knowledge score in the study.

Participants' Attitudes Towards Hygiene and Sanitation Practices Associated with Transmission of Coccidian Parasites
Some appropriate attitudes were demonstrated by participants towards bad hygiene and sanitation practices. These facilitated the transmission of coccidian parasitic infections in the population. A majority of participants 'agreed' to the statement 'boiling water before drinking removes diseases causing micro-organisms' [95% CI: 1.78-1.9] with a mean score of 1.84. Similarly, a majority neither agree nor disagree to the statement that "waste can be a breeding sites for flies and rodents" [95% CI: 2.41-2.62] with a mean score of 2.51, and also a majority of the participants disagreed to the statement: "Human waste from filled latrines should be emptied into rivers as good practices to get rid of waste from homes". A similar positive attitude was expressed when a majority also agreed to the statement that "defecating in water can lead to water borne diseases" (Table 4).

Participants Practices on Hygiene and Sanitation Towards Malaria and Coccidian Parasitic Prevention and Control
Participants who were found co-infected with both malaria and coccidian intestinal parasites were assessed on a wide range of practices that increases the risk of malaria-intestinal coccidian co-infection ( 1129 scores on practices to prevent malaria and coccidian infections, P-value <0.05 at the 95% confident interval (Table 6) P-value=0.052, P-value=0.051, P-value=0.019).

Association Between Knowledge and Attitudes and Between Attitudes and Practices Towards Prevention of Malaria and Coccidian Parasites
The link between knowledge and attitudes and between attitudes and practices scores were assessed. Significant associations were observed influencing knowledge and attitudes scores and between attitude and practices scores. The knowledge of the OIPs found in unsafe water was significantly associated with source of drinking water score P =0.001. Increase in knowledge of OIPs can be found in unsafe water by participants was associated with increased use of water from protected drinking sources with an odds ratio of 3.8 (95% C.I: 2.2-6.6). Increase in knowledge of swimming pools can be a source of infection for intestinal coccidian parasites was associated with increase in the use of protected water sources for drinking with an odds of 2.0 (95% C.I: 1.2-3.3). An increase in the knowledge that OIPs found in unsafe water was associated with a decrease use of hand washing facilities in the households with an odds of 0.3 (95% C.I: 0.2-0.5) Similarly, an increase in the knowledge of swimming pools being the source of coccidian parasites was associated with a decreases use of hand washing facilities in the households with an odds ratio of 0.3 (95% C.I: 0.2-0.5).

Discussion
This study was undertaken to provide information on the prevalence of pathogenic gastro-intestinal parasites in adult malaria patients, and to assess their knowledge attitudes and practices towards malaria and coccidian parasite prevention and control. We therefore incorporated the knowledge, attitude and practice survey which is recommended by the World Health Organisation as an important tool for health promotional campaigns. Surveys are very important in programme implementation as it helps planners adjust their educational messages aimed to improved public knowledge and attitudes towards any public health concern.
Where there is insufficient knowledge and negative attitudes prevailed, bad practices are bound to significantly contribute to high prevalence of diseases (Hassen Amer, Ashankyty, & Haouas, 2016). In our study we found varied knowledge scores of malaria and coccidian parasite among study participants. Poor practices as well as better practices were observed. Participants portrayed positive attitudes towards environmental hygiene and sanitation. Causes of malaria, mosquito resting places, and ways to prevent mosquito breeding sites, coccidian parasites can be found in unsafe water, people more susceptible to coccidian infection significantly predict the knowledge score. Materials used for hand washing, source of drinking water, and ITN usage significantly predict the practice scores. Significant correlation were also observed between knowledge-attitudes and between attitudes and practices. A Pearson product-moment correlation coefficient revealed significant correlations between attitudes and practice scores r=0.210, P-value=0.001, r=0.174, P-value=0.002., r=0.203 P-value=0.001, and between knowledge and attitude scores (r= -0.177, P-value=0.001, r= -0.133, P-value=0.015).

Knowledge of Malaria Parasite
From our study, a majority of participants had a good knowledge (90%) that malaria was transmitted through a mosquito bite. However, Participants expressed very poor knowledge of the malaria causative agent (2%). Higher rates of causative agent for malaria have been obtained elsewhere in Kojom and Lehman (2018) where 14.3% was obtained and in another study Mbohou Nchetnkou, Kojom Foko, and Lehman (2020), a rate of 9.4% was also reported in Tanzania (Mazigo et al., 2010) 6% was reported. The Tanzania study and our study have similar tendency of lower rates, due to the study setting (rural) often associated with lower levels of education when compared to urban settings. In addition, it could be an indication that in health sensitization campaigns the causative agent is usually not mentioned. It could be that many of

Knowledge of Coccidian Parasites
Our study disclosed that knowledge of opportunistic intestinal coccidian parasites was poor 19.4%. Our finding of 19.4% knowledge of opportunistic intestinal coccidian parasites, was very poor when compared with the 33.5% participant awareness of parasitic food borne diseases young adults in China (Ming & Huan, 2018) and the 40.5% participant poor knowledge of intestinal parasites reported in Yemen (Alharazi et al., 2020). These differences maybe as a result in study designs and settings.
Knowledge levels were also low in our study, as 31.2% knew animals as intermediate hosts for the transmission of intestinal parasites including coccidian parasites. This was similar to a study in rural Iran where knowledge was also low as more than half of the participants were unaware of the existence of zoonotic parasites (Sazmand et al., 2020). The trend clearly demonstrated a generalised low to high knowledge of pathogenic intestinal parasites including coccidian parasites as one moves from rural community setting to urban settings within countries in the tropics and at sub-continental levels. In this study Knowledge scores significantly associated with attitudes scores which in turn associated with participants' practices. The opportunistic intestinal coccidian parasites are causing emerging diseases associated with zoonotic transmission, human-to-human transmission, food borne and contaminated water. The diseases are among the most neglected tropical diseases (NTDs). In our current study 36% of the participants lived with children less than two years at home, a low proportion (26.4%) of the participants knew EBF can limit the transmission OIPs in children and hence to adults. In Yaoundé, Cameroon a low rate of EBF (38%) has been reported (Ndum Okwen et al., 2022). Generally, the rate of EBF in Cameroon is below average (Ndum Okwen et al., 2022) and evidence showed that higher rates of EBF are being associated with low infant mortality and morbidity (Division of Nutrition, Physical Activity and Obesity, 2020; Tombang et al., 2019). In Kenya a low rate of 39.4% among adult women (Mohamed, Ochola, & Owino, 2018). Thus, improving child care and nutrition would limit the transmission of intestinal parasites hence intestinal coccidian transmission in children and from children to adult.

Attitudes Toward Malaria and Coccidian Parasites
In general, positive attitudes toward good hygiene and sanitation practices aimed at reducing malaria and transmission of intestinal parasitic diseases were expressed in this study. In Ghana, 91% of the respondents showed positive attitudes towards good hygiene practices especially hand washing practices (Omari et al., 2022). With good level of knowledge and attitudes participants are more likely to have good practices to avoid those contracting infectious diseases including intestinal parasitic diseases. Prior knowledge and exposure probably had an influence on the positive attitudes expressed. The knowledge, attitude, and practice theories suggest that the acquisition of health-related knowledge, eventually enhance one's attitudes and leads to good behaviour formation that will ultimately lead to the prevention of diseases (Mazigo et al., 2010;Liu et al., 2016: Wang et al., 2020. Our current study found a significant association between education and previous knowledge on coccidian parasites. Studies in Cameron, Nigeria, Ethiopia and Zambia, had similar conclusions in which knowledge was significantly associated with the level of education and had a significant impact on diseases prevention practices (Muhammad, Oyewole, & Dipeou, 2021;Taremwa et al., 2017;Oguntade et al., 2018;Jumbam, Stevenson, & Matoba, 2020). Those who received formal education would have been sensitized empowered with knowledge regarding common diseases, their modes of transmission and prevention. A study by Njunda et al. (2016) in Cameroon indicated that higher educational levels were associated with better attitudes. The study concludes that participants who were previously infected with malaria were more aware of the way to prevent it than those who had been exposed but had not been infected. This conclusion was also echoed by Kader et al (2022) in a similar study carried out in Malaysia. We also found gender, age, marital status, and education to be significantly associated with knowledge scores and a correlation between education levels and knowledge score. These findings are similar to those of (Muhammad, Oyewole, & Dipeou, 2021;Taremwa et al., 2017). Both studies concluded that those with good knowledge associated with higher education levels have better practices in the prevention of diseases including malaria.
During interviews positive attitudes toward diseases prevention including malaria and coccidian prevention was expressed.

Practices Towards Prevention of Malaria and Coccidian Parasites
In our study we compared the how attitudes influence participants' practices to prevent and control malaria and intestinal coccidian parasitic infections. Eight malaria preventive methods currently used for malaria prevention were reported in varying proportions. The most reported good practices enlisted in decreasing order were: ITNs usage was (89%), cutting bushes to clean the environment (34.5%), and the least was closing windows early before dark (1.5%). In Douala, Cameroon a study  showed similarly eight preventive measures for malaria were reported by respondents where the most reported preventive practice was ITNs, and in contrast the least reported practice was keeping good hygiene and sanitation. This is also contrary to a study in Malaysia whereby the most reported good practices to prevent malaria among rural indigenous people was removing stagnant water (92.3%), and the least reported was larvicide use in stagnant water where 82% non-usage (Mbohou Nchetnkou,   Njunda et al., 2016;Mekachie Sandie et al., 2021).
Over the last five years, the Government of Cameroon supported by its partners have stepped up the distribution of ITNs in all Health Districts across the country. This explains the variations observed in the study with the highest prevalence of ITN usage in our current study. Despite the nation-wide sensitization campaigns, a disparity between ITN possession and usage seems to be wide thus negatively affecting the performance in different settings in Cameroon . Improving hygiene and sanitation will ultimately lead to a reduction in the mosquito permanent breeding sites. It will also create an environment where intestinal coccidian parasites cannot thrive. Good environmental hygiene remains a key control strategy for the control and elimination of both 1133 malaria and coccidian parasitic diseases. The use of ITN, was also significantly associated with malaria infection (P-value=0.05). Practices to prevent intestinal coccidian parasitic transmission were assessed. A very low proportion of the participants (9%), practiced washing hands with water and soap. This was lower than the rate reported in Colombia where a much higher proportion of 96% (Contreras-Puentes, Duarte-Amador, & Aparicio-Marenco, 2019). 1.
In our current study 4.8% of the participants domesticated animals such as chickens, pigs, goats, sheep, and cattle. Domestic animals in the region and elsewhere in the country have been documented to be an important intermediate host in the life cycles of intestinal parasites (Eshetu et al., 2001;Nfi, 1991) with high potential to cause infections in the human population. This reaffirms the zoonotic potentials of intestinal coccidian parasites to cause pathological conditions in humans if poorly prepared meat is eaten.
Qualitatively, we obtained similar trends during interviews in the community.
"I keep domestic animal such as pigs but since the beginning of the armed conflict in this region, I do not longer vaccinate them because people have been displaced including staff in the veterinary department that I used to contact for vaccines for my animals".

2.
Our study revealed that 9% of the participants boil water before drinking, 5% drink chlorinated water, 6% expose their water to solar energy as a means of disinfecting drinking water and a much high proportion (52%) allowed water to settle before drinking. Another study in Cameroon associated water treatment in households to the socio-economic status whereby those with low levels of education, and poverty were less likely to treat their water before drinking. Studies have demonstrated that boiling water before drinking remains the only way to get rid of intestinal coccidian parasites such as Cryptosporidium hominis in drinking water (Ssemugabo, et al., 2019;Escobedo, et al., 2009).
The practice of treating water before drinking has been low particularly in rural community settings. Even though considerable efforts have been made to improve water quality in Cameroon, rural community settings have largely been ignored. Our study showed health sensitisation campaigns in Cameron have largely ignored water treatment as an important issue to educate the population on disease prevention and control. A lack of information on health and ignorance is a contributory factor to poor knowledge and poor practices expose participants in the study to the risk of malaria and intestinal coccidian infections. Intestinal coccidian diseases are new and emerging to the public requiring that public sensitization about the existence, and the threat to public health. More so outbreaks related to these parasites are unknown to the public.
Similar findings were elicited during the interviews regarding outbreaks and treatment.
"We usually witness high diarrhoeal cases between January and April each year. This period coincides with acute water shortage in my health area. People turn to fetch drinking from all sort of places you can never imagine (River, stream). Our community water taps usually run dry and our health centre relies on the borehole. Sometimes community members approach us to beg us for water from the well to drink'' Another had this to say.
"We have never bothered in making request for medications that are specific to treating coccidian infection because we do not have adequate knowledge on the disease nor the clinical manifestations. We however always have medications to treat malaria".

Participants' Health Seeking Behaviours
In this study we compared participant's knowledge, attitudes and practices to understand their influence on health seeking behaviours. Eighty-seven (87 %) percent of the participants visited a health facility for medical attention depending on the severity of the disease condition. Six (6%) percent were worried about the cost of treatment, one (1%) percent preferred a tradition healer, thirty (37%) seven Our study also revealed that age, group, gender, marital status and occupation were key determinant of observed knowledge which influenced practices that were observed. This is contrary to (Nounouce et al., 2022) where the level of education was a key determinant factor of a household health seeking behaviour. A study in Turkey by Abudu et al. (2022) reported that participants were instead worried about the cost of treatment as a key factor to have influence patients seeking healthcare. We observed that 6% of the patient co-infected with intestinal coccidian diseases had simple malaria compared to 94% with severe malaria. Delay between onset of malaria and coccidian diseases and seeking healthcare is sufficient to increase the seriousness of the illness and death since malaria has the capacity to kill within hours of onset of symptoms (Nounouce et al., 2022).
Similar findings were obtained during the interviews regarding health seeking behaviours.
"We received patients in this health facility mostly when the health condition is already deteriorating. When they start to experience symptoms of malaria, the first thing they do is buy medications from nearby vendors or visit a traditional healer. Its only when they find out that their health condition is not improving that they rush to meet us".
In this current study, a low proportion (16.4%) of participants reported hand washing using soap, while 36% were living with children less than two years. Elsewhere in Cameroon, prevalence of hand washing with soap at 10.7% (Yakum et al., 2017) has been reported. A study in Ethiopia (Abuduxike et al., 2020) revealed good compliance to hand hygiene significantly reduce the risk of intestinal infection by 52%. Children have been associated with poor hygiene practices and their risk of intestinal diseases including coccidian infection is high (Mbouthieu Teumta et al., 2019). The risk of the human-tohuman transmission of the coccidian parasite from children to the adult is also heightened.

Conclusion
Knowledge of malaria and intestinal coccidian co-infection was below average among participants.
Misconceptions and bad behaviours are were observed that exposed the population to high risk of malaria and intestinal infections. Gender, marital status, education and age were significantly associated with knowledge, attitude and practice scores.
Health education should emphasise on the causes of malaria and educating the public on intestinal coccidian parasites diseases including associated environmental risk factors. Primary healthcare services are an important entry point to make any meaningful change.

1135
Medical Officer (DMO) for Fundong Health District and Chiefs of Centre for the various health facilities where data was collected. their laboratory services. Our appreciation goes to Mr Teh Emmanuel, Young Augustine, for laboratory analysis of blood and all stool samples and all community members that participated in the study.

Authors Contributions
ANL conceived designed and coordinated the study. JFA, participated in the design of the study, review statistical analysis and revised the paper, BPT, participated in the design of the study, review statistical analysis and revised the paper, FPA participated in data collection, took part in the analysis and interpretations, and conducted the literature search and review and wrote the final draft of the paper. All authors read and approved the final paper.

Data Availability Statement
All relevant data that supports the conclusion of this study are included in the article.