In this study, we found that relatively small percentage of febrile patients visiting Chagni health center had microscopically confirmed malaria parasitemia. The overall malaria positivity rate was 7.3%. This figure is comparable with the result of the study done in Kombolcha health facility, north-central Ethiopia that reported a prevalence of 7.52% . Nonetheless, the finding of this study contradicts with previous studies from southern and northern Ethiopia, reported overall malaria positivity rates between 11.5 and 28.1% among patients visited health facilities [5, 24, 25]. Possible factors for observed variations might be differences in the time of studies, microclimate, altitude, community awareness about malaria bed net application, its transmission, and health seeking behavior, and malaria intervention practices.
The dominant Plasmodium species detected in the current study participants was P. falciparum. This finding is congruent with national figures and other similar studies in parts of Ethiopia that reported preponderance of P. falciparum than P. vivax [3, 8, 26, 27]. However, this is incongruity with the previous report from Jimma Town, which reported a higher prevalence of P. vivax than P. falciparum . The reason why P. falciparum dominated over P. vivax in the study area could be related to drug resistance pattern, and gap of program performance.
In the present study, more males (55.4%) were affected by malaria than females (44.6%). This finding is concurrent with studies from several localities in Ethiopia that reported higher malaria burden among males than females [23, 26, 27]. The higher prevalence rate in males might be due to the fact that males are usually engaged in outdoor activities at dusks and dawns, coinciding with the peak biting hours of the exophagic mosquito species. In addition, males often travel as seasonal migrant laborers to different malarious parts of Ethiopia to perform agricultural activities, thereby exposing them to the higher risk of contracting malaria infection. Conversely, this was not similar with a study conducted in Amhara region where the prevalence of malaria was relatively higher among females (60%) than males (40%) .
Regarding the age groups, the burden of malaria morbidity was more concentrated in the adults of age 15 and above. Studies elsewhere in Ethiopia have also shown that the risk of malaria infection varied by age with some reporting more susceptibility to malaria infections among males in the age groups > 15 years [7, 26, 27, 30]. The contributing factors for such higher burden of disease among adults might be due to their frequent engagement in different activities like agriculture, trade and other occupational risks that increase the exposure to infective mosquito bites. Lower cases of malaria in children under 5 years of age was detected, which could be linked to their reduced exposure to infected mosquito bite due to good malaria awareness and control and prevention practices by their guardians.
The results revealed that most of the respondents (97%) had ever heard about malaria and similar number of respondents believed that malaria is one of the serious diseases of the community, which is in line with previous reports in Ethiopia and elsewhere [20, 31, 32]. Study subjects also cited that the most common source of information about malaria was mass media (radio and television) (86.1%), followed by health facility education (13.9%), indicating that these communication channels are essential vehicles to deliver malaria-related information to the community. Elements of IVM such as community malaria education using mass media such as radio and TV have been implemented by the National malaria control program since 2006 . This is similar with those previously reported results from Africa, in which over 90% of individuals in malaria endemic areas are aware of malaria and that mass media (television and radio) and health education by health facilities are the most commonly cited source of malaria information sources [34, 35].
Mosquito bite has been identified as the principal malaria transmission as shown in some studies in Ethiopia and elsewhere in Africa [18, 20, 34,35,36,37]. In Ethiopia, regular practice of awareness creation in the communities about health issues through health extension workers and mass media such as radio and television brought remarkable behavioral changes in the control and prevention of communicable diseases . It can be presumed that this factor has contributed to the high level of awareness observed in the study participants regarding the causes and transmission of malaria in the area.
Fever, headache, chills and shivering, loss of appetite and vomiting were mentioned as sign and symptoms of malaria. Similar results were found from different KAP studies in other regions of Ethiopia [18, 20, 36, 38]. Prominently, large majority of subjects linked mosquito biting time during night time and their main breed sites to stagnant water, which is comparable with previous studies in Ethiopia and elsewhere [33, 37, 38]. This correct understanding of mosquito behavior among participants of the present study is encouraging to implement appropriate malaria preventive measures and for the proper utilization of ITNs.
Similar to other studies in Amhara region and other parts of Ethiopia [18,19,20, 39], great majority (97%) of participants believed that malaria is preventable and curable disease. Taking drug, use of mosquito nets, drain stagnated water (mosquito breeding sites), and house spay with insecticides were the main types of malaria preventive measures frequently reported by the present study participants. This is in line with previous reports from Tanzania  and Iran .
Around 91.4% of participants go to the nearest health service within the 24 h upon the occurrence of the first malaria symptoms. This was further substantiated by the observation that about 91.4% of participants sought treatment at health facilities, suggestive of a good practice of treatment-seeking behavior at health structures. Generally, treatment seeking behavior for malaria diseases showed improvements across the country in recent reports . However, the commitment among few participants to bring people with fever to health facilities within 24 h since the onset of clinical symptoms remains low, and that they rely on the use of self-administered drugs and traditional medicines, which are common practices in parts of Africa [18, 34, 41]. Treatment seeking behavior is important for early case detection and management so that transmission would be reduced. Therefore, promotion of health education to raise awareness is very crucial to direct the wider community to seek timely treatments at the health structures earlier upon the occurrence of malaria symptoms.
This study also demonstrated that around 98% of participants had least one ITN, of which 75% of them claimed that they slept under a bed net the previous night, which is consistent with previous studies elsewhere in Ethiopia [19, 38, 42]. Yet, quarter of the respondents did not use bed net the previous night. It is strongly envisaged that ITN ownership itself will have little impact on the burden of malaria unless people regularly use it. Factors such as lack of access to ITNs, discomfort due to heat, fear of burning sensation, low level of awareness about its benefit, and lack replacement schemes for worn out ones were cited as the reasons for not using ITNs in this study. Scaling up community awareness through health education has proved to be effective and has effectively alleviated misconceptions on malaria disease, its transmission, and prevention practices [33, 43, 44]. The study further showed that most of the communities give priority for pregnant mother and children to sleep under bed net, which is comparable with results reported from other studies elsewhere in Ethiopia [20, 36].
Our data also showed that IRS is one of the most important malaria prevention methods practiced in the locality with the overall coverage of 99%. Houses of more than 77% of the respondents get sprayed during spraying campaign, result that is comparable with the reports from Jiga area and Shewa Robit district of north-western Ethiopia [6, 18]. This result asserts the demand to expand the coverage and frequency of IRS in malaria endemic areas in order to achieve an already targeted plan of 100% spraying of households before and throughout the transmission for effective prevention and control of malaria .
Limitations of the study design and the methods of data collection might create some potential for biases in this study. The cross-sectional design of the study with a focus of recruiting participants who sought healthcare might have influenced their knowledge and practices in malaria prevention and treatment. In addition, data collection relied on information given by the interviewees so that practices such as presence and use of ITN or treatment seeking practices could not be verified.