EXTENT AND PATTERNS OF UTILIZATION OF INSECTICIDE TREATED BED NETS AMONG ANTE-NATAL AND NURSING MOTHERS IN UDENU LOCAL GOVERNMENT AREA OF ENUGU STATE.

CHAPTER ONE Introduction

Background to the Study

Malaria  had  accompanied human kind  for  as  long  as 5,000  years; the  first  written evidence of disease dating back to 2,700 B.C. in the Chinese medical classic Nei Chin (Claudia, Corneille, Manuela, Bocar and Olaf, 2006).   They noted that, protection techniques against insects, have also been known for ages and were used long before the malaria transmission processes was discovered.  They also emphasized that, among the oldest approaches to prevent mosquito biting, was the use of bed nets and curtains, which in the ancient Roman and Greek world simply meant the spreading of gauze and muslin curtains over places to protect insects. Besides, the ancient Persians were said to destroy insects by using a powder dried flower of a Dalmatain pyrethrum.   Claudia, Corneille, Manuela, Bocar and Olaf (2006) asserted that in recent years, these two techniques have been combined into the powerful tool of insecticide impregnated bed nets or insecticide treated net (ITNs) and curtains.  According to their report, ITNs have consistently been shown to be very effective and sustainable in reducing malaria morbidity and mortality in children of different malaria endemic areas.

Park (2007) indicated that insecticides are substances which are used to kill insects.  Park further stated that the control of anthropoid borne diseases by insecticides is one of the greatest triumphs of public health during the 20th century.  She further stated that insecticides have not only controlled  malaria,  plague, typhus and  other  diseases transmitted by  insects,  but  also brought vast economic and social benefits through better health and increased food production. Sharp,  Ngxongo, Bothn,  Ridl and  Le  Sueur  (1988)  indicated that  the  first  malaria  control

programmes in South Africa began in the 1920s with larval control.  Anti-malaria committees were set up to co-ordinate preventive measures.  The identification of larval sites was a vital part of this programme, which also encouraged the use of house screening and bed nets.  They noted that oil and Paris Green were used in larval control in the year 1930s and continue to be the main method of control until 1946.  During this period, many larval sites were drained and frequently eucalyptus trees were planted in order to remove permanently any malaria breeding sites.

Brain, Abel, Habila, George, Emmanuel, William, Els, and Frank (2006) opined that malaria remains a major public health problem in sub-Sahara Africa.  Though all segments of

society are afflicted, children under 5 years of age (U-5) and pregnant women (P-W) suffer most of the morbidity and mortality.   They emphasized that the WHO and RBM initiative aims to decrease the burden of malaria disease through three proven interventions.

The first is concerned with the prompt management of presumed malaria cases, that is immediate investigation, diagnosis, treatment or management of persons with malaria diseases. The second is the intermittent preventive treatment of pregnant women.   This, according to Thomson (1996) refers to the Nigeria policy on prevention of malaria which recommends giving women of all parities two doses of chloroquine as intermittent preventive treatment (IPT) in the second and third trimester of pregnancy.  It has been observed that due to plasmodium resistance to choloroquine, sulfadoxine – pyrimethamine (SP) has been used to replace chloroquine.  SP is also given two doses during the second and third trimester (Mayor, Serra-Casas, Sanz, Aponti, Macete, Mandomando, Puvol, Berzosa, Debano, Aide, Sacarlal, Berrito, Alonso, & Mendendez

2008).  The third intervention is the wide-spread use of insecticide treated bed nets (ITNs), in which individuals especially pregnant and nursing mothers and children are encouraged to sleep under it to protect them against mosquito bites.

WHO (1997) asserted that in the past decade, much emphasis had been given to adapting existing vector control techniques and developing new methods to enable health personnel, communities and individuals to take action in defence of their own health.  Besides, education in recognizing the symptoms has reduced the number of cases in some areas of the developing world by as much as 20 per cent.  The report noted that recognizing the disease in the early stage can also stop the disease from becoming a killer.  Education can also inform people to cover over areas of stagnant, still water such as water tanks which are ideal breeding grounds for the parasite and mosquitoes, thus cutting down the risk of the transmission between people.  Priority has,  therefore, been given to the development of simple, safe, appropriate and  inexpensive measures for vector control.   This resulted in development of insecticide treated bed nets and curtains for the control of mosquitoes and sand flies.

Guyatt and Ochala (2003) defined insecticide treated bed nets as a bed net that has been treated with insecticide to protect against mosquitoes and malaria.   They maintained that the provision of insecticide-treated bed nets (ITNs) is universally accepted as an efficacious and essential public health service in most parts of Sub-Saharan African malaria endemic areas.  On the other hand, Olusola, Moshe and Olayemi (2008) defined a mosquito net as an insecticide

treated net (ITN), if it was pre-factory-treated or has been dipped in insecticide within the last 6-

12 months.

Kilama (2000) noted that, over the years, various attempts to reduce, control or eliminate malaria globally and at country level have not been successful because most measures instituted would not be sustained long enough to accomplish the task.   Besides, the lack of fund and inability of national malaria control programmes to apply appropriate epidemiological and socio- cultural aspects to control programmes hamper efforts to control the disease.  In response to the need  for  low-cost  preventive  measures, Adongo, Kirkwood and  Kendall (2005)  stated that renewed attention has been directed to assessing the potential benefits of insecticide treated bed nets  (ITNs),  which  reduce  man-vector  contact  and  child  mortality  and  morbidity.      They indicated that the impressive results achieved from efficacy trials of ITNs in Sub-Saharan Africa have given hope for programmes to prevent and control malaria related morbidity and mortality.

Curtis (1992) observed that ITNs prevent malaria by killing any mosquito that lands on them, and therefore create a barrier between people and mosquitoes during the night. D’Allesandro (2001) indicated that the use of ITNs can result in huge health benefits.   He provided strong evidence that ITNs can significantly reduce childhood mortality by 23 per cent.

Brierley (2007) opined that malaria is still the commonest and most dangerous disease in tropical Africa today.  He noted that in Tanzania, it kills over 80,000 children and is responsible for 36 per cent of the maternal mortality which is estimated at 578 per 100,000 live birth, one of the highest in the world.  He further appealed to the world community to give a support to the people of Africa, majority of whom live in abject poverty.  He also noted that protecting older children and adults with insecticides treated bed nets may be an effective way to combat malaria. He, therefore, asserted that current international guidelines recommend providing subsidized ITNs for young children and pregnant women in order to achieve over 80 per cent coverage in this high-risk groups.

WHO (2005) indicated that World Health Assembly in 2005, urged member states to establish policies and operational plans to ensure that at least 80 per cent of those at risk of or suffering from malaria, benefit by 2010 from major preventive and corrective interventions, so as to ensure a reduction in the burden of malaria of at least 50 per cent and 75 per cent by 2015. Anthony, Benjamin, Allan, Charles, Valeria, Tessh, Birkinesh, Awash and Fatoumata (2007) disclosed that these targets are echoed in the Roll Back Malaria (RBM) partnership global

strategic plans 2005-2015.  In addition, United National Millenium Declaration set a target to halt and begin to reverse the global incidence of malaria by 2015.   One of the measures of reducing the incidence or prevalence of malaria is by the use of ITNs.   Unfortunately, most people see bed nets as a nuisance reduction tool, which means that they will be used by adults instead of children to reduce nuisance caused by mosquitoes (Adongo, Kirkwood & Kendall,

2005).   However, it was observed that the use of ITNs provided adequate protection against malaria infections particularly in children (Lengeler & Snow, 1996).  Besides, WHO, CDS and RBM (2002) stated that Roll Back Malaria global partnership promotes the use of ITNs for everyone at risk of malaria especially children and pregnant women, irrespective of extent of use.

Person (2007) defined extent as how true something is or how great an effect or change is for example, to extent or to an extent. Firefox (2010) defined extent as the point or degree to which something extends. However, the point or degree could be the coverage, range, limit, surface area or scope to which something might extend, indicating the utilization of ITNs among ante-natal and nursing mothers in Udenu Local Government Area where the present study was conducted.  In this context, extent of utilization of ITNs may indicate the degree by which ITNs are being utilized at a particular period of time among nursing mothers.

Whitehurst and Jaco (1985) purported that utilization is the use or patronage of health services by the target population or by the people to whom the services are designed for.  Person (2007) noted that to utilize is to make use of something or put materials to a useful purpose.  In this present study, utilization of ITNs may be defined as the system by which ante natal and nursing mothers adopt or use insecticide treated bed nets for the protection against infectious mosquitoes.

Barillieres (2001) described ante-natal mothers as women under gestational period or pregnant women that are expecting to give birth to a baby. In this present study, ante-natal mothers are pregnant women that are expecting to give birth to a baby and are required to obtain complete ante-natal services including ITNs and ensure good gestational period. Hornby (2006) stated that a nursing mother is a woman who feeds a baby on the breasts, holds a baby or a child on the knees, clasps caressingly, and gives special care to him or her. In this study, a nursing mother is a woman who feeds a baby on the breasts, provides modern lactational services to the child such as exclusive breast feeding within the first six months of age, obtain immunization services and adequate use of ITNs especially for the under five years of age.   Person (2007)

stated that ante-natal care (ANC) is medical care given to women who are going to have a baby. USAID (2008) asserted that globally, 70 per cent of women seek ante-natal care (ANC) at least once during pregnancy, making it a key opportunity to provide a broad range of health services. These services include prevention and treatment of anemia; prevention, detection and treatment of malaria; service against tuberculosis, sexually transmitted infections (STIs) and HIV and tetanus toxid immunizations. The author further emphasized that ANC is an opportunity for providers to promote the benefit of skilled attendance at birth and post partum or post natal care, and to discuss new born care and optimal birth spacing.    It is also an essential link where the benefits and the pattern of use of ITNs are being discussed.

Hornby (2006) defined pattern as the regular way in which something happens, develop or is done.  Farlex (2008) opined that patterns have to do with any set conventional principles and  expectations that  are  binding on any  person who  is  a  member of a  particular group. Predemore, Andrew and Spivak (2003) classified patterns into three main types.  These include demographic, temporal and spatial patterns (or variations).

Maris (1981) and Stillion (1985) described demographic variations as patterns that is concerned with variables of age, gender, level of education, marital status, occupation, socio- economic and health status.  In this study, variables of demographic variations were concerned with variables such as age, sex, marital status, occupation and education.

The temporal variations are related to variables such as seasons, months, days of the week, presidential elections, public holidays, national holidays and so on (Predemore et al 2003). In this study, temporal variations were concerned with variables such as seasons, months, days of the week and period of the day.  The use of time in utilization of ITNs is important because it may be morning, evening, night or during the day or rainy season, which are good periods for mosquito breeding and attack.

Predemore et  al  (2003)  described  spatial  variations  or  pattern based  on  geographic regions in a particular country which could be divided into economic and administrative regions or as a result of the mixture of structural and cultural factors, which may be west or eastern part of a country.  In this study, spatial variations of utilization of ITNs were not utilized because Udenu Local Government is not an urban area.

Udenu Local Government Area is in guinea savanna zone.   In view of this, there is tendency of presence of mosquitoes due to some fringing forest present.   It is also clear that

forested areas relatively harbor mosquitoes due to beat cooling effect of this area, occasioned by some elements of evapo transpiration. Also the area lines within double maxima regime of rainfall; and this  very fact, makes the area a humid region that always favour weather for mosquito breeding.

Besides, inspite of the laudable message and objectives of ITNs, Olusola, Moghe, and Olayemi (2008) asserted that the substantial increase in ITNs utilization among children under five years of age and pregnant mothers in Nigeria is still far from the Abuja targets.  This may probably be due to some inter related and inter dependent factors such as the economic, season, educational, religion, cultural and social nature, that may appear to be influencing the poor utilization of ITNs among ante-natal and nursing mothers.  Ayalew and Amsalu (2009) pointed out that, an increase in educational level of the household head was associated with increased odds of possessing a net.  This could be explained firstly by the possible increase in awareness of mosquito nets and their advantages and probably better comprehending capability of mass media message related to mosquito nets with increase in educational status. Secondly, the possibility of earning a  better income with increase in educational status may increase the  likelihood of possessing a net.  They opined that income was a major predictor of mosquito net possession which could be explained by the increase in purchasing capability of mosquito nets with increase in income.  They further noted that households which have female heads have 0.44 times lesser odds of using their nets.  This negative association according to them might have resulted from the level of education of the female household heads; whom most of them are illiterate especially in rural areas.  Net Mark (2006), emphasized that in dry season, the transmission of malaria was relatively less, and many people do not feel they need to use nets when there may be fewer nuisance mosquitoes.

Dairo and Owoyokun (2010) indicated that married women were more likely to attend and use modern ANC services compared to women who were single, separated and divorced. This may be due to social stigma attached to gestational conditions; especially towards social mothers.  They further explained that most of the respondents that did not use ante-natal care services were single and reported not being part of decision making on matters that concerns their health.  Probably lack of support and inability to determine matters concerning their health might explain their limited use of antenatal care services including ITNs.  Dairo and Owoyokun, also observed that Muslims in most part of the Nigeria, for example, Sagamu Local Government

Area of Ogun State, utilize ANC services more than other religions.  This is probably because most Christians attend spiritual houses for care during pregnancy and most Christian organizations have spiritual houses that offer care for women especially their members.

Adongo, Kirkwood, and Kendall (2005) indicated that individuals who understand the connection between mosquitoes and malaria may also attribute the disease to other beliefs and attitudinal factors; making it difficult to convince them to adopt bed nets as a control measure. Furthermore, warm weather and perceived absence of mosquito bites are cited as some of the reasons for not using bed nets.   This may be one of the reasons why many people especially those in rural areas attribute malaria disease to exposure to excessive sunshine, consumption of excessive fats and alcohol; and pay little or no attention to adoption of ITNs as control measure to malaria disease or mosquito bites.   Besides, Jombo, Alao and Gyoh (2011) indicated that positive predictors for bed nets utilization were  increasing educational levels,  rising wealth index, presence of under five children and positive history of marriage.   On the other hand, factors that reduce bed net utilization are cultural beliefs, low wealth index and ignorance.

Furthermore, Korenromp, Miller, Cibulskis, Kabir, Aluwick and Dye (2003) noted that ITNs ownership was found to be between zero per cent and 16 per cent.  UNICEF and WHO (2003) pointed out that ITNs ownership has been found to be lowest among the poorest household, possibly linking possession to the cost of the net.  Simon, Larson, Zusman and Rosen (2002) predicated that reducing tariffs on insecticides and ITNs from 42 per cent to zero percent and the tariff on netting materials from 40 per cent to 5 per cent would increase demand for ITNs by 9-27 per cent.

Onwujekwe, Hanson and Fox-Rushby (2003)  found out that households with recent attack of malaria and those with higher willingness to pay were more likely to purchase a net and use than their counterparts.  Wiseman, Scott, Mc Elroy, Conteh and Stevens (2007) reported a significant  association  between  good  access  roads  to  the  community  and  net  ownership. Perceived risk of malaria and benefits of the nets by the population also drive demand.

Age, location, level of education, cultural and economic status, time of the day or seasons of the year had been identified as variables that influence the utilization of bed nets among nursing mothers.  The present study however determined the extent and pattern of utilization of ITNs among ante-natal and nursing mothers and also whether age, marital status, occupation,

level of education, seasons, months and period of the day have an impact on mothers’ extent and pattern of bed nets use in Udenu Local Government Area of Enugu State.

It   has   been   observed   that   malaria   is   a   global   health   problems   especially   in underdeveloped and developing countries of the world.  This has posed serious health problems especially in Sub-Saharan Africa where the study area, Udenu Local Government Area of Enugu State is located.  Though no age barrier has been identified, children and pregnant mothers have been noticed to be mostly affected.  There have been many methods instituted to halt against the menace of the disease.   As earlier indicated, these methods are concerned with prompt management of presumed malaria cases; intermittent preventive treatment of pregnant women; wide  spread  use  of  ITNs;  proper  sewage  drainage,  and  good  environmental  hygiene. Furthermore, many international and national studies and programmes have dwelt on the causes, prevention and treatment of the disease, including the use of ITNs.  Some of these studies and programmes that are carried out include WHO and RBM Initiative; Nigeria Malaria Status in World Malaria report (WHO, 2008); Burden of malaria in Nigeria, Nigeria Demographic and Health Survey (FMOH, 2003); and Insecticide-treated bed nets (ITNs) as a strategy in Roll Back Malaria at the grass root (Ayorinde, 2002) .  However, none of these studies had seem to deal on the  extent  and  patterns of utilization of ITN  in Enugu State  in general and  Udenu Local Government Area in particular where hospital records have revealed serious death tools due to malaria infections. It was in line with this that the investigator focused on ascertaining the extent and patterns of utilization of ITNs among ante-natal and nursing mothers in Udenu Local Area of Enugu State.

Statement of the Problem

It has been noted that insecticide treated mosquito nets are currently the only viable option  to  prevent  malaria  transmission  in  large  parts  of  Africa.    It  is  also  observed  that insecticide bed nets have proved effective in reducing morbidity and mortality due to malaria in some part of Africa, including Nigeria (Obionu, 2007).   ITNs can reduce child and  infant morbidity and mortality due to malaria, as well as reduce malaria in pregnancy, with significant reduction in parasitatmia, risk of low birth weight, still birth, abortion, intra-uterine growth retardation and other complications of malaria in pregnancy.  Besides, other authorities asserted that since vaccines are provided free of charge, a strong case could be made to provide free or heavily subsidized ITNs.   Cost  effective calculations have  shown that  ITNs and childhood

vaccination are of similar value.  Sustained efforts have been made by governments (National, State and Local) to provide bed nets (ITNs) to antenatal and nursing mothers and young children free of charge or at subsidized prizes (Lucas and Gilled, 2003).  Krezanoski, Comfort and Hamer (2010), emphasized that the use of ITNs was a two step process that involves, first acquiring an ITN and second, actual mounting and daily use of the ITNs.

Unfortunately, despite this  laudable programme on insecticide bed nets,  malaria still constitute a very serious health problem, especially among pregnant and nursing mothers and young children.  For instance, it has been observed that malaria accounts for one in five of all children deaths in Africa, Nigeria inclusive.  Besides, it has been noted that anemia, low birth weight, epilepsy and neurological problems are all frequent consequences of malaria, and they compromise the health and development of millions of children throughout the world.  Egwu (2006) disclosed that the slow adoption of some of the measures of Roll Back malaria for example, the use of ITNs, negates the advantages of WHO’s strategic plan, which includes among other things, to plan selective and sustainable preventive measures against malaria.  This may equally exist among the inhabitants of Udenu Local Government Area of Enugu State.

The above situation is very worrisome and it is of great concern, which seek answers to the following questions:   Does it mean that the ITNs which are provided by governments to antenatal and nursing mothers are not appropriately utilized? What is the extent of their use by ante-natal and nursing mothers? What are the patterns of use of these nets?  This study therefore answered these questions.

Purpose of the Study

The  purpose  of  this  study  was  to  identify  the  extent  and  pattern of  utilization  of insecticide treated bed nets among ante-natal and nursing mothers in Udenu Local Government Area of Enugu State.  Specifically, the study identified the:

1.        extent of utilization of ITNs by pregnant and nursing mothers during pregnancy;

2.        extent of utilization of ITNs by pregnant and nursing mothers after child birth;

3.         extent  of utilization of ITNs  by  mothers  in  protecting their  young  children against mosquito bites in Udenu Local Government Area of Enugu State;

4.        utilization of ITNs among ante-natal and nursing mothers in Udenu Local Government

Area of Enugu State based on demographic patterns;

5.        utilization of ITNs among ante-natal and nursing mothers in Udenu Local Government of

Enugu State according to temporal pattern.

Research Questions

The following research questions were used to guide the study.

1.         What  is  the  extent  of utilization  of ITNs  by  pregnant  and  nursing  mothers  during pregnancy in Udenu Local Government Area of Enugu State?

2.         What is the extent of utilization of ITNs by pregnant and nursing mothers after child birth in Udenu Local Government Area of Enugu State?

3.         What is the extent of utilization of ITNs by mothers in protecting their young children against mosquito bites in Udenu Local Government Area of Enugu State?

4.        What is the utilization of ITNs among ante-natal and nursing mothers in Udenu Local

Government Area of Enugu State based on demographic patterns?

5.        What is the utilization of ITNs among ante-natal and nursing mothers in Udenu Local

Government of Enugu State according to temporal pattern?

Hypotheses

The following hypothesis have been postulated for the study and were tested at .05 level of significance.

1.  There is no significant difference in the extent of utilization of ITNs among ante-natal and nursing mothers based on age.

2.  There is no significant difference in the extent of utilization of ITNs among ante-natal and nursing mothers based on marital status.

3.  There is no significant difference in the extent of utilization of ITNs among ante-natal and nursing mothers based on occupation.

4.  There is no significant difference in the extent of utilization of ITNs among ante-natal and nursing mothers based on level of education.

5.  There is no significant difference in the extent of utilization of ITNs among ante-natal and nursing mothers based on the period of the year.

Significance of the Study

The result of the study on extent and pattern of utilization of ITNs among ante-natal and nursing mothers during pregnancy will be beneficial to health workers, health educators, ministries of health, malarial control programme officer, WHO and USAID.   These are the

governmental and non-governmental agencies that are involved in the campaign against the spread of mosquitoes that cause malaria diseases.   They are also the agencies that carry out programmes on the proper control measures against the vector borne diseases, especially, on the use of insecticides and insecticides treated bed nets (ITNs).

The result of the study on the extent of utilization of ITNs among antenatal and nursing mothers after child  birth will be  beneficial to  health worker, health educators and  malaria programme officers. It will help them educate the mothers, that ITNs utilization after child birth reduces the morbidity and mortality rate among the mothers and their infants by preventing malaria infections through mosquito bite. The result will also help the health workers to educate mothers that the chemicals used for the nets have no ill-effects on them nor on their children; and that the nets need to be washed and retreated as the need arises.

The result of the study on the extent of utilization of the ITNs among the mothers in protecting their  young  ones against  mosquito  bites,  will  be  useful to  environmental health officers, malaria programme officers, doctors, nurses and governmental and non-governmental agencies. It will help them to design programmes for mothers so as to increase their knowledge on ITNs utilization and acceptance in their various household for protecting their young children. It will also help to educate the mothers that the use of ITNs are mostly needed by them and their children as they are the most vulnerable groups that are affected by mosquito bites.

The findings that were made concerning the demographic patterns of utilization of ITNs among ante-natal and nursing mothers which involved age, marital status, occupation and level of education will be useful to donor agencies. It will enable them to access the maturity and educational level of mothers, as it may influence the understanding of ITNs use among them.  It will also enable government to see the need of reducing tariffs and taxes on ITNs so that the operational plans of member states to ensure a reduction in the burden of malaria of at least 50 per cent and 75 per cent by 2015 will be achieved.

Findings that were made concerning temporal variations of utilization of ITNs which involved seasons, time of the day and period of the year, will be useful to health workers, health educators and health researchers. It will enable them to bring to the minds of mothers and the community members in general that the seasons or time of the year have no barrier to the use of ITNs. It will also help them to find out whether mothers’ use of ITNs embraces all seasonal variations especially in dry seasons in which gutters with dirty sewage are good breeding areas

for mosquitoes in urban and semi-urban areas. It will help the governments and these health professionals to educate the mothers on continuous use of ITNs especially during the dry seasons so as to reduce or prevent diseases associated with dry seasons.

The theories that were used in this study will be of benefit to the investigator.   The theories as were used, explained to the investigator how certain behaviours that lead to extent and pattern of ITNs utilization occur.   For example, diffusion of innovations theory (DIT) provides an explanation on how new practices diffuse or spread within a society or from one society to another.  The various pattern theory (VPT) explains how demographic, temporal and spatial variations affects individual’s risks, acceptance and adaptation to certain health services. The health belief model (HBM) explains how perceived susceptibility, perceived severity, perceived benefits and perceived barriers influence the likelihood that a person will adopt a recommended preventive action.

Scope of the Study

The study was delimited on the ante-natal and nursing mothers in Udenu Local Government Area of Enugu State.   It concentrated on the extent and pattern of utilization of ITNs among ante-natal and nursing mothers. The study was also be delimited to demographic variable of age, occupation, marital status and level of education and temporal patterns of time, days of the week, seasons of the year of utilization were determined.

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