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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 145-155

Ownership and utilization of long-lasting insecticide nets among caregivers of children under-5 years in Ogun State, Nigeria: A rural–urban comparison


1 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
2 APIN Public Health Initiatives, Sagamu, Ogun State, Nigeria
3 Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria

Date of Web Publication1-Nov-2018

Correspondence Address:
Dr. Temitope Wunmi Ladi-Akinyemi
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_30_18

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  Abstract 


Background: Long-lasting insecticides nets (LLINs) are a key prevention tool that has been found to reduce uncomplicated malaria by 51% and decrease all-cause mortality by 18% in children. LLINs have been shown to be effective in reducing childhood morbidity and mortality by reducing mosquito bites while sleeping. This is a comparative cross-sectional study designed to determine and compare the ownership and utilization of LLINs among caregivers of children under 5 years in a rural and an urban area of Ogun State. Materials and Methods: A community-based comparative cross-sectional study on 575 caregivers of children under 5 years living in the urban and rural area of Ogun State was done using a multistage cluster sampling technique to recruit respondents. A pretested semi-structured interviewer-administered questionnaire was used to collect information on LLINs ownership and use. Analysis and statistical calculation were done using SPSS version 20.0. Relationships between categorical variables were tested using Chi-square test with P = 0.05. Logistic regression model was used to describe predictors of LLIN ownership and utilization among the respondents. Results: The study shows that 80% of caregivers of under-five living in the rural area compared with 63.5% living in the urban area owned LLINs (P < 0.001). Percentage of children under-five who slept under LLINs the night prior the study was 50.2% in the urban versus 52.4% in the rural households (P = 0.252). Stagnant water and dirty surroundings were identified as mode of transmission of malaria among 32.6% urban versus 44.8% rural respondents and 44.2% urban versus 29.7% rural respondents respectively (P = 0.005). Children were identified as one of the most vulnerable groups for malaria infection by 44.6% urban versus 33.8% rural respondents (P = 0.008). The LLINs was hanged on the bed by 81.2% urban versus 64.4% rural respondents (P = 0.018). The predictors of ownership of LLINs were as follows: urban residence (OR 0.34 [95% confidence interval [CI] 0.22–0.53]), caregiver with higher education (OR 4.85 [95% CI 1.42–16.55]), and the predictors of utilization of LLINs were as follows: level of education of the caregiver (OR 2.87 [95% CI 1.11–7.41]), possession of LLINs at immunization (OR 2.92 [95% CI 2.02–4.22]). Conclusion: Free distribution of LLINs may not necessarily lead to use. Behavior change interventions that address the community level perceptions that positively position LLINs as an effective prevention tool to prevent malaria should be strengthened among the caregivers of children under-five generally and most especially in the urban areas of Ogun State.

Keywords: Children under-5 years, comparison, long-lasting insecticides nets, ownership, utilization


How to cite this article:
Ladi-Akinyemi TW, Ladi-Akinyemi BO, Olatona FA, Oluwole FA. Ownership and utilization of long-lasting insecticide nets among caregivers of children under-5 years in Ogun State, Nigeria: A rural–urban comparison. J Clin Sci 2018;15:145-55

How to cite this URL:
Ladi-Akinyemi TW, Ladi-Akinyemi BO, Olatona FA, Oluwole FA. Ownership and utilization of long-lasting insecticide nets among caregivers of children under-5 years in Ogun State, Nigeria: A rural–urban comparison. J Clin Sci [serial online] 2018 [cited 2019 Sep 23];15:145-55. Available from: http://www.jcsjournal.org/text.asp?2018/15/3/145/244744




  Introduction Top


Malaria is responsible for an estimated 800,000 deaths globally each year,[1] with the majority of morbidity and mortality occurring in young children in sub-Saharan Africa. In addition to its impact on health, malaria imposes a heavy economic burden on individuals and entire economies.[2] Malaria is the most significant public health problem in Nigeria.[3],[4] The disease is responsible for 60% outpatient visits to health facilities, 30% childhood death, 25% of death in children under 1 year, and 11% maternal death.[5] The financial loss due to malaria annually is estimated to be about 132 billion Naira in the form of treatment costs, prevention, loss of person-hours, etc., although it is a preventable and treatable disease.[5],[6]

The MDG report of 2011 indicated a remarkable surge in the production, purchase, and distribution of insecticide-treated mosquito net globally, and particularly, in Africa, with a marked increase in both ownership and use among children.[7] ITNs have been shown to be the most cost-effective measure to reduce malaria transmission.[8],[9] By preventing malaria, long-lasting insecticides nets (LLINs) reduce the need for treatment and the pressure on health services.[10]

According to the World Malaria Report 2009,[4] 31% of African households owned an ITN in 2008, and 24% of children slept under an ITN.[11] Although a study conducted in Bioko following the mass delivery of bed nets in late 2007 reported that over 95% of households owned at least one ITN, and over 70% of children from two to five slept under an ITN.[12] However, previous report had shown that even when there are bed nets available in the household, children under-five, the most vulnerable group, do not always have access to them.[13] The previous studies have investigated the determinants of bed net utilization and ownership;[14],[15],[16],[17],[18],[19] the results remain inconclusive.

The Nigerian National Demographic and Health Survey of 2013 recorded 35% household coverage with insecticide-treated nets (ITNs), and this varies with wealth quintiles and location of the respondents.[20] The percentage of use of existing ITNs was lower in rural areas than in urban areas (33% and 38%, respectively).[20] The proportion of net usage was highest in the middle wealth quantile (41%) and lowest in the lowest quantile (25%).[20] Some studies have highlighted poverty as a barrier to scaling up of ownership and utilization of ITN in Nigeria since a large proportion of the population still live under a dollar per day.[21],[22] Even when mass distribution of free nets was attempted, the limited resources of the country considering the very large population, make sustainability almost impossible without continuous support from donor agencies.[22] Between May 2009 and September 2011, the Nigerian government with support from several non-governmental organizations distributed approximately 30 million nets across all the states in Nigeria.

Two important core ITN indicators for malaria control programs are the proportion of households owning an ITN and the proportion of vulnerable populations sleeping under an ITN. Using these measures, many studies have shown that efforts to increase ITN ownership have made tremendous progress; however, most Sub-Saharan countries remain well below roll back malaria partnership (RBM) targets for ownership.[6] In addition, these evaluations have consistently found ITN use (vulnerable groups sleeping under an ITN) lower than household ownership.[23],[24],[25],[26] Despite the large-scale distribution of ITNs in many malaria-endemic countries, there is a wide variation in the availability[27] and use of ITNs/LLINs at the household level.[7],[12],[28],[29],[30],[31]

Every 40 s, a child dies of malaria resulting in more than 2000 deaths per day among children worldwide.[32] Malaria has been responsible for both direct and indirect causes of death in African children, hence the main public health concern is the scaling up of ITNs use by the larger populations.[33] Several pilot projects have demonstrated clearly that ITN use in children achieved a reduction in mortality of between 25% and30%, and a decrease in the number of malaria episodes by 50%.[34] ITNs have been shown to be the most cost-effective measures in the prevention of malaria.[1],[25] In view of the effectiveness of ITNs, the roll back malaria partnership (RBM) targets to protect 80% of children and pregnant women at risk for malaria with ITNs/LLINs.

There had been free distribution of LLINs to pregnant mothers at booking during the antenatal visit, and infants when they completed their immunization at 9 months by the Ogun State government and National Malaria Control Programme partners. To improve access to LLINs, the Government of Ogun State, Southwest Nigeria, under the National Malaria Control Program in collaboration with the RBM partners also embarked on free mass distribution of 1,639,028 LLINs, in 20 local government areas (LGAs) of Ogun State utilizing a strategy of two nets per household with the aim of ensuring wide-scale and equitable distribution of LLINs among other malaria control tools in the State.[35] The State Malaria Control programme unit distributed free LLINs from 21st to 24th December,2009 with end process monitoring for 25th – 26th December and follow up for 27th – 30th December, 2009.[36]

It has been observed that there is a wide variation in the availability[27] and the use of ITNs/LLINs at the household level,[7],[12],[28],[29],[30],[31] even in the rural and urban areas[10],[20] despite the large-scale distribution of ITNs in many malaria-endemic countries; hence, it will not be out of place to carry out a study to assess and to compare the proportion of caregivers of children under 5 years who owned and utilized the LLINs and to identify and to compare factors associated with ownership and utilization of LLINs among the caregivers of children under 5 years in the rural and an urban area of Ogun State.


  Materials and Methods Top


Study area

The study was carried out in a rural and an urban area of Ogun State, South-West Nigeria. Ogun State is one of the 36 States in the Federal Republic of Nigeria. It is bounded in the North by Oyo and Osun State, in the East by Ondo state, in the South by Lagos, and in the West by the Republic of Benin. The State has 20 LGAs. The people of the state belong to the Yoruba ethnic group of Southwest Nigeria. A greater proportion of the state lies in the tropical rainforest zone while the far northern part has features of the Guinea Savannah.[36] The main occupation in the state is farming, which is largely subsistence in scale. There are many areas in the state with poor housing and drainage layout. This often led to blocked drainages following rainfalls and which may result into floods. There are no proper refuse disposal systems in parts of Ogun State and dumping refuse in flowing water bodies is a common practice.

Study design

A community-based comparative cross-sectional study design was used.

Study population

The study population consisted of caregivers of children < 5 years of age residing in Sagamu and Ijebu-East LGAs of Ogun State as at the time of the study.

Eligibility criteria

The inclusion criteria were caregivers of children < 5 years who had been living in the selected area for at least 6 months before the study and slept in the selected houses a night before the study.

Sample size determination

The results of the 2010 National Malaria Indicator Survey indicated that ownership of at least one LLIN was 45% in rural households and 33% in urban households.[37] These values were used to calculate the estimated sample size. Using a power of 80% and confidence level of 95%, the minimum required sample size was obtained from the formula for comparing proportions between two groups.[38] This yielded a final sample size of 260. Thus, a minimum sample size of 260 households were required in each of the area. A total of 520 households were required for the study from both the rural and the urban areas.

A multistage cluster sampling technique was used to recruit respondents into the study. Hence, all the households with children under 5 years old in the selected streets in the urban areas and selected settlements in the rural areas were recruited into the study after obtaining their consent. These made total of 575 households with caregivers of children less than 5 years old in both the urban (285 households) and rural (290 households) areas.

Data collection tools and techniques

The study was conducted in April and May 2014. The questionnaire was adapted from the 2010 Nigeria Malaria Indicator Survey (NMIS).[37] A semi-structured interviewer-administered questionnaire was used to collect data from caregivers of children <5 years after obtaining their consent. The questionnaire was translated into Yoruba, for better understanding of the questions by the respondents. The questionnaire was then translated back into English to be sure that the questions still maintained its original meaning.

The questionnaire was in five sections as follows: Section A: sociodemographic characteristics of the respondents; Section B: knowledge of the respondents on symptoms and mode of transmission of malaria; Section C: knowledge of the respondents on the importance of LLINs; Section D: assessment of the respondents owning LLINs and sleeping under LLINs; and Section E: assessment of the factors associated with the use and nonuse of LLIN in the households.

Ten research assistants were trained to assist with data collection, their personal interest in the study, ability to take details, and ability to be observant were the major criteria for selection. They all have good communication skills, fluent in both English and Yoruba. The questionnaires were pretested in Ikenne LGA. The questionnaire was pretested on 55 caregivers of children <5 years. After the pretest, corrections were made on the tools appropriately.

Data management

Study variables

The response (outcome) variables were as follows:

  • Ownership of LLINS
  • Utilization of LLINs.


The explanatory variables were as follow:

Sociodemographic data of the respondents including age, sex, highest level of education, occupation, religion, marital status, and family size.

Information about children <5 years including number of children <5 years of age, child immunization status, and possession of LLINs after last dose of immunization.

Respondents' other characteristics including knowledge of malaria, information on and sources of LLINs, training on how to use LLINs, attitude to use of LLINs, experience of use of LLINs, and reason for nonuse of LLINs.

Statistical analyses

Information obtained from the questionnaire was entered into SPSS (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp) for analysis and statistical calculation. Data were summarized using mean, median and mode, standard deviation, and proportions. Relationship between categorical variables was tested using the Chi-square test. The level of significance was set at 0.05. Logistic regression model was used to determine the predictors associated with ownership and utilization of LLINs.

Ethical considerations

Ethical approval was obtained from the Olabisi Onabanjo University Teaching Hospital-Health Research Ethic Committee and Primary Health Care Board, Ogun State Ministry of Health. Permission to conduct research was sought from the Chairmen of the LGAs and the Medical Officer of Health. Informed consent (verbal) was obtained from the respondents before administering the questionnaires.


  Results Top


Total number of households who participated in the study were 575, these comprised 285 and 290 caregivers of children less than 5 years from the urban and rural areas of Ogun State, respectively. Overall ownership of LLINs was 71.9% (63.5% in the urban vs. 80.3% in the rural households), overall utilization of LLINs was 51.3% (50.2% in the urban vs. 52.4% in the rural households). Majority of the respondents were between the age range of 25–34 years in both the urban (49.5%) and rural (54.1%) areas of the state with the mean age of 30.8 ± 8.2 years and 30.3 ± 7.0 years, respectively. Gender (P = 0.006), highest level of education (P = 0.022), religion (P = 0.012), family size (P = 0.003), number of children under-five in the household (P < 0.001), and possession of LLIN after last dose of immunization (P ≤ 0.001) were statistically significantly associated with the location of the respondents [Table 1].
Table 1: Sociodemographic and the child characteristics of the respondents (n=575)

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[Table 2] depicts the percentage of respondents who were aware of malaria in both the urban (93.3%) and rural (90.7%) areas of Ogun state. A significantly higher percentage of the respondents in both the urban (92.3%) and rural (87.6%) area knew that mosquito is the insect that transmits malaria (P = 0.003). More of respondents in the urban (44.2% and 32.6%) and rural (29.7% and 44.8%) areas choose dirty surroundings and stagnant water as mode of transmission of malaria, respectively (P = 0.005).
Table 2: Respondents knowledge on malaria, malaria prevention and acquisition of long lasting insecticides nets

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There was a statistically significant association between ownership of LLINs and the following variables: location of respondents (P <0.001), level of education of respondents (P < 0.001), place where child was immunized (P = 0.010), collection of LLINs after last dose of immunization (P < 0.001), knowledge of caregivers of under-five on ways to prevent malaria (P = 002), seen slept under LLIN the previous night (P < 0.001) [Table 3].
Table 3: Association between characteristic of caregivers of under-five and ownership of long-lasting insecticides nets

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[Table 4] showed a slight increase in the utilization of LLINs among respondents in the rural compared with urban households (51.5% vs. 48.5%); however, there was no statistically significant association between the location of caregivers of under-five and the utilization of LLINs (P = 0.591). Other characteristics of caregivers of under-five that were significantly associated with the utilization of LLINs were level of education of the caregiver (P < 0.001), collection of LLINs after last dose of immunization (P < 0.001), knowledge of ways to prevent malaria (P < 0.001), and ownership of LLIN (P < 0.001).
Table 4: Association between characteristic of caregivers of under-five and use of long-lasting insecticides nets

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[Table 5] showed information on the respondents use and nonuse of LLINs. Urban area respondent's reasons for non-use of LLINs were due to non-receipt of free LLINs by government (52.9%), 17.3% did not think LLINs is important, 12.5% dislike LLINs and 10.5% lack money to purchase LLINs while reasons given by rural area respondents were non-receipt of free LLIN (33.3%), 24.6% were absent during distribution, 12.3% did not know where to get LLINs and 8.8% thought LLINs is not important. The urban and rural respondent reasons for not hanging their LLINs were possession of extra LLIN (33% and 25.6%), difficulty in hanging LLIN (20% and 23.3%) and absent of good place to hang LLIN (15% and 17%), respectively. Motivation for sleeping under the LLIN by the urban respondents were health workers (51%) and nonfrequent treatment of malaria (41.3%) while their rural counter-part were motivated by nonfrequent treatment of malaria (46.7%) and health workers (36.7%). The major problems encountered when sleeping under the LLIN by both the urban (91.6%) and rural (86%) respondents was heat.
Table 5: Information on respondents use and nonuse of long-lasting insecticides nets

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Respondents living in urban areas were 66% less likely to own LLINs compared with their rural counterpart (OR 0.34 [95% confidence interval [CI] 0.22–0.53]). Respondents with tertiary education were 5 times more likely to own LLINs compared with respondents with no education (OR4.85 [95% CI 1.42–16.55]). Children immunized at the primary and secondary health facilities were 2 times more likely to own LLINs compared with children immunized in private health facilities (OR 2.06 [CI 1.18–3.60]). Caregivers of under-five who had knowledge on ways to prevent malaria were almost two times more likely to own LLINs compared with respondents with no such knowledge (OR 1.97 [CI 1.12–3.48]) [Table 6].
Table 6: Predictors of ownership of long-lasting insecticides nets s among caregivers of children under 5 years

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Utilization of LLINs was almost three times higher among caregivers of under-five with tertiary education compared with respondents with no education (OR 2.87 [95% CI1.11–7.41]). Children who were given LLIN after they had completed their immunization were 3 times more likely to use LLINs compared with children who did not complete their routine immunization (OR 2.92 [95% CI 2.02–4.22]). Caregivers with knowledge on how to prevent malaria were 2 times likely to use LLINs compared with respondents without such knowledge (OR 2.3 [95% CI 1.34–3.95]).[Table 7].
Table 7: Predictors of utilization of long-lasting insecticides nets among caregivers of children under 5 years

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  Discussion Top


The study demonstrates that higher percentage of the respondents in the rural area own LLINs compared to their urban counterpart. Slightly higher percentage of respondents in the rural area (52.4%) utilizes LLINs compared to the urban (50.2%) respondents. The predictors of ownership of LLINs are rural dwellers, tertiary education, immunization at public health facilities and caregivers' knowledge on ways to prevent malaria. The predictors of utilization of LLINs are tertiary education, possession of LLINs after immunization, and caregivers' knowledge on ways to prevent malaria.

Over 90% of respondents in this study had heard of malaria, this finding is consistent with the result of the 2010 NMIS where 94% of the women interviewed had heard of malaria.[37] A community-based study conducted in Ethiopia also reported that 95.5% of the respondents had heard of malaria.[39] This is not surprising as almost everybody would have been treated for malaria sometime, somewhere. About 80% of the respondents knew that malaria is caused by mosquito bite, this finding is similar to finding from NMIS.[37]

Almost half of the rural caregivers of under-five (44.8%) identified stagnant water as a mode of transmission of malaria. Similar proportion of urban caregivers of under-five (44.2%) identified dirty surrounding as a mode of transmission of malaria, while few of the respondents identified mosquito as a mode of transmission of malaria. Greater awareness need to be done on mode of transmission of malaria because good knowledge about the mode of transmission of malaria will help in taking appropriate preventive measures.

More than three quarter (83.5% urban and 82.4% rural) of the respondents knew ways to prevent malaria, this finding is similar to finding from NMIS where 92% of the respondents described ways to prevent getting malaria;[37] this could be due to the fact that malaria is endemic in Nigeria and several awareness and intervention programs are on-going on the prevention of malaria. Majority (95% urban and 94.8% rural) of the respondents were trained on how to use LLIN and over 80% of the respondents identified that they must spread the LLINs outside away from sun for 24 h before use.

In this study, a larger percentage of respondents in the rural households own LLINs compared with their urban counterpart (80.3% vs. 63.5%), this finding is consistent with findings from NMIS where a larger percentage of rural households own LLIN (45%) compared with urban household (33%).[37] This may reflect the massive community level distribution campaign targeted at the rural communities. More than 50% of households owned at least two or more LLINs. This finding is consistent with finding from similar study in Imo State[40] and Anambra State.[41] Having at least two LLINs in most of the households could be as a result of the free net distribution where a household with a net card is entitled to two LLINs. Among children under-five, 50.2% urban versus 52.4% rural households had children under-five who slept under the LLINs night prior the study, this proportion is lower than finding from Ethiopia where 82% of the children under-five had slept under the LLINs; this finding is similar to the result of NMIS where it was reported that the percentage of children who slept under LLINs was more in the rural than in the urban areas.

Among the respondents who used the LLINs, reasons identified as motivation for sleeping under the LLINs, (urban vs. rural) were health talk by the health workers (51% vs. 36.7%) and decreased visits to health facility to treat malaria (41.3% vs. 46.7%). The challenges encountered among the respondents who used LLINs (urban vs. rural) were excessive heat (91.6% vs. 86%) and skin rashes (3.5% vs. 13.3%). This could be due to the fact that there is no constant supply of electricity so electric fans are not working and couple with the fact that the weather is very hot especially during the dry season.

Predictors of ownership of LLIN among caregivers of children under-five were location, (under-five children in urban areas are less likely to own LLINs compared with children in rural areas), this is because these caregivers were possibly not around during free distribution by government. Another predictor is education (caregivers of children under-five who had tertiary education were 5 times more likely to own LLIN compared with caregivers of children under-five who had no education), caregivers with tertiary education tend to understand mode of transmission and ways to prevent malaria more than the less educated.

With respect to place where immunization was received (children under-five who were immunized at the primary and secondary health facilities were 2 times more likely to own LLINs compared with children who were immunized in a private hospital). This may be as a result of LLINs given to children when they completed their routine immunization in these primary and secondary health facilities. Another important predictor of ownership of LLINs was caregiver's knowledge on ways to prevent malaria. Caregivers of children under-five with knowledge on ways to prevent malaria were 2 times more likely to own LLINs compared with caregivers with no such knowledge. These care givers already knew the role played by LLINs in preventing malaria, so owning one became of utmost importance.

The study also revealed that the predictors of utilization of LLINs by children under-five were caregivers of under-five with tertiary education. This is consistent with similar study in Kano.[42] Children who were given LLIN after they had completed their routine immunization were 3 times more likely to use LLINs compared with children who were not given LLIN after immunization. Children of caregivers of under-five with knowledge of ways to prevent malaria are more likely to use LLINs compared to children of caregivers with poor knowledge of ways to prevent malaria. This finding is consistent with result of similar study in Kenya.[43]


  Conclusion Top


Ownership was high and utilization of LLINs was average, although it has not met the RBM strategic plan.[8] This is the current target of a universal coverage which proposed that 100% of the population will have access to LLINs and at least 80% will sleep under LLINs.[8] More of caregivers of under-five living in the rural households own LLINs compared with their urban counterpart. Higher percentage of children under-five living in rural areas utilize LLINs compared with children under-five living in urban areas. The predictors of ownership and utilization of LLINs among caregivers of children under-five were level of education of the caregiver, possession of LLIN after completion of routine immunization, and caregiver's knowledge on how to avoid malaria. Free distribution of LLINs at antenatal clinics, immunization centers and community levels should be accompanied with behavior change communication interventions such as adequate and continuous health education that encourage the correct and consistent use of the bed nets, even when it is hot at night. This will address the community level perceptions of LLINs and positively position LLINs as an effective prevention tool to prevent malaria particularly in urban areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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