CHAPTER ONE
INTRODUCTION
BACKGROUND TO THE STUDY
Malaria is endemic in Nigeria, with year-round transmission. It is one of the biggest health problems in sub-Saharan Africa and its contribution to morbidity and mortality among people in Africa has been a subject of academic interest, political advocacy, and speculation. Meanwhile, malaria was described as a major public health and developmental challenge by World Health Organisation (2009a). It is a serious sickness that a person can get when mosquito bites him or her and it is rated as a major killer disease in Nigeria. Of which every year, 300 million to 500 million people get malaria sickness in the world and about 1 million children die of malaria (NDHS 2013).
In Nigeria, about 1 million die from malaria or malaria related complications and it is also one of the big reasons why people, especially young children (below the age of five), die and do not grow well. Similarly, about 70% of pregnant women suffer from malaria, which contributes to maternal lack of blood (anemia), miscarriages, low birth weight, still births, and other pregnancy- related entanglements (Federal Ministry of Health Abuja, 2005). However, Plasmodium falciparum is the predominant parasite species, mainly transmitted by Anopheles gambiae S.S., An. funestus, and An. arabiensis. Prior to 2010, available data were insufficient to clearly micro-stratify the country’s malaria epidemiological profile. Meanwhile, the 2010 Nigeria Malaria Indicators Survey revealed that malaria parasite prevalence is still high, with an average prevalence of 42 percent among children under age 5 and zonal variations ranging from 28 percent in the South East to 50 percent in the South West (National Population Commission, National Malaria Control Programme, and ICF International, 2012). Malaria remains an important cause of morbidity and mortality in Nigeria and long lasting insecticidal nets could be use in curbing it. Also, Nigeria is accounted for 32 percent of the global estimate of 653,000 malaria deaths in 2010 (World Health Organization, 2012).
According to World Health Organization 2017, 'Long-lasting insecticidal nets (LLINs) are the preferred form of insecticide-treated mosquito nets (ITNs) for public health programmes. In most settings, WHO recommends LLINs coverage for all people at risk of malaria and the most cost- effective way to achieve this is by providing LLINs free of charge, to ensure equal access for all.' Also, long lasting insecticidal bed nets are one of the most effective ways to prevent malaria and associated morbidity and mortality resulting from the disease (Lengeler 2004; Fegan et al. 2007). It is stated that in parallel, effective behaviour change "communication strategies" are required to ensure that all people at risk of malaria sleep under LLINs every night, and that the net is properly maintained.
Furthermore, the World Health Organization (WHO) World Malaria Report (2011) demonstrates the enormity of the burden of malaria, with 216 million cases and 653,000 deaths attributable to this mosquito-transmitted parasite in the year 2010 alone. Also, the burden was largely borne by Africa where 91% of deaths occurred, with pregnant women and children under five years of age most at risk of infection and adverse outcomes (World Malaria Report, 2011). In addition, there are an estimated 25 million pregnancies in sub-Saharan Africa at risk of malaria each year (WHO 2009a). Consequences of which can be serious for both mother and fetus in terms of morbidity and mortality (Kileen et al., 2007).
More so, Kileen et al., (2007) further indicated that adverse effects of malaria in pregnancy include maternal anemia and stillbirths; while malaria in pregnancy leads to delivery of premature infants and low birth weights due to intrauterine growth retardation (IUGR) resulting from placental parasitisation. For this reason, its enormous physical, emotional, social and economic impacts on the clients, families and the nation at large cannot be quantified (Van et al., 2011).
Consequently, Dolon et al (1993) asserted that long lasting insecticidal nets (LLINs) have been shown to be the most cost effective measure in the prevention of malaria. In view of the effectiveness of LLINs, the Roll Back Malaria (RBM) Partnership was targeted to protect 80% of children and pregnant women at risk of malaria with LLINs by 2015. This RBM was adopted by Ghana as an established policy guideline for the implementation and scaling-up use of ITNs in accordance with the provision of the Abuja declaration and a national strategic plan was in existence. It was evidential from other studies that consistent use of these nets was important in the prevention of malaria (Baume et al., 2011). The WHO and Roll Back Malaria (RBM) partnership now recommend that distribution of LLINs be free or heavily subsidized to achieve greater equity of coverage, and that a variety of distribution systems be used to achieve universal access, including targeted campaigns to deliver nets to most-at-risk populations, which include pregnant women and children under five years of age (Alukwo et al., 2012). Therefore, the evidence showed a strong correlation between the use of ITNs and reduction in stillbirths, improvements in birth weights of babies and a reduction in the prevalence of parasitaemia and anemia in pregnant women. A communal protective effect of LLINs and reduction in overall vector density has also been observed in some settings (Kileen et al., 2007).
The main delivery system for LLINs was through antenatal clinics (ANCs), using free distribution or a voucher system. Interestingly, attendance at an ANC was not found to be a major factor in limiting coverage. Supply has been identified by the WHO as the primary barrier to achieving optimal coverage, with the latest World Malaria Report suggesting that in the general population, there is a high correlation between ownership and use of LLINs (WHO, 2011). The relationship between LLINs ownership and use has been explored by not many authors, and largely neglected when concerning pregnant women. Given that pregnant women and their unborn children are particularly vulnerable group susceptible to malaria and its consequences. Therefore, a research study to determine the factors influencing bed net ownership and use among these pregnant women is useful.
In view of RBM program, the Lagos State government declared the Eko Free Malaria Treatment Program in 1998 for all children under age five at its various health facilities. The state provides long lasting insecticidal nets (LLINs) and intermittent preventive treatment of malaria in pregnancy (IPTp) to women during visits to antenatal clinics and LLINs to children under age five on completion of immunization. As of 2012, the state government has distributed about 4.2 million of LLINs to the aforementioned groups using hospital-based and house-to-house approaches (Lagos State Ministry of Health, 2012).
Malaria still continues to be a major cause of morbidity and mortality among young children and pregnant women living in endemic areas, so therefore the incidences of malaria infections among pregnant women and breastfeeding mothers are still high in spite of the acclaimed widespread of distribution of long lasting insecticidal nets. Meanwhile, the Lagos State Malaria Control Program 2017, while reporting on malaria control program in Lagos State, stated that hospital reviews show that it accounts for over 60% of outpatient visits and equally responsible for 30% and 11% mortality in children under five and pregnant women respectively.
Minja (2001) had earlier estimated that about 300 billion clinical cases of malaria are attributed to insect bites and that out of this figure, more than 1million die annually due to complications. Minja (2001) further stated that 90 percent of the 1million deaths were recorded in Sub-Saharan Africa, to which Lagos state and Surulere local government area belong. The Lagos State Ministry of Health in 2010, while reporting on the prevalence of malaria in Nigeria, observed that over 60% of medical ill-health presenting at Local Health Centres are preventable through effective use of LLINs. According to the Minister, “malaria is preventable and yet it continues to be responsible for over 60 percent of out-patients in public and private health facilities in Nigeria.” Chukwuocha, Dozie, Onwumeliri, et al. (2010) opined that malaria cases in Nigeria were mostly vector borne diseases which could have been prevented through effective use of Long Lasting Insecticidal Nets (LLINs).
STATEMENT OF THE PROBLEM
According to the background to this study, it is necessary that during community malaria health campaigns, health workers, Governmental Organizations and NGOs must endeavour to bring to the knowledge of pregnant women and nursing mothers on constant use of LLINs. Meanwhile, for wider promotion of the use and uptake of these malaria preventive strategies, mass media campaigns have been initiated to sensitize the general public, particularly pregnant women and nursing mothers on the knowledge, the term benefits of correct and consistent use of LLINs during pregnancy and breastfeeding. Most times, failure to use available nets and lack of knowledge about malaria prevention are important determinants of malaria risk among pregnant women and nursing mothers. This is due to their delicate stages and weak immunities of infants being breastfed. Generally, as part of the National Malaria Control Strategic Plan, free long-lasting insecticidal nets (LLINs) were distributed in 14 states of Nigeria through mass campaigns led by different organizations (the World Bank, UNICEF, and the Global Fund) and this was between May 2009 and August 2010. For instance, in Lagos State, health commission aids in making LLINs affordable and deployed to the communities and hospitals as way in preventing malaria.
However, respondents living in epidemic area of study do not have cognitive awareness of the nature of the health risks of pregnant women and mothers with infants to ages five are exposed to and the measures to be taken towards preventive actions against mosquito bite. While, the level of knowledge and perception of pregnant women and mothers are low due to behavioural change in adopting the daily use of LLINs as a measure in curbing morbidity and mortality. Others report having problems sleeping in the net because the chemical used in the treatment of the net causes skin itching, eye tearing, sneezing. This paved way to respondents’ behavioural change towards the use of LLINs. Subsequently, the impact of LLINs interventions under real life conditions is known to be influenced by a number of important socio-economic, cultural and ecological determinants (Rashed et al., 1999).
In response to this problem, this study proposed there is no doubt that the awareness and cognitive behaviour on the use of LLINs to prevent malaria has not been totally successful. In view of this, with previous research study, it is observed that one hundred and twenty-seven (37.9%) of the women had high knowledge of Malaria in Pregnancy (MIP) but only 70 (20.9%) demonstrated positive attitude towards the use of LLINs. Also, most pregnant women and nursing mothers rely solely on Vaccines or chemo-prophylactic drugs which are not total preventive measures against mosquito bites, and due to some mothers' attitudes and negligence on the use of LLINs. Also, between 2010 and 2015, the malaria mortality rate among children under 5 fell by an estimated 35%. Nonetheless, malaria remains a major killer of under-fives, which claims the life of 1 child every 2 minutes (WHO, 2016).
Consequently, effective motivational human efforts and procedures is required in creating awareness on the beneficial use of LLINs through educational programmes disseminated by media (Radio, television, newspaper, Magazine, community Journals, Facebook, Whatsapp), likewise hospitals, governmental and non-governmental organisations.
Despite the said governmental, intergovernmental and non-governmental efforts to control malaria, this study seeks to access knowledge, attitude and use of LLINs among pregnant women and nursing mothers and with a specific focus on communities situated in Surulere, Local Government Area of Lagos State, Nigeria.
OBJECTIVES OF THE STUDY
The aim of this study is to assess attitude of pregnant women and nursing mothers towards the use of LLINs in curbing mosquito bites and high rate of mortality. Specifically the study will seek to:
- Assess pregnant women and nursing mothers’ awareness and knowledge about LLINs.
- Examine respondents’ attitudes towards the use of long lasting insecticidal nets.
- Determine the rate of LLINs utilization among pregnant women and nursing mothers in Surulere L.G.A
- Identify factors which influence respondents’ utilization and non-utilization of LLINs.
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RESEARCH QUESTIONS
To achieve the above specified objectives, the following questions are outline in order to find out the opinion of the respondents on the research topic
- Do pregnant women and nursing mothers’ have awareness and knowledge about LLINs?
- What are respondents’ attitudes towards the use of LLINs?
- To what extent is the rate of LLINs utilization among pregnant women and nursing in Surulere L.G.A?
- Are there factors which influence respondents’ utilization and non-utilization of LLINs? And what are they?
SIGNIFICANCE OF THE STUDY
For further knowledge, Insecticide treated nets have been shown to be the most cost effective measure in the prevention of malaria (Dolon et al., 1993). In view of the effectiveness of ITNs, the Roll back malaria (RBM) partnership aims to protect 80% of children and pregnant women at risk of malaria with ITNs by 2015. Meanwhile, it is of importance to know that “the populations at highest risk of morbidity are young children and pregnant women, because of their low immunity against the disease” (Roca-Feltrer, Carneiro, Armstrong-Schellenberg, 2008; Rogerson, 2010).
Although, the research is to benefit significant number of the people in the society which pregnant women and nursing mothers are inclusive, and to the academia, the experience that will be gain in the process of the research together with the outcome will serve as a base for further research on how best to benefit from the use of LLINs in controlling insect bites. Also, to investigate whether the strategy of use of LLIN will be the best option in curbing mosquito bites and malaria attacks.
So therefore, the main justification to this research is that more enlightenment, information on long lasting insecticidal nets used in combating malaria in pregnancy and its prevalence in children under age 5, is important to the Millennium Development Authority and National Malaria Control Program to improve their various strategies that will be geared towards improving maternal health by three- quarters(MDG 5) and combat infectious diseases including malaria by the year 2015 (US Census Bureau, 2010). This research is seen as added advantage to the body of knowledge in mass communication and to fill the gap in the area of specialised media and contents for specific targeted audience.
SCOPE OF THE STUDY
This research has been narrowed down to knowledge, attitudes and use of LLINs among pregnant women and nursing mothers with a focus on Surulere Local Government Area of Lagos State, Nigeria. This area is selected because of its proximity to the researcher as it was difficult if not impossible to study all L.G.A in Lagos State, Nigeria and due to time available for this study; other considerable factors are geographical locations, age, sex and social status of the respondents.
The survey was conducted amongst the pregnant women and nursing mothers that were registered in the ten communities that make up Surulere Local Government Area. It is pertinent to note the fact that not all patients have the knowledge on the use or registered for the LLINs when that exercise was done. Even amongst those that have little knowledge of LLINs or registered for it, not all of them turned up for collection. The scope of the study is therefore limited to these attitudinal characteristics of the population in relation to recommended methods of use of long lasting insecticidal nets.
OPERATIONAL DEFINITION OF TERMS
Knowledge of LLINS: It refers to the awareness or familiarity gained by experience of a fact or situation in the usage of LLINs.
Attitudes: This is could be seen as feelings or opinions on the use of LLINs among respondents in Surulere Local Government Area of Lagos State, Nigeria
Use of LLINS: It refers to both frequency and method to which something is being used in a prescribed manner. The Long lasting insecticidal nets are meant to be use daily at bed time.
Long lasting insecticidal nets: It is a factory-treated mosquito net made with netting material that has insecticide incorporated within or bound around the fibers. The net must retain its effective biological activity without re-treatment for at least 20 WHO standard washes under laboratory conditions and three years of recommended use under field conditions.
Pregnant women: This refers to women having foetuses or offspring’s developing in the body. They are soon to be mothers that should be prevented from mosquito bites for the safety of their unborn children.
Nursing mothers: They are breastfeeding mothers that feed their babies or young children with milk from the breast. It is a stage, where mother should be considerate of their growing infants and help fight against malaria related complications by using LLINs.
