LITERATURE REVIEW

2.1 CONCEPTUALIZATION OF THE RESEARCH QUESTION AND

LITERATURE SEARCH METHOD

Conceptualization refers to the careful analysis of general ideas known as concepts thereby
forming clearer and more distinct constructs to aid better understanding (Henn 2010). It is a
process by which a researcher clearly defines the principal terms and ideas he intends to study
(Sequeira, 2014). This is based on the fact that the concepts or terms employed in research might
have various interpretations by different categories of people, making it vital for the researcher to
explicitly specify the context in which he intends to limit the terms of his research (Sedgeman,
2010). The principal concepts in the research question of this appraisal are pregnant women,
insecticide treated net use and influential factors.

Malaria remains one of the world’s most significant health and development problem (Bernard,

2011). More than 2.4 billion of the world’s population residing in 100 countries or territories are

at risk of malaria. This results in an estimated 300–500 million clinical cases each year, 90% of

which occur in Africa south of the Sahara. In this malaria high-burden area of Africa,

Plasmodium falciparum, the most dangerous species of human malaria, causes the great majority

of infections. In addition, Anopheles gambiae, the most efficient vector of malaria, predominates

throughout large areas of the African continent. This, in combination with a highly dangerous

pathogen carried from person to person by a highly competent, resilient vector, results in, at least,

one million deaths among young African children each year (Susan, 2010). Malaria also

challenges national authorities with a substantial impediment to economic development, costing

the region between $3 billion and $12 billion and inhibiting economic growth by as much as

1.3% each year (Sachs, 2011).

Insecticide-treated nets (ITNs) have become an important vector control tool for malaria and

some other vector-borne diseases, such as leishmaniasis. There is, however, a wide variation in
the implementation methods, from ITN components of National Malaria Control Programmes in

stable situations to deployment as part of humanitarian emergency relief. Logistical problems,

such as cost, make it difficult to achieve the same coverage, regularity of use and insecticide

treatment as when ensuring coverage, use and treatment of nets under trial conditions

(Lengeler,2010).

Background use of ITNs has become a central focus for the Roll Back Malaria campaign, and

many countries in Africa have now embarked on large-scale public health programmes aimed at

making ITNs available to those at greatest risk (Mathanga,2010). In order to increase ITN

coverage among persons at risk, two approaches are competing with each other in international

debate (RBM, 2012). The first group argues that ITNs should be considered as a necessity like

vaccines and consequently advocates provision of nets through the public sector free of charge

(Curtis, 2013). In contrast, the second group argues for the strengthening of commercial markets,

while acknowledging the importance of subsidies for the groups that are most at risk, e.g.

pregnant women and young children (Lines, 2010). The group in favour of free distribution of

mosquito nets and insecticide supports their argument by the evidence from a few East African

pilot projects regarding the feasibility of such an approach, the existence of a significant

community effect in most areas with high ITN coverage, the reality of a high proportion of rural

populations in Sub-Saharan Africa being unable to pay for such an intervention, and the hope

that rich countries would be willing to pay for malaria control in Sub-Saharan Africa (Curtis,

2013). It is in this view that many investigators have agreed that the provision of free ITN

through ANC services to all pregnant women would significantly contribute to reductions in the

rates of maternal morbidity, placental malaria and low birth weight children, and consequently

reduce maternal and infant mortality (Dolan, 2010). Moreover, the provision of ITNs through
ANC services is expected to strengthen these services and to give their counseling on malaria

prevention more credibility. Finally, the provision of ITNs would likely attract more women to

ANC services and may thus provide additional health benefits to this important target group

(Fraser, 2011). In the April 2000 Abuja Declaration, African Heads of State agreed to have, at

least 60% of pregnant women at risk of malaria sleep under insecticide treated nets by the year

2005 (The Africa malaria report, 2013).

Where effectiveness of use of insecticide treated nets has been studied, ITN users were, at

significantly lower risk of being infected with malaria, when compared to non-users (Abdulla,

2011).

A systematic review of randomised controlled trials involving use of insecticide treated nets

among pregnant women (four studies in Africa and one in Thailand) revealed that, women who

slept under ITNs, in the African study had lower numbers of parasites in their blood (Shulman,

2013). Miscarriages were also reduced by a third in those women who were in their first few

pregnancies (Browne, 2011). The overall proportion of babies who were low birth weight went

down by nearly a quarter (Njagi, 2012). In Thailand, the women using ITNs were less anemic

and the miscarriage rate was again lower although there was no change in the low-birth-weight

figures (Gamble, 2010). Two of the studies carried out in Africa, south of the Sahara showed that

insecticide treated bed nets reduce morbidity and mortality in pregnant women. Studies carried

out in Gambia in an area of high malaria endemicity, with seasonal transmission and parasite

inoculation rate of 1-10, demonstrated that during the rainy season there were significantly fewer

primigravidae with parasitaemia in villages with insecticide treated bed nets than in the control

villages even though there was no difference in the prevalence of severe anaemia or in the mean

haemoglobin level (D’Alessandro, 2013). Thus insecticide treated bed nets had an effect on
malaria prevalence, but not on severe anaemia which was demonstrated to be low during the dry

season in women using insecticide bed nets than in the control villages, but there was no

difference between the two villages during the rainy season (Dolan, 2010). On the other hand,

during the rainy season, there were fewer preterm deliveries among women, who used

insecticide treated nets than the women who did not use nets. The mean birth weight of children

born in villages with treated bed nets was 130g higher than that of children born in the control

villages and at the individual level (D’Alessandro, 2013). Protected pregnant women by bed nets

had 30% less anaemia than unprotected women and their offspring had a better chance of

survival (Marchant, 2011).

In an area of perennial malaria transmission in Western Kenya (Rarieda Division in Siaya

District), where women receive as many as 45 to 230 infective bites on the average during the 40

weeks of gestation, insecticide treated bed nets were associated, in the first four pregnancies,

with significant reduction a) in parasitaemia during pregnancy by 38%, b) at the time of delivery

by 23 %, c) in the risk of low birth weight by 28%, and d) in any adverse birth outcome by 25%

(Ter Kuile, 2013). This impact goes beyond primigravidae to include women of other higher

pregnancy order up to the fourth (D’Alessandro, 2013). However, unlike the Gambia study, the

effect was observed throughout the year, with little seasonal variation (Ter Kuile, 2013).

Review of recent information from published and some unpublished data suggests that in

pregnant women in malaria-endemic areas, multiple infections of P. falciparum malaria, anemia,

and HIV in pregnancy, contribute to disease severity and to the adverse outcomes of LBW

through prematurity or Intra-Uterine Growth Retardation and infant mortality. Overall, although

the contribution of malaria in pregnancy to infant mortality may be modest, the wide geographic

distribution of infection around the tropics and the high mortality rate in malaria-endemic
settings lead to a substantial number of infant deaths linked to malaria in pregnancy, estimated to

be 75,000 to 200,000 infant deaths annually (Steketee, 2011). Further, malaria infection is more

frequent and severe in primigravidae, both during pregnancy and at the time of delivery. A study

of pregnant women living under holoendemic conditions in western Kenya showed that the peak

prevalence of infection in primigravidae at 85.7% and multigravidae at 51.7% occurred at 13-16

weeks gestation. There were a similar number of recoveries from malaria in both groups during

the 2nd and 3rd trimesters. The loss of immunity in early pregnancy was equivalent to an 11-fold

decrease in the rate of recovery from infection (Ter Kuile, 2013). The recovery seen in late

pregnancy suggested that the women mount a satisfactory immune response to malaria infection,

reacquiring their pre-pregnancy immune status at about the time of delivery. The pattern of

infection in pregnancy was comparable to that observed in infants and children. Although

immunity in a child is achieved over several years, the mothers were shown to re-achieve

immunity in 9 months; the pattern is repeated in successive pregnancies (Brabin, 2010). A study

carried out in Kibaha District hospital in Tanzania to explore the determinants of uptake for both

ITNs and Intermittent Presumptive Treatment with Sulfadoxine-Pyrimethamine (IPT-SP) by

pregnant women and the role that individual knowledge and socio-economic status play for use

of ITNs, suggested that increased risk posed to pregnant women by malaria, was almost

universally recognized, but that knowledge of the health impact of that risk, especially to the

health of the fetus, was very low (Nganda, 2012). Over 90% of women thought that ITNs were a

good intervention against malaria during pregnancy, but less than half thought the same about

IPTp-SP. Knowledge of malaria in pregnancy was strongly associated with the use of a

combination of both ITN and IPTp (Nganda, 2012). Pyrethroid-treated bed-nets act against late-

night biting mosquitoes, like traps baited by the body odor of the occupant (Curtis, 2013). The
personal protective effect of treated nets is considerable, even if they are torn. Thus, a high

percentage of coverage of all members of malaria-endemic communities, irrespective of their

level of vulnerability to malaria infection will, in addition, provide protection to children and

pregnant women who are the most vulnerable (Curtis, 2013). Currently, only pyrethroid

insecticides are approved for use on ITNS (RBM, 2012). These insecticides have very low

mammalian toxicity but are highly toxic to insects and have a rapid knock-down effect, even at

very low doses. Pyrethroids have a high residual effect and they do not rapidly break down

unless washed or exposed to sunlight (Curtis, 2013). To maintain the efficacy of ITNs, the nets

must be retreated at intervals of 6-12 months, more frequently if the nets are washed (Snow,

2011). Re-impregnation is needed at certain intervals due to the loss of insecticide over time,

which is mainly influenced by washing frequency (Olaf and Albrecht, 2013). Such services

should be free of charge as otherwise coverage will be very low as demonstrated in many ITN

projects in Sub-Saharan Africa (Lines, 2010). Sleeping under insecticide treated net could halve

the number of episodes of clinical malaria. In a trial conducted in coastal Kenya, a substantial

reduction on cases of severe malaria arriving at the hospital was seen (Nevill, 2010). When used

widely in a community, ITNs reduce transmission of P. falciparum from an infected person to

uninfected individual, since there is a reduction of the population of sporozoite-positive

mosquitoes (Curtis, 2013), which is reflected in a reduction in the plasma antibody levels to

circum sporozoite protein among the bed net users (Metzger, 2011). High use of ITNs in areas of

intense, perennial malaria transmission will result in remarkable health benefits for affected

communities. The prize in reaching the level of coverage called for in the Abuja Declaration will

be healthier children and pregnant women, fewer child deaths, and improvements in economic

development (Bernard, 2010). The regular use of ITNs is currently one of the two primary
prevention tools against malaria in highly endemic areas of Sub-Saharan Africa (SSA), along

with indoor (house) residual spraying. When used properly, ITNs reduce child mortality by

nearly a fifth and the number of clinical episodes by one half, with no evidence of a mortality

delay effect (Lengeler, 2011). A similarly high impact was seen under program conditions

(Armstrong, 2010). Coverage of ITNs in sub-Saharan Africa is still low despite their proven

efficacy, effectiveness and cost-effectiveness (Jayne, 2010).

2.2 TYPES OF INSECTICIDE TREATED BED NET

There are several types of nets available. They vary by size, material and/or treatment. Most nets

are made of polyester but nets are also available in cotton, polyethylene, or polypropylene . Only

pyrethroid insecticides are approved for use on ITNs (Cutis CF, 2013). These insecticides have

been shown to pose very low health risks to humans and other mammals, but are highly toxic to

insects and knock them down, even at very low doses. ITNs are dip-treated using the synthetic

pyrethroid insecticide such as permethrin ordeltamethrin (Maseum, 2010). Pyrethroids do not rapidly

break down unless washed or exposed to sunlight (Vanden , 2010). The great importance of pyrethroid

deposit on the net arises because the body odour of sleepers attracts human seeking (anthropoliphic)

mosquitoes to make contact with the net so that many are killed. Thus, with widespread use of treated

nets, their mortality will be so high that one would expect a reduction in mean mosquito age and hence a

major reduction in the population of mosquitoes (Cutis CF, 2013)..

Previously, nets had to be retreated every 6-12 months and more frequently if the nets were

washed. They had to be replaced or retreated after six washes. Retreatment was done by simply

dipping them in a mixture of water and insecticide and allowing them to dry in a shade. The need

for frequent retreatment was a major barrier to widespread use of ITNs in malaria endemic

countries. Additional cost and lack of understanding of its importance also resulted in low

retreatment rates in most African countries (Vanden , 2010). More recently, several companies have
developed Long Lasting Insecticide treated Nets (LLINs) that maintain effective levels for at

least three years. There are three types of LLINs - polyester netting which has insecticide bound

to the external surface of the netting using a resin, polyethylene which has insecticide

incorporated into the fibre and polypropylene which also has insecticide incorporated into the

fibre. All types can be washed at least 20 times, but physical durability will vary ( Maseum H, 2010).

Long Lasting Insecticide treated Nets have now replaced ITNs in most countries.

These nets have been associated with sharp decreases in malaria in countries where malaria

programmes have achieved high LLIN coverage. In April 2000, African Heads of States met in

Abuja where they set among other targets in the Roll Back Malaria programme, a 60% use of

ITN among the high risk groups by year 2005.

A target that was subsequently raised to 80% by 2010. Few countries have however met this

target and under-five ITN coverage in Africa is currently only 3% with rates in Nigeria reflecting

these regional figures (Binka, 2010) . Several studies have shown that malarial parasitaemia is

positively correlated with anaemia and that parasitaemia is the primary cause of anaemia in very

young children in Africa (Baume, 2012) . Malarial infection is the norm in high transmission areas.

Consequently, anaemia is common in young children. Hopes for controlling malaria and malarial

anaemia have recently been revitalised by the demonstration that nets treated with insecticide can

reduce malarial morbidity and mortality (Baume, 2012).

2.3 HOW TO DEPLOY AN ITN

For effectiveness, it is important that the netting does not have holes or gaps large enough to

allow insects to enter. Because an insect can bite a person through the net, the net must not rest

directly on the skin. Mosquito nets can be hung over beds, from the ceiling or a frame, built into

tents .
When hung over beds, rectangular nets provide more room for sleeping without the danger of net

coming in contact with the skin, at which point mosquitoes may bite through untreated net ( Allai,

2013).The net is said to be properly used when the corners of the rectangular ITN are attached to

the eaves and walls of the room, with the net lowered during sleeping time and tucked under the

sleeping mattress or mat, or made to touch the ground all around. This ensures maximum contact

between the host seeking mosquitoes and the insecticide treated net, and minimises the contact

between the mosquitoes and potentially infective hosts. This is referred to as adherence ( Allai,

2013).

2.4 CURRENT STRATEGIES FOR MALARIA PREVENTION AND

CONTROL

2.4.1 VECTOR CONTROL

Over, 60 million LLITNs were distributed in Nigeria between 2009 and 2013 as part of the
universal LLITNs campaign to protect an estimated 29 million households in Nigeria (NMCP,
2014). However, findings from the 2013 National Demographic and Health Survey (NDHS)
have shown that only 36 percent of the households in the country have access to an ITN and only
18 percent of the pregnant women slept under some kinds of mosquito nets the night before the
survey. Thus, its poor utilization is a matter of great concern (NMCP, 2014).

On the other hand, indoor residual spray is another powerful way of rapidly reducing malaria
transmission. It has been found to be effective for 3 to 6 months depending on the nature of
surface sprayed and insecticide combination. In order to attain its full potential, at least 85% of
structures in the target area need to be covered and there may be the need for multiple sprays
(FMH, 2013). However, evidence has shown that only 2 percent of households surveyed by the
National Populations Commission in 2013 have been sprayed in the previous 12 months (NPC,
2014). Most of the IRS is carried out by state governments or by organizations supported through
government programmes. The rest is carried out by non-governmental organizations (NPC,
2014).
2.4.2 EARLY DIAGNOSIS AND TREATMENT

The principal approaches recommended for malaria cases is early diagnosis (through the use of
rapid diagnostic tests and microscopy) and institution of effective anti-malaria combination
therapy (Falade, 2016). This is aimed at reducing the number of cases progressing to severe
malaria, prevent the development of resistant strains to antimalarials and break the chain of
transmission (Mahende, 2016).

2.4.3 INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY (IPTp)

This refers to the process by which antimalarial medications are given to pregnant women at
predefined intervals in an effort to clear a presumed level of malarial parasitaemia in
asymptomatic pregnant women. The best and most effective medication recommended for IPTs
is the single dose antimalarial drug Sulphadoxine-pyrimethamine (SP) (Ezire, 2015). IPT is
given to pregnant women free of charge during antenatal visits at public health facilities and non-
governmental organization (NGO) facilities as part of the federal government’s protocol for
focused antenatal care. However, only 23 percent of pregnant women received IPT during their
last pregnancy in 2013 with a higher proportion of women in urban areas than rural area (NMCP,
2014). This has been associated with higher level of education and wealth quintile among
women in urban areas (NPC, 2014).

Evidence has shown that administering SP to pregnant women from early in the second trimester
and continued monthly until delivery reduces the incidence of low birth weight by 20% (FMH,
2014). It also reduces the incidence of maternal anaemia, miscarriage, stillbirth, preterm delivery
and maternal mortality (Kayentaol, 2013).

Despite the side effects attributable to sulphonamides, SP used in pregnancy for intermittent
preventive treatment is generally well tolerated and pose no demonstrable risk to the foetus
(Clarke, 2015). However, mild side effects such as nausea, vomiting, dizziness and weakness
have been reported by some pregnant women especially with the first dose (NMCP, 2014). These
side effects tend to decrease with subsequent doses (Kayentao, 2013).
2.5 BEHAVIOURAL CHANGE THEORIES

Behaviour refers to the range of actions and mannerisms made by individuals in association with
their environment as a response to various stimuli or imputes whether internal or external, overt
or covert, conscious or unconscious, voluntary or involuntary (Minton, 2014). The behaviour of
an individual, community or population is one of the main determinants of their health outcome.
Thus, achieving changes in health related behaviour is an important element of any health related
intervention (Davis, 2015). These changes in behaviour might involve reduction or elimination
of a harmful behaviour, promotion of a healthier lifestyle or adherence to medical regimens
(Young, 2014).

Health related human behaviours such as alcohol consumption, tobacco smoking, dietary
behaviours, sexual practices and physical activities play a significant role in many of the
principal causes of death (NICE, 2010). Evidence has shown that even minor changes in
behaviours can have significant effect on population health outcomes (Butts, 2013). This makes
it vital to understand these behaviours and the factors influencing their occurrence in order to
develop and incorporate effective evidence-based health behaviour change interventions and
policies for reducing avoidable morbidity and mortality (Davis, 2015).

Health related human behaviour is greatly influenced by socio-economic status of the individual
or the community and by extension the level of inequality within the society. As a result, policies
geared towards economic empowerment and reducing inequality will go a long way in
improving health outcome (Wilkinson, 2010).

The most dominant theories of health behaviour are the health belief model, the social cognitive
theory and the transtheoretical model (Butts, 2013). However, most studies on the determinants
of ITN use by pregnant women were based on the health belief model which hypothesizes that
personal health-related action is largely determined by the existence of adequate motivation or
health concern, perceived threats of serious outcome and the belief that the recommended health
action will reduce or eliminate the perceived threat (Ankomah, 2012).

A proper understanding of health behavioural theories is necessary for this systematic appraisal
as it will aid in understanding the actions of pregnant women and the factors or circumstances
that have influenced them to act in a particular way (Ankomah, 2012). This is based on the fact
that behaviour is mainly determined by the opportunities and conditions in which individuals are
placed (NICE, 2014). This will help policy makers to develop the most appropriate behavioural
change interventions that will encourage the utilization of ITNs.

2.6 FACTORS INFLUENCING ITN USE BY PREGNANT WOMEN

Factors that have been identified to influence ITN utilization are numerous but can be broadly
categorized into the following; knowledge of the health condition, sociodemographic factors,
misconceptions and access.

2.6.1 Knowledge of the health condition

Several studies have identified the presence of correlation between the level of knowledge about
malaria and its preventive measures and the utilization of ITNs among pregnant women across
varied socio-demographic groups (Russel, 2015). Pregnant women generally receive health
education including information on malaria prevention and control during antenatal care visits to
health facilities (Amako, 2016). This service is generally provided by doctors, nurses, midwives
and other auxiliary staff in English language and the local dialect of the community (Fagbamigbe
,2015)

Arogundade, (2011) found that one of the key predictors of ITN use among pregnant women in
Nigeria is the knowledge that ITN use prevents malaria. Pregnant women who knew about the
specific risks of malaria in pregnancy (such as anaemia, low birth weight, abortion) were more
likely to use ITNs than those who did not. This is similar to what was obtained by Russel, (2015)
and Deressa, (2010). However, Russel, (2015) found that despite knowing that mosquitoes cause
malaria, only 2.3% of the respondents knew that malaria could result in spontaneous abortion,
stillbirth, prematurity or intrauterine growth restriction.

Further evidence has also shown that education and correct knowledge about malaria, its modes
of prevention as well as its fatal consequences were found to be significantly associated with
increased use (Arogundade, 2011). However, Aluko and Oluwatosin (2012) found that despite
the relatively high knowledge of malaria by the respondents, the use of ITN is significantly low.
This has been attributed to the negative attitudes of the respondents to ITN use, poverty or
unavailability.

2.6.2 Socio-demographic Factors

Evidence has shown that the presence of social and emotional support is an important
determinant of increased ITN use (Russell, 2015). Wagbatsoma and Aigbe, (2010) found that
most married women use ITN compared to unmarried women. However, small family size is
another predictor of increased ITN usage. This finding is similar to findings obtained by
Ankomah, (2012) where women from monogamous families use ITNs more than polygamous
ones implying that a woman who is the only wife to her husband gets the necessary social and
financial support from him. In addition, women in middle-class families are more likely to use
ITNs (NPC, 2014). However, this is contrary to the findings by Belay and Deressa (2010) where
age, marital status, occupation, parity, number of rooms, family size and location of residence
did not influence the use of ITNs by pregnant women.

It was also found that women with higher number of previous pregnancies have increased
chances of sleeping under an ITN, this has been attributed to the fact that they are likely to have
better knowledge about the dangers of malaria and a better chance that they will attend ANC
clinics, thus increasing their chances of accessing ITN (Muhumuza, 2016).

Belay and Deressa (2010) found that urban residence is a key predictor of increased ITN access
and utilization with 76.2% of urban pregnant women using ITNs as against 56.7% of rural
women. However, there was no difference between rural and urban areas in terms of perceived
symptoms and knowledge about malaria and its preventive measures. This is despite the fact that
pregnant women in rural communities are at an increased risk (Ajayi, 2013). This might be
related to the fact that urban bias exists in terms of public health expenditure coupled with
inadequate financing and provision of incentives to attract health personnel to work in rural areas
(Omo-Aghoja, 2010). All these have resulted in inequalities in rural-urban health facilities and
reduced access to health services (Ajayi, 2013).
2.6.3 Economic Factors

Women from poor socioeconomic background and poor household wealth are less likely to use
ITN compared to those from higher socioeconomic class (Ruyange, 2016). However, Mugisha
and Arinaitwe (2010) found that women without formal education and from poor socioeconomic
background were more likely to use ITN compared to those from higher socioeconomic class.
This may be associated with their perceived vulnerability to malaria or due to targeted public
health campaigns and free ITN distribution in Primary and secondary health centres (Auta,
2012). Furthermore, women who are dependent were more likely to sleep under ITNs compared
to their counterparts who engage in at least one type of employment (Auta, 2012).

People in rural areas are at a disadvantage in terms of employment opportunities with majority
engaged in agriculture and other informal means of livelihood (Ekpe, 2014). However, women in
Nigeria have always been at a disadvantage when it comes to socio-economic activities where
men take most of the employment opportunities in the formal sector (Ekpe, 2014). Only 7% of
women are employed in the formal sector with the majority engaged in sales, unskilled services
and subsistence agriculture (Fapohunda, 2012). This has been attributed to their relative lack of
education and training, social and cultural barriers (marriage, childbirth, permission from
husband) and gender biased government policies (Fapohunda, 2012). As such, gender equality
and socio-economic empowerment of women must be considered in order to design any viable
health program (Emmanuel, 2016).

2.6.4 Education

The level of education was found to have variable effects on the utilization of ITNs among
pregnant women in several studies (Iwuafor, 2016). Some studies found a good correlation
between the possession of higher education and increased use of ITNs (Muhumuza, 2016).
Iwuafor, (2016) found that although possession of a higher education increases the likelihood of
possessing ITN, it was not found to increase utilization.

Belay and Deressa (2010) also found that higher education attainment is the strongest predictor
of ITN use by pregnant women. Education generally improves awareness and compliance to
therapy. This assertion is also supported by Muhumuza, (2016) who found that women with
post-primary education were two times more likely to use ITNs compared to lower education
levels. This has been attributed to their better knowledge about the dangers of malaria and the
need for prevention. This reinforces the importance of girl-child education as a means of women
empowerment.

Conversely, Auta (2012) found that women with lower level of education or those without
formal education were more likely to use ITNs. On the other hand, Yassin, (2010) found no
correlation between educational level and ITN use. However, the study did not explore the
physical attributes of ITNs in explaining user preferences and their potential influence on
consistent use of ITN.

2.6.5 Misconceptions

Misconceptions about malaria and its prevention have been some of the important determinants
of ITN use among pregnant women (Iwuafor, 2016). Women who had misconceptions about the
causes and prevention of malaria were less likely to use ITN even though they may have one
(Arogundade, 2011).

Some of the misconceptions that have been identified to reduce the ownership and utilization of
ITN include; perceiving malaria as ordinary fever caused by over-work, sunlight, excessive sex,
noise, witchcraft, not resting/sleeping enough, drinking too much alcohol/beer, eating too much
palm/groundnut oil, physical contact with a malaria patient, exposure to cold air or drinking
contaminated water (Iwuafor, 2016; Belay and Deressa, 2010). Identifying such misconceptions
for the purpose of designing appropriate educational interventions could significantly lead to
improvement in health-seeking behaviour and preventive practices (Iwuafor, 2016). However,
the study is limited by the fact that it did not measure the degree of exposure to the social
intervention necessary to have a significant influence on ITN use (Chirdan, 2010).

Due to the strong correlation between misconceptions and ITN use, there is the need for
correcting these misconceptions about malaria and its prevention through health education
(Belay and Deressa, 2010).
2.6.6 Access/Availability

Evidence from some studies found that the reason for the poor ITN utilization is attributable to
difficulty or lack of access to ITN by pregnant women. This is because ITNs are given out at
health facilities, some of which are far from the mothers (Muhumuza, 2016). Wagbatsoma and
Aigbe (2010) found that despite the fact that the respondents have good knowledge about malaria
and its prevention, ITNs are simply not available to them.

The health structure of Nigeria is divided into primary (primary health centres), secondary
(General hospitals) and tertiary (teaching hospitals, specialist hospitals and research centres)
which are managed by local, state and federal governments respectively (Oyedeji, 2014).
According to data from the federal ministry of health, 88.1 percent of health centres in Nigeria
are primary health centres, 11.7 percent are secondary facilities while only 0.2 percent are
tertiary (NMCP, 2014). Sixty-four percent of the population are within 20km of a hospital,
however, urban areas are more favoured with 78% of households within 20km of a hospital as
opposed to 58% for rural areas. In the same vein, 80% of households in urban areas being within
5km of a PHC as opposed to 66% in rural areas (NMCP, 2014).

It is thus evident that a lot of Nigerians especially those in rural areas do not have access to
public health facilities either as a result of the long distance between them or lack of well
equipped and manned facilities which affect their utilization of such services. Since malaria
prevention services are provided during ANC services in health facilities, a lot of pregnant
women will be left out (Teryla, 2014).

2.6.7 Others

Singh, (2013) found that some reasons given for not using ITNs include discomfort, heat or
inconvenience, limited perceived benefit or the preference to use other malaria preventive
methods. This is supported by a study conducted by Aluko and Oluwatosin (2012) where more
than one-quarter of women who slept under ITNs experience at least one form of discomfort
with excessive heat being the major discomfort. This might be attributable to the typical hot
weather of Africa and lack of electricity.
2.7 ACCEPTANCE AND FREQUENCY OF ITN USE
People’s belief, perception and knowledge have a large influence on their acceptance of and
compliance to ITNs (Gray, 2010). Past research in a variety of countries has revealed that
children may fail to sleep under bed nets for a number of reasons. For instance, parents attribute
malaria to causes other than mosquitoes and may not associate bed net usage with the prevention
of malaria. If people don’t see mosquitoes as transmitters of malaria then there is no way they
will consider the use of bed nets as a tool of preventing the disease. Therefore health educators
should sensitise people about the link between mosquito and malaria transmission through
persuasive health education programmes. Additionally, parents may consider using bed nets
difficult because to them sleeping under ITN can be hot and uncomfortable or they may believe
that bed nets resemble burial shroud or that insecticides used to treat the nets will harm their
children. Such beliefs often undermine the consistent use of bed nets and especially during the
dry season (Crookson, 2010).
Community perception, beliefs and attitudes about malaria causation, prevention and care
influence efforts to address the malaria problem but they are often overlooked in control efforts.
In the words of Agyapong and Manderson, “people’s ability to comply with interventions and to
treat sickness is affected by their acceptance of the intervention, their understanding of the nature
of the illness and the relationship between vector and infection and other socio-economic and
cultural factors” (Agyapong, 2010).
Apart from belief, perception and knowledge factors, many other factors will influence whether
insecticide treated net will achieve widespread acceptance and use or not. Among them are;
access to netting and insecticides for re-treatment, affordability and public education. Also,
essential will be improved natural, political and policy environment, refinement and adaptation
of ITN to specific circumstances and methods of use; an increase in knowledge base required to
support the design and implementation of national ITN programmes and the development of
public health communication tools and strategies to support national ITN programmes (Philips,
2010).
2.8 CHAPTER SUMMARY

This chapter has provided an extensive review of the available literature on the factors
influencing the utilization of ITNs among pregnant women. It also discussed the historical trend
in malaria prevention policies as well as the current strategies for malaria prevention. It also
discussed behavioural change theory in relation to ITN use.
 REFERENCE
Vanden J, Thwing J, Wolkon A, Kulkarni AM, Manga A, Erskine M, et al. Assessing bed net use
and non- use after long lasting insecticide net distribution: a simple framework to guide
programmatic strategies. Malar J 2010; 9: 133 42.

Roll Back Malaria. RBM Global Strategic Plan Geneva: Roll Back Malaria Partnership, 2012.
http://www.rollbackmalaria.org/gmap/1-2.html. (Accessed 2/12/12).

Cutis CF, Jana-Kana B, Maxwell CA. Insecticide treated nets: Impacts on vector populations and
relevance of initial intensity of transmission pyrethroid resistance. J vector Borne Dis 2013;
40:1-8.

Maseum H, Shar R, Schroeder K, Daars A, Singer P. Africa’s largest Long Lasting Insecticide
treated net producer. Lessons from A to Z textiles. BMC International Health and Human Right
2010; 10:1472-77.

Binka FN, Adongo P. Acceptability and use of ITN in Northern Ghana. Trop Med Int Health
2010; 5:499-501.

Baume AC, Marin CM. Gains in awareness, ownership and use of insecticide treated nets in
Nigeria, Senegal, Uganda, and Zambia. Malar J 2012; 2: 153-63.

‘Insecticide Treated Bed nets’. Centres for Disease Control and Prevention.
http://www.cdc.gov/malaria/malaria_worldwide. (Accessed 1/5/14).

Allai JA, Hawley WA, Kolczak MS, TerKuile FO, Gimnig JE, Vulule JM, et al. Factors
affecting use of permethrin treated bed nets during a randomised control trial in western Kenya.
Am J Trop Med Hyg 2013; 68: 137-41.

Abdulla, S., Schellenberg, JA., Nathan, R., Mukasa, O., Marchant, T., Smith, T., Tanner,

M. and Lengeler, C. (2011). Impact on malaria morbidity of a programme supplying insecticide

treated nets in children aged under 2 years in Tanzania: community cross sectional study. British

Medical Journal, 322:270-273.

Armstrong, S.J., Abdulla, S., Nathan, R., Mukasa, O., Marchant, T., Kikumbih, N., Mushi,

A., Mponda, H., Minja, H., Mshinda, H., Tanner, M., and Lengeler, C. (2010). Effect of

large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania.

Lancet, 357:1241-1247.
Armstrong, S. J., Minja, H., Mponda, H., Kikumbih N., Mushi, A., Nathan, R., Abdulla, S.,

Mukasa, O., Marchant, T. J., Tanner, M. and Lengeler C. (2010). Re-treatment of mosquito

nets with insecticide. Transactions of the Royal Society of Tropical Medicine and Hygiene

volume 96 issue 4, Pages 368-369.

Bernard, L. N., John, P.C. and David A. (2011). Insecticide-treated bed nets. American

Journal of Tropical Medicine and Hygiene, 68(4 suppl), pp. 1-2.

Brabin, B.J. (2010). An analysis of malaria in pregnancy in Africa. Bull World Health Organ;

61: 1005–1016

Browne, E.N., Maude, G.H., and Binka, F.N. (2011). The impact of insecticide treated bed

nets on malaria and anaemia in pregnancy in kassena-Nankana district, Ghana: A randomised

controlled trial. Tropical Medicine and International Health and Hygiene; 6:667-676.

Curtis, C. F. (2013). Impregnated bed nets; Malaria control and child mortality in Africa.

Tropical Medicine and International Health; 1(2):137-138.

D’Alessandro, U., Olaleye, B., Langerock, P., Bennett, S., Cham, K., Cham, B., and

Greenwood, B. (2013). The Gambian National Impregnated Bed Net Programme: evaluation of

effectiveness by means of case-control studies. Transactions of the Royal Society of Tropical

Medicine and Hygiene; 91: 638-642

Dolan, G., Ter Kuile, FO., and Jacoutot, V. (2010).Bed nets for the prevention of malaria and

anemia in pregnancy. Transactions of the Royal Society of Tropical Medicine and Hygiene 87,

620–626.

Fraser-Hurt, N., and Lyimo, E.O. (2011). Insecticide-treated nets and treatment service: a trial

using public and private sector channels in rural United Republic of Tanzania. Bulletin of the

World Health Organization 76, 607–615.

Gallup, J.L., and Sachs, J.D. (2011). The economic burden of malaria. American Journal of

Tropical Medicine and Hygiene 64: 85–96

Gamble C., Ekwaru, P.J., Garner, P., and ter Kuile, F.O. (2010). Insecticide-Treated Nets for

the Prevention of Malaria in Pregnancy: A Systematic Review of Randomized Controlled Trials.

Journal of Public Medicine, 4 (3):107

Jayne, W., Jenny, H., Jo, L. and Kara, H. (2010). Delivery systems for insecticide treated and

untreated mosquito nets in Africa: categorization and outcomes achieved. Health Policy Plan;

22(5):277-293.

Lengeler, C., and Snow, R.W. (2010). From efficacy to effectiveness: insecticide-treated

bednets in Africa. Bull World Health Organ, 74:325-332.

Lines, J. (2010). Mosquito nets and insecticides for net treatment: a discussion of existing and

potential distribution systems in Africa. Tropical Medicine and International Health 1, 616–632

Lines, J., Lengeler, C., and Cham K. (2010). Scaling-up and sustaining insecticide-treated net

coverage. The Lancet Infectious Diseases 3, 465–466.

Marchant, T., Schellenberg, J.A., Nathan, R., Abdulla, S., Mukasa, O., Mshinda, H., and

Lengeler, C. (2011). Anaemia in pregnancy and infant mortality in Tanzania. Tropical Medicine

and International Health, 9(2), 262-266

Mathanga, D.P., Campbell, C.H., Taylor, T.E., Barlow, R., and Wilson, M.L. (2010).

Socially marketed insecticide-treated nets effectively reduce Plasmodium infection and anemia

among children in urban Malawi. Tropical Medicine and International Health 11 (9), 1367–

1374.
Metzger, W. G., Maxwell, C. A. and Curtis, C. F. (2011). Anti-sporozoite immunity and

impregnated bednets in Tanzanian villages. Annals of Tropical Medicine and Parasitology

92:727-729

Nevill, C., Some E., Mung’ala, V., Mutemi, W., New, L., Marsh, K., Lengeler, C., and Snow

R. (2010). Insecticide-treated bednets reduce mortality and severe morbidity from malaria

among children on the Kenyan coast. Tropical Medicine and International Health 1: 139–146

Nganda, RY., Drakeley, C., Reyburn, H., and Marchant, T. (2012). Knowledge of malaria

influences the use of insecticide treated nets but not intermittent presumptive treatment by

pregnant women in Tanzania. Malaria Journal 12, 3:42

Njagi, J.K., Magnussen, P., Estambale, B., Ouma, J., Mugo, B. (2012). Prevention of anaemia

in pregnancy using insecticide treated bed nets and sulfadoxine-pyrimethamine in a highly

malarious area of Kenya: A randomised controlled trial. Transactions of Royal society of

Tropical medicine and Hygiene; 97:277-282.

Roll Back Malaria, (2012). World malaria report Geneva: WHO. Publication number

WHO/HTM/MAL/2005.1102

Rowland, M., Webster, J., Saleh, P., Chandramohan, D., Freeman, T., Pearcy, B., Durrani,

N., Rab, A., and Mohammed, N. (2012).Prevention of malaria in Afghanistan through social

marketing of insecticide-treated nets: evaluation of coverage and effectiveness by cross sectional

surveys and passive surveillance. Tropical Medicine and International Health 7:813-822

Snow, R.E., McCabe, E., Mbogo, C.N.M., Molyneux, C.S., Some, E.S., Mung’ala, V.O. and

Nevill C.G. (2010). The effect of delivery mechanisms on the uptake of bed net re-impregnation

in Kilifi District, Kenya. Health Policy and Planning 14: 18–25

Steketee, R.W., Nahlen, B.L., Parise, M.E., and Menendez, C. (2011). The burden of malaria

in pregnancy in malaria-endemic areas. American Journal of Tropical Medicine and Hygiene 64:

28–35

Susan, O. (2005).Betting on a Malaria Vaccine. The new England Journal of Medicine Number

18,Volume 355:1877-1881.

Tarimo, D.S., Lwihula, G.K., Minjas, J.N. and Bygbjerg, I.C. (2010). Mothers' perceptions

and knowledge on childhood malaria in the holoendemic Kibaha district, Tanzania: implications

for malaria control and the IMCI strategy. Tropical Medicine and International Health 5, 179–

184

Ter Kuile, F.O., Terlouw, D.J, Phillips- Hopward, P.A., Hawley, W.A., Friedman J.F.,

Kariuki, S., Ya Ping Shi., Kolczak, M. S., Lal, A. A., Vulule, J. M., ands Nahlen, B.J.

(2013). Permethrin- treated bed nets reduce malaria in pregnancy in an area of intense perennial

malaria transmission in western Kenya. American Journal of Tropical medicine and Hygiene; 68

(4 suppl):50-60.
CHAPTER THREE
3.0 METHODOLOGY
3.1 STUDY TYPE AND DESIGN
The study was basically observational without any interventions. A descriptive cross sectional design
was used to collect data from a section of the population in the ijebu igbo community.
Data on insecticide treated net ownership, consistent usage, awareness and acceptance etc was
obtained from the study subjects one at a time. Background information such as age, marital status,
socio-economic status, religion etc was also obtained. Both qualitative and quantitative data were
collected for the study.
3.2 STUDY POPULATION
The study engaged households in selected communities within the ijebu igbo community. The focus
was on pregnant women in the study households. Subjects were drawn from a number of
communities within the ijebu igbo community.
3.3 SAMPLING TECHNIQUE AND SIZE
A total of 384 pregnant women were selected for the study. A mix of sampling methods was used in
selecting the 384 study subjects. This included cluster sampling, simple random and systematic
sampling methods. A simple random sampling technique was used to select twenty (20) communities
and each community then formed a cluster. Subjects were selected from each cluster systematically.
The sample frame was the total number of house holds within the study communities. Each
household then constituted a sample unit. The sample size was obtained using statistical population
proportion method,
P = sample proportion (the proportion of the sample that is assumed to be using ITNs = 50% or
0.5)
d = the probability that the desired sample size will not be representative of the study population
(5%)
Z = level of confidence that the chosen sample will be representative of the population (95%)
The assumption that 50% or 0.5 of the sample using ITNs is based on the fact that there is no
baseline data from the district hence half of the population is assumed to be using ITN. Below is
the sample size calculation;
n = 1.962 x 0.5 (1- 0.5)
0.052
n = 3.8416 x 0.5 x 0.5
0.0025
n = 0.9604
0.0025
n = 384.16
n = 384
3.4 DATA COLLECTION TECHNIQUE AND TOOLS
Prepared questionnaires containing open ended and closed ended questions were given out to the
study subjects to respond with the aid of research assistants. The research assistants administered
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