ASSESSMENT OF POSSESSION AND USE OF ITNS/ BED NETS AMONG INHABITANTS OF AGARO TOWN, JIMMA : ZONE, OROMLA NATIONAL REGIONAL STATE SOUTH WEST ETHIOPIA BY YITAGESU HABTU | & RESEARCH PAPER SUBMITTED TO THE SCHOOL OF | ENVIRONMENTAL HEALTH, PUBLIC HEALTH FACULTY, JIMMA UNIVERSITY, IN PARTIAL FULFILLMENT OF THE — REQUIREMENT FOR DEGREE OF BACHELOR OF SCIENCE IN ENVIRONMENTAL HEALTH : JUNE 2006.ASSESSMENT OF POSSESSION AND USE OF ITNS/ BED NETS AMONG INHABITANTS OF AGARO TOWN, JIMMA ZONE, OROMIA NATIONAL REGIONAL STATE SOUTH WEST ETHIOPIA BY YITAGESU HABTU ADVISOR: BISHAW DEBOCH (BSC, MSC,) JUNE 2006 JIMMA, ETHIOPIAFINAL THESIS APPROVAL 1. Advisor Student & has completed his work per the advice, comments and recommendations given by the advisor. As | am his advisor | confirm the finalization of his thesis work by my signature. Advisor's Name Signature 4 AR 20. . ae thr BR 2006 Il, School Head School of environmental health appreciates and approves the successful completion of his thesis. \ Name: Fantahun Wassie (MSC) Signature and Date 7 N.B. It should be noted that the thesis is to be considered as finalized after the approval of the advisor.= is is to certify that the thesis evaluation committee of APPROVAL Vite get Leddy) Date__/2 16] 2006 The committee read and examined his thesis, supervised his defense of in an oral examination and decided to recommend that his study be submitted to dean of Public Health Faculty and through him to the president of the University in partial fulfillment of the requirement for the degree of Bachelor of Science in Environmental Health. ) w spay wena ( Asppaees Ww Dean of Public pe ae Chairman, reseai | oS x Members 1 1- £ Did be U = Cube ole Z- W RtABSTRACT Background: Malaria is a major public Health and Economic problems in the world, especially developing country like Ethiopia. Poor knowledge about the relationships of ITNs and malaria, cost of ITNs, lack of willingness to pay for ITNs and weak national and district mosquito intervention program makes the problem of malaria to be magnified. Objective: To determine the factors determining the bed net possession, use and the households’ willingness to pay for ITNs/ bed nets among inhabitants of Agaro town, Jimma zone, Oromia national regional state. Method: A cross sectional study was conducted from February 15 2006 to March 15 2006. To collect the required data, 294, households with 10% contingency was statistically determined and proportional allocation of households among 5- kebeles was employed to make the sample representative and sampling frame was prepared from list of households. Result and discussion: of the total households interviewed, 267 (90.82%) knew that malaria is transmittable from person to person and 63.61% knew it’s transmission being by the bite of mosquitoes, whereas 27(9.18%) didn’t know that malaria is transmittable. Among residents who knew malaria transmission, only 97(36.33%) of them knew the correct time of mosquito bite. Conceming prevention aspects, 257 (87.41%) of them knew that malaria is preventable, among them, 52.04%, 19.73%, 7.14%, 3.74% and 4.76%, practiced, Insecticide spraying, ITNs/ CBNs, smoke, plant repellent and others, respectively whereas, 37(12,59%) of residents did not know that it is preventable. Of the 215(73.13%) households that knew bed nets, 58 (19.73%) had regularly used the nets and the rest had not used because of different reasons. Among the total interviewed households, 134 (45.58%) of them were willing to pay for nets where as 160(54.42%) were not. Bed net possession and income (x°cal=25.92,df=4,p<0.005), educational status and willingness to pay for nets (x? cal =78.04, df = 6, p<0.005) and bed net possession and educational status (x°cal=44.52, df=6, p<0.005) were found statistically significant. Conclusion: There was a gap in knowledge and utilization of bed nets and influenced by socio-demographic factors that need fo be addressed.ACKNOWLEDGEMENT | would like to express my deepest gratitude to Ato Bishaw Deboch (BSc, MSC), vice dean of Public Health Faculty, for his advice, guide, strong and unlimited technical supports starting from topic selection until the completion of this research thesis. | would also like to express my heart felt thanks to all Jimma University librarians for their unreserved cooperation in searching valuable literatures and information from journals, books, midline and Internet. Also my heartfelt thanks goes to Environmental health students and TTP members who cooperated during data collection, public health faculty for its financial and material assistance, Agaro town administration and community of Agaro town for providing me genuine information and Ato Eliayas, head of CDC and malaria control in Gomma woreda health office for giving valuable background information. Finally, my last but not least heartfelt thanks gosto Wit Tsigereda Fisseha for typing this research thesis.Abbreviations (Acronyms) ITN= Insecticide treated bed net EPHA = Ethiopian public health association RBM= Roll back malaria UNICEF= United Nation's children's fund CBOs= Community-Based organizations MOH = Ministry of Health UNDP = United Nation's Development programme NGO= Non-governmental organization CDC= Communicable disease control P falcipalum = Plasmodium falciparum G.C. = Gregorian calendar E.C. = Ethiopian calendar SNNPR = South Nation Nationality and peoples regional state CBNs= Conventional bed nets LL- ITN = Long lasting ITNs C. ITNs= Conventional ITNs KAP= Knowledge, attitude and practiceTABLE OF CONTENTS Content PABSHEG! esaccncscunnsitinscaairacioan ‘Acknowledgement ‘Acronyms (Abbreviations) . Table of content .. List of tables List of Figures Chapter — One 1.1 Background information ..... 1.2 Introduction... 13 Statement ofthe problem. 1.4 Significance of the study 15 Definition of terms Chapter - Two Literature review Chapter - three Objective 3.1. General objective 3.2. Specific objectives Chapter four Methods and materials. 4.1. — Study atea and period 42. Study design 4.3. Source population 44. Study population 4.5. Study variable 4.5.1. Independent variables. 4.5.2. Dependent variables 4.6. Sampling size and sampling technaues 4.7. _ Ethical consideration 48. Pre-test (pilot study) 4.9. Data collection .. 4.10, Data analysis and interpretation 4.11. Dissemination of the study finding 4.12. Limitations of the study Chapter - Five Result Chapter - six Discussion Chapter - seven Conelusion and recommendation 7.4. Conclusion 7.2. Recommendation Annex |. Reference 11, Questionnaire 50 50 51LIST OF TABLES Number Page Table - 1 Socio-demographic characteristics of inhabitants of Agaro town, Jimma zone, Oromia regional, state February, 2008.......... 26 Table - 2. Knowledge of inhabitants about malaria transmission and how it is transmitted or way of transmission in Agaro town, Jimma zone, Oromia regional state February-2006 i 29 Table - 3 Knowledge of prevention and methods of prevention about malaria among inhabitants of Agaro town, Jimma Zone, Oromia regional, state Feb- 2006 ese 31 Table — 4 Reasons of respondents who knew bed nets but not used, among inhabitants of Agaro town, Jimma zone, Oromia regional, state Feb- 2006....32 Table — 5. Occurrence of morbidity/mortality by malaria after and before bed net usage, among inhabitants of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. 7 20 3 Table ~ 6 Number of bed nets (ITNs/CBNs) per household and corresponding sleeping bed among inhabitants of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. ...-...csosseesnee ie varraretasieee 38 Table ~ 7 Educational status and willingness to pay for nets among households in Agaro town, Jimma zone, Oromia regional, state Feb- 2006. 39 Table ~ 8 Bed net possession and average monthly income among residents of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. viccoeO) Table - 9 Bed net possession and used and occupational status among residents of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. .....41 Table ~ 10 Educational status and possession and use of bed nets among inhabitants of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. : oe 42 Table - 11 Occurrence of morbidity or mortality and number of victim after and before use of ITNs, among residents of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. se 43 Table - 12__ top ten disease in Agaro town, Jimma zone, Oromia regional, state From 2005- 2006 See realLIST OF FIGURES. Figure - 1 Pi-chart showing knowledge of inhabitants about time of transmission of malaria ( bite of mosquito) in Agar town, Jimma zone, Oromia regional, state Feb- 2006. en 30 Figure - 2 Pi- Chart showing the way how nets were utilized by inhabitants of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. eee 34 Figure - 3. Months of the year that mosquitoes are abundant in Agaro town, Jimma zone, Oromia regional, state Feb- 2006. i 08 Figure - 4 Months of the year that fever is more common based on the responses of inhabitants of Agaro town, Jimma zone, Oromia regional, state Feb- 2006. c 37 Figure - 5. Sketch map of Agaro town (study area). leaden ee viCHAPTER- ONE 1.1, BACKGROUND INFORMATION ‘Agaro was a capital town of Gomma Woreda, but now it is a special woreda having its own administration in Jimma zone, Oromia National Regional State. It is found at the distance-of about 380 kms from the capital city of Ethiopia, Addis Ababa. It has five kebele administration units. It is an area where coffee is produced and found at an altitude of 1420-2280 m above sea level. It has annual rainfall of about 108 mm through out the year and a temperature of maximum 38°C. The total population of the town is estimated to be 32, 680 from 2005 census of the administration bureau, and 6537 houses holds. Among the total population, 42% Oromo, 1930% Amhara, 15.76 Gurage and the remaining 22.74% are owned to other nation and nationalities. Muslim, Orthodox and other religions, respectively are ranked religion in the town, In the town there are, one training health center, one health station, three private clinics, four drug venders and one governmental postal service and tele- communication center. Moreover, four elementary schools, one preparatory school and one high school are also found within the town. Communicable diseases including, malaria, diarrhoeal diseases, tuberculosis and acute respiratory tract infections were the major public health problems in the town. Asthma is also prevalent. ‘Among these, malaria has remained the leading causes of high morbidity and mortality in the town. The climatic conditions of the town, such as annual rainfalls throughout all 1seasons, high temperature enough to favor the life of the vector anopheles mosquitoes makes the epidemic to appear with short periods. (33) The woreda health bureau has done more on family planning methods, but least in malaria prevention methods, such as bed nets (ITNs). Some inhabitants has a habit of buying bed nets even if the use and coverage of ITNS is not definitely known and no governmental supports or subsidize. But inhabitants are suffering many times with the disease burden in the town. Especially high risk groups such as pregnant women’s and children under five years, which covers 1.9% and 20% respectively in the town (33). That is why; it is necessary to conduct the study of possession and use of ITNs in the ‘community,Table ~ 12. Top ten disease in Agaro town Jimma zone, Ormia regional state from 2005- 2006, Disease Coverage Malaria Heh tRTI 18.5% intestinal parasitosis 10.6% AGE 79% un 72% Bacilary dysentery 65% URTT 65% Gastritis 48% Rheumatism 32% ‘Skin infection 300%1.2. INTRODUCTION Malaria has been a major challenge to both public health and socioeconomic development in the world, particularly in sub-Saharan Africa like Ethiopia (1). In Ethiopia, about 75% of land is malrious and 68% of the population is at risk of malaria (2). The nature of the topography, variations in climatic conditions and concentration of population in highland, malaria free areas indicates the long history of malaria in oromia and the country as a whole. Recognizing the disease as priority health problems, organized intervention efforts were initiated during the late 1950's. Since then, strong malaria prevention and control activities have been carried outland significant achievements were made through control (1) In developed countries where life treating is not a focal point, personal protecting measures are the way of preventing malaria effectively. Before the developments of insecticide treated bed nets (ITNS) as a new technology in the mid 1980s; people in many countries were already using nets, mainly to protect themselves against biting insect and for cultural reasons. It was only recently appreciated a net treated with insecticides offers much greater protection against malaria. It provides protection both to individuals sleeping under them and other community members (3). ‘Agaro town, which is found in oromia region of Jimma zone, is one of the epidemic as well as endemic prone areas, which cover 6.5% cases of malaria among all causes in the region (1995-2001) (1), ‘Some inhabitants have a habit of ITNs use, even if there is no free distribution of ITNs by government funds or NGO donors (13)1.3. STATEMENT OF THE PROBLEM Malaria kills more than any other single infectious disease except tuberculosis. It represents about 2.35% of the entire total disease burden in the world. It affects population in more than 90 countries across the tropics and even reaches into more temperate regions. Over 2- billion people are at risk of malarial in the world; about 1- million are died, the majority of death occurs in under five children and second highest groups is pregnant women. It is estimated that there are 300-500 million cases each year, 10 new cases every second. Endemic and epidemic malaria contribute loss of productivity, tourism income, and external investments of the poorest in the world (6). Malaria continuous to be one of the foremost public health problems facing sub-Saharan Africa, whether one considers malaria associated mortality and morbidity or social and economical impact (6). It is estimated that 90% of all malaria cases are in sub-Saharan Africa, where it accounts for about 9% of the total disease burden of the region (5) and 20.3% of all deaths under five children (7). Malaria contributes a poverty, which accounts for annual losses of upto US-dolars-12 billion in sub-Saharan countries (8). Malaria is a leading public health problem in Ethiopia where an estimated 48 million people (68%) of population live in areas at risk of malaria (2). Although data was not available in Amhara, Oromia and Somali, malaria is the primary cause of outpatient visits, out patient visits for female, infants and cause of admission by 15.5%, 14.6%, 10.8% and 20.4% respectively of all cases reported in 1995 G.C. and leading causes of death for female and infants by 27% and 21.1% respectively of all deaths reported in the same year, but data was not available again from Addis Ababa region (9) Oromia region, as on e of the nine regional states in the country, the nature of topography, climatic condition, concentration of the population in highland, malaria free areas indicates the long history of malaria in the region. Malaria has been a major causeof both morbidity and mortality, primarily occurs in epidemic forms from months, September to December, peaking in October and November, Despite intensive control efforts made, malaria still stands top in the list of other common disease (1) From the total examined cases, malaria cases by parasite species in six respective years (1991- 1996 E.C.), malaria cases (positive) covers by 45.14%, 29.39%, 39.44%, 34.83%, 43.5% and 48.8% respectively only for P. Falciparum and p.vivax in the region, even if there is no evident for fluctuation (9). The total number of outpatients registered at all health facilities during 1995-2000 were 23,522,714 with 17.7% accounted for by malaria in the region, even there is an information gap (9). Jimam zone is one of the malarious zone in Oromia region, 65% of the areas is malarous. The prevalence of malaria in the zone is about 7.37% (11) and the total death due to the cause of malaria in the zone was 45 people and total cases about 60,000 with confirmed case of about 13,871 only during 2005 G.C. report (12). ‘Agaro town, found in Jimma zone is one of the epidemic prone areas which has a malaria attack rate of minimum 10 cases per weeks and maximum of 270 cases per week (13) and five year retrospective study shows, from all health except private health facility, malaria covers, 6.5% of all causes in Oromia National regional state form 1995- 2000 G.C. (11) The importance of malaria as health and development problem is well recognized in Ethiopia and has always been given emphasis and priority by governments. The recent health policies clearly places control of communicable disease and epidemics on the top of its priority list. In different occasions, MOH has clearly expressed its commitment to malaria control at different workshops intemally and in its participation on WHO meeting, to realize the commitment to improve the design of malaria control programme and stated preventive strategy (10)According to the comment given during panel discussion insecticide treated nets are known to be effective to prevent and control malaria epidemics, but the pace of using this mode of intervention is very low (14). Although, prevention is the major foci of WHO's RBM movement, different barriers make the problem of malaria getting worse in the sub-Saharan countries like Ethiopia (15). As nets are one of the prevention methods of humans from contacts of the malaria vector (Anopheles), the barrier would be discussed as follows: First, in view of the fact that nets (ITNs) are generally seen as comfort and luxury items, the finding that there is little relationships between ITNs use and knowledge of mosquitoes role in malaria transmission is not surprising knowledge of the malaria vectors is no more common in people who owns ITNs than those who don't. In many areas the relation ship between mosquitoes and malaria is known, but people are not aware that only night biting anopheles mosquitoes can transmit the malaria parasite and some people especially; poors perceive ITNs are for a rich people (16) Secondly, the cost of nets is also difficult for the poor, especially sub-Saharan countries like Ethiopia. For example, in West Africa, the cost of ITNs was calculated that it would cost $ 21.8 million to provide 80% of the population of Malawi, 49.9% of malaw’s budget for the government health services 44 million. Therefore, most of he funds for the purchase of nets will therefore have to come from households (17). A third barrier is that most people appear to see nets as a mosquitoes control measure, rather than as malaria control measures. Such cases are appeared when promotion about nets and malaria is absent (18) A fourth barrier is lack of a structure at the village level to assume responsibility for ensuring high rates of regular re-treatment of nets with insecticide. Once an insecticide wears off, the effectiveness of the nets as a malaria control measure is also lost. Many rprojects pay litte attention to this barrier. Once the nets are given or sold, there is no re- treatment. A structure is needed at the village level that can not only arrange for regular retreatment of the nets, but also create and sustain community wide demand for it (18). A fifth barrier is lack of willingness to pay for the insecticide treated nets. This is driven by lack of appreciation of the role of the insecticide in health protection, and by the cost and personal inconvenience that arise from having to re treat the net periodically. Unless people have an appreciation for the benefits of the INT, it is unlikely they will invest in this more costly netting. For netting requiring re treatment, people must not only be willing to pay for insecticide, but also to invest time and effort in bringing their nets to a central location for re treatment or to purchase the insecticide and retreat the netting on their own (18). The last barrier is lack of national and district commitment to mosquito net interventions. Although governments generally list malaria as priority, inadequate funding and lack of trained personnel would make the prevention programme spoiled (18). In most malaria ‘endemic African countries, the public sector does not have the financial or logistic capacity to extend net use to the scale required, most countries spend only us $ 4 Percapita a year on health, which is the equivalent average cost of an untreated net (38). Effective implementation of insecticide treated bed net programmes requires a strong input of education and promotion, especially in populations who don't have experience of insecticide treated nets. If ITNs are distributed freely without strong education campaigns, they may not be valued or used correctively.Within the donor and research community, there is a universal acceptance of ITNs as an essential public health intervention and current debates concerns how best to achieve the target of ensuring that all those at risk of malaria sleep under ITNs (19). Insecticide treated bed nets use is a new in our country. They protect from mosquitoes through repellent and knocking down effect of insecticides used to impregnate the nets, but more effective when the users understand peak feeding times. Most people in the country don’t aware how the nets should be used, for example, some people make the nets to be lowered on the floor round leading mosquitoes to enter the sleeping place is the repellent property of nets wear away (20).1.4 SIGNIFICANCE OF THE STUDY Community perception relating to the control and perception about malaria are the main socio cultural factors and different barriers that face the community influence the malaria prevention and control (19). After this study, different determinant factors about the ITNs/ bed net use, barriers not to use, coverage of ITNs and participation of the community & organizations towards the ITNs as the major personal protection from malaria, t'fe extrapolated and informed to the community and responsible body. This will: Increase the knowledge and practice of the community about malaria prevention Increase the community interest to use ITNs to be protected from malaria Increase the relation between ITNs and malaria disease Reduce the mortality and morbidity of vulnerable groups by malaria Increase the willingness to pay for ITNs Increase productivity of the community because it reduces mortality & morbidity of child and pregnant women Be used as a reference for others, who are interested about protection methods of malaria. 101.5. DEFINITION OF TERMS Conventional bed nets ~ bed nets which are not totally treated by insecticide (34) ITNs — Insecticide treated nets that have repellant or killing capacity due to insecticide Repellent- a chemical applied to the skin or clothing or other places to discourage host seeking behavior of vectors Insecticide — Arm chemical substance used for the destruction of insects whether applied as powder, liquid, atomized liquid, aerosols or as a “paint” spray, residual action is usual (38). Endemic: The constant presence of a disease or infectious agent within a given geographic area or usual prevalence of a given disease within such area (39) Epidemic: The occurrence in a community or region of cases of an illness (out break) clearly in excess of expectancy (39). Roll back malaria — A partnership which was launched in 1998 by WHO, UNICEF, UNDP and World Bank to combat malaria, Vulnerable groups- higher risk groups who are very susceptible hosts for any agents Long-lasting ITN: ready to use, or factory pretreated nets that require no further treatment during their expected lifespan of 4-5 years (resist washing) (38). Conventional ITN — requires regular re-treatment at least for 6-month and non- resistant to wash.CHAPTER TWO LITERATURE REVIEW The WHO, UNICEF, UNDP and the World Bank to provide a coordinated global approach to fight malaria launched the roll back malaria partnership in 1998. The goal of the partnership is to halve malaria mortality by 2010 and again 2015. Since its launch, the RBM partnership has grown rapidly and now consists of various partners, including malaria endemic countries, their bilateral and multilateral development partners, NGOs and CBOs, foundations and academic national expansion of malaria prevention interventions, WHO and UNICEF recommended free distribution of ITNs, to highly susceptible groups, children and pregnant women. (21) Insecticide treated bed nets are an option for personal protection against malaria, which presently one of the major foci of WHO's roll back malaria movement. In any trials, ITNs have been shown to be highly protective against malaria in several African countries. However, their effectiveness in acute emergencies has not yet been demonstrated. In chronic emergencies effectiveness has been demonstrated in Afghan refugee camps of Pakistan (22). Another option, which again has been tested in Asia but not in Africa, is the use of impregnated blankets and items of clothing (23). Now days, many agencies are turing to the distribution of ITNs in emergencies. However: as with treatment of malaria there are many operational and technical issues, which needs to be addressed, coordination between agencies is ‘once again vital in achieving high levels of understanding by the community of the role of the net and insecticide (22). In the year 2000, African countries committed themselves to a series of malaria control targets to be reached by the end of 2005, chiefly protection through the use of ITNs for 60% of the people at highest risk and intermittent preventive treatment for 60% of 126% Acts Artemisinin bated (ompahebion Hepapi pregnant women some countries have been able to reach or even exceed some of the targets most remaining countries are now pdjéed to begin scaling up antimalarial efforts. A total 23 African countries are now using the new and effective drugs (ACTS) and 22 have adopted the RBM-recommended strategy of home management of malaria for children under 5 years of age. Based on the strategy, the number of ITN, distributed has increased 10 fold during the past 3-yea¥fin over 14 African countries. And surveys have shown remarkable increase in ITN coverage for children under 5-years of age (34) Regarding to the coverage, nine African countries surveyed between 1997 & 2001, 18% of households’ possessone or more nets and 1.3% households surveyed in 3- countries own at least one ITNs. The proportion of under fives, sleeping under nets also low about 15% across 28 countries surveyed. Even fewer children (< 2%) sleep under ITNs. Even if the current rates of coverage are generally low, the availability and use of ITNs have increased appreciably over the past 10 years, particularly in countries where nets were not normally used (36). se 4 Net possession and use have to increase considerably if the gap between the number of to under fives who would benefit from a net and those who currently sleep under be reduced. The challenge is to find the balance between covering the costs of increasing ITNs. Coverage and stimulating the growth of commercial markets, ensuring the poorest and most vulnerable are protected. Subsidy of ITNs- distribution and stronger roles are needed (37) The impact of ITN, on mortality was determined by intervention studies cuffed out in four African countries. In Gambia bed nets are commonly used with permethrin nets and a national programme had the objective of treating nets in use in large villages over a two yeaf%period, during the first year insecticide was distributed free of charge, but in subsequent years a small fee was demanded, in the first year about 80% of existing nets 13well treated with insecticide, and a 25% decrease in all causes of mortality was observed among children under ten (27). Randomized controlled trials in African setting of different transmission intensities have shown that ITN can reduce the number of under -5 deaths, by one fifth (28). If properly used, ITN can cut malaria transmission by up to 90%. (3). Saving about 6-lives for every 1000 children aged, 1-59 months protected each year. The incidence of clinical episodes of p. Falciparum infection reduced by 50% on average when used by a pregnant women, ITNs, are also efficacious in reducing maternal anemia, placental infection and low birth weight (29) This may even be underestimate of the efficacy of TNs, because the impact of a reduced mosquito burden extends to households and communities without nets, which reduces the a apparent differences between study areas with nets and study areas with out nets, the protection afforded to non users in the vicinity is difficult to quantify but it appears to extend our several hundred meters (30) In Ethiopia, use of ITNs, was introduced as one of the important control measures in 1997 and is being supplied to affected areas on cost recovery basis in four regions: Tigray, Amhara, Oromia and SNNPRs (31) Malaria mosquitoes usually bite from gigi Su nets are especially good for protecting young children who are already asleep by sunset and protecting older children and adults because some mosquitoes bite during the might set to sunrise. There fore mosquito Malaria is particularly dangerous for young children and pregnant women. Because when women is pregnant, her body is weak (less immune) than the non pregnant women so become ill more easily and child's body is also less immune than adults “4 uneiLeagainst malaria. So these risk groups need to go to asleep early under insecticide treated bed nets or conventional bed nets to avoid mosquito bites during evening (23). Insecticide treated nets (ITNs) have become an important tool in the prevention of malaria in highly endemic areas. At present large scale ITN, programmes are being implemented in sub-Saharan Africa, Asia, and Latin America using a number of operational approaches. However, if the targets of the Abuja deciaration, set in April 2000 at the African summit on roll back malaria (RBM) are to be reached, the scale up of operations need increased substantially. No less than 81 trials and over 30 descriptive studies carried out in every type of malaria setting worldwide have documented the positive impact of ITNs on child and adult morbidity and mortality (23) Previous trials of insecticide treated netting in Africa have reported 15-33% reductions in child mortality, but this findings have not been translated into large scale implementation because of concerns that the intervention might slow development of clinical immunity leading merely to a shift in child mortality to older ages. (24) According to the research done in N. Ethiopia, Tigray region, Humera area with a joint efforts of WHO, the vulnerability of highland migrants, laborers to malaria during migration to the lowlands for Agriculture work has been a problem of increasing magnitude of malaria, since 1991. As more large scale agricultural investors move into Humera area, laborers often sleep on fields or at work at night, which is at high risk of malaria, and a number of laborers have died. Due these problems, community health workers were trained to work in all settlement areas but malaria morbidity remained high even if treatment and follow-ups were made. Therefore, the feasibility of introducing treated nets as a strategy for intensified control was investigated by KAP survey, affordability and willingness of the community to ITNs, implementation in pilot areas and 15coverage in terms of cost. And then 45% reduction in death rate was observed, hence since 1996-1997 in the area had impregnated bed nets (25). Analysis of all randomized controlled trials shows that ITNs use has an overall protective efficacy against all cause of child mortality and malaria disease episode of 18% and 50% respectively. Frequent washing, lack of reteratment, inconsistent use, other social and technical factors were shown to influence the efficacy of bed nets at field trials. To date, however experiences with local factors influencing the effectiveness of ITNs programmes remain very limited and it is not known whether the impact of treated nets in the context of well controlled randomized trial can be replicated under programme conditions in all set ups (26). ‘A research finding in southern’ Ethiopia shows, among malaria attack from September to December in 2004 G.C. regular ITN users was 43.5% less than in those who didn't use/own insecticide treated bed nets, there is a strong statistical significance between the two. The household factors that were found to influence the effectiveness of ITNs, were, large family size, keeping livestock inside the living rooms, using a bed net obtained two years or more than 12 months, presence of holes tears in the bed net, frequently washing the bed nets and reported history of rolling out of the child from the bed nets during night time (26), According to a research done in Ethiopia, Amhara region north Showa, on bed net utilization and average monthly income of inhabitants have a strong statistical significance and among those who know ITNs, most of them gave the importance’s or values as it also the insecticide repels, inhibits or kills any Mosquitoes other than malaria mosquitoes in addition to a conventional bed nets (32) 16CHAPTER THREE OBJECTIVE 3.1, General Objective To determine the factors determining the bed net possession, use and the household's Willingness to pay for ITNs/bed nets among inhabitants of Agaro town, Jimma zone, Oromia National regional state. 3.2. Specific Objectives: 1. To describe the knowledge and practices about the cause, transmission and preventive practices of malaria regarding to ITN/bed nets, among inhabitants. 2. To assess what factors are associated with the possession of ITNs/bed nets and use by the households in the study population. 3. To assess factors determining the use of vulnerable groups to ITNs/bed nets within the households. 4, To Asses the determinants of the household's willingness to pay for bed net and the average price of bed nets. 5. To forward recommendations to concerned bodies involved in malaria prevention and control interventions. v7CHAPTER FOUR METHOD AND MATERIALS 4.1. Study area and period The study was conducted from February 15, 2006 to March 15, 2006 G.C. in Agaro town, Jimma zone, Oromia national regional states. The town has estimated population of 32,680 with 6537 total households. There exist 844, 807, 1707, 1734 and 1445 households in kebele 1, kebele 2, kebele 3, kebele 4 and kebele 5 respectively. 52, 680 18reTCH MAP OF AGARO Fig. 5. Sketch map of Agaro town (study area) 5 +4.2. Study design A cross sectional study was conducted to assess the possession and use of ITNs/bed nets among inhabitants of Agaro town. 43. Source population All households found in Agaro town were the source population 4.4. Study population All household heads that would have a chance of being included in the sample that was taken from the source population. 45. Study variables 4.5.1. Independent variables - Age - Marital status - Occupational status - Education status - Income = Religion - Ethnicity 4.5.2. Dependent variables - Bed net possession by households - Use of ITNs/bed nets = Willingness to pay for ITNs/bed nets 204.6. Sampling size and sampling techniques By setting confidence interval of 95% and margin of error 5%, the sampling size (n) is calculated as (40) NZ* pq (N=1+ + where n= sample size to be determined Ns total households (source population) = 6537 Z= The standard normal deviate corresponding to the confidence level of 95%, ie. 1.96. Q +p= 100% =1, > g=1-p, p= 0.3 and $0. z d= degree of accuracy desired = 5%, = 0.05 ae 6537(1.96)' (0.7) (0.3) _ (0.05)° (6537-1) + (1.96)? (0.7\(0.3) Because the source population is less than 10,000, itis corrected as n nf = —"_ , where f, correction factor a 1+ N 21nf +294. To compensate for non-response of some households 10% of the household was added. Then 6,12% of non response rate was compensated by contingency and 294 samples was analyzed. For each of 5- kebeles proportional allocation was done to make sample representative of all kebeles. Accordingly: k,= Kitiousehotd yy 844 994 03g N 6537 K, household yy _ 807 994 0 36 N 6537 K, household Safe 1707 294.877 N 6537 K, household. yy. 1734 994. 7g N 6537 K, household yp. 1443 994 038 N 6537 Where K stands for kebele The lists of all head of households were taken from each kebeles 8- days before the actual data collection time for preparing sampling frame. Thereafter, from the sampling frame the predetermined households were randomly selected by lottery method. 4.7. Ethical consideration Before data collection, interests and concern of individuals, the community and local officials was approached politely and addressed through formal letters from the public 22health faculty, Jimma University. Appropriate time of data collection was done as possible as the head of houses reside in the house by resurveying of local community behave. After completing the research, the copy of research result was sent to the woreda health office to inform the community. 4.8. Pre-test (Pilot study) Participants of the actual data collector together with the principal investigator tested the questionnaire on randomly chosen residential houses of the source population, who were not included in the sample. This would help the investigator to check the research instrument, reaction of respondents, language barriers, and mood of the population according to his/her religion/culture and the time required for the data collection. 4.9. Data collection Data was collected from Feb- 15 to march 15, 2006; by using a structured questionnaire designed by the investigator (Annex - 1). Five data collectors from Environmental health students two from TTP members and two from Agaro town had been selected & trained. 4.10 Data Analysis and interpretation The raw data was compiled, summarized and statistically analyzed by the principal investigator using scientific calculator. The result was displayed by Percentages, graphs, and tables. 4.11 Dissemination of the study findings The copy of the research findings was sent to the woreda health office or department through the investigator. This responsible body will inform the result to the community and initiate intervention actions.4.12. Limitations of the study * Unwillingness of people to correctly disclose their income either in cash or in kind was the difficulties during data collection.CHAPTER -5 RESULT 5.1. Socio-demographic characteristics A total of 294 sampled inhabitants living in Agaro town were interviewed. The minimum age of respondents was 18 and maximum 65 years. The mean age of respondents was 35. The mean family size was 5.8 and the average monthly income of respondents was 261.63. Most of respondents were Oromo, 131(44.56%), and next Amhara 61 (20.75%) and 14(4.76%) other nation and nationalities. Muslim 145 (49.32%) and 113(38.44%) Orthodox are the leading religion respectively. (Table - 1), Regarding means of communication, it was found that radio 171 (58.16%), Television 31(10.54%), daily newspaper 41(13.95%) and 20(6.80%) get information from health service counseling. And 61(20.75%) of the respondents did not have any means of communication. 25Table 1- Socio-demographic characteristics of inhabitants of Agaro town, Jimma Oromia regional state, Ethiopia, Feb. 2006 G.C. Characteristics Number Percentage ‘Age in year <20 aT 7054 20-40 143 aB64 4060 9 3367 + a 714 Total 204 100% Ethnicity ‘Oromo 131 cr “Ammara a 20.76 Guraghe 39 13.27 Dawa a 714 Sillie 7 374 Kefa 7 578 Others 1% 476 Total 284 700% Marital status Maried 34 73.58 Single 7 12.59 Divorced 6 544 Widowed 7 238 Total 294 700% Zone, 26Contd. Religion Muslim 745 49.32 ‘Orthodox 113 36.44 Protestant 18 6.46 ‘Others 7 238 Total 294 100% Educational Titerate 33 18.02 Read & write 56 79.05 14 Ey 1 58 ry oa 840 7 1255 1-12 6 1224 12+ 2% 10.86 Total 234 700 Tncome < 240 123 41.84 240-480 a 2755 480-720 3 11.97 720-960 30 10.20 ‘960+ Fy B50 Total 234 700 a0Contd, ‘Occupational status | Self employee 38 33.67 Merchant 86 30a7 Govtempioyee 5 19.05 NGO-employee a a8 ‘Student 16 544 ‘Others 10 340 Total 294 100 285.2. Non socio-demographic parts Of the total households asked whether malaria is transmittable or not 267 (90.82%) knew that malaria is transmittable but 187(63.61%) knew how it is transmitted, that is the bite of mosquitoes and 27(9.18%) did not know that malaria is transmittable. The results are shown below (table -2). Table — 2 Knowledge of inhabitants about malaria transmission and how it is transmitted or ways of transmission in Agaro town, Jimma zone, Oromia regional state, Ethiopia, Feb. 2006 G.C. ‘Knowledge Ways of transmission | Number of households Percent Mosquitoes 187 63.61 Tdon't know 35 11.97 Yes Water 25 8.50 he Respiration 7 2.38 Others 13 4.42 Total 267 90.82 No 27 918 Total 294 700At the same time, the inhabitants were interviewed when did the malaria is transmitted (time of mosquitoes bite) 97(36.33%) of the respondents replied as sun rise and sun set, the responses are presented below (Fig.1) and the knowledge of prevention and Methods (s) they had been using was asked, 257(87.4%) knew the preventability of malaria and 37 (12.58%) did not kow that malaria is preventable (table 3). Night only @ don't know @ Sunrise & sun set © Day time only Fig. 1 Pi-chart showing knowledge of inhabitants about time of transmission of malaria (bite of mosquito) in Agaro town Jimma zone, ‘Oromia regional state, Ethiopia, Feb, 2006 G.C. 30Table- 3. Knowledge of prevention and methods of prevention about malaria among inhabitants of Agaro town, Jimma zone, Oromia regional state, Ethiopia Feb, 2006, G.C. ‘Knowledge Method of prevention | Number of households | Percent Insecticide spraying 753 52.04 TTNsibed nets 58 19.73 Yes ‘Smoke 2 7.14 Piant repellent "1 374 Others 4 476 | Total 287 87.41 No 7 12.59 Total | 294 700 ! Concerning the knowledge of bed nets as personal protective measures, inhabitants were asked, 215 (73.13%) knew bed nets and 79(26.87%) did not know it. Among them who knew bed nets, 58(19.73%) were found to have it and 157(53.40%) did not. Totally, 236(80.27%) households did not have bed nets. The respondents who knew bed nets but not use. Were also asked the reasons why they were not use, the reasons were depicted below (Table 4). aTable - 4. Reasons of respondents who know bed nets but not used, among inhabitants of Agaro town, Jimma zone, Ormia, regional state, Feb. Ethiopia, 2006 G.C. Reasons Number (Frequency) | Percent Lack of money 104 66.24 For conformable & Lexury 87 55.44 No provision (access to buy) 7 23.57 Lack of awareness En 17.19 For mosquito control but not 7 10.83 malaria No insect (mosquito) around 3 328 here Others 70 6.37 N.B. Percentage is calculated from 157, not by total reasons.Out of 58 households (bed net users), 51(87.93%) used insecticide treated nets and 7(12.07%) were conventional bed nets (CBNs). And how the inhabitants get the bed net, was asked, 41 (70.69%) got with some subsidy sale from health service, (18-25.00) Eth. Birr, and 17(29.31%) with fee (35-60.00) Ethi birr. Among households owned a bed net they bought, 22(37.93%) last year, 24(41.38%) this year, 5(8.62%) two years before and 7(12.07%) three years before, There is no organization (100%) at all for pregnant women. Also inhabitants were interviewed whether or not encouraging organ to use bed nets, the response was, 87 (29.59%) from Media, 49(16.67%) Agaro health center, 5(1.70%) health professionals and 153(52.04%) no encouraging organ. Those inhabitants who used bed nets were asked for whom the nets were used, of these, 23(43.10%) heads only, 16(27.59%) children under five, 8(13.797%) children under five and mother together and 9(15.52%) all family in home. And the pattern or ways how the nets were utilized was observed as follow (Figure 2) and they also replied no health professionals visit the users whether the net are retreated or not. With regard to net washing and retreatment rate 27/46.55%) washed the nets and 3(6.17%) retreated again, 13(22.41%) of nets were torn or damaged. Occurrence of morbidity or mortality by malaria before and after bed net usage was assessed, the result was as below (table 5). 33peperdicular to the center of bed Swining the net at walls near by bed 25.86% lowering on the floor round Some times not used Fig2 Pl-chart showing th eway how nets were utilized by inhabitants of Agaro town, Jimma zone Oromia regional state, Feb., 2008. © Swinging the net at 4Table 5- Occurrence of morbidity/Mortality by malaria after and before bed net usage, among inhabitants of Agaro town, Oromia regional state, Feb. 2006. Victim Before After Number Percent Number Percent Children five 23 39.68 13 22.41 wren os 2 Pregnant women 9 12.06 15 25.86 Some one else 19 32.76 21 36.21 ‘As to when mosquitoes are abundant and fever is more common, it was found that, 117(39.79%) did not know in which months mosquitoes are abundant and also 77(26.19%) did not know that fever is more common. The result was shown below (figure 3 and 4). 35,60.00% » 50.00% - 47.9648.64% 40.00% 30.00% 20.00% 18.03% 10.00% 14% Number of respondents (Houesholds ) by percentage 0.00% ae Pelee ioe ae os SIF IO LMS FEW FO I Fig. 3 Months of the year that mosquitoes are abundant in Agaro town based on responses of inhabitants, Jimma zone Oromia regional state, Feb., 2006 auuy August Sept Oct Nov. Dec Jan aFeb Mar | April | May 3660.00% > BApril | May June Number of respondents (households by percentage Fig.4. Month of the year that fever is more common, based on the responses of inhabitants of Agaro town, Jimma zone, Oromia Regional state, Feb,, 2006 G.C, ‘Among the population studied (294), 134 (45.58%) were willing to pay for nets /ITNs, from this 74 (55.22%), 54 (40.29%) and 6(4.48%) had willingness of paying with current price, greater than current price and only less than current price, respectively. Preferred sleeping place for all and sleeping arrangement for bed net owners was interviewed, as a result, 283(96.26%) said inside house and the rest, 11(3.74%) of them said outside the house. Incase of sleeping arrangement, 8(13.79%) of households have one bed net to one corresponding bed and 4(6.89%) have two bed net to two corresponding bed, generally, the arrangement is indicated below (table — 6). 37Table — 6 Number of bed nets (ITNs/CBNs) per household and corresponding sleeping bed among bed net users in Agaro town, Oromia regional state, Feb. 2006. Number of ‘Number of Number of ‘Number of % ITNs/CBNs | users | comresponding| household perahouse | (households) | bed 7 8 7379 2 26 44.83 1 49 3 1 18.97 | 4 4 6.89 Total 49 84.48 1 - ™ 2 4 6.89 2 9 3 2 345 lz gi [5.17 Total 9 15.52 Total 58 | 58 100% Finally, inhabitants were asked whether they do have a domestic animals or not and where the animals lived, in bed net owners, so that, 34(58.62%) didn't have, 24(41.38%) 38did have, from this 13(22.41%) lived in the some house, 7(12.07%) in separated house and 4(6.89%) at the backyard Statistical correlation with some socio-demographic factors of the respondents was tested. The result was, indicated below by cross-tabulated tables ( Table 7, 8, 9, 10, and 11). Table - 7, Educational status and willingness to pay for nets among households in ‘Agaro town, Jimma Zone, Oromia regional states, Feb. 2006 G.C. Educational Willingness to pay for nets X7— result status Yes No Total Titerate 3 50 53 | X’cal= 78.04 Read & Write 16 41 56 df=6 | 1-4 14 ai 35, P<0.005 45-8 30 15 45 C= 0.457 9-10 20 17 37 | 11-12 26 10 36 | 12+ 26 6 32 [Total } 134 760 204 | l Has statistical significant 39.Table 8: Bed net possession and average monthly income among inhabitants of Agaro town, Jimma zone, Oromia regional state, Feb. 2006. Income Possession of bed net Total X — result Yes No CBNs | TTNs | Total <240 4 [7 | 112 123 240 - 480 2 [3 | 66 at 480-720 1 1 | 12 23 35 Xcal=25.92 720 - 960 ae a ae 30 dea | ‘960+ - [7 |7 18 25 p< 0.005 Total 7 |i | 18) 236 294 C= 0.28 | * has statistical significantTable.9. Bed net possession and occupational status among inhabitants of Agaro town, Jimma Zomne Oromia regional state, Ethiopia, Feb.2006 G.C ‘Occupational Possession of bed net Total X2 = result Yes No. X2 cal=8493 status Die4 P<0,01 ‘Selfemployee | 13 86 99 O20 16 70 86 Merchant 2B 33 56 Gov't employee 3 24 27 Employee 3 23 26 Others. 58 236 204 Total Has statistical significance. Others:- student = 16 = Others = 10 yous. 41Table 10- educational status and possession and use of bed nets among inhabitants of Agaro town, zone Orima regional states, Ethiopian, Feb, 2006, Educational Possession of bed net Total |X status recut Yes ‘No ‘Xcal=44,52 CBNs TIN Total literate ze 1 3 30 33 D6 Read and write |= 4 4 32 36 P<0.005 C=0.36 1-4 3 3 6 29 35 58 - 6 6 39 45 9-10 2 6 8 29 37 11-12 - 4 14 22 36 12+ - 17 7 15 32 Total 7 SI 38 236 294 a2Table 11. Occurrence of morbidity or mortality and number of victim after and before use of ITNs, among inhabitants of Agaro town, Jimma zone, Oromia regional state, Feb 2006. G.C. Possession of X? = result bed net Victim Total Yes Before | After Children under five 23 13 36 X? cal=4.34 Pregnant women 9 15 24 df= 2 ‘Some one else 19 21 40 p> 0.10 Total 51 49 100 * has no statistical significance N.B. the sum total is taken as 100, because it is considered the frequency of occurrence & number of victim. 4BCHAPTER - SIX DISCUSSION Malaria is caused by a microscopic protozoan parasite called plasmodium species and transmitted to humans by the bit of Anopheles mosquito (41). The result in this study indicated that 267 (90.82%) of residents knew that malaria is transmittable and 27(9.18%) did not know at all. However, 187 (63.61%) knew the transmission of the disease being through the bite of mosquitoes where as others thought that it can be transmitted by water (8.5%), respiration (2.38%) and other means of transmission (4.42%). 35(11.91%) of them did not know how it can be transmitted. This finding is not in agreement with the study done in southern Ethiopia, that showed 43.7% of respondents knew that malaria could be transmitted by the bite of mosquitoes (42). The reason for the low percentage in the southern Ethiopia might be the study is done in rural parts of the country which might have low media coverage or the study covers large sample size than this study, thereby the denominator could decrease the percentage. However, misconceptions by the respondents as how it can be transmitted (water, respiration) and lack of knowledge could be adversely affecting the preventive behavior especially in breaking the vector- man contact. Understanding about malaria vectors helps the users to use personal protective materials such as ITNs. Regarding time of transmission (mosquito bite time), the result depicted that 97(36.33%) of respondents replied as sun rise and sun set, 86 (32.21%) only at night, 17(6.37%) at day time only and 67(25.09%) did not know when it can be transmitted. The former thought (36.33%) is scientifically correct even if the density of mosquito at sun set differs from sun rise, there is also a probability of residents to be bitten at sun rise (day time). the second two (only at night and only day time) are misunderstanding and the last (lack of knowledge) should not be totally acknowledged. Knowing the Peak biting time, 4