Caregivers’ knowledge and utilization of long-lasting insecticidal nets among under-five children in Osun State, Southwest, Nigeria

Malaria occurs mostly in the poor, tropical and subtropical areas of the world. It is a leading cause of death and disease in many developing countries especially in sub-Saharan Africa, where under-five children and pregnant women are the groups most affected [1]. In 2016, there were an estimated 216 million cases of malaria, with the WHO African Region accounting for 90% of the malaria cases and 91% of malaria deaths [2]. In areas with high transmission of malaria, more than two-thirds (70%) of all malaria deaths occur in children under 5 and this accounted for 285,000 deaths among under-5 in 2016 [2]. It is the third leading cause of death in children less than 5 years worldwide, after pneumonia and diarrhoeal disease and accounts for almost one out of five deaths in children less than 5 years [3]. Malaria also contributes to malnutrition in children, which indirectly causes the death of half of all children under the age of five throughout the world [4]. Nigeria bears the greatest malaria burden among countries in the world, with over 300,000 malarial deaths each year, most of them occurring in children less than 5 years of age [5]. In Nigeria, malaria is responsible for 30% of the under-five mortality and 11% of maternal mortality rate [6].

Ownership and use of long-lasting insecticidal net (LLIN) is one of the proven interventions adopted by Roll Back Malaria (RBM) partners in Nigeria to stem the high incidence of malaria [6]. It is an important tool for the control of malaria and other vector–borne diseases [7]. Utilization of LLIN has been associated with the reduction in the number of infective mosquito bites by 70–90%, malaria morbidity by 50%, child mortality by 27%, incidence of the malaria parasitaemia by 40% and malaria anaemia by nearly 50% [1, 8, 9]. There has been a rapid scale-up of LLIN distribution in African countries in the recent years [5]. Despite attaining high levels of LLIN coverage [5] many under-five children do not sleep under the net [10]. The 2013 Nigeria Demographic and Health Survey revealed that Osun State had the lowest proportion (5.7%) of under-five children who slept under a LLIN the night before the survey in south-west zone and was second least in the country [11]. Evidence suggests that when large number of people uses LLINs the burden of malaria is reduced, resulting in a reduction in child mortality [12]. Thus, this study assessed caregivers’ knowledge about LLIN, utilization of LLIN and factors influencing LLIN use among under-five children in Osun State, Nigeria.

A total of 1020 caregivers were interviewed and 1008 questionnaires were returned properly filled and analysed, giving a response rate of 98.8%. Majority of the respondents 588 (58.3%) fall between age 25 and 34 years. Overall, 838 (83.1%) had at least primary education and 170 (16.9%) had no formal education. Nine hundred and sixty-four (95.6%) of them were employed, 828 (82.1%) were skilled workers, 87 (8.6%) were unskilled workers, 49 (4.9%) were professionals and 44 (4.4%) were unemployed. Four hundred and sixty (45.6%) respondents had two or more under-five children in their household and half (50%) of them resided in rural areas (Table 1).

This study aimed to assess caregivers’ knowledge about LLIN, utilization of LLIN and the determinants of LLIN utilization among under-five children. The level of awareness of the respondents about LLIN was very high as all respondents in this study have heard about LLINs and all of them could state correctly what it is. This high level of awareness about LLIN have been similarly reported in previous studies conducted among caregivers in Nigeria [20, 21] and other parts of Africa [22]. This pattern is encouraging but may not be surprising in view of the massive investment of the government and non-governmental organizations to reduce the incidence of malaria in recent years. Distribution of respondents according to the knowledge categories of LLINs showed that most of the respondents had good knowledge on LLINs; this suggests exposure to education on LLIN through the mass media, health care providers and community interventions. Community oriented intervention to create awareness are vital to the achievement of the malaria control in the community. A community-based intervention study among mothers in Plateau state showed an increase in the level of awareness of LLIN from 59.2 to 97.6% after health education intervention [23]. Similar to what was reported in previous studies [24‐26] and also affirmed by findings from the FGDs, the most common sources of information on LLINs among respondents in this study were radio/television and health workers. This finding is encouraging as this suggests that health workers are frequently in contact with mothers/caregivers. It has also been previously reported that access to health workers and mass media plays an important role in prevention and control of malaria [24].

More than half (58.6%) of the under-five children slept under LLIN the night before the study, this is similar to the findings in previous studies done in malaria endemic countries such as Burkina Faso (70.0%) and Kenya (52.2%) [22, 27]. A high rate (67.5%) was also found in a study done in Southwest Nigeria (6). However, lower use rate was found among under-five children in a Ghanaian study (43.0%) [28], which was adduced to the respondents believe that mosquitoes were few or absent in their environment and their perceived harmlessness of malaria as a health problem [28]. The Nigeria Demographic and Health survey (NDHS) 2013 report showed that only 16.1% of under-five children slept under an LLIN the night before the survey [11]. The 2015 Nigeria Malaria Indicator survey reported that 43% of under-five children slept under an LLIN the night before the survey [29]. Though there seem to be a gradual increase in the rate of utilization of LLIN, the goal is to achieve at least 80% [6] so as to reduce malaria morbidity and mortality. Despite the level of utilization in this study, only two-fifth of all the under-five children sampled slept under the net on regular basis. This is not encouraging as regular use of the net is necessary to reduce the incidence of malaria among under-five children.

The common barriers to utilization of LLIN among under-five children include excessive heat (96.4%), reactions to chemical (75.5%), unpleasant odour (41.3%) and cost 25 (6%). These findings are similar to the barriers to utilization found in previous studies in Enugu, Anambra, Ogun and Ghana [20, 30‐32].

The determinants of utilization of LLIN were having formal education by caregivers and their knowledge about LLIN. Previous studies have confirmed our results that formal education influences use of nets in children [8, 33, 34]. Formal education exposes caregivers to knowledge [35] on health issues including LLIN. It was also found in this study that 6 out of 10 respondents with good knowledge of LLINs used the net for their children as compared to 4 out of 10 of those with poor knowledge. This is similar to what was found in a study in Kenya [22], where utilization of LLINs by under-five children was found to be positively associated with knowledge. Several reports confirmed that regular use of insecticide-treated nets increased when individuals received information about bed nets [36, 37]. In a study conducted in malaria endemic area of Iran, regular use of LLINs increased from 58.3% to 92.5% following educational intervention [38]. Therefore, effective educational programmes may further increase use of LLINs in this studied population. However, barriers to use of LLINs among under-five children in this study need to be addressed through health education. There is need for better understanding of proper handling of the net prior to utilization by caregivers to avoid most of the side effects of the chemicals. Some caregivers believed that the free nets were more effective than the net purchased, some also think the net comes only in white colour which makes it difficult to maintain and some were ignorant of the fact that the net comes in different sizes. These misconception and ignorance of caregivers can be corrected through health education.

The strength of this study is the fairly large sample size, being a community based study and the probability sampling technique used which makes the sample to be representative.

The limitations of this study should be noted. The total number of persons in the household was not collected which makes the estimate of ownership difficult. This was probably so because the focus of the study was mainly on under-five children. Also, the information obtained from this study was based on recall, which could lead to recall and social desirability bias. However, the researchers encouraged caregivers to speak the truth and assured that the information obtained will be kept confidential.

The study revealed that the level of awareness about LLIN among respondents was high, and their knowledge about LLIN was correspondingly high. The utilization of LLIN among under-five children was above average, however, it is still far below the 80% target. The daily use is poor with only two-fifth sleeping under the net on daily basis. Factors identified to influence LLIN use were respondents’ level of education and knowledge of respondents on LLIN. Educative programmes on the use of LLIN should be intensified through the television/radio in other to capture caregivers with poor knowledge on LLIN. Adult education should be encouraged among caregivers in other to improve uptake of LLIN. Improvement of electricity power supply by the government may also encourage utilization of LLIN and amelioration of the discomforting properties of the net by manufacturers also stands to further improve utilization.