Background
Malaria, which is linked to high morbidity and mortality particularly among women and children, has been described as an urgent public health priority [
1]. In 2017, there were 219 million cases of malaria which resulted in 435,000 deaths [
2]. It has been reported that almost half of the world’s population was at risk as at 2017 [
2]. Malaria among women of reproductive age has attracted attention due to its effects on the women and their reproductive process. In this light, malaria infection during pregnancy has been described as a major public health challenge with significant implications for pregnant women, the fetus and the new born [
3].
As a result of malaria, an estimated 10,000 women and 200,000 infants die annually in Africa [
4]. In order to prevent and control malaria, huge resources have been committed to different initiatives and strategies by international bodies. In 2017, about 3.1 billion dollars was spent on such programmes with 28% provided by governments of endemic countries [
2]. One of these strategies is the Global Technical Strategy for Malaria 2016–2030 of the World Health Organization (WHO). It was adopted in 2015 by the World Health Assembly and designed to achieve the following by 2030: (i) reduce malaria mortality rates by at least 90% (ii) eliminate malaria from at least 35 countries and (iii) prevent resurgence of malaria in all countries that are malaria-free [
5]. Guided by this Global Technical Strategy, many agencies including the WHO, Global Fund, Roll Back Malaria support countries to control and eliminate malaria [
6].
Malaria has been one of the major health concerns in Nigeria. In 2017, the country was ranked among the five countries that were responsible for almost half of the global malaria cases [
2]. It has also witnessed the establishment of programmes directed at preventing and controlling malaria. One of these is National Malaria Strategic Plan 2014–2020. The programme, among other things, aimed at ensuring that: at least 80% of targeted populations utilize appropriate preventive measures by 2020; all persons with malaria receive prompt treatment with an effective anti-malarial; and at least 80% of the population practice appropriate malaria prevention and management by 2020 [
7]. The preventive aspect of the programme included the promotion of the use of insecticide-treated mosquito nets [
8]. Since 2011, about 24 million nets have been provided free of charge in the country [
9]. Despite these efforts at promoting net use and the resources committed to the programme, less than half of the women in the country use mosquito nets [
10].
Attempts have been made by researchers to examine the factors influencing mosquito net use among women or caregivers that possessed mosquito nets. Some of the factors attributed to this include age, education, household wealth [
11‐
13], household size, distance to health facility, ideational factors [
10,
14,
15], knowledge about efficacy of mosquito nets to prevent malaria, source of knowledge of mosquito nets and socioeconomic class [
16,
17]. Only few of these studies considered the effects of contextual factors on mosquito net use. Since individuals are nested within the community and the community is nested within the state, considering individual factors alone would not provide adequate explanation for mosquito nets use. This study aimed at filling this gap by examining the effects of individual and contextual factors on mosquito net use among women of reproductive age in Nigeria.
Discussion
This study has demonstrated that the use of mosquito nets among women of reproductive age in Nigeria is influenced by both individual and contextual factors. It is revealed that women who are from poor households used mosquito nets more than their counterparts who are from rich households [
24,
25]. This may be attributed to the fact that women from rich households may have devised other means of protecting themselves from mosquito bites. Such means may include living in houses fortified by mosquito-net-doors and windows and application of mosquito repellent formulae or insecticides which keep mosquitoes away from home. At the same time, such women may have the advantage of living in an environment that does not enhance mosquito breeding, unlike those from poor households who live in squalid environment with poor drainage and waste disposal systems. It is noteworthy to state that indoor residual spraying practice is relatively new in Nigeria and not all households have benefitted from it [
18]. Based on these facts, poor women would avail themselves of the opportunity offered by the availability of mosquito nets.
It is also shown in the study that women who claimed that malaria is caused by mosquitoes are more likely to use mosquito nets than those who responded otherwise [
26]. This indicates that knowledge about the cause of malaria is an important predictor of mosquito net use. In fact, not attributing malaria to mosquitoes may not only lead to non-use of mosquito nets, but may also lead to application of wrong therapy to treat malaria. This has serious health implications particularly when such women are pregnant. Exposure to messages about malaria impacts positively on mosquito net use as women who reported that they heard or saw messages about malaria have higher likelihood of using mosquito nets compared to women who did not have exposure to such messages [
27,
28]. Messages about malaria particularly those that comprise information on means of preventing malaria, methods of treating malaria and time and cost implications of malaria generate a good platform for awareness creation. Women who have the opportunity of obtaining such information would appreciate any initiative aimed at preventing malaria.
Results further show that women who posited that the chances of getting malaria are the same whether mosquito nets are used or not were more likely to use mosquito nets. The reason for this may be that the women find other advantages of using nets such as prevention of bed bugs and other insects. Having knowledge of the efficacy of malaria prevention drugs enhances the use of mosquito nets as women who affirmed that drugs used by pregnant women to prevent malaria are effective used mosquito nets more than their counterparts who did not affirm the efficacy of such drugs. The former may have had the experience of not getting malaria during pregnancy after using the drugs. This provides them the assurance that mosquito nets would be another effective means of preventing malaria. Women who had malaria during pregnancy because they did not use malaria prevention drugs but knew about their counterparts who had the opportunity of having malaria-free experience during pregnancy due to their use of such drugs may also be among those that affirmed the efficacy of malaria prevention drugs.
Findings from the study also reveal that the likelihood of using mosquito nets is higher among women who supported the view that tests are a good way to detect malaria status of individuals. This is very important because conducting tests would not only result in correct diagnosis but would also lead to the application of appropriate therapy to treat malaria. Whenever a person attends a health service e.g. to receive an RDT test—it is an opportunity to reinforce health behaviours like net use—this is why it is good to use every opportunity of an encounter with the health service to reinforce positive health behaviours—as sustaining these behaviours is critical for malaria control. The number of household members is another factor influencing use of mosquito nets [
29,
30]. Women from households with less than 5 members were more likely to use mosquito nets than those whose household members were 5 or more. This shows that the smaller the household, the higher the probability of using mosquito nets. This may be attributed to the fact that mosquito nets could only accommodate a sizeable number of household members at a time. Socioeconomic status of communities and states also influenced mosquito net use.
The odds of using mosquito nets increased tremendously for women who lived in the most socioeconomically disadvantaged communities and states. Living conditions in such communities and states are grossly poor. Lack of infrastructural facilities gives room for poor environmental conditions which enhance the growth and spread of mosquitoes. More so, the poor socioeconomic status of women in such communities and states most often obstructs their access to adequate medical care in the event of getting malaria. It could be that these women embraced the use of mosquito nets in order to avoid being caught up in such a situation.
Policy implications
Reducing mortality rate due to malaria among women has become a global objective. Achieving this objective through the distribution of mosquito nets may be unrealistic with only half of the women who possess mosquito nets actually using them. It further generates much concern when it is considered that huge resources have been committed to the procurement of such nets by donor agencies and international organizations. Since this study focused on women who possess mosquito nets, the questions that come to mind are: why were the nets not used for the purpose for which they have been distributed? What can be done to improve mosquito net use among such women? Although the study has provided answers to the first question by revealing that individual, community and state-level factors influenced mosquito net use, answers to the second question would constitute policy recommendations which would also address components of the first question. First, there is a need to look at the way mosquito nets are being distributed. The nets should be given to those who are really in need of them particularly those who live in mosquito-infested areas and do not have means of protecting themselves against mosquitoes. A situation where the nets would be distributed to inhabitants of rich households who may already have means of protecting themselves should be avoided. This can be achieved by embarking on a pre-distribution survey which is aimed at identifying households that fulfil the condition of those that are really in need of the nets. A follow-up visitation should be carried out at regular intervals after distribution to monitor utilization among beneficiaries. Health care workers need to work in collaboration with government media houses to intensify efforts at promoting malaria prevention messages on radio and television. Such messages should also be disseminated at gatherings organized at community level. Emphasis should be placed on educating women on causes of malaria, the efficacy of drugs recommended for preventing malaria during pregnancy and the importance of going for tests to detect malaria. At the same time, attention should be paid to gender power relationships. In most cases, it is the male partner who influences a women’s behaviour about spending money, going for and using health services. This influence of men on women may need to be addressed in respect of mosquito net use. To address the challenge of non-use of mosquito nets by large households, efforts should be made to increase the number of nets per household. Government at state and federal levels should commit more resources to improving socioeconomic status of every individual on the one hand and that of states and communities on the other hand. Programmes that would alleviate poverty and improve the economic conditions of individuals should be given utmost priority. This may come in form of offering economic opportunities and providing enabling environment for small and medium-scale enterprises. Future studies on mosquito net use should consider complementing quantitative surveys with some qualitative studies in order to understand the issue more in depth.
Study strengths and weaknesses
It should be noted that this study used a cross-sectional data set which prevented us from providing information on immediate causes of non-use of mosquito nets despite the fact that the women possessed them. Such information would be better obtained with the use of longitudinal data set which will ensure a follow-up of respondents at regular intervals. There was also the possibility of recall error during the interview with respondents as they were asked some questions that relate to events that occurred in the past. In spite of these limitations, this study has used a large data set which provided an opportunity to generalize the findings and relate such to countries in similar circumstances. The study also provided information on the role of contextual factors in mosquito net use among women.
Acknowledgements
The authors wish to acknowledge the National Malaria Elimination Programme, National Population Commission and National Bureau of Statistics for the implementation of the survey and ICF International for provision of technical supports. The data was made available through DHS Archive. Neither the original collectors of the data nor the Data Archive bear any responsibility for the analyses or interpretations presented in this project.
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