Malaria Parasitaemia and the use of insecticide-treated nets (INTs) for malaria control amongst under-5 year old children in Calabar, Nigeria

During the survey, caregivers were asked if they knew specific measures to prevent malaria attack. Fifty-five point six percent (55.6 %) of the caregivers mentioned using nets on doors and windows, 51.5 % mentioned sleeping under a mosquito net, while other responses were: destroying mosquito breeding places (51.1 %) and spraying insecticides every night (29.3 %). The Nigerian Malaria indicator survey of 2010 [12] reported sleeping under a mosquito net (77.2 %, South-South region), destroying mosquito breeding places (8 %), and spraying insecticides (20 %). There is no readily available answerto the 25 % decline in awareness concerning sleeping under the mosquito nets as an effective means of preventing malaria. Perhaps, the perceived rise in distribution of ITNs over the region was not accompanied by adequate information, education and communication (IEC).

Net ownership, as determined by possession of at least one mosquito net in a household was found to be 71.5 %. The proportion of households who had at least one mosquito net has risen far above the reported proportion of 42 % obtained in 2010 [12], 8 % in 2008 (NDHS, 2008) and 2 % in 2003 [21]. This finding was consistent with the finding of one recent study in Abuja, Nigeria [22] in which mosquito net ownership pre-and post-intervention study were 58 % and 100 % respectively. Daboeret al. [23] in their survey in Jos, Nigeria reported that 55.3 % of caregivers of under-5 children owned nets; a rise the authors attributed to the on-going campaigns of ITN distribution. A contrary finding was obtained in a study in Guinea [24] in which there was a decline in net ownership from 97 % in 2008 to 65 % in 2009. This sharp scale-up in bed net ownership by households in this current study is traceable to more aggressive ITN mass distribution through the support of the Global Fund, DFID, World Bank and Support for the National Malaria Control Programme, and the MDG-assisted funds in Nigeria. The nets were given free of charge most of the time, via Primary Health Centres which are usually at close proximities to households including rural dwellers.

Some variables are known to influence ownership of mosquito nets. Some of these factors have been reported to include level of education, wealth index, family size and residence among others [25]. In this study, variables like caregiver’s tribe, age and education were tested; only caregiver’s educational level was statistically significantly associated with net ownership. It can also be used as a predictor for net ownership, with care-givers with lower educational attainments more likely to own at least one mosquito net than those with higher educational status. Oresanyaet al. [26] observed that the presence of an educated caregiver in the household raised the odds of owning a net by 42 % in the north, while this was not predictive in the south part of Nigeria after controlling other variables. Whereas the above mentioned study tested education and none education, ours, conducted also in the southern part of Nigeria examined higher and lower educational status. Contrary to our finding, a similar study in Kenyareported that higher education was associated with possession of mosquito nets. Higher education, we expected, should have the ability to better equip caregivers with necessary information about the importance of ownership and utilization of mosquito nets in malaria prevention and control. Obtaining a contrary finding in our study is indeed puzzling.

About two-third of the respondents who do not own at least a net stated that ‘nets were not available’ as a reason for not having one. For most of them, the non-availability of the nets meant they did not know where/how to get one. Other reasons given for not having mosquito net included: ‘does not like to use net’ and ‘there is no mosquito in my residence’. Misconceptions about causes of malaria and prevention modalities are also valid reasons for non-ownership and utilization of nets [27].

Twenty five-point four percent (25.4 %, 68/267) of children under age 5 among those interviewed slept under a net the night before the survey. Compared to previous NDHS and NMIS surveys in Nigeria, the sustained rise in net utilization was lost. The percentage of children under age five who slept under ITNs has increased steadily and substantially from 6 % in 2003 [21], to 12 % in 2008 [28] and to 26.7 % in 2010 by NMIS survey (26.7 % specifically for South-South zone where Calabar belongs, and 30.3 % generally) [12]. The decline in net utilization was also noticed among households that owned at least one ITN, only 35.6 % slept under an ITN the night before the survey as against 55.1 % in NMIS survey [12]. The rate of net use has varied over time and in different geopolitical regions in Nigeria. Oresanyaet al. [26] in their study in Abuja reported net utilization of 11.5 %, while 37.2 % was reported in Rivers State by Tobin-West and Alex-Hart [29].

This current study showed that whereas 71.5 % caregivers with under- 5 children owned at least one ITN, only 25.4 % of the children used a net a night before the survey. The high discrepancy (46 %) between ownership and utilization of ITN in this study could not easily be explained out and as such calls for great concern. It probably shows that there is need for adequate motivation before ownership will translate to utilization. It does appear that in the last 2 years before this index study, large scale net campaigns and distribution was carried out in Calabar and since ITNs were given free of charge, caregivers were poised to have them; however, they lacked the motivation to use them. Tobin-West and Alex-Hart [29] also reported a similar finding in their study where only one-third of those that owned nets, slept under a net the night before survey. In another study, out of the 55.3 % caregivers with under- 5 children that owned ITNs, only 40 % utilization was recorded a night before study.

The most common reason given among the caregivers; that had at least one ITN for not using it was that the weather was too hot (77.2 %). This same reason has also been reported in other similar studies and has been attributed to the hot tropical climate of the sub-Saharan African region [12, 26, 30, 31]. Other reasons were: having difficulties hanging it, and that there were no mosquitoes around their residence and these findings were consistent with an earlier study [12].

Higher educational levels in previous studies [22, 26] have been associated with appropriate net usage. In our study, possession of higher education was not statistically associated with net utilization (p > 0.05). Demographic characteristics like child age, care-givers’ age, education, and ethnicity have been known as possible predictors of net use in other studies [26]. In this study, only care-givers age was established as predictor (p < 0.05). Our study showed that older care-givers are more likely to have their children sleep under net than younger care-givers. This finding could have been as a result of past experience these older care-givers have had with caring and parenthood.

Assessment of the impact of ITN coverage and/or utilization on health outcomes is usually difficult. This is usually due to poor routine health information and vital registration systems; making determination of malaria-specific mortality and morbidity almost impossible [32]. Few studies that have attempted analysing the impact of mosquito net ownership and usage on children have used different approaches [33, 34]. In this study, the relationship between household use of ITNs among under-5 children and malaria parasitaemia was analysed using logistic regression analysis. We observed a 32 % reduction in malaria parasitaemia among under-5 net users which was not statistically significant. Lack of statistical significance may have stemmed from the small sample size involved. Previous studies by Lim et al. [32] reported a pooled relative of 24 % reductionin parasitaemia prevalence in children while Lengeler [35] reported a 50 % reduction in clinical episodes and malaria parasitaemia.

Malaria prevention and control measures aim at preventing mortality and reducing morbidity and also malaria-associated economic losses. Lack of knowledge about malaria and its mode of transmission will hamper appropriate preventive measures. In our study, care-givers were asked questions to ascertain their knowledge of causes, signs and symptoms, and means of prevention of malaria. Almost all the caregivers (97.8 %) identified mosquito bite as the cause of malaria. This finding was consistent with those of previous studies [12, 36] but higher than the finding by Oreagbaet al. [37]. This awareness is a good one and could have contributed to the high level of ownership of mosquito nets among care-givers observed in this study. Most of the care-givers also identified fever as the commonest symptom of malaria. This finding was in agreement with the findings of previous studies [38, 39]. The recognition of fever by the majority of the caregivers as a symptom of malaria is a welcome development because early treatment depends on prompt recognition of symptoms and signs of malaria in the household [40]. A worrisome finding was that only 4.1 % of the caregivers acknowledged that disorientation/incoherent speech, which occurs in severe malaria, was a complication of malaria. The implication of this finding is that most caregivers would exclude malaria much the same way they behave when their children have febrile convulsion and might resort to other means of intervention like going to the Traditional healer [41]. The association between ‘incoherent speech’ and severe childhood malaria should be highlighted and incorporated into health education and health promotion programmes. This will correct anomalies in care-givers’ treatment seeking behaviour. Ability of the caregivers to recognize danger signs of malaria is an important factor for early home management or for seeking treatment at health facility [42].

Treatment seeking behaviour among caregivers has been shown to be related to the cost, availability and cultural beliefs about the causes and effective cures for malaria-like symptoms [43]. Among the caregivers who had under-5 children with febrile illness two weeks prior to this survey, 47.7 % sought for treatment first at government hospital nearby. This finding was low compared to reported value of 65.6 % in a previous study in Nigeria [23] and 71.5 % in a study in Ethiopia [36]. The finding in this study that 28.4 % of the caregivers would resort to self-treatment at home was fairly high compared to 1.4 % found in Ethiopia [36] and 3 % in Nigeria. Only few caregivers (10.1 %) resorted first to Chemist/Patent medicine vendors compared to 37 % [37] and 57.4 % [12] reported by previous studies. Unlike other previous similar studies in Nigeria [44, 45], where traditional/herbal homes were among preferred health facilities care-givers sought after, none of the care-givers in this study accepted ever going to the herbalist for treatment of their febrile children. Perhaps, variation in study areas between the previous studies which were carried out in rural areas and this current study carried out in the metropolitan town of Calabar, Nigeria could explain the difference. The preferred choice of the care-givers to seek treatment first in government hospital for their febrile children may not be unconnected with the high literacy level of the respondents who probably knew they would get better care delivery from such centres. The cost of health care delivery has been one of foremost determinants of treatment seeking behaviour of care-givers [46]. The free medical services in government hospital in Ethiopia could have contributed to higher proportion of health seekers that used government hospitals there, than it was found in this study. The high number of under-5 care-givers that indulged in self-treatment of their febrile children at home in this study highlights the need for Health extension workers to educate care-givers on home-based management of malaria. Such enlightenment programmes should include recommended anti-malarial drugs and dosages and to be able to detect signs and symptoms of severe malaria that may demand expertise management.

Our study has some limitations. First, we tried to replicate a Nigerian Malaria Indicator Survey (NMIS) of 2010 [12], however we believed that the findings would not very much compare with NMIS; in that, ours was facility-based and the tools used were different. We observed that our sample size was small, and thought this could have been responsible for the study’s lack of power to detect many significant relationships from our data. The tool used in our research (for example questionnaire) encouraged “self-reported data”, not allowing for independent verification. Self-reported data has many sources of potential bias we considered as limitations such as selective memory and exaggeration. Finally, the sampling technique we used (convenience sampling) helped us to have easy access to the study participants in good time, however it could have introduced sampling bias, not allowing for good representation of the entire population.