|Year : 2012 | Volume
| Issue : 3 | Page : 163-168
The use and misuse of mass distributed free insecticide-treated bed nets in a semi-urban community in Rivers State, Nigeria
Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
|Date of Web Publication||5-Jun-2012|
P. O. Box 162, Omoku, Onelga, Rivers State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Insecticide-treated bed net (ITN) is currently distributed free of charge to vulnerable groups in Nigeria, for malaria control. Consistent use of the nets is required for maximum effectiveness; but studies indicate that the nets are often jettisoned in periods of low mosquito activity and high night time temperature. The objective of this study has been to assess the use of mass distributed nets in a semi-urban community in Rivers State, south-south Nigeria, during the late dry season, when mosquito activity is at the lowest in the community.
Materials and Methods: The study was carried out in Ishiodu - Emohua, using a cross-sectional study design. The data was collected using a structured, interviewer-administered questionnaire, administered to female head of households in the community, with under-five children.
Results: A total of 170 respondents were studied; they had an average age of 34.3 ± 7.6 years, most were married (86.5%), and had secondary school education (68.2%). All the households owned at least one ITN, and an average of 1.7 nets, with 75.3% of the households owning two or more ITNs. Almost all the nets (99.4%) were obtained free of charge. Of the 170 households that received the nets, 71.8% had hanged the nets as at the time of the survey; 83.6% of these hanged the nets over a bed, while 10.7% used the nets as window curtain. Of the 102 ITNs that were properly deployed, only 27.5% were occupied the night before the survey, by an average of 2.5 persons, mainly under-five children (37.7%).
Conclusion: The distribution of free ITNs has resulted in universal household ownership, but the use of the nets is still very poor. Proper health education is required to encourage the consistent use of the nets, even in hot night, with low mosquito activity.
| Abstract in French|| |
Contexte: Imprégnées d'insecticide moustiquaire (MII) est actuellement distribué gratuitement aux groupes vulnérables au Nigéria, pour lutter contre le paludisme. L'usage systématique des filets est requis pour une efficacité maximale; mais des études indiquent que les filets sont souvent largués dans les périodes d'activité faible contre les moustiques et les températures nocturnes élevées. L'objectif de cette étude est d'évaluer l'utilisation de filets de masse distribuées dans une communauté semi-urbaines dans l'état de Rivers, Sud-Sud, Nigéria, au cours de la fin de la saison sèche, lorsque l'activité moustique est à la plus basse dans la communauté.
Des matériaux et des procédés: L'étude a été réalisée en Ishiodu - Emohua, à l'aide d'une conception de l'étude transversale. Les données ont été recueillies à l'aide d'un questionnaire structuré, intervieweur, administré à la femme chef de ménages dans la communauté, avec moins de 5 ans enfants.
Résultats: Un total de 170 répondants ont été étudiés ; ils avait un âge moyen de 34.3 ± 7.6 ans, la plupart étaient mariée (86.5 %) et d'études secondaires (68.2 %). Tous les ménages appartenant au moins un MII et une moyenne de 1.7 filets, 75.3% des ménages possédant deux ou plus des MII. Presque tous les filets (99.4%) ont été obtenues gratuitement. Des 170 ménages ayant reçu les filets, 71.8% avait pendu les filets comme au moment de l'enquête ; 83.6% de ces pendu les filets sur un lit, tandis que 10.7% sert les filets de Rideau de la fenêtre. Les MII 102 qui ont déployé correctement, seulement de 27.5% occupaient la nuit précédant l'enquête, en moyenne de 2.5 personnes, principalement des enfants enfants (37.7%).
Conclusion: La distribution de MII libres a permis propriété universelle le ménage, mais l'utilisation des moustiquaires est encore très pauvre. L'éducation sanitaire appropriée est nécessaire pour encourager l'utilisation cohérente des filets, même dans la nuit chaude, avec une activité faible de moustiques.
Mots clés: Imprégnées d'insecticide moustiquaire, moustiques faible activité, la lutte contre le paludisme, la bon déploiement, Nigeria sud-sud
Keywords: Insecticide-treated bed net, low mosquito activity, malaria control, proper deployment, south-south Nigeria
|How to cite this article:|
Ordinioha B. The use and misuse of mass distributed free insecticide-treated bed nets in a semi-urban community in Rivers State, Nigeria. Ann Afr Med 2012;11:163-8
|How to cite this URL:|
Ordinioha B. The use and misuse of mass distributed free insecticide-treated bed nets in a semi-urban community in Rivers State, Nigeria. Ann Afr Med [serial online] 2012 [cited 2019 Aug 17];11:163-8. Available from: http://www.annalsafrmed.org/text.asp?2012/11/3/163/96879
| Introduction|| |
Malaria exerts a significant health and economic burden on Nigerians. According to the statistics of the Nigerian National Malaria Control program, it is responsible for 60% of outpatient visits to health facilities, 30% of childhood deaths, 25% of infant deaths and 11% of maternal death; and an estimated annual loss of 132 billion Naira, in the form of treatment and prevention costs, and loss of man-hours, amongst other losses. 
Although an integrated management approach is said to be the best for malaria control, the insecticide-treated bed Net (ITN) is however considered as the most efficacious of all the currently feasible interventions for malaria control in Africa.  Its cost-effectiveness in preventing malaria-related morbidity and mortality is comparable to that of measles vaccination;  and is generally found to be easier to implement and better accepted by the local communities than most other control measures. 
This explains the current efforts at providing free ITN to vulnerable groups, as part of the attainment of the millennium development goal, and the recognition by the Nigerian government that access to ITN and other malaria preventive and curative services is a right to all vulnerable Nigerians. 
However, several studies have revealed that net ownership does not always translate to use; ,, with factors such as low mosquito activity and high night time temperature capable of reducing use to as low as 20%. , Low mosquito activity has particularly been noted to be a very important deterrent to ITN use in several communities in Nigeria, where the net is predominantly used for mosquito nuisance control, even as malaria transmission is stable and perennial in the communities. 
This is worrisome, considering that the ITNs have to be regularly used, and properly deployed to be effective for malaria control.  The net is said to have been properly deployed when it is tucked under the sleeping mat (or mattress) or made to touch the ground all round.  A study has found that the proper deployment of all the nets in a household could reduce the indoor resting densities of fed anopheline mosquitoes in the house by as much as 77.8%, in a single night; whereas the non-coverage of even a single person in the household is capable of reducing the effectiveness of the nets to 23.8%. 
The Rivers State government, south-south Nigeria has distributed more than two million nets, especially during the Immunization Plus days, and stand alone campaigns, in its effort to meet the target of providing two nets to every household in the State. A 2009 survey conducted to assess this program showed 43.5% ownership, and 62.9% utilization rate, during the wet season, when mosquito activity is at the highest in the State. This study is however aimed at assessing the use of the nets during the late dry season, when mosquito activity is at the lowest, even as the intensity of malaria transmission remained high. , Previous studies had indicated that ITN is used by most households in Nigeria for the control of the biting nuisance of mosquito, and not for malaria control, as the nets were originally designed to achieve, and therefore are likely to be jettisoned in periods of low mosquito activity. 
| Materials and Methods|| |
Rivers State is one of the 36 States that make up the Federal Republic of Nigeria, and the most populous State in the Niger delta, with a total population of 5,185,400, according to the results of the 2006 national census. The study was carried out in Ishiodu - Emohua, a semi-urban community in the Emohua Local Government Area of Rivers State, of less than 5,000 inhabitants, located about 15 km from the University of Port Harcourt. Most of the inhabitants of Ishiodu were subsistence farmers and fishermen, traders and civil servants. Like most other communities in south-south Nigeria, malaria is holoendemic in the study area, with transmission occurring throughout the year, with seasonal peaks corresponding to the wet season.  Most of the malaria transmissions are carried out by Anopheles gambiae and Anopheles funestus that are most active between 10 pm and 1 am, and therefore very susceptible to the use of ITN. ,
A descriptive, cross-sectional study design was used, with the data collected using a structured interviewer-administered questionnaire. The questionnaire was administered to female head of households in the community, with under-five children; and used to collect information on the socio-demographic characteristics of the respondents, ownership and use of ITN, and reasons behind the ownership and consistent use of the nets.
Sample size estimation
The study was designed to detect a 5% difference in ITN use, with an alpha error of 5%, acceptable beta error of 20%, and a statistical power of 80%; the south-south Nigeria average of ITN use amongst under-five children of 9.4%  was also used. The minimum sample size for the study was thus determined to be 131, using the usual formula for sample size determination for descriptive studies,  but made up to 170 to take care of non-responses.
The survey was carried out by four trained final year medical students and a local assistant, between March and April 2010 (just before the commencement of the wet season), when the mosquito activity in the community was at its lowest. This was so timed because the survey was interested in identifying those who continued to use the net during this period. ,,
The respondents for the questionnaire were systematically chosen from every third house in the community, starting from the house of the community Chief. For each house selected, a maximum of three of the youngest households were selected. A household was defined as an aggregation of persons who lived together and shared a common source of food.
Data handling and analysis were manually carried. The RBM outcome indicators were calculated following standard guidelines.  Household ITN possession was defined as the number of households surveyed with at least one ITN, over a denominator of the total number of households surveyed. The level of ITN utilization was defined as the number of nets that were occupied the previous night, over a denominator of the total number of nets owned by the surveyed households; while the proportion of ITNs hanging was calculated as the number of ITNs suspended over a sleeping space the previous night, over a denominator of the total number of ITNs in households surveyed. Based on survey responses about ownership, bed net characteristics, and individual use, individuals were classified into one of the following four categories of ITN use, as suggested by Vanden Eng et al.  Households without ITN; households owning but not hanging an ITN; households that have an ITN hanging but who are not sleeping under an ITN; and households where members sleep under a hung ITN.
The approval to undertake the study was sought and obtained from the department of Preventive and Social Medicine of the University of Port Harcourt Medical School, Port Harcourt, as well as from the Chiefs of the Ishiodu community. Informed consent was also sought and received from all the study participants.
| Results|| |
A total of 170 questionnaires were administered and retrieved. The socio-demographic characteristics of the respondents are presented in [Table 1]. The respondents had an average age of 34.3 ± 7.6 years; several of them (42.4%) were traders, married (86.5%), and had secondary school education (68.2%).
[Table 2] shows the ownership of ITN amongst the households surveyed. All the households were found to own at least one ITN, and an average of 1.7 nets, with 128 (75.3%) of the households owning two or more ITNs. Only one (0.6%) of the nets was bought, while most (94.7%) were obtained when the nets were distributed free of charge in the community.
Of the 170 households that received the nets, 122 (71.8%) had hanged the nets as at the time of the survey; 48 (28.3%) that did not, gave reasons for their decision that are presented in [Table 3]. The reasons include low mosquito activity (41.7%) and lack of suitable place to hang the net (22.9%). However, of the 122 households that hanged their nets, only 102 (83.6%) hanged the nets over a bed or mat, while 13 (10.7%) used the nets as window curtain.
Of the 102 ITNs that were properly deployed, only 28 (27.5%) were occupied the night before the survey, by an average of 2.5 persons, mainly under-five children (37.7%), as presented in [Table 3]. The reasons why 74 (72.6%) of the nets were not occupied are presented in [Table 3], and include hot night time temperature (86.5%) and low mosquito activity (4.1%).
| Discussion|| |
The study showed that the households in the study community had an average of 1.7 ITNs. This indicates that the Rivers State government was close to reaching its target of two ITNs per household in the study community, but has exceeded the RBM target of 80% ownership by 2010.  This is a remarkable feat considering that the national average was 0.3 nets per household,  and the fact that the social marketing of the nets in a comparable community, in the same State had an uptake rate of 1.10 ITN per month, and was only able to cover 6.5% of the target population, after six months of intense social marketing activities.  This shows that the free distribution of the nets is not only cost-effective,  but also a fast way of reaching the ITN coverage targets. 
The study also showed that a large number of the nets were not hanged, improperly deployed and unoccupied. Although this is consistent with the findings in several other communities in Nigeria,  it is however contrary to the findings of two other surveys in the State,  and elsewhere in the Niger delta.  The State survey  found a net utilization rate of 62.9%, while the survey carried out in Brass and Oshimili, two communities in the Niger delta found that 61.3% of the under-five children in both communities slept under an ITN, the night prior to the survey.  These are more than twice the 27.45% obtained by this study. The possible reason for this difference is the fact that this survey, unlike the two others, was carried out during the period of low mosquito activity, when the use of the nets in the communities is at its lowest. 
Low mosquito activity was also the reason given by 42% of the respondents in our study that did not even unpack their nets. It was also the reason given for the massive difference in net utilization between households in the Niger delta, and those in the Sahel region of Nigeria.  It is a huge and widespread problem that demands a deliberate IEC/BCC effort to tackle, considering its impact on the use of the net.  It needs to be emphasized in the IEC/BCC campaign that the nuisance caused by mosquitoes is often by culicine mosquitoes, whereas malaria, especially in south-south Nigeria is transmitted by anopheles mosquito species that have a peak biting time between 10pm and 1 am, and therefore not much of a biting nuisance. , There is also the need to communicate to the users of the net that low mosquito activity does not represent a significant decrease in the likelihood of malaria infection, especially in southern Nigeria where malaria transmission is intense throughout the year. , These emphases would help draw a line between ITN use for nuisance control, and ITN use for the prevention of malaria that would help drive up consistent utilization of the net. Hang-up-and-use-consistently campaign is therefore recommended in Nigeria, as the nets are handed over to users, and repeated during the late dry season, when the nets are likely to be jettisoned.
This study also found that a large proportion of the nets were not used over beds and mattresses, but as screens for windows and doors. This was probably to escape the discomfort from heat that is a common complaint amongst users of the net. ,, This improper deployment is likely to reduce the effectiveness of the nets, but the mere presence of a hung ITN in the room has been found to have a certain level of protection. 
A study carried out in Burkina Faso recorded substantial reduction in the levels of malaria transmission when permethrin treated curtains were hanged on doors, windows and eaves. 
The consistent use of the net is required for maximum effectiveness.  This study found that only 27% of the nets were occupied, which is much lower than the 62.9% obtained in the State's survey. Again, this difference can be attributed to the timing. Most of the respondents in our study were discouraged from occupying the nets by the hot night-time temperature. This problem can be solved by making the net with a less heat generating material, with the mesh size big enough to allow maximum air entry, yet able to restrict the entry of mosquitoes.  This is important because most of the nets that are currently in use in Nigeria are made with polyester material, which though long-lasting and dirt resistant, also generate lots of heat, and therefore very uncomfortable when the night time temperature is high. Nets made with material that has a more cooling effect would be welcome relief to lots of ITN users in tropical Africa, and would no doubt promote the consistent use of the net.
Disruption in sleeping arrangement and forgetting, or too tired to hang the net were some of the other reasons given for not using the nets, the night before the study. All these can be linked to poor motivation to use the net, in a hot night, with low mosquito activity. This finding in our study is however not as significant as observed in other African countries.  This might be because householders in our study reside in more spacious accommodation that permits the hanging of the nets.
Torn net was the reason given by just 2.7% of our respondents who did not use the net, the night before the survey. This is much smaller than the 40% reported by users in Kenya, where the sticks used to support the net, and open tin lamps were said to constantly create holes in the nets.  These are not common in our study community, but the problem of torn and worn-out nets must be addressed by the Malaria Control Program, to stop users from abandoning the nets, because of the holes. Although experimental studies have reported that perforated ITNs can still prevent mosquito bites, the holes often accelerate the loss of the insecticide, and make it harder to convince the users that the net is still effective.  The distribution of the free nets should not therefore be a one-off event, but should be carried out at most every three years, to encourage prolonged and consistent use of the nets, as recommended by the 2009 - 2013 Nigeria National Malaria Control Strategic Plan. 
| Conclusion|| |
The distribution of free ITNs has resulted in universal household ownership, but the use of the nets is still very poor. Proper health education is required to encourage the consistent use of the nets, even in hot night, with low mosquito activity.
| Acknowledgement|| |
I wish to thank the Chiefs, members of the Community Development Committee and the entire people of Ishiodu- Emohua community for their assistance and cooperation during the study. I also wish to thank Uduak Akpan, Joshua Ateke, Charles Ikenga, Bright Mbanisi and Chris Imoh for their efforts during the survey.
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[Table 1], [Table 2], [Table 3]
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