Factors Affecting Uptake and Utilization of Insecticide Treated Net Among Women of Reproductive Age (15 – 49 years) Group Attending Antenatal Clinics in Nasarawa State Nigeria

Background: Vector control is the main path to preventing and reducing malaria transmission. The ownership and use of Insecticide-Treated Nets (ITNs) is the core vector control method and a proven intervention for the control and elimination of malaria in several malaria-endemic countries. This study determined the factors affecting the uptake and utilization of ITN by women in their reproductive age group in Nasarawa State Nigeria. Methods: A descriptive cross sectional study among women of reproductive age group (15 – 49 years) attending Ante Natal Clinic at the Dalhatu Araf Specialist Hospital Lafia, General Hospital Akwanga and Medical Centre Mararaba Gurku in Nasarawa State Nigeria. An interviewer administered questionnaire was used after obtaining an informed consent. Ethical approval was gotten from the state research ethics committee. Data analysis was done using SPSS version 23.0. Results: The mean age of this study population was 27.9 ± 10.6 years. Of the total number of 772 participants in this study, a larger chunk of 707 (91.6%) have heard of insecticide treated net. In addition, most 538 (69.7%) participants said healthcare workers emphasizes the use of insecticide treated net during their antenatal care visits. More than half of the participants, 432 (56.0%) owned an ITN at home. Utilization of insecticide treated nets showed that, 451 (58.4%) sleeps under an insecticide treated net, with 334 (74.1%) of these sleeping under it daily. Reasons for not using ITN for some were; due to heat 137 (30.4%), due to smell 83 (18.3%) and others for no good reason 86 (19.1%) respectively. Beliefs about usefulness of ITN showed 320 (71.0%) felt it is very good and useful in preventing malaria. Conclusions: Most participants are aware of ITN. More than half owned (56%) and sleeps (58.4%) under the ITN. About 71% believed ITN is useful in preventing mosquito bites and malaria. Reasons for declining using ITN among some were due to the ITN’s heat and smell. While more than two-third felt ITN is useful in preventing mosquito bites and malaria.


Introduction
Insect borne diseases such as malaria, yellow fever, dengue fever, sleeping sickness, filariasis etc, have always been a global public health issue with malaria incidence being the commonest of all. 1 The burden of these diseases is highest in tropical and subtropical areas and they disproportionately affect the poorest populations. 2 Since 2014, major outbreaks of dengue, malaria, chikungunya, yellow fever and Zika have afflicted populations, claimed lives and overwhelmed health systems in many countries. 3 Malaria, a major challenge here occurs mostly in the poor tropical and subtropical areas of the world. 4 It is the leading cause of morbidity and mortality in many developing countries especially in Sub-Saharan Africa, where under-five children and pregnant women are the groups mostly affected. 3,5 Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. 4,6 Transmission is more intense in places where the mosquito lifespan is longer (so that the parasite has time to complete its development inside the mosquito) and where it prefers to bite humans rather than other animals. 2,7 The long lifespan and strong human-biting habit of the African vector species is the main reason why approximately 90% of the world's malaria cases are in Africa by World Health Organization (WHO). 1 Transmission also depends on certain climatic and environmental conditions such as rainfall patterns, temperature, humidity, presence of bushy areas and stagnant waters around the home which encourage the breeding of these mosquitoes. 5,8 In many places, transmission is seasonal, with the peak during and just after the rainy season. Human immunity is also another important factor. 9 The estimated number of malaria cases stood at 217 million in 2016 and rose to 219 million in 2017. 1.10 Children under 5 years of age are the most vulnerable group affected and accounted for 61% (266,000) of all malaria deaths worldwide. 10 The effects of malaria are also strong among pregnant women, for whom malaria may cause maternal anaemia, preterm delivery, and low birth weight. 11 African region continues to carry a disproportionately high share of the global malaria burden. 12 They (African countries) accounted for nearly half of all malaria cases worldwide with Nigeria contributing 25%. 1 In Nigeria, malaria is responsible for 30% of the under-five mortality and 11% of maternal mortality rate. 3,10 Malaria is preventable and curable. Early diagnosis and treatment of malaria reduces disease and prevents deaths. It also contributes to reducing malaria transmission. The best available treatment, particularly for P. falciparum malaria, is artemisinin-based combination therapy (ACT). 13 However, Vector control is the main path to preventing and reducing malaria transmission. 9 The use of Insecticide-Treated Nets (ITNs) among other forms such as Residual Spraying is one of the core vector control methods for preventing malaria and other vector-borne diseases and has been shown to reduce malaria incidence by 50% in several malaria-endemic countries. 10 Ownership and use of insecticide net is one of the proven interventions adopted by Roll Back Malaria (RBM) partners in Nigeria to stem the high incidence of malaria. 1 The ITN programs depend to a much greater extent on the acceptance and active involvement of individuals and communities. The success or failure of ITN programs may in many cases be related to several human behavioural factors that affect coverage and proper usage. 7,13 Factors contributing to the uptake and utilization of ITN in recent time need to be evaluated. This study therefore, seeks to assess caregivers' knowledge about ITNs, utilization of ITNs and factors influencing the uptake and use of ITNs among women of child bearing age in Dalhatu Araf Specialist Hospital.

Justification for the Study
Where ITN appear to fail, this is in many cases due to human behavioural factors related to coverage, proper and consistent use of ITNs. These human factors are underrated, not systematically monitored, or at least go underreported in many publications and reports. Also, no such study has been conducted in this locality. This study therefore seeks to evaluate the factors affecting the uptake and utilization of ITNs among women of child bearing age in Dalhatu Araf Specialist Hospital.

Study Objectives
1. To determine the current uptake and utilization of Insecticide Treated Nets among women of reproductive age (15-49years) group attending ANC in DASH. 2. To assess the knowledge and beliefs of caregivers towards the usage of ITNs.

Methodology Study area
This was a hospital-based prospective cross-sectional study of women of reproductive age group (15 - Non-response = 10% = n = x = 36.9 The study was conducted on sample size of 406

Sampling method
All women attending Ante Natal Clinic (ANC) that consented to the study during the period under review were recruited.
Inclusion criteria: all clients undergoing ante-natal care were enrolled during the period of study Exclusion criteria: all clients who declined participation.

Ethical consideration
Ethical clearance was obtained from Research Ethics Committee of the State. Confidentiality of information collected was treated with utmost regards.

Funding
This study was funded by Saving One Million Lives, Programme For Result (P4R) Nasarawa state. Data collection: Questionnaires were administered by researchers and three research assistants (one per site) to patient that met the inclusion criteria.

Data analysis
Data was analysed using SPSS (Statistical Package for the Social science) version 23.0. Frequencies and percentages were computed for categorical variables while means and standard deviation were determined for continuous variables. Results obtained after analysis are presented in tables and charts below. Significant p is any value < 0.05.

Socio-demographic characteristics of study participants
The mean age of this study population is 27.  Table 3 below.
Concerning the duration of usage of insecticide treated net among participants, 36 (8.0%) had used insecticide treated nets for less than 6 months, 164 (36.3%) used ITN between 6 months and one year, 160 (35.5%) between one year and five years and 91 (20.2%) used ITN for more than five years.
Perceptions of the participants was assessed about insecticide treated nets and 320 (71.0%) feel it is very good and useful in preventing malaria, 58 (12.8%) said they were using it out of compulsion, 46 (10.2%) prefer spray to insecticide treated net and 27 (6.0%) said it is very uncomfortable to use Table 3.

Discussion
This study revealed that most participants know that insecticide treated net do prevent mosquito bites and malaria. More than half are aware of the ITN and are using it. Among the users, more than two-third used it efficiently. Factors contributing to non usage or inefficient use by some responders were the perceived heat it generates and the chemical smell from the ITN. The mean age of the study participants was 27.9 ± 10.6 years comparable to the report by Babalola et al 14 in Kaduna among women 29.3 ± 6.2 years. Both studies were among women of reproductive age group (15 -49 years).
The present study showed that 91.6% have heard and are aware of the insecticide treated net, comparable to the 93.2% and 96% reported in other studies. 14,15 This finding further validates the report of Ezire et al 15  This study showed that slightly more than half of the participants (56%) owned an insecticide treated net. This is better than the 28.8% reported by Ankomah et al 16 in a population based survey in Nigeria. The varying study design with the present hospital based study may account for the difference, so also is the variation in time (over a decade). The relative higher level of education of the responders in this study where close to half are with tertiary level of education, may also be a contributor to the finding in this study. Our finding is lower than the 64.6% found by Ezire et al. 15 Aside the time difference of ten years which may explain the difference, the varied study population of women of reproductive age only in the current study may also be a factor.
The prevalence of ITN utilization in this study of 58.4% falls short of the minimum standard global coverage target of 60% by 2015. It is slightly higher than the 55.1% reported by Osuchukwu et al 17 in Ogoja area of Cross River State. It is equally higher than the 40.68% reported by Komomo et al 18 in Calabar. Both studies were in Cross River state in South-south Nigeria, with the discrepancies in climate, culture and beliefs a possible reason for the observation. It is far higher than the 19.2% reported by Ezire et al 15 , in a multi-state population based study among males and females.