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Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 1037-1042
Determinants of use of insecticide-treated nets among caregivers of under-five children in Enugu, South East Nigeria

1 Department of Paediatrics, College of Medicine, University of Enugu Campus, Enugu, Nigeria
2 Department of Community Medicine, College of Medicine, University of Enugu Campus, Enugu, Nigeria

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Date of Web Publication5-Oct-2017


Background: Malaria accounts for 90% of the 1.5–3 million deaths occurring annually in Africa. Insecticide-treated nets (ITNs) have proven to be highly effective in preventing malaria. It can reduce malaria transmission by up to 90% and avert up to 44% of all-cause malaria in children <5 years. Aim: The aim of the study determined to explore the reasons why the available insecticide-treated nets were not put to use. Methods: This was a cross-sectional study of 389 caregivers of under-five children in the three local government areas of Enugu, Southeast Nigeria. Study participants were recruited through a multistage stratified sampling process. Results: The results showed that net ownership rate was 85.6%. Mean possession rate of ITN was 4.8 nets per household. About 93.8% had heard about ITN, while 91.8% of the participants knew that it was used to prevent mosquito bites. Only 53.9% used their ITN. Educational status of the caregiver was the most consistent factor affecting ITN use (P = 0.001).

Keywords: Enugu, insecticide-treated nets, under-five children

How to cite this article:
Bisi-Onyemaechi AI, Obionu CN, Chikani UN, Ogbonna IF, Ayuk AC. Determinants of use of insecticide-treated nets among caregivers of under-five children in Enugu, South East Nigeria. Ann Trop Med Public Health 2017;10:1037-42

How to cite this URL:
Bisi-Onyemaechi AI, Obionu CN, Chikani UN, Ogbonna IF, Ayuk AC. Determinants of use of insecticide-treated nets among caregivers of under-five children in Enugu, South East Nigeria. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Feb 19];10:1037-42. Available from:

   Introduction Top

Malaria affects half of the world's population.[1] The WHO reported that in 2015, 95 countries and territories had ongoing malaria transmission. It is prevalent in the poorest countries of the world [2] and more often than not, a consequence rather than a cause of poverty. In 2015 alone, Sub-Saharan Africa was home to 88% of malaria cases and 90% of malaria deaths. Nigeria, DRC, Ethiopia, and Uganda account for nearly 50% of global malaria deaths.[1] The under-five children are most vulnerable. One of the every five deaths for children <5 years in Africa is due to malaria.

Malaria is a major source of economic loss in tropical countries including Nigeria. Economic loss to malaria in Sub-Saharan Africa has been put at 12 billion dollars.[1]

In Nigeria, malaria is endemic with the greatest prevalence in children 6–59 months which is highest in Southwest, Northcentral, and Northwest and lowest in the Southeast regions.[2] With increase in drug/parasite resistance, human and natural disasters causing displacements, there has been resurgence in the incidence of malaria with further increase in economic loss. This further emphasizes the role of prevention and control in reducing the burden of malaria.

The Roll Back Malaria project is the current policy for the control of malaria in Nigeria, and it includes the use of insecticide-treated nets (ITN). Its target was to get 60% of the under-five children and pregnant women, sleeping under ITN by 2005 and 80% by 2020; however, ITN use was still well below the projected value – 17% in 2013 National Demographic Health Survey. ITN use reduces the incidence of complicated malaria episode by 39% compared to using untreated net and by 50% compared to not using nets.[3] For every 1000 children protected with ITN, 5.5 lives are saved each year.[3] Studies have shown that this low-cost preventive strategy caused a 20% reduction in under-five mortality.[3],[4],[5],[6],[7] Considering the limited resource in Africa, there is need to periodically monitor and encourage sustained use of such malaria prevention strategy.

This study therefore set out to determine the pattern of use of ITN among caregivers of under-five children in Enugu. This would help inform policy development and engineering and provide a scientific basis for government to scale up interventions. Findings from this study may help refine ITN distribution programs and further assist in developing information and communication activities to maximize the impact of ITNs in reducing malaria morbidity and mortality.

   Methods Top

Study area

The study was done in Enugu Metropolis, Southeast Nigeria. Enugu has good climatic condition all year sitting at about 223 m above sea level. The mean temperature in the state in the hottest month of February is 30.04°C while the lowest temperature occurs in the month of November is 15.56°C.[8]

Study design

This was a cross-sectional study of caregivers of under-five children residing in Enugu Metropolis. Study participants were selected from within their communities using multistage sampling. The metropolis was stratified into its three local government areas; Enugu North, South, and East. Two geographical areas were selected from each local government using simple random sampling. Within each selected area, one public health facility offering antenatal and immunization services was selected simple randomly. Consenting mothers/caregivers of under-fives who live within each study area were interviewed from antenatal and immunization clinics in the selected health facility. Every second client was interviewed each immunization/antenatal day ensuring that the respondent was not repeated. Data were collected consecutively using pretested, interviewer-administered, structured questionnaire.

Study instruments

The questionnaire was reviewed by a panel of experts and pretested at the children outpatient of the University of Nigeria Teaching Hospital, Enugu, among caregivers presenting with under-five children.

Ethical consideration

Before commencing the study, ethical approval was sought and obtained from the Human Research and Ethics Committee of the University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu. Information gathered from participants was treated with utmost confidentiality.

Data analysis

The data were analyzed using the SPSS Software (IBM, Armonk, NY) Version 21 for Windows. Data presentation was done with frequency tables and charts. P value was set at 0.05 and confidence interval at 95%. Level of significance was sought for among association of the categorical variables.

   Results Top

General data

Four hundred questionnaires were distributed while 389 were retrieved and analyzed giving a response rate of 97%. There were a total of 660 under-five children and 850 persons altogether in the 389 households. The age and sex distribution of the respondents are presented in [Table 1].
Table 1: Demographic characteristics of the caregivers of under-five in Enugu Metropolis

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Knowledge on insecticide-treated net

Three hundred and sixty-five (93.8%) of the respondents had heard of ITN. This was through electronic media in 110 (28.3%), health facility in 202 (55.5%), friends in 40 (11%) respondents, and 13 (3.6%) from places of worship. Three hundred and fifty-seven (91.8%) thought that ITN was used for protection against mosquito bites, three as a protection from cold, two people thought that it can be used for decoration, while 3 had no idea what ITN was for.

Sixteen (4.4%) of those who had heard of ITN had no formal education, 22 (6%) had primary education, 130 (35.6%) had secondary education, while 197 had tertiary education (P = 0.001). Among respondents with no formal education, 80% (16) had heard of ITN, 100% of respondents with primary education had heard of ITN, 89.7% of those with secondary education had heard of ITN, while 97.6% of those with tertiary education had heard of ITN.

Sixty-three (17.3%) of those who had heard about ITNs were homemakers, 136 (37.3%) were traders, 120 (32.9%) were civil servants, 44 (12.1%) were artisans, while 2 (0.5%) were farmers. This was not found to be significant (P = 0.899). Among the homemakers, 94% had heard about ITN, 93.2% of the traders had heard about ITN, 95.3% of the civil servant had heard about ITN, 91.7% of the artisans were also aware of ITN, while both farmers (100%) had also heard about ITN.

About 96% of households headed by women were aware of ITN, while 93.2% of the households headed by men had heard of ITN (P = 0.803). Among those who had heard about ITN, 30.1% were from media, 55.3% from a health facility, 11% from friends and neighbors, while 3.6% with from religious organizations.

Ownership of insecticide-treated net

Three hundred and thirty-four households had ITN representing a net ownership rate of 85.9%. There were 1862 ITNs in the 334 households giving a mean possession rate of 4.8 ITN per household and 2.2 ITN per person. Two hundred and eighty-three of those who had ITNs received theirs free either from a health facility or at home during house-to-house distribution while 51 purchased theirs.

Use of insecticide-treated net

Two hundred and fifty (64.3%) of the respondents agreed for using ITN. Two hundred and ten (53.9%) of the respondents reported that their children actually slept in the net the night before the interview. There were 139 (35.7%) who did not use ITN. Various reasons were given for not using ITN: 48 respondents attributed it to worsening hot weather in an already tropical climate, 46 preferred to use other malaria preventive strategies, namely, insecticide sprays and window/door nets, 26 respondents did not have space for it due to small living accommodation, 14 did not know how to use it, while five respondents did not give any reason for not using it. Approximately 48.4% of the households headed by women use ITN, while 55.5% of households headed by fathers use ITN. One household each headed by an uncle and a grandparent use ITN for their under-five children.

Education and insecticide-treated net use

Five of the 210 respondents who use ITN have no formal education, six have primary education, 75 had secondary education, while 124 had tertiary education. Twenty-five percent of those with no formal education use ITN, 27.3% of respondents with primary education use ITN, 51.7% of those with secondary education use ITN, while 61.4% of those with tertiary education use ITN. This showed a strong association between education and use of ITN (P = 0.04).

Seven of the households who use ITN have heads with no formal education; this constitute 38.9% of households whose heads have no formal education. Fifteen of the 210 households who use ITN have heads with primary education, i.e., 48.4% of household whose heads have primary education only use ITN. Eighty-one households who use ITN have heads with secondary education only; this constitutes 51.6% of household headed by secondary education holders. One hundred and seven of the 210 respondents who use ITN have heads with tertiary education, i.e., 58.5% of those who head have tertiary education use ITN (χ2 = 8.91, df = 3, P = 0.03).

Housing and insecticide-treated net use

Thirty-one (14.8%) of those use ITN live in single rooms, 43.1% of those who live in single rooms use ITN, 64 (30.5%) of those use ITN in double rooms, 53.3% of those who live in double rooms use ITN. One hundred and three (49%) of those who use ITN live in flat is 59.9% of those that live in flats use ITN. Five (2.4%) of those who use ITN live in duplex, while 45.6% of those who live in duplex use ITN. Seven (3%) respondents using ITN live in bungalow, i.e. 50% of those living in bungalow use ITN. Type of accommodation did not determine the use of ITN (P = 0.19).

Family size and insecticide-treated net use

One hundred and six (50.5%) of those who use ITN have four or less number of persons in their houses; 55.5% of those with four or less number of persons in their houses use ITN. One hundred and four (49.5%) of those who use ITN have more than four persons in the house; 52.5% of those who have more than four persons in the house use ITN. The number of persons in the household was not significantly associated with ITN use (P = 0.53).

   Discussion Top

The modal age group of the respondents represents the peak of child-bearing. The data were collected from antenatal and immunization clinics which have majority of its clients as women in their child-bearing ages. This explains also why most of the respondents were females. Most of the respondents and household heads had secondary and higher education probably because the study was done in the metropolis where there is better access to education. The major occupations of the workforce of the metropolis also reflected in the occupations of the respondents as majority were civil servants and traders. The net ownership rate was higher than what was documented in some other studies [9],[10],[11],[12] but similar to findings by Dagne and Deressa [13] and Baume et al.[14] The mean possession rate reflects a good ITN concentration in the metropolis. The high ITN concentration in this study and the latter reports could be because these studies were done in populations that had received free ITNs as against the former studies.

This study shows a consistent improvement in ITN awareness as a previous report documented an awareness level of 7% and 60% in 2000 and 2004, respectively, in Nigeria.[12] However, Musa et al. in 2009 reported a low level of awareness in a northern state in Nigeria.[15] This level of awareness may also be because the study was done in the metropolis where there is better access to education and information. More than half (55.3%) of the respondents heard of ITN from health facilities. This is similar to the reports from Ibadan, Sokoto, and Calabar, where public hospitals were the major source of awareness among respondents.[9],[16],[17] It reflected a positive impact and importance of health talks at antenatal and immunization clinics. Where the facilities exist, the media should also be engaged in the promotion of behavioral change communication programs since as much as 30% head of ITN from the media. As much as 97.8% of those aware of ITN also knew what it was used for. Education had a significant impact on the level of awareness as there was a consistent increase in awareness as educational status increased. This finding is also consistent with other reports.[16],[18],[19],[20] There was no significant relationship with occupation of the respondents and awareness of ITN in contrast to studies by Aluko and Oluwatosin [9] and Iloh et al.[21]

The utilization of ITN by caregivers of under-five children in Enugu Metropolis was similar to previous findings on ITN use.[13],[14],[21],[22],[23] ITN use ranged between 50% and 69% for children <5 years in these reports but significantly lower in some reports where ITN Were 11% and less [24],[25] Awareness and possession were also low in the latter reports. The most common reason for nonuse of ITN was worsening of hot weather conditions. This is the same reason for nonuse given by respondents in Western Kenya.[26] To ensure use, caregivers can be advised to put the children under an ITN with minimal clothing.

There was a significant association between the level of education and use of ITN [Table 2]. Beyond primary education, the use of ITN by caregivers of under-five children doubled. Other studies also documented similar findings.[14],[21],[24] This may be because higher levels of education were associated with the correct knowledge of the cause of malaria as was found in these studies. The increase in the use of ITN among household heads with higher educational status was also reported in Mali (P=0.03) This is important in our environment where the consent of the head of the household is considered before any decision is taken in the house; therefore, an educated head of the household is more likely to understand the etiology of malaria and also to accept the use of an ITN. Maternal education and, by extension, educational status of caregiver have been associated with infant and child morbidity and mortality,[27],[28] and malaria is a major cause of childhood morbidity and mortality in the tropics.[2] It therefore follows that at every point that maternal education is ongoing, e.g., at antenatal and immunization clinics, ITN use should be an integral part of the lectures. There was progressive increase in the use of ITN as more space became available up to duplexes though it was not statistically significant [Table 3]. People living in duplexes may be able to afford other malaria control measures. Dagne and Deressa,[13] Alaii et al.,[26] and Galvin et al.[29] however reported that availability of separate rooms made it more convenient to use ITN. More spaces available results in a more stable sleeping arrangement and therefore more convenient for families to use a bed net. There is need for education during net distribution on how households can adjust if necessary to accommodate the nets or how it can be hung up more conveniently. The type and size of house also determine the amount of ventilation and studies have also documented that intense room temperatures [Table 4] make using a bed net not feasible as a times household members opt to sleep outside.[11],[30],[31]
Table 2: Relationship between educational status of caregivers of under-five and insecticide-treated nets use

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Table 3: Association between type of house and use of insecticide-treated nets

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Table 4: Association between family size and insecticide-treated nets use

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This study is similar to other reports which noted that family size had no effect on the use of ITN.[23],[24] However, Okafor and Odeyemi and Iloh et al. documented that family size of four or less was associated with higher use of ITN.[21],[22] Rhee et al. noted that larger family sizes was associated with lower use of ITN.[25] Larger family sizes, especially when associated with limited spaces and low ITN per person ratio, may make it less convenient to use a bed net.

   Conclusion Top

Awareness, knowledge, and possession of insecticide-treated bed nets among caregivers of under-five children in Enugu metropolis are high and probably signify a good distribution and communication program; however, after a decade, the target of 2005 to get at least 60% of the vulnerable population sleeping under treated bed nets is yet to be reached and efforts should be strengthened to meet the current target of 80%.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Adaobi I Bisi-Onyemaechi
Department of Paediatrics, College of Medicine, University of Nigeria, Enugu Campus, Enugu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_758_16

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