|Year : 2016 | Volume
| Issue : 1 | Page : 6-11
Factors influencing the use of malaria prevention methods among women of reproductive age in peri-urban communities of Port harcourt city, Nigeria
Charles Ibiene Tobin-West1, Esther Njideka Kanu2
1 From the Department of Preventive and Social Medicine, College of Health Sciences, University of Port Harcourt, Port Harcourt, Nigeria
2 Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
|Date of Web Publication||13-Apr-2016|
Charles Ibiene Tobin-West
From the Department of Preventive and Social Medicine, College of Health Sciences, University of Port Harcourt, Port Harcourt
Source of Support: None, Conflict of Interest: None
Background: Malaria remains a huge national concern in Nigeria with severe implications for maternal and child health.
Aims: This study was aimed at investigating factors that influence malaria prevention among women of reproductive age in line with the National Malaria Control objectives.
Subjects and Methods: A descriptive, cross-sectional study design and cluster sampling technique was used to recruit study participants. Respondents had 'correct' knowledge of malaria if they knew the cause and symptoms of malaria. Otherwise is classified as 'incorrect'. Data were analysed in Epi Info version 7 with the level of statistical significance set at P 0≤ 0.05.
Results: Most respondents, 709 (89%) had good knowledge of malaria. Their educational level was significantly associated with this knowledge (χ2 = 3.6993, P = 0.0544). There were, however, some myths and misconceptions about malaria. Of 390 (49.3%) that owned insecticide treated bed nets (ITNs), only 59 (18.2%) used them consistently, while only 31 (50%) of the pregnant women received intermittent preventive treatment (IPTp). Malaria knowledge, ITNs ownership and female education were not significantly associated with ITN and IPTp usage. Married women had 3 times higher odds of ITN usage than the unmarried, (odds ratio [OR] = 2.69, 95% confidence interval [95% CI] = 1.56-4.62), and women with children had 2 times higher odds of usage than those without (OR = 2.42, 95% CI = 1.42-4.12).
Conclusions: The use of malaria prevention measures among women of reproductive age is still sub-optimal. We advocate for intensified education of women on malaria in local languages, using role plays and community dialogues. Efforts must also be directed at dispelling myths and misconceptions about malaria for maximum impact.
Keywords: Malaria, Nigeria, prevention, Rivers State
|How to cite this article:|
Tobin-West CI, Kanu EN. Factors influencing the use of malaria prevention methods among women of reproductive age in peri-urban communities of Port harcourt city, Nigeria. Niger Postgrad Med J 2016;23:6-11
|How to cite this URL:|
Tobin-West CI, Kanu EN. Factors influencing the use of malaria prevention methods among women of reproductive age in peri-urban communities of Port harcourt city, Nigeria. Niger Postgrad Med J [serial online] 2016 [cited 2019 Aug 19];23:6-11. Available from: http://www.npmj.org/text.asp?2016/23/1/6/180114
| Introduction|| |
Malaria is a major health problem in sub-Saharan Africa, where 74% of the population live in highly endemic areas, and additional 18% live in epidemic areas.  In 2013 alone, about 198 million cases of malaria and an estimated 584,000 deaths occurred, with 90% of these deaths occurring in sub-Saharan Africa. , Nigeria bears the brunt of this burden, being the country with the most malaria morbidity and mortality in the world.  The country experiences an estimated 100 million malaria cases with over 300,000 deaths per year, with most of these deaths occurring in children.  Malaria in pregnancy is of significant concern in the developing countries, with substantial risks to mothers and their unborn babies. Pregnancy compromises a woman's immune response to malaria attacks, exposing them to increased risk of infection, severe anaemia, spontaneous abortion, premature delivery or death while subjecting the foetus to the risk of low birth weight or stillbirth. , In Nigeria, it accounts for up to 11% of maternal deaths.  The consequent deficiency of foetal nutrition plays a role in low birth weight and reduced infant survival rates. 
At the dawn of the new millennium, African leaders committed to reducing the burden and mortality from malaria in the region by implementing strategies of the Roll Back Malaria Initiative.  This commitment was to be realised by the coverage of at least 60% of at-risk populations with appropriate anti-malaria interventions.  The target was subsequently redefined to 80% coverage by 2010, and further raised higher with the introduction of the Global Malaria Action Plan for universal coverage. 
The use of preventive measures against malaria among women of reproductive age is a key factor for the actualisation of the malaria control targets in Nigeria. This has been observed to be generally sub-optimal in all the six geo-political regions of the country. , The non-use of preventive measures has severe morbidity and mortality implications, especially for pregnant women and under-five children. , It also has adverse socio-economic effects on the individual, community and national economy. For instance, it is estimated that Nigeria loses about 132 billion naira annually from the cost of malaria treatment, transportation to sources of treatment, absenteeism from school, farming, work, etc. , The National Malaria Control Program noted in its 2006 report that the non-use of preventive measures was one of the major challenges of the Roll Back Malaria programme in Nigeria.  Therefore, considering the culturally diverse nature of the people in Rivers State, there is an obvious necessity to explore factors that influence the use of malaria prevention measures. This will be relevant for the realisation of Roll Back Malaria targets and to make a realistic assessment of the state's progress towards the 2015 elimination goals. The information will be useful in specifying strategies for programmatic direction in malaria interventions in the state.
This study was commissioned as part of a baseline of a larger study in the state, designed to determine the health-seeking behaviours of women of reproductive age as it concerns infectious diseases. The study was funded by the World Bank through the Centre of Excellence for the control of infectious and zoonotic diseases of the Universities of Calabar and Port Harcourt, Nigeria. The specific objectives were therefore to determine the factors that influence the use of malaria preventive measures among women of reproductive age in peri-urban communities of Port Harcourt city, Rivers State, to enable the development of locally appropriate interventions for the control of malaria in the state.
| Subjects and Methods|| |
The study was conducted in peri-urban communities of Port Harcourt city, the administrative capital of Rivers State, Nigeria. The communities are Alakahia, Aluu, Rumuekini and Rumuosi. These communities are located in western fringes of the city and form part of the Obio/Akpor Local Government Area, one of the two that make up the city. The communities were the traditional homelands of the Ikwerre people, but presently there is a mix of several other ethnic groups which include Ibo, Ijaw, Efik, Ibibio, Ogoni, Urhobo, etc., as a result of increasing urbanisation.
Malaria is holo-endemic in these communities with the perennial transmission, typical of the entire Niger Delta region. Only one of the communities (Aluu) has a Primary Health Centers (PHCs). The PHCs provide health services that include free treatment of malaria to children under 5 years and adults above 65 years. Pregnant women are also offered free courses of sulfadoxine-pyrimethamine (S-P) for intermittent preventive treatment (IPTp) for prevention of malaria in pregnancy. Others, however, depend on patent medicine vendors, traditional birth attendants, herbal medicine practitioners, and spiritual healers for medical care. The Malaria Control Program of the Rivers State Ministry of Health is responsible for the free distribution of long-lasting insecticide treated nets in the state to all vulnerable populations.
Study design and population
A descriptive, cross-sectional design was used for the study. A simple random method was used to select the four peri-urban communities out of the over 25 identified. The study population comprised all consenting women of reproductive age residing in selected communities of Obio/Akpor LGA, between December 2012 and February 2013.
Sample size and sampling
A minimum sample size of 798 was determined for the study, using the formula for descriptive studies; n = Z2pq/d2 , with n = minimum sample size, Z = normal standard deviate 1.96 at 95% confidence level, P = proportion of women with good knowledge of malaria 71.5% from a Nigerian study,  q = 1-p, d = error margin of 5%, with adjustments made for a design effect of 2 and non-response rate of 20%. The total population of the communities were: Rumuekini 3506; Rumuosi 3405; Alakahia 3214 and Aluu 3456. The estimated population of women aged 15-49 years in the communities (22%)  were: 771, 749, 707 and 760, respectively. A cluster sampling method proportionate to size was used to recruit a range of 189-206 women from each of the communities as follows: From Rumuekini 3506/13,581 × 798 = 206; Rumuosi 3405/13581 × 798 = 200; Alakahia 3214/13,581 × 798 = 189 and Aluu 3,456/13,581 × 798 = 203. Interviewers assumed a central position in each of the communities, spun a pen on the ground to identify the direction of the first house to be included in the study. Within the first house, all households were identified and all eligible women of reproductive age were interviewed. Where more than one eligible woman was found in a household, balloting was used to select one to avoid 'pocketing'. Thereafter, consecutive houses and households were interviewed. When two houses or households were of equal distance away, the one on the right was chosen according to the survey protocol. This procedure was followed until the requisite sample size for that community was achieved.
Data collection methods
Information was collected using semi-structured interviewer-administered questionnaire, developed by the research team of the Centre for Infectious and Zoonotic Diseases of the University of Calabar and University of Port Harcourt, and pre-tested before use. The pre-testing was done in Emohua community, a different community with similar demographic attributes as the study communities. The questionnaire was administered by four residents doctors from the Department of Community Medicine, University of Port Harcourt Teaching Hospital, on mobile data capture devices (smartphones). It was administered in English as most respondents have basic education. It was however, interpreted into Pidgin English which is widely spoken in the state for respondents who had difficulties with English. The questionnaire comprised questions on socio-demographic characteristics, obstetric history, knowledge on cause and symptoms of malaria, the attitude of women to malaria, use of insecticide-treated bed net (ITN), and IPTp in pregnancy. Data were automatically transmitted to the central database of the project.
Data were analysed with Epi Info version 7 statistical software (Centre for Disease Control, Atlanta, USA). It was summarised and presented in frequency tables and graphs. Some variables were dichotomised for further analysis. Bivariate analysis and multiple logistic regression were performed to test associations and relationships between categorical variables. The level of significance was set at P ≤ 0.05.
Respondents' knowledge of malaria was assessed with questions on the cause of malaria and was rated as 'correct' if respondents identified mosquito bite alone as the mode of transmission, and 'incorrect' if respondents mentioned anything else as the cause of malaria.
Knowledge on the symptoms of malaria was graded as 'correct' if respondents mentioned, at least, three of the following symptoms; fever, malaise, body aches, loss of appetite and nausea/vomiting, and 'incorrect' if the respondent did not mention any of the listed symptoms.
A composite measure of the knowledge of malaria was if respondents had 'correct' knowledge of the cause and symptoms of malaria. Otherwise is classified as 'incorrect' knowledge.
Ethical approval was obtained from the Research Ethics Board of the University of Calabar and the Federal Ministry of Health, Abuja. Furthermore, verbal informed consent was obtained from each respondent before commencement of the interview. Respondents were assured of confidentiality of information provided.
| Results|| |
Socio-demographic characteristics of respondents
A total of 800 questionnaires were administered and 797 had complete responses, giving a completeness rate of 99.6%. The age distribution of the respondents is shown in [Table 1]. Majority of the women 646 (83.5%) were aged between 15 and 34 years, mainly single 413 (51.8%), nulliparous 432 (54.2%) and 495 (62.1%) had secondary level of education.
Knowledge of malaria
A total of 668 (83.8%) of the women identified malaria as the most common disease in their environment. Majority of them, 709 (89%) linked malaria transmission with mosquito bite, however a high proportion cited at least one incorrect cause of malaria, such as eating oily foods - 188 (23.6%), too much sunlight - 106 (13.3%), hard work - 78 (9.8%), witchcraft - 6 (0.8%), and repercussion of past evil deeds - 2 (0.3%) as causes of malaria [Table 2]. Most of the women further mentioned fever 687 (86.2%), tiredness and sleepiness 527 (66.1%), sour/bitter taste in the mouth 463 (58.1%), and loss of appetite 438 (55%), as common symptoms of malaria [Table 3].
|Table 2: Respondents' knowledge of malaria and the use of preventive measures|
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A total of 481 (60.4%) had correct knowledge on the cause/transmission of malaria while 316 (39.6%) had incorrect knowledge. Similarly, a total of 335 (46.4%) had correct knowledge of symptoms of malaria, while 387 (53.6%) had incorrect knowledge of symptoms of malaria. A composite measure of knowledge of malaria was therefore determined for the cause and symptoms of malaria. It showed that 410 (51.4%) of the women had correct knowledge of the cause and symptoms of malaria against 387 (48.6%) who did not. There was a significant association between their level of education and their knowledge of malaria (χ2 = 3.6993, P = 0.0544). Schools (25.72%), hospitals (23.46%) and family members (19.32%) were the major sources of information on malaria.
About three-quarters of the women, 600 (75.3%) identified the use of ITNs as a method of malaria prevention. Few 52 (6.5%) mentioned 'keeping the environment clean', 50 (6.3%) did not know any malaria preventive method, while 9 (1.1%) each mentioned drinking clean water and the use of drugs as malaria preventive measures [Table 2].
The use of malaria prevention methods
Use of insecticide treated bed nets
Three hundred and ninety respondents (49.3%) owned at least one mosquito bed net. Among those who owned the mosquito nets, 325 (88.3%) had ITNs, while the rest 65 (16.7%) had ordinary nets. Only 59 (18.0%) of those that owned ITN actually used them the night prior to interview.
Use of intermittent preventive treatment
Sixty-two (7.78%) women were pregnant at the time of the study, of which 31 (50.0%) had taken IPTp in the index pregnancy. About one-tenth, 101 (12.67%) had delivered babies in the 12 months before the study, of which 60 (59.41%) used S-P during pregnancy [Table 2].
Factors associated with the use of malaria prevention measures
Married women were 3 times more likely to use ITN than those not married (odds ratio [OR] = 2.69, confidence interval [CI] = 1.56-4.62). Women who had ever delivered babies were 2 times more likely to use ITN the previous night before the survey than nulliparous women (OR = 2.42, CI = 1.42-4.14). There was no statistically significant association between knowledge of malaria transmission, ownership of ITN, educational level of respondents and the use of ITN by the women. There was also no significant association between knowledge of causes of malaria, marital status, educational level, and parity and use of IPTp among the pregnant women in this study [Table 4].
|Table 4: Factors associated with use of insecticide treated bed nets by women in the communities|
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| Discussion|| |
Most of the respondents correctly recognised common symptoms of malaria such as, fever, malaise, nausea, vomiting and loss of appetite. This was good and expected among those residing in an area highly endemic for malaria like the Niger Delta region. Their correct knowledge might be linked with their appreciable educational level and their sources of health information, which were schools, health facilities, family members and the mass media. This is a positive development and underscores the value of female education as a prerequisite for disease recognition, prevention and care seeking. It might further represent a good first step in the process of preventing the disastrous consequences malaria, especially among pregnant women and under-five children. The finding was in agreement with those from similar studies conducted in Lagos, Nigeria, among pregnant women attending prenatal clinics,  and elsewhere in Ethiopia  and Kenya,  but was at variance with those from rural communities in northern parts of Nigeria where female literacy is considerably lower, coupled with limited knowledge about the role of mosquitoes in the transmission and cause of malaria. 
There were however, also various myths and misconceptions and about malaria among the respondents. These myths and misconceptions deceive mothers and caregivers in giving inappropriate interpretations to malaria symptoms and taking inappropriate actions which result in delayed treatment and often times fatal outcomes, especially among children under 5 years of age. ,
The use of ITN among the respondents was found to be very low compared with the level of ownership of the nets. There was no statistically significant association between the educational level of respondents, their knowledge of malaria transmission, and ownership of ITNs with the use of the nets. Although similar findings have been well documented in the last couple of years, highlighting reasons for non-use as poor belief in the effectiveness of the nets, ignorance of how to use the nets, and that bed nets generate heat and disturbs sleep etc. ,, It demonstrates that efforts at malaria prevention and control in Rivers State might needs to go beyond net provision alone. This brings to fore the necessity to augment the regular net campaigns for universal access to ITNs with other innovative ways of addressing associated challenges.
The ITNs were more significantly used by married and parous women than their unmarried and nulliparous counterparts. The observed differences might be linked with the knowledge acquired in prenatal clinics during pregnancies, where pregnant women are usually exposed to health education about malaria in pregnancy and in caring for their new-borns. Similarly, the prevalence of IPTp use was low among the pregnant respondents. There was also no significant association between knowledge of the cause of malaria, marital status, educational level and parity with the use of IPTp. Low IPTp use puts women at risk of malaria in pregnancy and its adverse outcomes like anaemia, spontaneous abortions, prematurity or low birth weight. , Although the observed IPTp use was sub-optimal, it was higher than the national average of 23%  and those obtained in some settings in South-Western Nigeria, , where only 40.4% and 27.3% of women respectively, reported S-P use for malaria prevention during pregnancy. The finding might be associated with the general reluctance among pregnant women in taking drugs during pregnancy, especially when there are no clear symptoms of illness or convincing need to do so, and the assumptions that S-P could cause harm to their unborn babies. 
| Conclusions|| |
The study underscores the fact that the use of malaria preventive measures by women of reproductive age is still sub-optimal despite their appreciable knowledge and access to ITNs. We therefore advocate for intensified formal and informal health education for women using culturally sensitive approaches, like the use of local dialects in information dissemination, role plays and community dialogues. Efforts should also be targeted at dispelling myths and misconceptions about malaria that often constitute barriers to uptake of malaria prevention.
We express our gratitude to the Resident doctors of the Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt used for data collection for the study, in spite of their busy work schedule.
Financial support and sponsorship
Funding was provided by the World Bank under the Nigeria Step-B Project Grant (Credit No. CR 4304 UNI) to the Centre of Excellence for Infectious and Zoonotic Diseases of the University of Calabar and University of Port Harcourt.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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