ABSTRACTS
CONTEXT
Malaria in pregnancy poses a serious public health threat in Nigeria due to its antecedent adverse consequences on the mother and her foetus. It can be prevented through the correct and consistent use of insecticide treated mosquito nets. However, its use is deficient among pregnant women I Nigeria. Therefore, this study explores the various factors that influence the use of insecticide treated nets among pregnant women in Nigeria.
OBJECTIVE
The objective of this study is to systematically appraise primary studies on the utilization of insecticide treated nets among pregnant women in Nigeria and to formulate a concept map of these factors.
METHODS
This study utilized systematic review procedures although it has a narrower scope. Literature search was conducted across four electronic databases namely; MEDLINE, CINAHL, Web of Knowledge and BioMed. In addition, the references of articles were further examined to identify articles which may not have been captured in the initial search. A total hit count of 3305 was arrived at and seven high quality studies were selected for critical and systematic appraisal after all relevant studies were subjected to a predefined inclusion and exclusion criteria.
FINDINGS
This study found that several issues have been identified as factors that influence the utilization of insecticide treated nets among pregnant women in Nigeria. However, the main factors include; socioeconomic and demographic factors, level of knowledge about malaria and its consequences, level of misconceptions about malaria, access to antenatal care facilities and availability of the mosquito nets. However, the socioeconomic class of the pregnant woman is the strongest predictor of utilization as it directly or indirectly influences other factors.
CONCLUSION
There is the need to make antenatal care services more available and accessible especially to the rural poor communities. There is also the need to widen the scope of free ITN distribution to include tertiary hospital and also enhance free community distribution in association with the provision of social and behavioural change enlightenment and interventions to the pregnant women, their husbands, community leaders and traditional birth attendants. Furthermore, preconception care should be incorporated into the focused antenatal care services in order to provide early access to malaria prevention enlightenment. In addition, malaria prevention enlightenment should be provided to young girls in primary and secondary schools. It is also important to ensure socioeconomic empowerment of women, reduce gender inequality and encourage girl child education.
LIST OF ABBREVIATIONS
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CHAPTER ONE INTRODUCTION
1.1 CHAPTER OVERVIEW
This chapter aims to provide a general introduction to this research. It puts the study in relevant context of available literature and justifies the rationale behind the need to understand the factors that influence the utilization of Insecticide Treated Nets (ITNs) in the prevention and control of malaria among pregnant women in Nigeria. It concludes by providing a statement of the aims of the research and the research question.
1.2 BACKGROUND
Malaria is a serious and sometimes life threatening disease caused by the plasmodium parasite which is transmitted through the bite of infected female Anopheles mosquitoes (Adebayo et al., 2015). There are five species of the plasmodium parasite, however plasmodium falciparum is the major cause of malaria infection and is the main cause of life threatening malaria (Ezire et al., 2015). According to the World Health Organization (WHO), about half of the global population is at risk of malaria (WHO, 2016a). It was estimated that there were about 212 million cases and 429,000 malaria related deaths in 2015 (Falade et al., 2016; WHO, 2016a).
However, the greatest percentage of the global burden of malaria is disproportionately carried by sub-Saharan Africa with 90% of cases and 92% of malaria deaths, thus making malaria a serious public health threat and a huge epidemiological burden to Africa (WHO, 2016b). According to the National Malaria Control Program (NMCP), malaria is endemic in Nigeria as 97% of the population live in high malaria risk areas (NMCP, 2014). Further evidence have also shown that Nigeria carries a significant proportion (25%) of the burden in Africa with an estimated 110 million clinically diagnosed cases per year and about 110,000 malaria related deaths in 2015 (WHO, 2016c; Federal Ministry of Health [FMH], 2009). It is also responsible for 60% of all outpatient attendance and 30% of all hospital admissions (Ezire et al., 2015; Salihu and Sanni, 2013).
1.3 BURDEN AND CONSEQUENCES OF MALARIA IN PREGNANCY
It has been estimated that malaria in pregnancy has a prevalence of about 48% in health facilities in Nigeria. This figure is likely an underestimation considering the fact that 40% of pregnant women in Nigeria do not attend health facilities for antenatal care (Onyeneho et al., 2014). Furthermore, 70% of pregnant women in Nigeria suffer from malaria, thereby putting them at risk of negative pregnancy outcome (Adebayo et al., 2015).
Nigeria has one of the highest maternal mortality in the world with 814 maternal deaths per 100,000 live births and an estimated 58,000 maternal death with malaria in pregnancy being responsible for 33% (WHO, 2016c; Ezire et al., 2015). Other major causes of maternal mortality in Nigeria include; Obstetrics hemorrhage, eclampsia, obstructed labour and complications from unsafe abortions (Ezugwu et al., 2014). It is also responsible for 12-30% of under-five mortality (Ezire et al., 2015; FMH, 2009), thus making it one of the most serious public health problem in Nigeria (WHO, 2016c). Furthermore, it results in significant danger to the mother, her foetus and infant which leads to increased morbidity and mortality (Salihu and Sanni, 2013; WHO, 2007). It also leads to abortion, intrauterine foetal death, low birth weight and infant mortality (Ankoma et al., 2012).
Evidence has shown that the prevalence and susceptibility to malaria parasitaemia is highest during the second trimester and may persist into early postpartum period (NMCP, 2014). Pregnant women are also susceptible to sub-clinical malaria infection which may lead to negative consequences such as maternal anaemia, preterm delivery and low birth weight (Obieche et al., 2015; NMCP, 2014).
It has been estimated that malaria in pregnancy causes about 15% of maternal anaemia and 35% of preventable low birth weight and neonatal mortality (Onyeneho et al., 2014). Recent estimates in developing countries including Nigeria have shown that 60% of pregnant women are anaemic with 7% being severely anaemic (Olatunbosun et al., 2014). And the severity of anaemia is directly related to the density of parasitaemia especially among primigravidas (Agan et al., 2010).
This is compounded by the fact that most pregnant women in Nigeria have background nutritional deficiency anaemia which results from lack of healthy diet especially in women due to poverty (Oye-adeniran et al., 2014). This is even more severe in pregnant women with sickle cell anaemia considering the fact that Nigeria has one of the highest prevalence of sickle cell anaemia globally (Adewoyin, 2015).
On the other hand, low birth weight secondary to malaria is also responsible for between 3 and 17 deaths per 1000 live births and has been associated with increased risk of foetal and neonatal morbidity and mortality, growth inhibition and impairment in cognitive development (Ezire et al., 2015; Onyeneho et al., 2014). Furthermore, malaria in pregnancy causes an estimated 11.4% of neonatal deaths and 5.7% of infant deaths in malaria endemic areas of Africa (Onyeneho et al., 2014).
1.4 MALARIA CONTROL STRATEGIES IN PREGNANT WOMEN
The enormous public health burden of malaria among pregnant women in Nigeria has led the Federal Government of Nigeria in 2004 to adopt the WHO strategic framework for the prevention of malaria among pregnant women (FMH, 2014). The strategy involves Focused Antenatal Care (FANC) which incorporates the provision of malaria prevention services and antenatal care in health facilities with a view to reducing its burden in Nigeria (Onyeneho et al., 2014). However, evidence from the National Demographic and Health Survey (NDHS) has shown that despite the fact that malaria prevention services among pregnant women are free in health facilities across the country, utilization has remained very low (less than 30%) especially in northern states due low antenatal attendance (NPC, 2014). Major reasons behind the low ANC attendance in Northern Nigeria includes; poverty, low education, cultural beliefs, distance from health facility, unavailability of transportation as well as violence due to insurgency that has led to destruction of health facilities and massive internal displacement (WHO, 2017a; Fagbamigbe and Idemudia, 2015; Adamu and Salihu, 2002).
The principal strategies for malaria prevention include; vector control which reduces mosquito bites through the use of insecticide treated bed nets (ITNs) and indoor residual spray; intermittent preventive treatment (IPTp) of asymptomatic pregnant women with Sulphadoxine-pyrimethamine in order to suppress blood- stage infection and early diagnosis, prompt and effective case management of malaria (WHO, 2015; Olatunbosun et al., 2014). These services are provided free especially in primary and secondary health facilities as such people from poor socio- economic background and rural communities can have access to them too (NMCP, 2016). However, despite the evidence that the use of ITN is the best strategy for malaria prevention and control in Nigeria, only 36% of households have access to it and only 18% of pregnant women slept under ITN the night before the survey (NPC, 2014). This makes programmes that target its improved utilization a vital part of malaria control among pregnant women (Ezire et al., 2015).
Furthermore, appropriate prevention and treatment of malaria in pregnancy will lead to a reduction in the number of pregnant women requiring blood transfusion due to severe anaemia thus reducing their risk of transfusion-related infections such as HIV and Hepatitis B (FMH, 2014). In addition, studies have also shown that effective prevention of malaria infection through intermittent presumptive treatment and use of ITNs reduces the risk of severe maternal anaemia by 38%, perinatal mortality by 27% and low birth weight by 45% (a leading cause of infant mortality) (Onyeneho et al., 2014; Hughes, 2011). It also reduces the risk of spontaneous abortion, premature delivery and still birth (WHO, 2017b).
1.5 JUSTIFICATION OF THE STUDY
Considering the fact that ITN use is the single most important strategy to prevent malaria in pregnancy when used consistently and correctly, improving its utilization can effectively reduce the burden of malaria among pregnant women and improve pregnancy outcome (Ezire et al., 2015; FMH, 2014; Hill et al., 2013). However, It has been found that despite the fact that ownership of ITN might promote its use, it does not necessary lead to increased usage based on the fact that increasing household number of ITNs did not translate to any significant increase in its utilization, thus the need to identify the facilitators and inhibitors of ITN use among pregnant women (Ezire et al., 2015; Ankomah et al., 2012). Some of the factors that have been identified by individual studies to influence the level of utilization of ITNs include; ethnic origin, educational level, socio-economic and cultural factors as well as knowledge and perception about the medical condition and interventions (Onyeneho et al., 2016; Singh et al., 2013; Ankomah et al., 2012).
Findings from this study will help to improve the strategies employed by the government for malaria control among pregnant women by shedding more light on the factors influencing their perception and reception to those programs and services (Adebayo et al., 2014; Salihu and Sanni, 2013). This will subsequently contribute towards the attainment of the Sustainable Development Goal (SDG) three which is concerned with the improvement of maternal and child health (United Nations [UN], 2017).
Furthermore, preliminary search of literature have shown that there is deficiency of reviews on the topic conducted in Nigeria and most of the primary studies found were limited in context in the sense that they involve single locality or region of the country, as a result their findings cannot be generalized. Thus, this appraisal becomes necessary as it will provide a better picture of the Nigerian context and more reliable evidence on the factors influencing ITN utilization among pregnant women in Nigeria.
1.6 RESEARCH QUESTION
1. What factors influence the utilization of Insecticide Treated Nets (ITNs) among pregnant women in Nigeria?
1.7 AIMS OF THE STUDY
1. To systematically appraise published studies and determine the factors that influences the utilization of Insecticide Treated Nets among pregnant women in Nigeria.
2. Attempt to draw a conceptual map of the various factors that influence the utilization of ITNs among pregnant women in Nigeria.
1.8 CHAPTER SUMMARY
This chapter has provided a brief overview of malaria in pregnancy, its consequences and control interventions. It also discussed why a systematic appraisal is important and gave the aims and research question.
CHAPTER TWO LITERATURE REVIEW
2.1 CHAPTER OVERVIEW
This chapter presents a comprehensive review of the relevant literature surrounding the utilization of ITNs among pregnant women. It begins with brief notes on the conceptualization of the research question and trend in malaria control policies and strategies. It will also discuss theories relating to behavioural change and the factors that influence the utilization of ITN among pregnant women.
2.2 CONCEPTUALIZATION OF THE RESEARCH QUESTION AND LITERATURE SEARCH METHOD
Conceptualization refers to the careful analysis of general ideas known as concepts thereby forming clearer and more distinct constructs to aid better understanding (Henn et al., 2009). It is a process by which a researcher clearly defines the principal terms and ideas he intends to study (Sequeira, 2014). This is based on the fact that the concepts or terms employed in research might have various interpretations by different categories of people, making it vital for the researcher to explicitly specify the context in which he intends to limit the terms of his research (Henn et al., 2009; Sedgeman, 1996). The principal concepts in the research question of this appraisal are pregnant women, insecticide treated net use and influential factors.
The population involved in this study is pregnant women who are within the reproductive age group of 15 to 49 years (WHO, 2017a; United Nations Population Fund [UNPF], 2016). According to the WHO, pregnancy refers to the nine month period in which a woman carries a developing embryo or foetus in her uterus (WHO, 2017a).
On the other hand, insecticide-treated nets (ITNs/LLITNs) are any form of mosquito nets that have been treated with insecticides (Padonou et al., 2012), while their use refers to the conceptualized use of ITN/LLITN when sleeping by pregnant women. The influential factors in this appraisal refer to the factors that can either encourage or discourage the utilization of ITNs/LLITNs among pregnant women in Nigeria. They may include poverty, education, misconceptions or access to health facilities and services.
2.3 EVOLUTION OF POLICIES AND STRATEGIES FOR MALARIA PREVENTION AND CONTROL
Several global and national strategies to reduce the burden of malaria have been implemented even prior to the establishment of the WHO in 1948 (WHO, 2017c). The period between the 1940s to the mid-1960s following the discovery of Dichlorodiphenyltrichloroethane (DDT) and the establishment of the WHO was considered a period of optimism (WHO, 1999). This ushered in the DDT era of malariology which involves special campaigns of DDT spraying, chloroquine chemotherapy and active surveillance which led to tremendous success in reducing the incidence of malaria (Van den Berg, 2009). However, resistance to DDT developed as well as concerns about its safety which ultimately led to its abolishment (Van den Berg, 2009). In the following decades, several control strategies were developed outside the health system with no clear guidelines, these strategies coupled with the development of resistance to chloroquine were largely unsuccessful (Borrmann, 2002; WHO, 1999). However, vital lessons about the importance of a supportive health system in control strategies were learnt (WHO, 1999).
By the year 1998, the Roll Back Malaria Partnership (RBM) was initiated with the objective of reducing the global malaria burden by half by the year 2010 (WHO, 2001). It is a global framework formed by a partnership between the WHO, United Nations International Children Education Fund (UNICEF), United Nations Developmental Programme (UNDP), World Bank and other development partners (WHO, 2015). It is aimed at harmonizing and mobilizing the fight against malaria in endemic areas through a coordinated global response (WHO, 2015).
In the year 2008, the RBM partnership developed the Global Malaria Action Plan (GMAP) endorsed at the 2008 MDG malaria summit. It was regarded as the single most comprehensive blueprint for malaria control and elimination outlining strategies, goals, costs, and timeline to build on the momentum towards malaria control globally (GMAP, 2008). This strategy has succeeded in achieving its target of stopping the increasing incidence of malaria and beginning its reduction globally by the year 2015 (WHO, 2015).
Despite the fact that the technical strategy for malaria control between 2000 and 2014 was quite successful, malaria continues to be a major public health threat. As a result, a new strategy was formulated by the WHO called the Global Technical Strategy for Malaria 2016-2030 (GTSM) which was adopted by countries that are working towards the reversal and elimination of malaria (WHO, 2015). It aims to reduce the global malaria incidence and mortality by 90% and eliminate malaria from at least 35 countries (WHO, 2015).
Nigeria, as one of the countries with a huge burden of malaria has worked hand in hand with the WHO and other development partners in the development of programs and strategies for malaria prevention and control along the line of the WHO strategic malaria control framework (NMCP, 2014). These include; Roll Back Malaria Initiative (1998), Abuja Declaration and Framework for Action on Roll Back Malaria (2001), Road Map for Malaria Control in Nigeria- Strategic Plan 2009-2013, National Malaria Strategic Plan (NMSP) 2014-2020 (NMSP, 2014; FMH, 2009; African Union [AU], 2007).
The global efforts to prevent malaria have succeeded in preventing 663 million cases since 2001 in Sub-Saharan Africa alone. This success is largely attributed to the use of ITNs which accounted for about 69% of prevented cases through control interventions (WHO, 2017d).
2.4 CURRENT STRATEGIES FOR MALARIA PREVENTION AND CONTROL
2.4.1 VECTOR CONTROL
This remains the principal method to prevent and reduce the transmission of malaria (WHO, 2017e). It consists of Insecticide-treated mosquito nets and indoor residual spray. The WHO recommends the use of Long-lasting insecticide nets (LLINs) as the ideal form of ITNs for preventive public health programs (WHO, 2017e). It recommends that all people at risk of malaria should have access to LLITNs. In an effort to ensure equality in access, the WHO advocates the free distribution of LLITNs coupled with effective behavioural change communication strategies to encourage people to use the nets appropriately and consistently (WHO, 2017e; Ezire et al., 2015). Over, 60 million LLITNs were distributed in Nigeria between 2009 and 2013 as part of the universal LLITNs campaign to protect an estimated 29 million households in Nigeria (NMCP, 2014). However, findings from the 2013 National Demographic and Health Survey (NDHS) have shown that only 36 percent of the households in the country have access to an ITN and only 18 percent of the pregnant women slept under some kinds of mosquito nets the night before the survey. Thus, its poor utilization is a matter of great concern (NMCP, 2014; NPC, 2014).
On the other hand, indoor residual spray is another powerful way of rapidly reducing malaria transmission. It has been found to be effective for 3 to 6 months depending on the nature of surface sprayed and insecticide combination (WHO, 2017e). In order to attain its full potential, at least 85% of structures in the target area need to be covered and there may be the need for multiple sprays (FMH, 2009). However, evidence has shown that only 2 percent of households surveyed by the National Populations Commission in 2013 have been sprayed in the previous 12 months (NPC, 2014). Most of the IRS is carried out by state governments or by organizations supported through government programmes. The rest is carried out by non-governmental organizations (NPC, 2014).
2.4.2 EARLY DIAGNOSIS AND TREATMENT
The principal approaches recommended for malaria cases is early diagnosis (through the use of rapid diagnostic tests and microscopy) and institution of effective anti-malaria combination therapy (Falade et al., 2016). This is aimed at reducing the number of cases progressing to severe malaria, prevent the development of resistant strains to antimalarials and break the chain of transmission (Mahende et al., 2016).
2.4.3 INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY (IPTP)
This refers to the process by which antimalarial medications are given to pregnant women at predefined intervals in an effort to clear a presumed level of malarial parasitaemia in asymptomatic pregnant women (WHO, 2013). The best and most effective medication recommended for IPTs is the single dose antimalarial drug Sulphadoxine-pyrimethamine (SP) (Ezire et al., 2015; FMH, 2014). IPT is given to pregnant women free of charge during antenatal visits at public health facilities and non-governmental organization (NGO) facilities as part of the federal government’s protocol for focused antenatal care. However, only 23 percent of pregnant women received IPT during their last pregnancy in 2013 with a higher proportion of women in urban areas than rural area (NMCP, 2014). This has been associated with higher level of education and wealth quintile among women in urban areas (NPC, 2014).
Evidence has shown that administering SP to pregnant women from early in the second trimester and continued monthly until delivery reduces the incidence of low birth weight by 20% (FMH, 2014; WHO, 2012). It also reduces the incidence of maternal anaemia, miscarriage, stillbirth, preterm delivery and maternal mortality (Kayentao et al, 2013).
Despite the side effects attributable to sulphonamides, SP used in pregnancy for intermittent preventive treatment is generally well tolerated and pose no demonstrable risk to the foetus (Clarke et al., 2008). However, mild side effects such as nausea, vomiting, dizziness and weakness have been reported by some pregnant women especially with the first dose (NMCP, 2014; WHO, 2014). These side effects tend to decrease with subsequent doses (Kayentao et al., 2013).
2.5 BEHAVIOURAL CHANGE THEORIES
Behaviour refers to the range of actions and mannerisms made by individuals in association with their environment as a response to various stimuli or imputes whether internal or external, overt or covert, conscious or unconscious, voluntary or involuntary (Minton and Khale, 2014). The behaviour of an individual, community or population is one of the main determinants of their health outcome. Thus, achieving changes in health related behaviour is an important element of any health related intervention (Davis et al., 2015; National Institute for Health and Clinical Excellence [NICE], 2010). These changes in behaviour might involve reduction or elimination of a harmful behaviour, promotion of a healthier lifestyle or adherence to medical regimens (Young, 2014).
Health related human behaviours such as alcohol consumption, tobacco smoking, dietary behaviours, sexual practices and physical activities play a significant role in many of the principal causes of death (NICE, 2010; WHO, 2008). Evidence has shown that even minor changes in behaviours can have significant effect on population health outcomes (Butts and Ridge, 2013). This makes it vital to understand these behaviours and the factors influencing their occurrence in order to develop and incorporate effective evidence-based health behaviour change interventions and policies for reducing avoidable morbidity and mortality (Davis et al., 2015; Ramsier and Suvan, 2015).
Health related human behaviour is greatly influenced by socio-economic status of the individual or the community and by extension the level of inequality within the society. As a result, policies geared towards economic empowerment and reducing inequality will go a long way in improving health outcome (Wilkinson and Pickett, 2009).
The most dominant theories of health behaviour are the health belief model, the social cognitive theory and the transtheoretical model (Butts and Ridge, 2013). However, most studies on the determinants of ITN use by pregnant women were based on the health belief model which hypothesizes that personal health-related action is largely determined by the existence of adequate motivation or health concern, perceived threats of serious outcome and the belief that the recommended health action will reduce or eliminate the perceived threat (Ankomah et al., 2012).
A proper understanding of health behavioural theories is necessary for this systematic appraisal as it will aid in understanding the actions of pregnant women and the factors or circumstances that have influenced them to act in a particular way (Ankomah et al., 2012; NICE, 2006). This is based on the fact that behaviour is mainly determined by the opportunities and conditions in which individuals are placed (NICE, 2014). This will help policy makers to develop the most appropriate behavioural change interventions that will encourage the utilization of ITNs.
2.6 FACTORS INFLUENCING ITN USE BY PREGNANT WOMEN
Factors that have been identified to influence ITN utilization are numerous but can be broadly categorized into the following; knowledge of the health condition, sociodemographic factors, misconceptions and access.
2.6.1 KNOWLEDGE OF THE HEALTH CONDITION
Several studies have identified the presence of correlation between the level of knowledge about malaria and its preventive measures and the utilization of ITNs among pregnant women across varied socio-demographic groups (Russel et al., 2015; Ankomah et al.,2012; Arogundade et al., 2011). Pregnant women generally receive health education including information on malaria prevention and control during antenatal care visits to health facilities (Amako, 2016). This service is generally provided by doctors, nurses, midwives and other auxiliary staff in English language and the local dialect of the community (Fagbamigbe and Idemudia, 2015)
Arogundade et al., (2011) found that one of the key predictors of ITN use among pregnant women in Nigeria is the knowledge that ITN use prevents malaria. Pregnant women who knew about the specific risks of malaria in pregnancy (such as anaemia, low birth weight, abortion) were more likely to use ITNs than those who did not. This is similar to what was obtained by Russel et al., (2015) and Belay and Deressa, (2008). However, Russel et al., (2015) found that despite knowing that mosquitoes cause malaria, only 2.3% of the respondents knew that malaria could result in spontaneous abortion, stillbirth, prematurity or intrauterine growth restriction.
Further evidence has also shown that education and correct knowledge about malaria, its modes of prevention as well as its fatal consequences were found to be significantly associated with increased use (Arogundade et al., 2011; Deressa et al., 2011). However, Aluko and Oluwatosin (2012) found that despite the relatively high knowledge of malaria by the respondents, the use of ITN is significantly low. This has been attributed to the negative attitudes of the respondents to ITN use, poverty or unavailability.
2.6.2 SOCIO-DEMOGRAPHIC FACTORS
Evidence has shown that the presence of social and emotional support is an important determinant of increased ITN use (Russell et al., 2015; Glanz et al., 2008). Wagbatsoma and Aigbe, (2010) found that most married women use ITN compared to unmarried women. However, small family size is another predictor of increased ITN usage. This finding is similar to findings obtained by Ankomah et al., (2012) where women from monogamous families use ITNs more than polygamous ones implying that a woman who is the only wife to her husband gets the necessary social and financial support from him. In addition, women in middle-class families are more likely to use ITNs (NPC, 2014). However, this is contrary to the findings by Belay and Deressa (2008) where age, marital status, occupation, parity, number of rooms, family size and location of residence did not influence the use of ITNs by pregnant women.
It was also found that women with higher number of previous pregnancies have increased chances of sleeping under an ITN, this has been attributed to the fact that they are likely to have better knowledge about the dangers of malaria and a better chance that they will attend ANC clinics, thus increasing their chances of accessing ITN (Muhumuza et al., 2016; Ankomah et al., 2012).
Belay and Deressa (2008) found that urban residence is a key predictor of increased ITN access and utilization with 76.2% of urban pregnant women using ITNs as against 56.7% of rural women. However, there was no difference between rural and urban areas in terms of perceived symptoms and knowledge about malaria and its preventive measures. This is despite the fact that pregnant women in rural communities are at an increased risk (Ajayi, 2013). This might be related to the fact that urban bias exists in terms of public health expenditure coupled with inadequate financing and provision of incentives to attract health personnel to work in rural areas (Omo-Aghoja et al., 2010). All these have resulted in inequalities in rural-urban health facilities and reduced access to health services (Ajayi, 2013).
2.6.3 ECONOMIC FACTORS
Women from poor socioeconomic background and poor household wealth are less likely to use ITN compared to those from higher socioeconomic class (Ruyange et al., 2016; Auta, 2012). However, Mugisha and Arinaitwe (2003) found that women without formal education and from poor socioeconomic background were more likely to use ITN compared to those from higher socioeconomic class. This may be associated with their perceived vulnerability to malaria or due to targeted public health campaigns and free ITN distribution in Primary and secondary health centres (Auta, 2012). Furthermore, women who are dependent were more likely to sleep under ITNs compared to their counterparts who engage in at least one type of employment (Auta, 2012; Aluko and Oluwatosin, 2012).
People in rural areas are at a disadvantage in terms of employment opportunities with majority engaged in agriculture and other informal means of livelihood (Ekpe et al., 2014). However, women in Nigeria have always been at a disadvantage when it comes to socio-economic activities where men take most of the employment opportunities in the formal sector (Ekpe et al., 2014; NPC, 2014). Only 7% of women are employed in the formal sector with the majority engaged in sales, unskilled services and subsistence agriculture (NPC, 2014; Fapohunda, 2012). This has been attributed to their relative lack of education and training, social and cultural barriers (marriage, childbirth, permission from husband) and gender biased government policies (Fapohunda, 2012). As such, gender equality and socio-economic empowerment of women must be considered in order to design any viable health program (Emmanuel et al., 2016; Ekpe et al., 2014).
2.6.4 EDUCATION
The level of education was found to have variable effects on the utilization of ITNs among pregnant women in several studies (Iwuafor et al., 2016; Ashikeni et al., 2013; Ankomah et al., 2012). Some studies found a good correlation between the possession of higher education and increased use of ITNs (Muhumuza et al., 2016; Ashikeni et al., 2013; Oresanya et al., 2008). Iwuafor et al., (2016) found that although possession of a higher education increases the likelihood of possessing ITN, it was not found to increase utilization.
Belay and Deressa (2008) also found that higher education attainment is the strongest predictor of ITN use by pregnant women. Education generally improves awareness and compliance to therapy. This assertion is also supported by Muhumuza et al., (2016) who found that women with post-primary education were two times more likely to use ITNs compared to lower education levels. This has been attributed to their better knowledge about the dangers of malaria and the need for prevention. This reinforces the importance of girl-child education as a means of women empowerment.
Conversely, Auta (2012) found that women with lower level of education or those without formal education were more likely to use ITNs. On the other hand, Yassin et al., (2010) found no correlation between educational level and ITN use. However, the study did not explore the physical attributes of ITNs in explaining user preferences and their potential influence on consistent use of ITN.
2.6.5 MISCONCEPTIONS
Misconceptions about malaria and its prevention have been some of the important determinants of ITN use among pregnant women (Iwuafor et al., 2016; Ankomah et al., 2012). Women who had misconceptions about the causes and prevention of malaria were less likely to use ITN even though they may have one (Arogundade et al., 2011).
Some of the misconceptions that have been identified to reduce the ownership and utilization of ITN include; perceiving malaria as ordinary fever caused by over-work, sunlight, excessive sex, noise, witchcraft, not resting/sleeping enough, drinking too much alcohol/beer, eating too much palm/groundnut oil, physical contact with a malaria patient, exposure to cold air or drinking contaminated water (Iwuafor et al., 2016; Wagbatsoma, and Aigbe, 2010; Belay and Deressa (2008). Identifying such misconceptions for the purpose of designing appropriate educational interventions could significantly lead to improvement in health-seeking behaviour and preventive practices (Iwuafor et al., 2016; Chirdan et al., 2008). However, the study is limited by the fact that it did not measure the degree of exposure to the social intervention necessary to have a significant influence on ITN use (Chirdan et al., 2008).
Due to the strong correlation between misconceptions and ITN use, there is the need for correcting these misconceptions about malaria and its prevention through health education (Belay and Deressa, 2008).
2.6.6 ACCESS/AVAILABILITY
Evidence from some studies found that the reason for the poor ITN utilization is attributable to difficulty or lack of access to ITN by pregnant women. This is because ITNs are given out at health facilities, some of which are far from the mothers (Muhumuza et al., 2016). Wagbatsoma and Aigbe (2010) found that despite the fact that the respondents have good knowledge about malaria and its prevention, ITNs are simply not available to them.
The health structure of Nigeria is divided into primary (primary health centres), secondary (General hospitals) and tertiary (teaching hospitals, specialist hospitals and research centres) which are managed by local, state and federal governments respectively (Oyedeji and Abimbola, 2014). According to data from the federal ministry of health, 88.1 percent of health centres in Nigeria are primary health centres, 11.7 percent are secondary facilities while only 0.2 percent are tertiary (NMCP, 2014). Sixty-four percent of the population are within 20km of a hospital, however, urban areas are more favoured with 78% of households within 20km of a hospital as opposed to 58% for rural areas. In the same vein, 80% of households in urban areas being within 5km of a PHC as opposed to 66% in rural areas (NMCP, 2014).
It is thus evident that a lot of Nigerians especially those in rural areas do not have access to public health facilities either as a result of the long distance between them or lack of well equipped and manned facilities which affect their utilization of such services. Since malaria prevention services are provided during ANC services in health facilities, a lot of pregnant women will be left out (Teryla et al., 2014).
2.6.7 OTHERS
Singh et al., (2013) found that some reasons given for not using ITNs include discomfort, heat or inconvenience, limited perceived benefit or the preference to use other malaria preventive methods. This is supported by a study conducted by Aluko and Oluwatosin (2012) where more than one-quarter of women who slept under ITNs experience at least one form of discomfort with excessive heat being the major discomfort. This might be attributable to the typical hot weather of Africa and lack of electricity.
2.7 CHAPTER SUMMARY
This chapter has provided an extensive review of the available literature on the factors influencing the utilization of ITNs among pregnant women. It also discussed the historical trend in malaria prevention policies as well as the current strategies for malaria prevention. It also discussed behavioural change theory in relation to ITN us
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