ABSTRACT
Introduction: Malaria poses public health challenge in endemic African countries. Malaria contributes nearly 20% to low birth weight babies in endemic areas, still births and maternal deaths. Pregnant women are more likely to be anaemic and give birth to low birth weight or stillborn babies with malaria infection during pregnancy. Regular use of insecticide treated nets by pregnant women is a vital intervention in the prevention of malaria among pregnant women in endemic areas.
Objective(s): The general objective of this study is to explore the perception and attitude towards insecticide treated nets in the control of malaria amongst pregnant women attending Ante Natal Clinic at Taraba Specialist hospital and Federal Medical center Jalingo.
Methods: Phenomenolgical approach was adopted using Taraba Specialist hospital and Federal Medical center Jalingo as a case study organization in the Taraba state Region. Data was obtained through interviews and documentary review. The interview data was coded using Nvivo software application and analysed using framework analysis. The Health Belief Model was used to interpret the findings of the study.
Findings: Most of the pregnant women have appreciable knowledge of what insecticide treated nets are; knew the purpose and importance as well as how they are used. Almost all the respondents demonstrated good attitude towards insecticide treated nets‘ usage. They view the insecticide treated net as good, better and comfortable and sleeping under it does not affect pregnancy, but rather prevents malaria. Furthermore, most of the respondents perceive that socio-cultural factors do not influence their acceptance and use of insecticide treated net. On the other hand, while health personnel provide pregnant women with the nets and educate them on the importance through public health education, the challenge they face include shortages as a result of government‘s delay in delivering as well as lack of cooperation between health personnel and pregnant women on the appropriate use of the nets.
Conclusions / Recommendations: The findings contradicts findings from earlier studies, which indicated that knowledge of insecticide treated net among pregnant women was still low despite government policy of free supply to vulnerable groups and subsidized nets for other people. The need for health policy makers and health promotion practioners to focus on creating demand for insecticide treated nets and usage through all available health information channels including social marketing is recommended. The design of educational materials and information on intermittent treated nets usage should take account of the perceptions and attitude of community members especially pregnant women to ensure their maximum acceptance and use.
CHAPTER ONE
INTRODUCTION
1.1. Background
Malaria poses a public health challenge in endemic African countries (WHO,2014). Global estimates of malaria indicates at least,3.3 billion people are at risk of being infected with malaria and developing disease, and 1.2 billion are at high risk. The latest global estimates,198 million cases of malaria occurred in 2013 and disease led to 584,000 deaths (WHO,2014).
Global estimates of the malaria disease burden for 2000 indicated that there were at least 300 to 500 million clinical cases annually, of which 90% occurred in Sub-Saharan Africa (Lengeler, 2009). Though with a reduction in clinical cases in 2009, worldwide estimates of the malaria disease burden for 2009 indicated that there were 225 million cases annually (WHO, 2010). Thus, malaria still continues to represent a major public health problem in areas of endemicity. Further reduction was also noticed in 2010, where there were 219 million malaria cases, leading to approximately 660,000 malaria deaths, mostly among African children (WHO, 2010).
Particularly, in malaria endemic African countries, pregnant women are highly vulnerable to malaria infection due to reduced immunity (WHO, 2010). Auta (2012) observed that malaria constitutes a major health problem, with children and pregnant women being the most vulnerable to its morbidity and mortality. According to a United Nations Children‘s Fund (UNICEF) report, pregnant women are more likely to be anaemic and give birth to low birth weight or stillborn babies with malaria infection during pregnancy (UNICEF,2013). The report notes that regular use of Insecticide-Treated Nets (ITNs) by pregnant women is a vital intervention in the prevention of malaria among pregnant women in endemic areas (UNICEF, 2013).
However, the use of ITNs by pregnant women is very low among pregnant women in Nigeria (UNICEF, 2013). According to Multiple Indicator Cluster Surveys (MICS) report, only 33% pregnant women sleeps under ITNs in Nigeria (MICS,2011). Another report shows that although some progress has been made across Sub-Saharan Africa, the percentage of pregnant women sleeping under an ITN remains too low (UNICEF, 2013).
Meanwhile, ITNs have been revealed to be the most cost effective measures in the prevention of malaria (Lengeler, 2004; WHO, 2008). The evidence shows that ITNs usage had reduced malaria mortality by 17% in children (Lengeler 2004). In view of the effectiveness of ITNs, the Roll Back Malaria Partnership (RBM) programme has a target to protect 80% of children and pregnant women at risk for malaria with ITNs by 2023 (Eisele et al., 2009).
Nigeria, has also established policy guidelines for the implementation and scaling-up the use of ITNs in accordance with the Roll Back Malaria Partnership (RBM) programme and has developed a strategic framework to guide its implementation (Nigeria Health Service, 2014). Accordingly, the malaria prevention programme in Nigeria was expected to reduce malaria specific morbidity and mortality by 50% by the year 2010 (Nigeria Health Service, 2014). To achieve the goal, four main strategies are being pursued. These are to (Nigeria Health Service, 2014):
1. Promote multiple prevention which includes promotion of treated bed nets usage; chemoprophylaxis in pregnancy and environmental management;
2. Improve malaria case management at all levels (from household to health facility);
3. Encourage evidence-based research to come up with effective interventions; and
4. Improve partnership with all partners at all levels.
Despite all efforts to combat malaria among pregnant women, the disease has continued to be one of the main causes of morbidity and mortality in Nigeria (WHO, 2010). Malaria in pregnancy has been reported to cause high rate of infant and maternal mortality, low-birth weight, school absenteeism, low productivity in farming and other vocation (Nigeria Health Service, 2014). Therefore, in order to make all these efforts a reality, it is imperative to explore the knowledge, attitude and perception of ITN in the control of malaria amongst pregnant women; and the contributions as well as challenges encountered by health personnel in the promotion of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo.
1.2. Statement of the Problem
Global estimates of malaria disease burden for 2009 indicated that there were 225 million cases annually (WHO, 2010). According to the National Malaria Control Programme (NMCP), malaria accounts for about 32.5% of all OPD attendances, and 48.8% of under five years‘ admission in Nigeria (NMCP, 2009). Malaria infection in pregnancy has been found to be one of the major public health problems with substantial risks for the mother, foetus and neonate (WHO, 2012).
Several studies have shown that there is a huge gap between availability of ITNs and usage, due to unaddressed knowledge, practices, attitudes, perception and beliefs towards ITN usage by pregnant women (Jima et al., 2005; Runsewe-Abiodun et al., 2012, 2013). A WHO (2013) report says that in most malaria endemic countries of Africa, less than 40% of pregnant women sleep under ITNs. This shows that the use of ITNs in pregnancy remains poor in spite of increased health education and awareness campaigns mounted by government agencies (WHO, 2013). It is against this backdrop that the researcher seeks to explore the perception and attitude of ITNs in the control of malaria amongst pregnant women attending antenatal clinic at Taraba Specialist hospital and Federal Medical center Jalingo.
1.3. General Objective
The general objective of this research was to explore the perception and attitude towards ITNs in the control of malaria amongst pregnant women attending antenatal clinic at Taraba Specialist hospital and Federal Medical center Jalingo.
Specific Objectives
The specific objectives of the study were:
1. To assess the knowledge of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo.
2. To explore the attitude of pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo towards ITN.
3. To assess the perception of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo.
4. To explore the influence of socio-cultural factors on ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo.
5. To identify the contribution of health personnel towards the promotion of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo.
6. To identify challenges facing health personnel in the promotion of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo.
1.4 Research Questions
The objectives of the study were achieved by addressing the following questions:
1. What is the knowledge of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo?
2. What is the attitude of pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo towards ITN?
3. What is the perception of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo?
4. How do socio-cultural factors influence ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo?
5. What are the contributions of health personnel toward the promotion of ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo?
6. What are the challenges facing health personnel in promoting ITN amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo?
1.5 Significance of the Study
Although several studies have shown that there is a huge gap between availability of ITNs and usage, due to unaddressed knowledge, practices, attitudes, perception, and beliefs, towards ITN usage by pregnant women (Jima et al., 2005; Runsewe-Abiodun et al., 2012, 2013) no study has been conducted to examine these factors amongst pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo. This study will fill this gap.
This study is very relevant because even as a WHO (2013) report says that in most malaria endemic countries of Africa, less than 40% of pregnant women sleep under ITNs, this fact has not yet been ascertained with respect to pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo.
While it has been established that the use of ITNs in pregnancy remains poor in spite of increased health education and awareness campaigns mounted by government agencies (WHO, 2013) this reality has not been verified with regards to health providers giving education on the usefulness of ITN to pregnant women attending ANC at Taraba Specialist hospital and Federal Medical center Jalingo. This study seeks to establish the contribution and challenges facing health providers in this direction.
The researcher has some background knowledge of the key issues as a health / medical practitioner and was be able to explore the perception and attitude of ITNs in the control of malaria amongst pregnant women attending antenatal clinic at Taraba Specialist hospital and Federal Medical center Jalingo. Thus, the outcome of the study contributes to knowledge and literature in this field.
1.6 Limitations to the Study
The following limiations to the study can be addressed in future research:
The study was conducted to assess the perception as well as attitude towards ITNs usage amongst pregnant women attending antenatal at Taraba Specialist hospital and Federal Medical center Jalingo. Due to the study location, some of the responses expected were not given. This would have been different if the study was done in a rural setting. Another study can be conducted to explore the perceptions and attitude towards ITNs usage amongst pregnant women in a rural area.
The researcher could not go to the pregnant women‘s house(s) to interview them as well as to establish the real ownership and use. They were rather interviewed at the antenatal clinic of the Taraba Specialist hospital and Federal Medical center Jalingo. There might have been information bias as all the respondents said they were using the ITNs: meanwhile, they may not be using them at home. The effective way to confirm whether pregnant women use the ITNs or not, is to conduct the interview(s) at home and physically check if they have fixed them or not.
The overall findings are not generalizable to all health facilities in the La Dadekotopon Municipal area due to the fact that a phenomenology/case study produces data that can not be generalized. This means that,there could be sampling bias. (Creswell, 2007). There is the need to apply quantitative research method and extend the study to cover many ANCs in other hospitals in Taraba state.
1.6 Organization of study
Chapter one presents the background, the problem statement, the significance, the objectives and the research questions of the study. Chapter two presents the literature review and conceptual framework. Here, literature on the quality of ITNs in the control of malaria amongst pregnant women was reviewed, which served as a springboard for the determination of the contextual framework of the research. Chapter three presents the research methodology adopted, including the research design, data collection procedure and development of data collection instruments. Data preparation and thematic analysis procedures are also covered in this chapter. Chapter four presents the data analysis resulting from the interview data. Chapter five is the discussion of findings of the study and how they relate to existing literature. In chapter six the summary, conclusions and recommendations of the study are presented. The chapter also presents the limitations and contributions made to the study of ITNs in the control of malaria amongst pregnant women. Implications for practice and recommendations for future research are also highlighted.
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