1.1 BACKGROUND OF THE STUDY
Disease control and prevention are an important component of health security. A growing body of evidence shows globally those ambitious health goals such as the health related Millennium Development Goals (MDGs) cannot be achieved without greater attention to and more effective investment in health systems. A handful of disease-specific interventions are being financed through various global health initiatives (GHIs). These unprecedented investments have undoubtedly yielded returns in terms of improved specific health outcomes for AIDS, tuberculosis (TB) and malaria (WHO, 2007).
However, malaria control will not eliminate the mosquito vector, the parasite, or the favorable environmental conditions for transmission in many locations. To keep malaria at bay, countries must maintain high levels of coverage of preventative interventions even in the absence of a large number of cases. Relaxation of control – whether because of the decline in political will, a decrease in funding, or some other reasons – increases the risk of resurgence in transmission and of epidemics. The goal of sustained control is to maintain universal coverage with interventions until countries enter the elimination stage. Sustained control will require strong political commitment at country level and a continued focus on the health systems activities started during scale-up (particularly communication and behaviour change efforts and monitoring and evaluation). In addition, maintaining high coverage levels will require effective distribution approaches aimed at strengthening all routine delivery mechanisms and improving integration with other disease programmes where appropriate. Strong inter-programme collaboration, robust procurement and supply chain management systems and accurate forecasting capabilities are pre-requisites. Increased decentralization of decision-making and budgeting will facilitate strengthened community participation in the delivery of interventions (Oyeyemi, Alawode and Sogunro, 2010).
Malaria is an infectious disease caused by Plasmodium parasite. The four identified species of this parasite causing human malaria are Plasmodium falciparum, P. vivax, P. ovale and P. malariae. In Nigeria, 98% of all cases of malaria are due to P. falciparum. This is the species that is responsible for the severe form of the disease that leads to death. It is transmitted from bites of an infected female anopheles mosquitoes to man (Oyeyemi, Alawode and Sogunro, 2010).
Malaria is a disease that is preventable and curable, yet it continues to be responsible for over 60% of outpatient visits and 30% hospital admissions in Nigeria (WHO, 2011). The magnitude of malaria problem is such that it is one of the leading causes of infant mortality and maternal morbidity in African. The morbidity of malaria is such that it affects the productive capacity of adults, and children affected will either not be able to participate actively in class or will not attend school at all. The disease has impacted negatively on the economy with about 132 billion Naira lost to the disease as cost of treatment and loss in man-hours (RBM/WHO, 2000).
Although immunity is developed by individuals over time, an average child or adult still has 2-3 bouts of malaria in one year. This translates to significant loss of household income and productivity man hours and economic loss for any state, region or country. The implication is that malaria is not just a health problem but also a socio-economic and development problem. This explains why it has continued to engage the attention of development partners all over the world, as one of the diseases of interest, in the concerted efforts towards the achievements of several Millennium Development Goals (MDGs), especially MDGs 1, 3, 4 5 – which focus on poverty, universal education, infant and maternal morbidity and mortality (MDG, 2008).
After years of unco-ordinated and insufficient responses to this global health threat, the Roll Back Malaria Partnership (RBM) was formed in 1998 to align global health and development advocates, raise malaria on political and development agendas and unite key stakeholders behind an ambitious but achievable strategy to end malaria worldwide. RBM is a global partnership founded by the World Health Organization (WHO), the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF) and the World Bank with the goal of halving the world’s malaria burden by 2010 – estimated to be greater than 300 million acute illnesses and 1 million deaths per year (WHO, 2008).
The RBM partnership includes national governments, civil society and non-governmental organizations, research institutions, professional associations, UN and development agencies, development banks, the private sector and the media. The strength of RBM is the diverse strengths and expertise of its many partners. RBM was founded in response to a growing concern by governments, particularly in Africa, about the continuing and increasing burden of disease and death due to malaria. RBM is being built on the shoulders of recent successful efforts in malaria-affected countries and regions to improve and support capacity to scale up action against malaria. The RBM partnership supports efforts to tackle malaria wherever it occurs. However 90% of the malaria burden is in Africa, south of the Sahara (RBM/WHO 2002). In addition, almost everywhere that malaria occurs, but particularly in Africa, the burden of disease and death falls mainly on two vulnerable groups: young children and pregnant women. As a result, the focus of RBM and its greatest challenges are in reducing the burden of malaria in these two vulnerable groups in the African region.
Sustained country leadership and commitment are essential in overcoming malaria. The Roll Back Malaria (RBM) partnership has developed the Global Malaria Action Plan (GMAP), first and foremost to support countries. The GMAP provides a global framework for action around which partners can co-ordinate their efforts. Developed through an intensive consultative process, it consolidates the collective input of 30 endemic countries and regions, 65 international institutions and 250 experts from a wide range of fields. The GMAP presents:
- a comprehensive overview of the global malaria landscape,
- an evidence-based approach to deliver effective prevention and treatment to all people at risk, and
- an estimate of the annual funding needs to achieve the goals of the RBM Partnership for 2010, 2015 and beyond. The GMAP is a living document: as approaches and tools evolve to fight malaria, so will the plan.
The GMAP outlines the RBM partnership’s vision for a substantial and sustained reduction in the burden of malaria in the near and mid-term, and the eventual global eradication of malaria in the long term, when new tools make eradication possible. To reach this vision, the targets of the GMAP are to:
- Achieve universal coverage, as recently called for by the UN Secretary-General, for all populations at risk with locally appropriate interventions for prevention and case management by 2010 and sustain universal coverage until local field research suggests that coverage can gradually be targeted to high risk areas and seasons only, without risk of a generalized resurgence;
- Reduce global malaria cases from 2000 levels by 50% in 2010 and by 75% in 2015;
- Reduce global malaria deaths from 2000 levels by 50% in 2010 and to near zero preventable deaths in 2015;
- Eliminate malaria in 8-10 countries by 2015 and afterwards in all countries in the pre-elimination phasetoday; and
- In the long term, eradicate malaria world-wide by reducing the global incidence to zero through progressive elimination in countries (GMAP, 2008).
The RBM partnership’s control strategy aims to reduce malaria morbidity and mortality by reaching universal coverage and strengthening health systems. The GMAP defines two stages of malaria control:
- scaling-up for impact (SUFI) of preventive and therapeutic interventions, and
- sustaining control over time.
In scaling-up for impact, the goal is to rapidly reach universal coverage for all populations at risk with locally appropriate malaria control interventions (i.e. LLINs, IRS, IPTp, drugs and diagnostics), supported by strengthened health systems. Delivery strategies may involve mass campaigns, distribution of interventions through existing public- and private-sector outlets, and by community health workers, for example. Strengthening health systems, including capacity building, for malaria control must begin during scale-up and continue beyond this.
To achieve universal coverage by 2010, core malaria control interventions needed are:
- 730 million LLINs globally (about 350 million for Africa). In Africa, approximately 50 – 100 million nets needed will be distributed in 2008, leaving 250-300 million new LLINs that need to be distributed in 2009 and 2010,
- 172 million households sprayed annually with insecticides,
- 25 million treatment courses of IPTp for pregnant women in Africa,
- 5 billion diagnostic tests (microscopy or RDTs), and
- 228 million treatments of ACTs ( falciparum); 19 million doses of CQ and PQ (P. vivax).
Sustaining control is important to prevent the resurgence of malaria. After core interventions are scaled up, the malaria burden will drop and the need for case management is expected to fall dramatically (GMAP, 2008). RBM in Nigeria builds on the global strategies for malaria control. Multi-pronged and proven to work, these strategies include prompt and effective case management, intermittent preventive treatment (IPT) of malaria in pregnancy and integrated vector management which includes the use of insecticide-treated nets (ITNs), indoor residual spraying and environmental management. Other cross-cutting interventions include advocacy, communications and social mobilization, effective programme management, monitoring and evaluation, and partnerships and collaboration.
In order to minimize socio-economic impact of malaria in the country, the Federal Ministry of Health (FMOH) and Roll Back Malaria (RBM) partners have adopted Scale Up for Impact (SUFI) approach in the revised National Malaria Strategic Plan (NMSP). As part of effort to scale up Long Lasting Insecticidal Net (LLIN) ownership and utilization in the country, the target was to increase LLIN access and utilization in Nigeria. The NMCP and the State Malaria Control Programme at state level, with the support of partners, recently committed to a strategy of universal access for all malaria interventions as the optimal approach to malaria control. This new strategy expands the programmatic focus from children under five and pregnant women to the entire population at risk. This includes ensuring universal coverage with Long Lasting Insecticide Treated Bed-nets (LLINs) across the entire country by the end of 2010 which amounts to the distribution of over sixty million nets within a two year period, a scale-up of a magnitude not witnessed anywhere else in the world (RBM/WHO, 2002).
Over the past two decades, the use of ITNs has been established through multiple randomized trials as an effective and cost-effective malaria control strategy for sub-Saharan Africa (Lengeler, 2004). But access rates with ITNs remain low. Until recently, one of the key challenges to widespread coverage with ITN was the need for regular re-treatment with insecticide every 6 months, a requirement a few households complied with (Alessandro, 2001). This problem was solved recently through a scientific breakthrough: LLINs, whose insecticidal properties last at least as long as the average life of a net (4-5 years), even when the net is used and washed regularly. The prototype LLIN, the Olyset Net, was approved by WHO in 2001, but did not get mass-produced until 2006.
ITNs are a low-cost and highly effective way of reducing the incidence of malaria in people who sleep under them, and they have been conclusively shown in a series of trials to substantially reduce child mortality in malaria-endemic areas. By preventing malaria, ITNs reduce the need for treatment and the pressure on health services, which is particularly important in view of the increase in drug resistant falciparum malaria parasites. It is often considered that one of the main drawbacks of ITNs is the low re-treatment rate, however, with the LLINs, the issue of net re-treatment may be resolved as long as the price is not prohibitively increased by the specific treatment (Kolaczinski, 2010).
1.2 STATEMENT OF THE PROBLEM
Ultimately it has been recognised that in order to reduce the burden of malaria disease, everyone should sleep under a LLIN. In April 2000, RBM and African Heads of states established the “Abuja targets,” which includes LLIN use by at least 60% and above of pregnant women and under-fives in Africa by 2005. However, a few countries have met this target, and ownership of LLINs among pregnant women in Africa is currently only 3 percent, with rates in Nigeria reflecting this regional figure.
Achieving the Abuja targets has not been easy, and the logistical challenges have received most attention to date. What has now become apparent is that universal access effort today will not lead to achievement of the Millennium Development Goals of reduced malaria morbidity and mortality unless there are:
- provision of nets through routine services to ‘keep-up’ coverage into the future and, more importantly, and
- insurance that people who receive the nets actually sleep under them on a regular basis.
The determination of distribution mechanisms that will assure high coverage with the LLINs remains a topical issue in Nigeria and in many sub-Saharan African countries. The public health care system was initially used to distribute LLINs in Nigeria, but the coverage was quite low. Currently, commercial sector distribution and social marketing of LLINs is being promoted in some states in Nigeria, but the coverage remains low.
It should be said that the first priority of a LLIN programme is to get adequate numbers of nets out to households. Analysis of data from 15 country Demographic and Health Surveys showed that among LLIN-owning households, intra-household access to LLINs (the ratio of household members per LLIN) was the strongest and most consistent household factor associated with LLIN use among children (Elsele et al, 2009). Recent efforts promoting the use of LLIN have shifted their emphasis from a focus on vulnerable populations to a broader objective of universal coverage, defined as the household level of the use of insecticide-treated nets by all household members regardless of age or gender. There is an emerging consensus that a ratio of at least one LLIN for every two household members is typically sufficient to achieve universal coverage in a population (WHO, 2007). Simply put, if there are not enough nets in a household, use by vulnerable populations will be jeopardized.
Besides access, use of LLIN is another factor. The use of LLIN may not be significant in households because of habit. In order words, behavioural change becomes the issue. This may be dependent on lack of belief of the messages being spread in favour of use of LLIN. Apathy to government programmes may be a hinderance to use of LLIN. Fear of side-effects might also limit use of LLIN by households, just like sleeping arrangements inside the home. Other factors that can possibly limit the use of LLIN are nets in non-bed sites interfering with daily activities, perceived absence of mosquitoes limits use of LLIN among households, and lack of perceived net effectiveness. The extent of use and factors militating against the use of LLIN need, therefore, to be investigated.
1.3 OBJECTIVES OF THE STUDY
The purpose of the study is to ascertain access and use of LLIN among households in Enugu East Local Government Area (EELGA) of Enugu State, Nigeria. The specific objectives of the study are to:
- Ascertain the access to LLIN among households in EELGA.
- Ascertain the use of LLIN among households in EELGA.
- Ascertain the effects of behavioural change on the use of LLIN among households in EELGA.
1.4 RESEARCH QUESTIONS
- How significant is the access to LLIN among households in EELGA?
- How significant is the use of LLIN among households in EELGA?
- How does behavioural change affect the use of LLIN among households in EELGA?
1.5 RESEARCH HYPOTHESIS
H01: There is no significant access to LLIN among households in EELGA.
H02: The use of LLIN is not significant among households in EELGA.
H03: Behavioural change has no significant effect on the use of LLIN among households in EELGA.
1.6 SIGNIFICANCE OF THE STUDY
The study will primarily be of immense benefit to households, as it will sensitize them on the use of LLINs to prevent and control malaria. It will equally benefit the government, NGOs, agencies and all stakeholders involved in disease control and prevention to know the level of coverage and use of LLINs among households, especially those in rural communities. As a country, the study will also help appraise efforts made in the fight against malaria, to help in economic development planning.
1.7 SCOPE AND DELIMITATIONS OF THE STUDY
This research work focuses on households in Enugu East Local Government Area (LGA) of Enugu State. Enugu East LGA of Enugu State is one of the seventeen (17) LGAs in Enugu State. The districts that make up the LGA are Mbulujodo, Mbulu Oweghe, Mbulu Iyiukwu, Emene and Trans Ekulu. There are 24 communities in EELGA.
LLINs are said to have been distributed in the LGA by various health programmes. The study covers the access and use of LLINs among households. The limitation of the study is that its findings cannot be generalized for Enugu State, let alone, Nigeria. The study would need to be replicated in other locations to enable generalisation of findings.