Bednet Use and Malaria Knowledge in Zaria City, Nigeria
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The distribution of insecticide-treated bednets (ITNs) to protect mothers and children from mosquitoes, and, thus, to prevent malaria, is widely accepted as a community health intervention. While this initiative has strong support from the World Health Organization, questions have been raised about recipients’ knowledge of optimal use of bednets and their importance in reducing malaria. Last year, researchers from the University of Michigan and from Ahmadu Bello University-Zaria conducted a preliminary study of knowledge about bednet use and malaria in Zaria City in Kaduna State, Northern Nigeria, to address questions of who has bednets, how people are using them, and whether they have experienced malaria. This project had three primary goals: to improve ITN use, to provide education about malaria prevention, and to strengthen links between public primary schools and primary health care clinics in Zaria City.
Preliminary Research Findings, Summer 2007
Four U-M researchers participated in the project, including Stuart Batterman (Public Health and Engineering), Elisha Renne (Center for Afroamerican and African Studies and Anthropology), Kelly Kirby, a graduate student in Anthropology (with funding from the U-M-GHRT program), and Roopa Akkineni, an undergraduate in cellular/molecular biochemistry and anthropology (with funding from UROP). In June 2007, Professors Renne and Batterman met with Ahmadu Bello University project co-investigators, Mairo Bugaje, a Pediatrics physician, and Rabiu Isah, a Theater Arts lecturer, to discuss the summer research project that was carried out in association with the ABUTH Institute of Child Health-Ban Zazzau. They also met with Alhaji Ismaila Nabara, the headmaster of a primary school to obtain permission to interview students’ mothers and to work with teachers on a malaria education program. In mid-July, household surveys began, which were conducted by Renne, Hassana Yusuf, an experienced research assistant, Binta Haruna, a teacher from a local school, and Ms. Kirby (Inset 1).
When questioned, all women interviewed referred to malaria as zazzabi cizon sauro, literally, “fever of the bite of mosquito.” A majority of the women (69 percent) attributed malaria to mosquito bites, while a minority (27 percent) noted “bad water” as its cause. Of 100 mothers, 65 percent had one or more children with the malaria symptom of fever (zazzabi) during the month prior to the interview (Inset 2).
One of the main findings of the pilot survey was that while 27 percent of the women interviewed owned bednets, only 13 percent were using them at the time of the first interview, a figure that coincides with other studies showing low bednet use in northwestern Nigeria. Several reasons were given for not using nets: nets were torn, lost, given away, the wrong size, dirty and being washed, being used by husband, too hot, or not yet put up. Also, some mothers were using other forms of mosquito control; over 40 percent of rooms had window screens and/or fans, and many women reported using insecticide spray or liquid (41 percent) or coils (25 percent). Of 27 women who owned nets, 19 had obtained them either through special immunization distributions or through antenatal classes at local clinics, while another four women had received them from their husbands, who worked at hospitals/clinics or were associated with the local government. Only four of 27 bednets had been purchased, two by husbands and two by women themselves. While the sample size is small, these findings support results from a study of urban residents of Accra, Ghana, which showed that other expenses took precedence over buying bednets, suggesting that increasing private sector (market) supply of ITN/bednets may not affect ownership in Zaria City. Once the survey was completed, a bednet of an appropriate size was given to mothers, along with mounting materials and instructions on how to put them up. In some cases, Ms. Tanimu and Ms. Haruna showed mothers how to store nets during the day; they also stressed the importance of bednet use by mothers with children under five years and by pregnant women.
Assessment of Bednet Use
A follow-up assessment of bednet use was conducted in mid-August 2007 among 52 mothers (selected on the basis of previous ITN non-use or non-ownership) who had received bednets. Of 39 women who did not own ITNs in July 2007, 72 percent were using the bednets they had received through the project. Reasons for not using them included: could not put up net, wrong size net, using as window curtain because too small, washing net, or waiting for a new bed. As a result of these follow-up interviews, assistance was given in hanging nets and larger king-size nets were exchanged for the family-size nets that were too small. Of six women who had ITNs in July but had not been using them at the time, five were using them at the August visit. These results underscore the importance of adequate instruction, assistance, and follow-up to accompany ITN distribution.
The 2007 pilot study included distribution of booklets on malaria to teachers, a coloring book contest based on the children’s book, Stop Malaria Stop, and presentation of a play on malaria and bednets. Parents were invited to the school performance and several mothers attended, which has important implications for future malaria education and ITN distribution in Zaria City. In Zaria City, married women generally leave their houses only for socially-approved reasons, such as illness of a child or themselves, Islamic education classes, visits to family members for birth and marriage ceremonies or illness, or for work as nurses or teachers. The fact that several mothers were able to attend a school performance indicates that this setting offers an underexploited site for the education of mothers and their children.
Establishing Links with ABUTH Institute of Child Health-Ban Zazzau
Another aspect of the summer 2007 project included data analysis at ABUTH Institute of Child Health-Ban Zazzau. Ms. Kirby and Ms. Akkineni worked closely with the ABUTH Institute staff in data compilation and analysis, an initial step in building capacity for disease monitoring in this clinic. Analysis of patient files of children during January-April 2007 shows that malaria and upper respiratory tract infections (URTIs) are the primary health problems for infants and children under five attending the ABUTH Institute of Child Health-Ban Zazzau clinic, dramatically supporting the importance of improving effective ITN use in Zaria City.
Elisha Renne is Associate Professor of Anthropology at U-M, and with the Center for Afroamerican and African Studies (CAAS). Kelly Kirby is a U-M graduate student in Anthropology, and Roopa Akkineni is a U-M undergraduate student in Cellular/Molecular Biochemistry and Anthropology. In July 2007 the authors traveled to the town of Zaria, in Kaduna State in Northern Nigeria, to conduct a survey on bednet use and the incidence of malaria.