Utilization and Effects of Long-Lasting Insecticide Treated Nets on Malaria Prevention Among Pregnant Women in Ondo State, Nigeria

Introduction: Malaria is a public health threat especially in the endemic regions including Nigeria. The Long-Lasting Insecticide Treated Nets (LLINs) is a crucial tool used for malaria prevention, particularly for pregnant women. The adoption of LLINs is central to reducing malaria-related morbidity and mortality especially among the vulnerable groups. This study was conducted to determine knowledge and utilization of LLINs among pregnant women in Ondo State, Nigeria.

Methodology: A descriptive cross-sectional study was conducted among pregnant women attending selected antenatal clinics women in Ondo State, Nigeria. A sample size of 290 was derived using a formula to calculate it. Multistage sampling technique was used to select respondents in the study location. Experts validated instruments, which were divided into five sections, were used for collection of data. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 25.0 and the results were presented using descriptive statistics. Hypotheses were tested between level of education and knowledge as well as between ethnicity and utilization of LLINs.

Results: Findings revealed high knowledge (96.6%) of LLINs. Utilization rate of LLINs was (74.8%) but 42.8% of the respondents reported facing challenges such as discomfort or heat while income was a key determinant in positive utilization outcomes. Chi-square analysis showed significant associations between ethnicity and utilization (χ²= 14.819; p = 0.002. However, no significant relationship was found between education and knowledge (χ²= 0.422; p = 0.810); and between parity and impact of LLINs on malaria (χ²= 6.862; p = 0.231).

Conclusion and Recommendations: The knowledge of LLINs among the respondents was high but its utilization remains a challenge due to discomfort and financial constraints. It is recommended that public health campaigns should be organized to further emphasize the benefits of LLINs and government intervention to address the barriers to their regular use.

The term "malaria" is derived from the Italian words “mal” and “aria,” meaning “bad air,”. Malaria was once thought to be caused by swamp fumes (Talisuna, et al., 2004). Thousands of years ago, malaria afflicted the human populations and still is. The evidence of the presence of malaria has been found in ancient civilizations such as those of Egypt, Greece, and China (Mharakurwa, 2020). Malaria is a major public health challenge, particularly affecting people especially pregnant women in sub-Saharan Africa. It also affects the vulnerable groups due to low immunity which increases the risk of anemia, weight and mortality. The understanding of the cause of malaria has advanced significantly with the discovery of the Plasmodium(P) parasite by Charles Louis Alphonse Laveran in 1880, and Sir Ronald Ross in 1897 identifying mosquitoes as the vectors. This has laid the foundation for modern malaria control and prevention efforts (Lozano-Fuentes et al., 2020). Over the years, the Long-Lasting Insecticide Nets (LLINs) have emerged as a critical intervention in reducing malaria transmission and preventing adverse pregnancy outcomes (Tiono et al., 2021). 

Approximately 249 million cases of malaria occurred globally in 85 malaria endemic countries and areas (including the territory of French Guiana), an increase of 5 million cases compared with 2021 (WHO, 2023). The main countries contributing to the increase were Pakistan (+2.1 million), Ethiopia (+1.3 million), Nigeria (+1.3 million), Uganda (+597 000) and Papua New Guinea (+423 000) with an estimated 608,000 deaths (WHO, 2023). According to the World Health Organization (WHO, 2022), the South-East Asia accounted for about 2% of malaria cases globally with, India accounted for 66% of cases in the region. The Eastern Mediterranean region, malaria cases decreased by 38%, from about 7 million cases in 2000 to about 4 million in 2015 while cases rose by 92% to 8.3 million in 2022, and Western Pacific region numbers of malaria cases decreased by 48% in 2021, from 2.6 million cases in 2000 to an estimated 1.4 million cases (WHO, 2023). An increase of 23% was seen between 2021 and 2022, reaching 1.9 million cases, with Papua New Guinea accounted for nearly 90% of all cases in this region (WHO, 2023). 

The WHO (2023) estimates that North and West Africa alone accounts for 40.1% and 39.3% respectively of all malaria cases in sub-Saharan Africa. Although Africa bears the highest burden, several non-African countries, particularly in South-East Asia, Eastern Mediterranean, and Western Pacific region continue to struggle with malaria transmission (WHO, 2023). There were an estimated 229 million cases of malaria and over 400,000 deaths in 2020 with the majority occurring in sub-Saharan Africa (World Malaria Report, 2021). The sub-Saharan Africa accounted for almost 95% (234 million) of all malaria cases and 96% (593,000) of all deaths from the disease (WHO, 2022). 

The Plasmodium(P) species responsible for malaria infections include P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. The P. falciparum is the most prevalent and deadliest species, particularly in Africa, while P. vivax is more common in Southeast Asia and Latin America (Baird, 2021). Malaria typically presents symptoms such as fever, chills, headache, and muscle aches, often resembling flu-like symptoms. The incubation period of malaria varies from 7 to 30 days depending on the Plasmodium species involved. In severe cases, particularly with P. falciparum, the disease can progress to life-threatening complications such as cerebral malaria, severe anemia, and multi-organ failure (Abdulkareem & Imam, 2024). 

Pregnant women are especially vulnerable due to the immunosuppressed state of pregnancy, which also increases the likelihood of adverse birth outcomes, such as low birth weight and preterm delivery (Chua et al., 2021; Iwachukwu & Vicent, 2021). However, maternal under nutrition, including inadequate gestational weight gain can also have direct impacts on the growth and development of the fetus, resulting in babies being born too soon or underweight (Christian et al., 2020). Approximately 30 million pregnancies are at risk of malaria infection each year in Africa, contributing significantly to maternal and neonatal morbidity and mortality. Due to their vulnerability, pregnant women require special attention. The World Health Organization recommends intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), as it significantly reduces the risk of maternal malaria and associated complications (Odoko et al., 2023). Effective management of malaria involves both prevention and treatment. The treatment of uncomplicated malaria involves the use of Artemisinin-based Combination Therapies (ACTs) which are the first-line therapy, particularly for P. falciparum infections. This has shown resistance to older antimalarials such as chloroquine (Okore et al., 2021). In the case of severe malaria, intravenous artesunate is recommended due to its rapid action and effectiveness in reducing mortality (Sutherland et al., 2020). However, challenges such as drug resistance and access to healthcare services continue to hinder effective malaria management in many endemic areas.

According to the National Malaria Elimination Programme (2022), malaria is endemic in all parts of Nigeria, with varying transmission intensities across different regions. The prevalence rates across regions in Nigeria ranges from 7.7% in Lagos to 41.6% in Argungu (Kebbi State), and even higher in some areas (Agomo, et al., 2020). Various strategies have been employed in Nigeria to combat malaria. These strategies include vector control measures, intermittent preventive treatment in pregnancy (IPTp), and the distribution of Long-Lasting Insecticide Treated Nets (LLINs). In the 1980s, the use of Insecticide Treated Nets (ITNs) for malaria prevention began, but the LLINs were developed in the early 2000s and this has significantly improved malaria control efforts. The introduction of LLINs marked a significant advancement in malaria prevention. The LLINs are pre-treated with insecticides which remain effective for up to three years without requiring further treatment (Tungu, 2024). The LLINs provide dual protective effects through a physical barrier and an insecticidal action that targets malaria vectors. It works by both repelling and killing mosquitoes, thus reducing the incidence of malaria transmission (Iyer et al., 2019). Long Lasting Insecticide Treated Nets (LLINs) have been proven to be highly effective in preventing malaria among pregnant women. Studies have shown that Long Lasting Insecticide Treated Nets (LLINs) reduce malaria infections by 50% and decrease the incidence of low birth weight by 23% (Iwachukwu & Vicent, 2021)

The World Health Organization (2021) recommends the use of LLINs, particularly for vulnerable groups such as pregnant women and children under five as a cost-effective, efficient strategy and intervention in the fight against malaria. In Ondo State, between 2020 and 2021, there were nationwide campaigns to distribute LLINs to households, with a specific focus on pregnant women and children under five. This was part of a broader national strategy that saw the distribution of over 200 million LLINs across Nigeria (National Malaria Elimination Programme, 2022). Unfortunately, The NMEP (2021) reported that although 78% of households owned at least one long lasting insecticide treated net, only 45% of pregnant women used the nets regularly, which is below the national average (NMEP, 2021).

A descriptive cross sectional study design was employed to determine the level of knowledge and utilization of LLINs among pregnant women accessing antenatal care services in Ondo State, Nigeria. The sample size for the study was calculated using Cochran’s formula to reach 290 respondents. Multistage sampling technique was used to select 2 out of the 18 LGAs, 3 out of 11 wards and 2 health facilities in each of the 3 wards in the state using simple random sampling. In the selected 6 health facilities, respondents were selected based on their willingness to participate in the study. The instrument for the collection of data was validated by research experts and reliability test conducted through a pilot study analysis. Five research assistants with the researcher collected the data for the study after obtaining ethical approval. The obtained data was entered into an SPSS software package 25.0 and this was coded and analyzed using descriptive statistics. Inferential statistics of Chi-square test were used at a significant level of p lessthan 0.05.

The mean age of the respondents was 32.34±9.1. Majority 271(93.4%) of the respondents had tertiary education and 250(86.2%) are from Yoruba region (Table 1).

Table 1: Sociodemographic Characteristic of the Respondents.

The results on the level of knowledge of use of LLINs among pregnant women revealed mean knowledge score of 4.63±0.75 with 214 (73.8%) having high knowledge equal to or above the mean score and 76 (26.2%) having low knowledge below the mean score (Table 2).

Figure 1: The Mean Score of the Level of Knowledge on LLINs among the respondents.

Furthermore, findings from the study revealed that the mean utilization score was 9.79±3.04. A total of 105 (36.2%) respondents reported poor utilization, scoring below the mean, while 185 (63.8%) of them revealed good utilization, scoring equal to or above the mean.

Figure 2: Mean score of utilization of LLINs among the respondents.

The hypotheses testing using the Chi square test revealed no significant relationship between the education level of pregnant women and their knowledge of LLINs in Ondo State, Nigeria (χ² = 0.422, p = 0.810) – (Table 2).

Table 2: Association Between the Education Level of Pregnant Women and Knowledge of LLINs.

On utilization of LLINs among the respondents, the Chi square test revealed a significant relationship between ethnicity and the utilization rate of LLINs in Ondo State, Nigeria (χ² = 14.819, p = 0.002) – (Table 3).

Table 3: Association Between Ethnicity of Pregnant Women and Utilization Rate of LLINs.

The results of the study which revealed the ages of the respondents as between 27 and 38 years (51.0%) suggests that the study population consisted of women of reproductive age. This aligns with findings from similar study conducted in Lagos, where most pregnant women who attends antenatal care were between the ages of 25 and 35 years (Ademuyiwa et al., 2021). This age range is a critical one that can be employed for targeted health interventions. Most of the respondents had attained tertiary level of education (93.4%). This is consistent with urban studies in Southwest Nigeria, where access to education is relatively high (Odeyemi et al., 2022). However, it is important to consider that this may limit the generalizability of findings to less educated populations in rural areas where LLINs utilization might differ due to lower awareness levels. The findings from the study indicate a high knowledge 214(73.8%), a score above the mean regarding LLINs among the respondents. This is consistent with Pooseesod et al. (2021), who reported that 74% of pregnant women in Ethiopia had accurate knowledge of LLINs usage due to antenatal counseling. However, it contrasts with findings from Ajayi et al. (2021) in Nigeria, where only 60% of pregnant women who owned LLINs knew how to use them correctly. This discrepancy highlights the impact of context-specific health education programs, as robust antenatal care and counseling were emphasized in Ethiopia compared to the limited rural outreach in Nigeria. In terms of frequency of use, there was good utilization 185(63.8%.), a score which was above the mean. This is a positive outcome, yet it contrasts with studies showing lower utilization rates. In a study by Hill et al. (2019) in Uganda, it was revealed that the perception of discomfort, particularly the heat associated with LLINs, contributed to reduced usage among pregnant women. This is consistent with the response of respondents in this study who reported discomfort or heat as a challenge when using LLINs. 

The study concluded that while there is substantial knowledge of LLINs among pregnant women in Ondo State, there is the challenge of common consistent utilization. The inconsistent utilization was due to discomfort, difficulty in setting up, and damaged or worn-out nets. Despite these challenges, LLINs were found to be effective in reducing the prevalence of malaria during pregnancy, supporting their continued use and distribution. The association between age and awareness, as well as ethnicity and utilization, suggests that targeted interventions could enhance LLIN uptake, particularly in specific demographic groups.

Funding

None.

Conflict of interest

None declared.

Ethical approval

UCH/UI Ethical Review Committee.