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MALARIA PREVENTION PRACTICES AND THE USE OF INSECTICIDE-TREATED NETS: A STUDY IN UNIVERSITY OF CALABAR TEACHING HOSPITAL, CROSS RIVER STATE.
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Malaria has continued to be one of the greatest challenges to the public health systems in sub-Saharan Africa, which has a higher burden on children under five years and pregnant women. The 2022 World Malaria Report states that there were 241 million cases of malaria in the world in 2020, and some 627,000 deaths, a negative trend compared to 2019 partly due to the disruption of malaria services by the COVID-19 pandemic (WHO, 2022). With the world bearing the largest malaria burden, Nigeria has a significant burden of about 27 percent of all malaria cases and 31 percent of all deaths due to malaria every year.
The most evidence-based and cost-effective malaria prevention methods include insecticide-treated nets (ITNs), especially long-lasting insecticidal nets (LLINs). The impact of consistent and proper use of the LLINs can be up to 50 percent reduction in the spread of malaria as well as safeguarding households against the attack of mosquitoes during the peak hours and the related malaria morbidity and mortality, especially among the at-risk groups. Successive rounds of the Nigeria Demographic and Health Survey (NDHS) and the Nigeria Malaria Indicator Survey (NMIS) have followed the pattern in the ownership and use of LLIN, finding their continued disparity between distribution and use.
The Cross River state is a city in the South-South geopolitical region of Nigeria with a tropical rainforest climate that forms the year-round environment that has been conducive to the breeding of the Anopheles mosquitoes and malaria. Although there were extensive ITN distribution interventions such as a mass campaign with the President Malaria Initiative (PMI) of the USAID deploying 2.3 million LLINs in Cross River State, and a novel school-based distribution program that increased use of ITNs to a 80 percent household net ownership in intervention regions (Acosta et al., 2018) sustained ITN use in the state is sub An ITN access and use geospatial analysis of NDHS and NMIS data found that affluent, urbanized households with more educated heads were more inclined to have bed nets in Cross River State, indicating that equity gaps persist (Ekezie et al., 2025).
The National Malaria Elimination Programme (NMEP) in Nigeria has set up targets to achieve universal ITN coverage and utilization and several interventions such as free distribution of LLIN at antenatal care clinics, community-based interventions, and school-based interventions have been initiated in Cross River State. Even with those attempts, however, a 2023 study of the adherence to malaria control guideline within Cross River State health facilities reported that USAID-funded projects reported issues with sustainability when there was no additional funding by the state government counterpart, and that cultural and socioeconomic factors still restricted the use of ITNs (Akpan et al., 2023). There is still a household-level income, education, and local opinions on the prevention of malaria that determine the distribution of nets and the regular use of nets.
1.2 Statement of the Problem
The malaria transmission in Cross River State remains high even after massive distribution interventions of ITNs. There is a critical divide between ITN possession and regular and proper use a phenomenon recorded in various Nigerian states but not well researched in Cross River State specifically. The rationale behind the gap is complex: nets used in mass campaigns can be used in alternative ways (like fishing or crop protection), seemingly net use causes discomfort in humid tropical climates, cultural attitudes that malaria is not caused by mosquito bites, and the lack of knowledge of the proper use of ITNs.
Moreover, the determinants of malaria prevention activities in Cross River State are not limited to the use of ITN to also encompass environmental management, indoor residual spraying, intermittent preventive treatment in pregnancy (IPTp), and health-seeking behaviour with regard to febrile illness. However, no recent in-depth study has determined the entire range of malaria prevention action and the factors in the state of Cross River State especially in the backdrop of the unique geographic, cultural, and socioeconomic landscape of the state. Such evidence gap hinders focused programming and resource allocation. This paper thus seeks to thoroughly evaluate malaria prevention behavior and determinants in the use of ITN in Cross River State.
1.3 Aim of the Study
To assess malaria prevention practices and the use of insecticide-treated nets among households in Cross River State, Nigeria.
Specific Objectives
- To determine the prevalence of ITN ownership and utilization among households in Cross River State.
- To assess knowledge and attitudes toward malaria prevention among household heads and caregivers in the study area.
- To identify sociodemographic and economic factors influencing ITN utilization in Cross River State.
- To evaluate other malaria prevention practices (indoor residual spraying, environmental management, chemoprophylaxis) in the study communities.
- To determine barriers to consistent ITN use among households in Cross River State.
- What is the prevalence of ITN ownership and utilization among households in Cross River State?
- What is the level of knowledge and attitudes toward malaria prevention among the study population?
- What sociodemographic and economic factors influence ITN utilization in the study area?
- What other malaria prevention practices are employed by households in Cross River State?
- What are the barriers to consistent and correct ITN use in the study communities?
1.5 Research Hypotheses
H₀: There is no significant association between household wealth status and ITN utilization in Cross River State.
H₁: There is a significant association between household wealth status and ITN utilization in Cross River State.
H₀: There is no significant association between level of education and malaria prevention practices in the study area.
H₁: There is a significant association between level of education and malaria prevention practices in the study area.
1.6 Scope of the Study
In this study, the researcher will concentrate on households within Cross River State and the three Local Government Areas that in total represent the north (Ogoja), central (Ikom), and southern (Calabar South) senatorial areas within the state so as to guarantee geographic representation among different ecological and socioeconomic conditions. The target population will be the household heads and primary caregivers to children under five and the pregnant women. Variables of interest would be ITN ownership, patterns of usage, malaria transmission and prevention knowledge, socioeconomic status and other malaria prevention practices. The research will be undertaken in the 2024-2025 school year.
1.7 Significance of the Study.
The research has implications on policy and practice in the field of public health at various levels. In the case of the Cross River State Ministry of Health, and the National Malaria Elimination Programme, the findings will give state specific evidence at any particular time to guide the design of the ITN programs, including the strategies to overcome the ownership-use gap. To USAID through the PMI and other international organizations that are involved in investing in malaria control projects in the Cross River State, the study provides essential evidence regarding sustainability of the LLIN programs regardless of mass distribution campaigns. Evidence will help healthcare workers engaged in malaria prevention counselling especially within ANC clinics and community health posts to better their health education messaging. To community leaders and local government officials, the research indicates community specific beliefs and practices that affect malaria prevention so that culturally-appropriate communication interventions can be developed. This study is academically valuable as it contributes to the empirical body of literature on the malaria prevention in South-South Nigeria and offers a paradigm of state-specific malaria prevention evaluation in accordance with the national monitoring and evaluation system in Nigeria.
1.8 Operational Definition of Terms
- Malaria prevention practices: Behaviours and actions undertaken by individuals or households to reduce the risk of malaria infection, including use of ITNs, indoor residual spraying, environmental management, and chemoprophylaxis for pregnant women.
- Insecticide-treated net (ITN): A mosquito net that has been treated with an insecticide recommended by the WHO Pesticide Evaluation Scheme, including long-lasting insecticidal nets (LLINs) that retain insecticidal properties for three or more years.
- ITN utilization: Sleeping under an ITN the previous night, as a standard indicator used by the Nigeria Malaria Indicator Survey and the NDHS to measure ITN use.
- Household: A group of individuals residing in the same dwelling unit, sharing meals and household resources, and recognized as a unit by the community.
- Caregiver: The primary adult responsible for the health and well-being of children under five in the household, typically the mother or female guardian.
References
Acosta, A., Obi, E., Selby, R. A., Ugot, I., Lynch, M., Maire, M., Belay, K., Okechukwu, A., Inyang, U., Kafuko, J., Greer, G., Gerberg, L., Fotheringham, M., Koenker, H., & Kilian, A. (2018). Design, implementation, and evaluation of a school insecticide-treated net distribution program in Cross River State, Nigeria. Global Health: Science and Practice, 6(2), 331-345. https://doi.org/10.9745/GHSP-D-17-00350
Akpan, U., Edet, E., Arogundade, K., Akpanika, C., Ekott, M., Etuk, S., & Udoma, E. (2023). Implementation of the revised national malaria control guidelines: Compliance and challenges in public health facilities in a southern Nigerian state. Public Health Genomics, 25(6), 1-9. https://doi.org/10.1177/11786329231211779
Ekezie, W., Onuoha, E. C., & Nwofor, C. (2025). Mapping of access and usage of insecticide-treated nets in Nigeria. Malaria Journal, 24(1), 89. https://doi.org/10.1186/s12936-025-05457-9
National Malaria Elimination Programme (NMEP). (2021). Nigeria malaria indicator survey 2021: Key indicators. Federal Ministry of Health.
Ukwueze, L. O., Asogwa, N. T., Mbachu, C. O., Ndukwu, G. O., Ezenwaka, U., Onwujekwe, O., & Ezumah, N. (2022). Drivers of long-lasting insecticide-treated net utilisation and parasitaemia among under-five children in 13 states with high malaria burden in Nigeria. PLOS ONE, 17(5), e0268113. https://doi.org/10.1371/journal.pone.0268113
World Health Organization. (2022). World malaria report 2022. WHO Press. https://www.who.int/publications/i/item/9789240064898