MOI UNIVERSITY

SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF ENVIRONMENTAL HEALTH

CHALLENGES FACING THE UTILIZATION OF INSECTICIDE TREATED NETS

AMONG MOTHERS OF CHILD BEARING AGE ATTENDING IMMUNIZATION

CLINIC, KERICHO SUB-COUNTY HOSPITAL.

Research report submitted in partial fulfillment of the degree in BSc. Environmental

Health, Moi University.

DATE: 17TH

APRIL, 2014.

i

DECLARATION

I hereby declare that this research is an initiative of my own independent work and that the

information herein has never been submitted in the same form or in different form to this or

any other institution for academic qualification or implementation, except where

acknowledged.

RESEARCHER REG. NO SIGN DATE

KIRUI K. ERNEST EVH/25/10 ...…………. …………

SUPERVISORS

1.) Dr. Simon Mburu (Lecturer Department of Environmental Health, School of

Public Health, Moi University College of Health Sciences)

Sign……………………..

Date…………………….

2.) Dr. J.B. Baliddawa (Senior Lecturer Department of Behavioural Sciences and

Ethics, School of Medicine, Moi University College of Health Sciences)

Sign………………………

Date………………………

ii

DEDICATION

I dedicate this research to my family members for their invaluable material and moral support

throughout the research period. Also to my able lecturers for refining me this far; to be a

researcher.

iii

ACKNOWLEDGEMENT

I would like acknowledge the Almighty God for His care and protection throughout the

research period.

I also acknowledge Moi University School of Public Health, Environmental Health

Department., Mr. T. Obaire, course coordinator, Dr. S. Mburu and Dr. J. Baliddawa my

supervisors, Mr. Toweett (CPHO), and the respondents for their great commitment in all

aspects towards the development of the final research.

iv

TABLE OF CONTENTS

DECLARATION ........................................................................................................................ i

DEDICATION ........................................................................................................................... ii

ACKNOWLEDGEMENT ....................................................................................................... iii

LIST OF FIGURES AND TABLES........................................................................................ vii

ACRONYMS ......................................................................................................................... viii

OPERATIONAL DEFINITIONS ............................................................................................. ix

ABSTRACT ............................................................................................................................... x

CHAPTER ONE .................................................................................................................... 1

1.0 INTRODUCTION AND BACKGROUND INFORMATION ........................................... 1

1.1 STUDY AREA .................................................................................................................... 1

1.2 MALARIA AS A MENACE ............................................................................................... 1

1.3 PROBLEM STATEMENT .................................................................................................. 4

1.4 STUDY JUSTIFICATION .................................................................................................. 5

1.5 RESEARCH QUESTION .................................................................................................... 5

1.6 STUDY OBJECTIVES ........................................................................................................ 5

1.6.1 BROAD OBJECTIVE ...................................................................................................... 5

1.6.2 SPECIFIC OBJECTIVES ................................................................................................. 5

CHAPTER TWO.................................................................................................................... 6

2.0 LITERATURE REVIEW .................................................................................................... 6

CHAPTER THREE .............................................................................................................. 11

3.0 METHODOLOGY ............................................................................................................ 11

3.1 STUDY AREA .................................................................................................................. 11

3.2 STUDY POPULATION .................................................................................................... 11

3.3 TARGET POPULATION .................................................................................................. 11

3.4 STUDY DESIGN............................................................................................................... 11

3.5 SAMPLING CRITERIA .................................................................................................... 11

3.6 ELIGIBILITY CRITERIA................................................................................................. 11

3.6.1 INCLUSION CRITERIA................................................................................................ 11

3.6.2 EXCLUSION CRITERIA .............................................................................................. 11

3.7 SAMPLE SIZE DETERMINATION ................................................................................ 11

3.8 Data collection method ...................................................................................................... 12

3.9 Data analysis and presentation ........................................................................................... 12

v

3.10 Validation ......................................................................................................................... 12

3.11 Ethical consideration ........................................................................................................ 12

3.12 Research feasibility .......................................................................................................... 13

3.13 Study limitations .............................................................................................................. 13

CHAPTER FOUR ................................................................................................................ 14

4.0 FINDINGS ......................................................................................................................... 14

4.1 SOCIO-DEMOGRAPHICS ............................................................................................... 14

4.1.1 Age of the respondents.................................................................................................... 14

4.1.2 Education Level .............................................................................................................. 14

4.1.3 Marital Status .................................................................................................................. 15

4.1.4 Religion ........................................................................................................................... 15

4.1.5 Occupation ...................................................................................................................... 16

4.2 KNOWLEDGE .................................................................................................................. 16

4.2.1 EVER HEARD OF MALARIA...................................................................................... 16

4.2.2 SOURCE OF INFORMATION ...................................................................................... 16

4.2.3 CAUSES OF MALARIA ............................................................................................... 17

4.3 ATTITUDE AND PRACTICE .......................................................................................... 18

4.3.1 PERCEPTION TOWARDS ITN USE ........................................................................... 18

4.3.2 IMPORTANCE OF SLEEPING UNDER AN ITN ....................................................... 18

4.3.3 TREATED NETS SAFE TO SLEEP UNDER ............................................................... 18

4.3.4 MOST PEOPLE SLEEP UNDER ITNS ........................................................................ 18

4.3.5 PEOPLE AT RISK OF MALARIA DURING RAINY SEASON ................................. 19

4.3.6 MOSQUITO NETS OWNERSHIP ................................................................................ 19

4.3.7 TREATED MOSQUITO NETS ..................................................................................... 20

4.3.8 FREQUENCY OF TREATING NETS .......................................................................... 20

4.4 SOCIO-ECONOMIC FACTORS ...................................................................................... 21

4.4.1 ABUSE OF MOSQUITO NETS .................................................................................... 21

4.4.2 OTHER MEANS OF PREVENTING MOSQUITO BITES .......................................... 21

4.4.3 WHERE TO GET A MOSQUITO NET ........................................................................ 22

4.4.4 WHAT HINDERS MOSQUITO NET USE ................................................................... 23

CHAPTER FIVE .................................................................................................................. 24

5.0 DISCUSSION .................................................................................................................... 24

CHAPTER SIX .................................................................................................................... 26

vi

6.0 CONCUSION .................................................................................................................... 26

6.1 RECOMMENDATIONS ................................................................................................... 26

REFERENCES ..................................................................................................................... 27

APPENDICES ...................................................................................................................... 30

APPENDIX I: QUESTIONNAIRE ......................................................................................... 30

APPENDIX II: KERICHO COUNTY MAP ........................................................................... 34

APPENDIX III: RESEARCH BUDGET................................................................................. 35

APPENDIX IV: TIME FRAME .............................................................................................. 36

vii

LIST OF FIGURES AND TABLES

Figure 1: Age of the respondents ............................................................................................. 14

Figure 2: Level of Education ................................................................................................... 14

Figure 3: Marital Status ........................................................................................................... 15

Figure 4: Religion .................................................................................................................... 15

Figure 6: Source of Information .............................................................................................. 16

Figure 7: Causes of malaria ..................................................................................................... 17

Table 1: Level of Education versus the Causes of Malaria ..................................................... 17

Figure 8: Most people sleep under ITNs.................................................................................. 18

Figure 9: People at risk of malaria only during rainy season .................................................. 19

Figure 10: Mosquito net ownership ......................................................................................... 19

Figure 11: Treated mosquito nets ............................................................................................ 20

Figure 12: Frequency of treating nets ...................................................................................... 20

Figure 13: Abuse of nets .......................................................................................................... 21

Figure 14: Apart from mosquito net, what else?...................................................................... 21

Figure 15: Where to get a mosquito net ................................................................................... 22

Figure 16: Occupation versus Where to obtain an ITN ........................................................... 22

Figure 17: Marital status versus Where to obtain an ITN ........................................................ 23

Figure 18: What hinders mosquito net use .............................................................................. 23

LIST OF TABLES

Table 1: Level of Education versus the Causes of Malaria ..................................................... 17

viii

ACRONYMS

ACSD Accelerated Child Survival and Development

ANC Ante-Natal Clinic

BSc. Bachelor of Science

CHW Community Health Worker

CPHO County Public Health Officer

DFID Department for International Development

Dr. Doctor

EPI Expanded Program for Immunization

HRIO Health Records Information Office

IRS Indoor Residual Spraying

ITN Insecticide Treated Net

KDHS Kenya Demographic Health Survey

KNBS Kenya National Bureau of Statistics

LLITN Long lasting insecticide-treated net

MCH Maternal and Child Health

Ms. Microsoft

NGO Non-Governmental Organization

NMS National Malaria Strategy

SPSS Statistical Packages for Social Sciences

SSA Sub-Saharan Africa

UNF United Nations Foundation

UNICEF United Nations Children’s Emergency Fund

URTIs Upper Respiratory Tract Infections

US$ United States Dollar

USAID United States Agency for International Development

VCT Voluntary Counseling and Testing

WHO World Health Organization

ix

OPERATIONAL DEFINITIONS

An insecticide-treated net is a mosquito net that repels disables and/or kills mosquitoes

coming into contact with insecticide on the netting material.

A long lasting insecticide-treated net refers to an insecticide treated net that lasts for five

years without being treated.

x

ABSTRACT

Title: Challenges facing the utilization of insecticide treated nets among mothers of child

bearing age attending Kericho Sub-County Hospital MCH department.

Introduction: Malaria accounts for a large burden of disease in developing countries

especially in sub-Saharan Africa (SSA). Out of 190-330 million global episodes of malaria

each year, SSA accounts for about 90%. Insecticide-treated nets (ITNs) are an effective

intervention against malaria, which is one of the most important causes of child mortality in

Africa.

Problem statement: Malaria continues to be a life-threatening disease with high rates of

morbidity and mortality in Kenya, with close to 70 percent of the population at risk. It comes

first among the top ten diseases in Kericho County.

Objectives: Broad objective: To determine challenges facing utilization of ITNs among

mothers of child bearing age in prevention of malaria in the study area. Specific objectives:

To assess the level of knowledge on utilization of ITNs. To assess the attitude and practices

among mothers on the use of ITNs. To determine the socio-economic factors affecting the

use of ITNs.

Methodology:The study design was a cross-sectional study.Sampling technique was

convenience sampling. The tools used were questionnaire, interview schedule, and record

viewing. Data was analysed by use of SPSS, microsoft excel.

Findings

A proportionate 73% of the respondents were aware of the mosquito bite as the cause of

malaria. 85% of those interviewed owned mosquito nets. Half of the respondents alluded to

nursery beds as a way most people abuse ITNs..

Conclusion and Recommendations.

From the study findings, it was concluded that level of ITN ownership among mothers of

child bearing age in Kericho County was high; however, putting the nets into proper use was

far from reality. Awareness on the cause malaria in Kericho County was high though not all

the respondents knew the cause of malaria. The county government should ensure adequate

supply of ITNs to the government health facilities. The policy implementors should also

increase awareness on the need to put the ITNs into proper use.

1

CHAPTER ONE

1.0 INTRODUCTION AND BACKGROUND INFORMATION

1.1 STUDY AREA

The study was carried out in Kericho Sub-County hospital, in Ainamoi Sub-County, Kericho

County. Kericho County is located in the Rift Valley, it borders the following counties; Nandi

to the North, Uasin Gishu and Baringo to the North East, Nakuru to the East and South East,

Bomet to the South, Nyamira and Homa-Bay to the South West, and Kisumu County to the

West and North West. It has a total population of 752,396 (Kenya National Census, 2009)

and covers an area of 2,479.0 Km2

(KNBS, 2010). Temperatures range from a minimum of

16°C to a maximum of 20°C. The average rainfall ranges between 1,400 mm and 2,000mm

per annum. Kericho County has 122 health facilities: 3 Level-five hospitals, 2 Level-four

hospitals, 9 health centres, 105 dispensaries and 3 VCT centres (Kericho Sub-County

Hospital HRIO, 2013). The county also has a doctor to patient ratio of 1: 15,000, infant

mortality rates of 35/1000 and under five mortality rates of 100/1000. The county’s poverty

level lies at 42.8 % and an age dependency ratioof100:87.The County also has a population

growth rate of 2.4%.

The most prevalent diseases in Kericho county include malaria, skin infections and upper

respiratory tract infections (URTIs), (KDHS, 2009). According to the county’s health

records, malaria comes first among the top ten diseases affecting not only the under-fives but

also the general population.

1.2 MALARIA AS A MENACE

Malaria accounts for a large burden of disease in developing countries especially in sub-

Saharan Africa (SSA) and understanding the most cost effective methods for malaria control

is both an economic and a public health priority. According to the World Health

Organization, an estimated 190-330 million episodes of malaria occur each year globally and

SSA accounts for about 90% of the global burden of malaria. (WHO, 2011).

Insecticide-treated nets (ITNs) are an effective intervention against malaria, which is one of

the most important causes of child mortality in Africa. They have been shown to reduce the

number of childhood deaths by about one-fifth, therefore saving around six lives for every

2

1000 under-five children protected per year in countries of sub-Saharan Africa (Lengeler,

2004).

All mosquito nets act as a physical barrier, preventing access by vector mosquitoes and thus

providing personal protection against malaria to the individual(s) using the nets. Pyrethroid

insecticides, which are used to treat nets, have an excito-repellent effect that adds a chemical

barrier to the physical one, further reducing human–vector contact and increasing the

protective efficacy of the mosquito nets. Most commonly, the insecticide kills the malaria

vectors that come into contact with the ITN. By reducing the vector population in this way,

ITNs, when used by a majority of the target population, provide protection for all people in

the community, including those who do not themselves sleep under nets. A recent study has

shown that relatively modest coverage (around 60%) of all adults and children can achieve

equitable community-wide benefits (Killeen et al., 2007). ITNs thus work in this case as a

vector control intervention for reducing malaria transmission.

ITNs have been delivered to households through the public sector, through the private sector,

and through a mix of public and private sectors. Delivery of long lasting insecticide-treated

nets (LLITNs) through antenatal care services and immunization programs allows advantage

to be taken of existing health services to reach both pregnant mothers and children under the

age of 1 year. Delivery of LLITNs to pregnant mothers through antenatal care is practiced or

planned in many countries and can be done in two ways:

• giving a free or subsidized LLITN (i.e. direct product), or

• giving a voucher or coupon that can be exchanged for an LLITN at a distribution point such

as a commercial outlet.

Mass distribution of free ITNs (catch-up) followed by routinely providing ITNs or subsidized

vouchers for ITNs to pregnant mothers and/or children through public health clinics or

commercial outlets has dramatically increased coverage and usage in the intervention areas

(Gething et al., 2011). Likewise, free mass distribution of ITNs alone or subsidized voucher

programs alone have each successfully increased coverage, usage and equity of distribution

among the intervention areas (Tabala et al., 2009). Despite the dramatic success of these

campaigns to increase both ownership and usage of ITNs, the proportion of ITN users

remains less than that of ITN owners. Recent data show that despite the proportion of

households that own an ITN increased to 65% in one study, the use of ITNs among currently

pregnant mothers the night before the survey in that study was only 23% (De Smet et al.,

2010).

3

Malaria prevention and control activities in Kenya are guided by the National Malaria

Strategy (NMS) and the National Health Sector Strategic Plan 2005-2010. The NMS outlines

malaria control activities based on the epidemiology of malaria in Kenya. The strategy aims

to achieve national and international malaria control targets. With one of its core

interventions adopted in Kenya as Vector control—using ITNs and (IRS) (KDHS, 2009).

An ITN consists of a mosquito net and insecticide, which may be delivered separately or in

combination. When delivered in combination the ITN may be a LLITN, a pre-treated net or

an untreated net that is packaged (bundled) with an insecticide treatment kit. There is,

however, still some confusion over free versus subsidized nets, commercial delivery versus

public delivery, and how best to achieve a balance between ‘quick wins’ today versus

sustaining coverage for tomorrow (Curtis et al., 2006; Lines et al., 2011).

4

1.3 PROBLEM STATEMENT

Malaria continues to be a life-threatening disease with high rates of morbidity and mortality

in Kenya, with close to 70 percent (24million) of the population at risk of infection (Ministry

of Public Health and Sanitation, 2007).

Although malaria affects people of all age groups; tourists and people from non-endemic

zones are more susceptible. However, children under five years of age and pregnant mothers

living in malaria endemic zones are most vulnerable. The human toll that malaria exacts and

the economic and social impacts are devastating: sick children miss school, working days are

lost, and tourism suffers. Malaria becomes a self-perpetuating problem, where the disease

prevents growth of the human and economic capital necessary to bring the disease under

control. Moreover, malaria disproportionately affects the rural poor who can neither afford

insecticide-treated bed nets for prevention nor access appropriate treatment when they fall

sick (KDHS, 2009).

Pregnant mothers also face high risks. There are approximately 1.1 million pregnancies per

year in malaria endemic areas. During pregnancy, malaria can cause miscarriages and

anemia. Each year, an estimated 6,000 pregnant mothers suffer from malaria-associated

anemia, and 4,000 babies are born with low birth weight as a result of maternal anemia.

Economically, it is estimated that 170 million working days in Kenya are lost each year

because of malaria illness (USAID, 2013).

Though there have been concerted efforts by government, non-governmental organizations

(NGOs) and other relevant agencies to distribute free ITNs to pregnant mothers visiting

clinics and children less than five years, there are still high incidences of malaria breakout

and high child mortality rates (Eiselle et al., 2011). Improper use of the nets may be

attributed to a number of factors ranging from economic to cultural, most of which can be

overcome through appropriate intervention mechanisms. Use of mosquito nets as chicken

rearing structure, for instance, is a good demonstration of how most people misuse the ITNs.

Experience has shown that possession and appropriate use of ITNs do not automatically go

hand-in-hand. In the past, insufficient attention has been paid to designing and implementing

locally appropriate communication strategies to accompany ITN distribution, to inform

communities of the importance of ITNs and of how to hang, use and maintain them properly.

As a result, many people who received ITNs did not sleep under them, re-sold them, reduced

their efficacy through inappropriate washing practices, or failed to replace them when they

became damaged or torn.

5

1.4 STUDY JUSTIFICATION

Malaria is acknowledged to be the leading cause of morbidity and mortality, in the countries

of Africa Sub-Sahara and causes great suffering and loss of life, it remains one of the serious

infection diseases in the world killing up to 2.5 million people annually which is easily

prevented through use of ITNs (U.N.F, 2011).

Insecticide-treated nets (ITNs) are an effective intervention against malaria, which is one of

the most important causes of child mortality in Africa. They have been shown to reduce the

number of childhood deaths by about one-fifth, therefore saving around six lives for every

1000 under-five children protected per year in countries of sub-Saharan Africa (Lengeler,

2004).

Despite efficacy of ITNs in malaria control, recent studies carried in Kenya revealed that use

of ITNs among children under five years and expectant mothers is low 5% and 10%

respectively, therefore need to identify factors challenging its efficacy (Wallon et al., 2012).

With malaria coming first among the top ten diseases in Kericho County, there is need to

improve prevention measures and efficacy which include LLITNs.

The findings of this study will therefore be useful in improving the prevention and control

measure against malaria menace by advocating for proper use of ITNs.

1.5 RESEARCH QUESTION

What factors affect the utilization of ITNS among mothers of child bearing age visiting

Kericho Sub-County Hospital?

1.6 STUDY OBJECTIVES

1.6.1 BROAD OBJECTIVE

To determine challenges facing utilization of ITNs among mothers of child bearing age in

prevention of malaria in the study area.

1.6.2 SPECIFIC OBJECTIVES

i. To assess level of knowledge on utilization of ITNs

ii. To assess the attitude and practices among mothers on the use of ITNs

iii. To determine the socio-economic factors affecting the use of ITNs.

6

CHAPTER TWO

2.0 LITERATURE REVIEW

Insecticide-treated nets (ITNs) are an effective intervention against malaria, which is one of

the most important causes of child mortality in Africa. They have been shown to reduce the

number of childhood deaths by about one-fifth, therefore saving around six lives for every

1000 under-five children protected per year in countries of sub-Saharan Africa (Lengeler,

2004). An ITN consists of a mosquito net and insecticide, which may be delivered separately

or in combination. When delivered in combination the ITN may be a long lasting insecticidal

net (LLITN), a pre-treated net or an untreated net that is packaged bundled with an

insecticide treatment kit. There is, however, still some confusion over free versus subsidized

nets, commercial delivery versus public delivery, and how best to achieve a balance between

‘quick wins’ today versus sustaining coverage for tomorrow (Curtis et al., 2006; Lines et al.,

2011).

Two main channels of delivery have been utilized for delivering ITNs through routine health

facilities: routine clinics, such as antenatal clinics (ANC) and the Expanded Programme on

Immunization (EPI), and intervention ‘packages’, such as the UNICEF Accelerated Child

Survival and Development (ACSD) Programme in Africa. Delivery through routine health

facilities has involved either full or partial subsidies to the end user (Curtis et al., 2006).

Although there are now many examples of delivery of free ITNs through ANC and to a lesser

extent EPI in Africa, documented experiences are few (WHO, 2005; Worrall et al., 2005).

Most community-based distribution of ITNs has been through small-scale projects. Such

projects have been implemented in many countries since the 1980s, and most have focused

on a few villages or Sub-Counties (Chavasse et al., 2009). Projects involving community-

based delivery are heterogeneous in structure, some with governmental support, and others

with no governmental input (Dembo Rath and Hill, 2008). Some projects have delivered

ITNs to the community free of charge but most have involved partial subsidies, the small

charge to the end user often providing some level of incentive to the community-based

volunteer or sales agent.

There has been a noticeable increase in international funding for malaria control in the past

decade. This increased financing has led to tremendous progress in increasing access to ITNs.

It is reported that by the end of 2010, approximately 289 million ITNs were delivered to sub-

7

Saharan Africa, about enough to cover 76% of the 765 million persons that are at risk of

malaria.

It is estimated that 42% of households in Africa owned at least one ITN in mid-2010, and that

35% of children slept under it (Binka et al., 2001). The percentage of children using ITNs is

still below the World Health Assembly target of 80% partly because up to the end of 2009,

ITN ownership remained low in some of the largest African countries.

Occupational status of the household head and family size are among the factors affecting the

ownership of ITN in studies. Similar findings have been documented in other studies. In one

study in Ethiopia, government employees and self-employed traders were less likely to own a

net (Allan et al., 2006). , family size was associated with the possession of net. Similarly in

Tanzania a unit increase in family size increased the odds of ownership of a net more than

twice while controlling for all other variables, where for households who had at least one

under-five child the odds of owning any net was about 60% higher than those with no under-

five children . In another study, mothers’ and head of household’s education, head of

household’s occupation, marital status, household size, household wealth, living in rural

areas, and expenditure on other malaria prevention products and practices were found to be

associated with ITN ownership(Murray et al., 2012).

Several studies suggest that perceived malaria risk and malaria knowledge are important

determinants of bed net ownership and use (Killen et al., 2009). For instance, knowledge of

malaria amongst mothers of under-five children was associated with ITN use for their

children. Factors significantly associated with ITN use were mothers’ knowledge of ITNs and

mothers’ lack of problem in using ITNs (Belay et al., 2008)

Previous studies have shown the effectiveness of public awareness raising campaigns and

free distribution of mosquito nets to encourage people to use them. However, no long-term

assessment of their utilization had hitherto been conducted.

The 2004 Cochrane review discussing the impact of ITNs on under-5 mortality appears to

advocate primarily for coverage of children under five and as of 2006 this seemed to be the

focus of the Roll Back Malaria Partnership, the United Nations Millennium Development

Goals. However, in 2007 the World Health Organization issued a recommendation for

universal coverage that appears to have been an explicit change in position (Gamble,

Ekwaru, and Kuile, 2008)

8

ITNs are distributed free of charge to all age groups in 38 countries within the African region

and a majority of the remaining countries have mechanisms to sell ITNs at subsidized prices

(WHO, 2011). While mass, free ITN distribution campaigns and subsidized voucher

programs for ITNs targeting pregnant mothers and children <5 years have been successful at

increasing the proportion of households that own and use an ITN , ITN use among currently

pregnant mothers in many intervention areas remains low(Grabowsky and Selanikio, 2007).

A recent synthesis of coverage data estimates that 23 million pregnancies in sub-Saharan

Africa were unprotected by ITNs in 2007.

Mass distribution of free ITNs (catch-up) followed by routinely providing ITNs or subsidized

vouchers for ITNs to pregnant mothers and/or children through public health clinics or

commercial outlets has dramatically increased coverage and usage in the intervention areas

(Gething et al., 2011). Likewise, free mass distribution of ITNs alone or subsidized voucher

programs alone have each successfully increased coverage, usage and equity of distribution

among the intervention areas (Tabala et al., 2009). Despite the dramatic success of these

campaigns to increase both ownership and usage of ITNs, the proportion of ITN users

remains less than that of ITN owners. Recent data show that despite the proportion of

households that own an ITN increased to 65% in one study, the use of ITNs among currently

pregnant mothers the night before the survey in that study was only 23% (De Smet et al.,

2010).

According to the findings of a research by department of pediatrics Olabsi Ohabanjo

University, Nigeria on levels of awareness and knowledge about ITNs amongst pregnant

mothers, 82% of those with tertiary education were aware of ITNs importance in malaria

control. It also found that pregnant mothers were more likely to be influenced to use ITNs by

an advertisement on radio/poster than being given free of charge without any prior awareness.

The research recommended that target groups in Nigeria should be continually sensitized

through radio and community participation to ensure acceptance and utilization of ITNs.

(Van Bortel, 2006).

Inadequate or complete lack of knowledge regarding malaria transmission and prevention

presents a major barrier against the use of ITNs (Malaria Journal, 2005).

In institutions of higher learning and awareness, for example, high level of formal education

e.g. through media and posters has been attributed to high use of ITNs (Jorge et al., 2009).

9

Knowledge of people’s perceptions of malaria and of the socio-economic implications of the

disease is of considerable value when control programmes are being planned and

implemented. Health education appears to be improving malaria-specific knowledge, which

in turn is reportedly having some positive impact on ITN ownership at the household level.

(Kudom and Mensah, 2010)

Despite reasonable knowledge on malaria and its preventive measures, there is a need to

improve availability of information through proper community channels. Special attention

should be given to illiterate community members. High acceptance of high level of bed net

ownership should take as an advantage to improve malaria control (Vundule, 1996).

Several social and cultural factors influence the acceptance of use of ITNs. Rumors and

myths have fuelled the negative attitudes and limited use of ITNs. Concerns have been raised

on the insecticides which are thought to be toxic family planning aid. In some communities

mixing of ITNs during net retreatment violate cultural taboos. Certain people have claimed

that ITNs may even cause suffocation while others in hot regions avoid their use due to high

temperatures (Okonofua and Snow, 2010).

Provision of ITNs to pregnant mothers and children below five years has not resulted to their

maximum use. According to Kenya Malaria Indicator Survey, ITNs have been diverted to

other unintended uses. Communities along the coast and around the lake have used them as

fishing nets. They have also been used to fence around kitchen gardens to keep off animals as

well as making cages for chickens. ITNs have also been used in houses as curtains and as

material cloths in the making of wedding gowns. The stated diversions of ITNs use have

complicated efforts in control and prevention of malaria (Alail et al., 2003).

The vast majority of malaria deaths occur in Africa, where malaria also presents major

obstacles to social and economic development. Malaria has been estimated to cost Africa

more than US$ 12 billion every year in lost Gross Domestic Product, even though it could be

controlled for a fraction of that sum (WHO, 2000).

The poor housing conditions due to low economic status promote mosquito bites and hence

increase chances of contracting malaria. This led DFID to begin its social marketing of ITNs

programmes in Kenya in 2002 with a budget of 17.8 million. Its goals was to contribute to

reduction in under five and maternal mortality rates in Kenya and thus the achievements of

millennium development goals (MDGs) by increasing the ITNs use (DFID, 2005)

10

In some African countries where ITNs are sold at subsidized prices, certain members of the

public cite high cost as the reason for not using them (Okonofua and Snow, 2010).

The gap in any net ownership between the employed and the unemployed in Kenya is more

than 26% in favor of the employed. This gap narrows to about 15% in LLITN ownership.

There is no gap between employed and unemployed pregnant mothers when it comes to

LLITN use, whereas a gap of more than 15 per cent exists in any net usage in this population

group. Among children less than five years of age, the gap in the use of any net is more than

20 per cent and the gap in LLITN use is about 15 per cent. While inequities in any net and

LLITN use among children less than five years and pregnant mothers are acknowledged, this

gap is significantly reduced for LLITN use. The reduction mainly results from the free

distribution of LLITNs to children less than five years of age and pregnant mothers. (NMS,

2009)

11

CHAPTER THREE

3.0 METHODOLOGY

3.1 STUDY AREA

The study was carried out in Kericho Sub-County hospital, in Ainamoi Sub-County, Kericho

County, Kericho Municipality.

3.2 STUDY POPULATION

The target population was all mothers of child bearing age in MCH department, Kericho Sub-

County Hospital, Kericho Municipality.

3.3 TARGET POPULATION

Mothers of child bearing age attending post-natal clinic, MCH department.

3.4 STUDY DESIGN

Descriptive cross-sectional study.

3.5 SAMPLING CRITERIA

Convenience –Kericho Sub-County Hospital, Kericho municipality since it was the

attachment station. Mothers meeting the eligibility criteria were interviewed randomly

until a convenient sample size was achieved.

3.6 ELIGIBILITY CRITERIA

3.6.1 INCLUSION CRITERIA

All mothers of child bearing age (aged 18-49 years), visiting Kericho Sub-County Hospital

post-natal clinic and willing to be interviewed.

3.6.2 EXCLUSION CRITERIA

All mothers below 18 and above 49 years, visitors and those not willing to be interviewed.

3.7 SAMPLE SIZE DETERMINATION

The researcher used fisher et al method of 1998 to determine sample size since the study had

less than 10,000 respondents. The following formula was used:-

n = Z2pq

d2

When n = desired sampling size > 10,000

Z = Standard normal (95% df) is 1.96

P = population

12

q = 1 – p

d = degree of accuracy at 0.05 for 95% df

p = proportion of target population estimated at 0.50 confidence level

n = 1.962 x 0.5 x 0.5 = 384 rounded off to 400

0.052

nf = n

1+ (n/N)

n = 400 (constant for populations less than 10,000)

N = total population

nf = 400

1 + (400)

150 =108.

However, due to logistics and duration for this study, only 60 respondents were interviewed.

3.8 Data collection method

Data was collected by use of a structured questionnaire and interviewer schedules.

3.9 Data analysis and presentation

Raw data was cleaned before being entered in the computer for tallying.

Data analysis was executed by use of two statistical soft wares; SPSS for cross-tabulations,

Ms. Excel for summaries into percentages and frequencies then generate figures, charts,

tables and graphs for presentation.

3.10 Validation

Pre-testing of the data collection tool was carried out on a population with similar

characteristics but in a different locality.

3.11 Ethical consideration

Topic was approved by Moi University; School of Public Health.

Consent was also sought from all the relevant offices within the study area through

the office of CPHO.

Verbal consent was sought from the respondents before the interview.

The respondents were assured that research was basically for academic purpose and any

information given was strictly confidential and their names were not required.

13

3.12 Research feasibility

Free ITNs are issued to expectant mothers and children under five years at the MCH clinic,

besides malaria being the top disease in Kericho County, therefore forms a basis to conduct a

research.

3.13 Study limitations

Respondents’ unwilling to give the information slowed down the data collection

process.

Insufficient duration and funds for the study.

14

CHAPTER FOUR

4.0 FINDINGS

4.1 SOCIO-DEMOGRAPHICS

4.1.1 Age of the respondents

Figure 1: Age of the respondents

Majority of the respondents represented by 62.5% were aged between 18 and 27 years with

none of the respondents aged above 48 years.

4.1.2 Education Level

Figure 2: Level of Education

Slightly more than half the respondents, (55%), had attained secondary level of education,

25% with primary level and the least (20%) with tertiary level of education. All the

respondents had at least primary level of education.

62.5

25

12.5

0 0

10

20

30

40

50

60

70

18-27 28-37 38-47 48 and above

Pe

rce

nta

ge

Age

Primary 25%

Secondary 55%

Tertiary 20%

15

4.1.3 Marital Status

Figure 3: Marital Status

Half of the respondents, (50%), were married, 32% were single and the rest were widowed,

separated and divorced represented by 10%, 5% and 3% respectively.

4.1.4 Religion

Figure 4: Religion

As illustrated in the pie chart above, almost all the respondents (95%) were Christians, with

only 5% being Muslims.

32%

50%

5% 10% 3%

Single

Married

Separated

Widowed

Divorced

95%

5%

Christian

Muslim

16

4.1.5 Occupation

Figure 5: Occupation

The above graph shows that cumulatively, 80% of the respondents were non-salaried while

only 20% were depended on salaried employment.

4.2 KNOWLEDGE

4.2.1 EVER HEARD OF MALARIA

All the respondents (100%) said they had heard about malaria.

4.2.2 SOURCE OF INFORMATION

Figure 6: Source of Information

As illustrated above, 70% of the respondents heard about malaria at the health facility with a

proportionately 5% obtaining the information from friends and 5% from CHWs.

20

45

35

0

10

20

30

40

50

Employed Self-employed Not employed

Per

cen

tage

Occupation

0

10

20

30

40

50

60

70

12.5 5

70

5 7.5 Per

cen

tage

Source of information on malaria

17

4.2.3 CAUSES OF MALARIA

Figure 7: Causes of malaria

From the pie chart above, only 73% of the respondents knew precisely the cause of malaria to

be the mosquito bite while the rest attributed the cause of malaria to being rained on (15%),

drinking dirty water (5%), consumption of fatty foods (5%) and witchcraft (2%).

Table 1: Level of Education versus the Causes of Malaria

The causes of malaria

Mosquito bite Others Total Odds Ratio

Education

Level

Primary 4 11 15 11/15*100=73%

Post- Primary 41 4 45 4/45*100=8.9%

Total 45 15 60 OR= 73: 8.9

Relative Risk= 73/8.9 = 8.2

The cross tabulation table above shows that 73% of those with primary education and below

do not know the cause of malaria whereas only 8.9% of those with post-primary education

are not aware of the cause of malaria. The odds ratio indicates that the respondents with

primary level of education are 8 times more likely not to be aware of the cause of malaria as

compared to those with a higher level of education.

Witchcraft

2%

Mosquito bite

73%

Being rained

on

15%

Eating fatty

foods

5%

Drinking dirty

water

5%

18

4.3 ATTITUDE AND PRACTICE

4.3.1 PERCEPTION TOWARDS ITN USE

All the respondents who owned the nets said they were very comfortable using them.

4.3.2 IMPORTANCE OF SLEEPING UNDER AN ITN

All the respondents (100%) agreed that it was extremely important for young children to

sleep under an insecticide treated net.

4.3.3 TREATED NETS SAFE TO SLEEP UNDER

All the respondents (100%) strongly agreed that treated nets are safe to sleep under at all

times.

4.3.4 MOST PEOPLE SLEEP UNDER ITNS

Figure 8: Most people sleep under ITNs

Majority of the respondents (72%) strongly agreed that most people slept under ITNs every

night in the area of study, 23% agreed while 5% disagreed.

Strongly

agree

72%

Agree

23%

Disagree

5%

19

4.3.5 PEOPLE AT RISK OF MALARIA DURING RAINY SEASON

Figure 9: People at risk of malaria only during rainy season

As illustrated above, majority of the respondents represented by 73% agreed that people are

at risk of contracting malaria only during rainy season, 15% disagreed while 12% strongly

agreed that people risk contracting malaria only during the rainy season.

4.3.6 MOSQUITO NETS OWNERSHIP

Figure 10: Mosquito net ownership

Majority of the respondents (85%) had mosquito nets in their homes, only 15% had no nets.

Strongly

agree

12%

Agree

73%

Disagree

15%

Yes

85%

No

15%

20

4.3.7 TREATED MOSQUITO NETS

Figure 11: Treated mosquito nets

Of those who had mosquito nets, 88% had their nets treated whereas 12% did not know

whether their nets had been treated.

4.3.8 FREQUENCY OF TREATING NETS

Figure 12: Frequency of treating nets

Majority of the respondents (75%) had long lasting treated nets issued at the government

health facilities.

Yes

88%

No

0%

Don't

know

12%

Long

lasting

75%

Not

applicable

25%

21

4.4 SOCIO-ECONOMIC FACTORS

4.4.1 ABUSE OF MOSQUITO NETS

Figure 13: Abuse of nets

Out of the 60 respondents, half (30) alluded to nursery beds as the way most people abuse

ITNs, 26 mentioned the abuse of ITNs as poultry sheds, and others for beautifying houses,

tethering and selling to get income represented by 10, 3 and 2 respondents respectively.

4.4.2 OTHER MEANS OF PREVENTING MOSQUITO BITES

Figure 14: Apart from mosquito net, what else?

Three quarter of the respondents (75%) mentioned environmental hygiene as an alternative

method of preventing mosquito bites apart from an ITN.

2 10

30 26

3 0

10

20

30

40

Selling to

get income

Beautifying

houses

Nursery

beds

Sheds for

poultry

Tethering

Fre

qu

ency

Abuse of ITNs

Burning

mosquito coils

25%

Environmental

hygiene

75%

22

4.4.3 WHERE TO GET A MOSQUITO NET

Figure 15: Where to get a mosquito net

Majority of the respondents (75%) obtained their nets freely at a government health facility,

while the least percentage (10%) purchased theirs at the chemist/pharmacy.

Occupation Versus Where to obtain an ITN

Figure 16: Occupation versus Where to obtain an ITN

The bar graph above indicates that majority of the respondents (87%) who were given free

nets at the health facility were not salaried whereas only 25% of those who bought from the

chemist or pharmacy were not salaried. This indicates that salaried mothers are less likely to

obtain free nets at the government health facilities as compared to non-salaried mothers.

75%

10%

15% Health facility

Buy fromchemist/pharmacy

N/A

13

75

17

87

25

83

0%

20%

40%

60%

80%

100%

given free at thehealth facility

buy fromchemist/pharmacy

N/APe

rce

nta

ge

Where to obtain an ITN

Non-salaried

Salaried

23

Figure 17: Marital status versus Where to obtain an ITN

Of those interviewed, all the mothers who were separated, widowed, or divorced got their

nets freely from a government health facility. Only a smaller percentage of the single and

married mothers (15% and 10% respectively) obtained their nets by buying them from the

chemist/pharmacy.

4.4.4 WHAT HINDERS MOSQUITO NET USE

Figure 18: What hinders mosquito net use

Majority of the respondents (70%) said that most of the people in the study area did not use

the mosquito nets because they thought it wasn’t not necessary, 25% due to irritation while

5% said the nets were expensive to buy.

62 75

100 100 100

15 10

23 15

0%10%20%30%40%50%60%70%80%90%

100%

Per

cen

tage

Marital status

N/A

buy fromchemist/pharmacygiven free at thehealth facility

5%

70%

25% Very expensive to

buy

not necessary

24

CHAPTER FIVE

5.0 DISCUSSION

This discussion is structured based on the objectives previously mentioned and in line with

the findings of this study. It relates the findings to previous studies and from them generates

new information.

In terms of demographic data, majority of the respondents (62.5%) were aged between 18 and

27 years. Of those interviewed, half (50%) were married and had their families with them. A

larger proportion (75%) of those interviewed had attained post-primary education. 95% of the

respondents were Christians while only 5% were Muslims. Only 20% of those interviewed

had formal employment and were salaried.

Regarding the knowledge of the respondents about malaria, all those interviewed were aware

of malaria. This suggests that high level of awareness had actually been carried out by

relevant authorities. However, they gave varied sources of information including media when

one listens to a radio, watches a television or even reads a newspaper or journals, from

friends, at the health facility when one was sick and brought for treatment, being told by the

CHWs and at school. These findings concur with those of a study carried out by (Bortel et

al., 2006) in Nigeria which recommended that mothers should be continually sensitized

through radio and community participation to ensure acceptance and utilization of ITNs.

It was quite unfortunate to find out that a proportionate 27% of those interviewed attributed

malaria to other causes despite high level of awareness. Some linked malaria to being rained

on, others to consuming fatty foods, drinking dirty and witchcraft. This relates to the study

(Hulden, 2005) that a barrier to ITNs use may be lack of knowledge regarding malaria

transmission and prevention. It was evident; however, that education plays a significant role

in knowing the cause of malaria.

The findings on the attitude and practice saw a positive response with only 5% saying that

most people did not sleep under ITNs every night. Considering the fact that majority of the

respondents (85%) had mosquito nets, this is a positive development. This however concurs

with the study (Sangare et al., 2012) in Anambra, Nigeria that an improvement in awareness

and ITN use has been reported in most African countries. However, the same results contrast

with a study (Oche et al., 2011) that actual ownership and use of ITNs was low; attributing it

to the free samples at the government health facilities.

25

On the socio-economical perspective, it was found out that people abuse mosquito nets in a

number of ways including using them as sheds for poultry, nursery beds, beautifying houses,

tethering and selling to get income. This finding is thus supported by (WHO, 2007) that most

people who received ITNs did not sleep under them, re-sold them, reduced their efficacy

through inappropriate washing practices or failed to replace them when they became

damaged or torn.

All the respondents who had used the nets said they were comfortable using them; concurring

with (Belay et al.,2008) that factors significantly associated with ITN use were mothers’

knowledge of ITNs and mothers’ lack of problem in using ITNs. Occupation also plays a

critical role in determining the source of an ITN; most of those with formal employment

obtained their nets from chemists or pharmacy, hence there is a higher likelihood for those

not salaried getting their nets freely from the government health facilities.

26

CHAPTER SIX

6.0 CONCUSION

The present study concludes that though the level of ITN ownership among mothers of child

bearing age in Kericho County was high, putting the nets into proper use was far from reality

justifying the high prevalence of malaria which has been reported in the region.

The study findings indicate that there is increased attitude towards ITN use with most of the

respondents owning LLITNs.

Environmental hygiene was the most known method of preventing mosquito bites apart from

an ITN.

Mosquito nets are still being misused due to the socio-economic status of the residents.

Awareness on the cause of malaria in Kericho County was high.

The public health implication is that more work needs to be done by both the government and

health workers to raise awareness on proper use of ITNs since this is the most effective way

of winning war against malaria.

6.1 RECOMMENDATIONS

The county government should ensure adequate supply of ITNs to the government

health facilities.

Adequate health education and campaigns on importance, proper use and methods of

treatment of ITNs should be undertaken.

Community mobilization should be intensified to ensure a 100% mosquito net

ownership for mothers with children under the age of five years.

Supply of LLITNs should be implemented at all levels of health care facilities.

Demonstrations on proper control measures for malaria should be carried out

intensively through health action days.

Future research areas should cover; challenges of ITNs use among pregnant women,

cultural influence on the use of ITNs.

27

REFERENCES

1. Bassat, Q., & Alonso, P. L., (2011). Defying malaria: Fathoming severe Plasmodium

vivax disease. WHO Press Release, 17(1), 48-49.

2. Belay, M., &Deressa, W., (2008). Use of insecticide treated nets by pregnant mothers

and associated factors in a pre‐dominantly rural population in northern Ethiopia.

Tropical Medicine & International Health, 13(10), 1303-1313.

3. Browne, E. N. L., Maude, G. H., & Binka, F. N., (2001). The impact of

insecticide‐treated bednets on malaria and anaemia in pregnancy in Kassena‐Nankana

district, Ghana: a randomized controlled trial. Tropical Medicine & International

Health, 6(9), 667-676.

4. County Government of Kericho, Kericho Sub-County Hospital Health Records, 2013.

5. Curtis, C., Maxwell, C., Lemnge, M., Kilama, W. L., Steketee, R. W., Hawley, W. A.,

... & Snow, R. W., (2006). Scaling-up coverage with insecticide-treated nets against

malaria in Africa: who should pay? The Lancet infectious diseases, 3(5), 304-307.

6. Dembo Rath, A., & Hill, J., (2008). Evaluation of the community-based malaria

control project in Samfya District, Luapula, Zambia.

7. Eisele T.P., Keating J., Littrell M., Larsen D., Macintyre K., (2009): Assessment of

insecticide-treated bed net use among children and pregnant mothers across 15

countries using standardized national surveys. 80:209-214.

8. Gerstl S., Dunkley S., Mukhtar A., Maes P., De Smet M., Baker S., Maikere J.,

(2010). Long-lasting insecticide-treated net usage in eastern Sierra Leone – the

success of free distribution. 15:480-488.

9. Gething, P. W., Patil, A. P., Smith, D. L., Guerra, C. A., Elyazar, I. R., Johnston, G.

L., ... & Hay, S. I., (2011). A new world malaria map: Plasmodium falciparum

endemicity in 2010. 10(378), 1475-2875.

10. Government of Kenya, The Kenya National Bureau of Statistics, 2010.

11. Government of Kenya, The Kenya Population and Housing Census, 2009.

12. Hulden, L., Hulden, L., &Heliovaara, K., (2005). Endemic malaria: an 'indoor' disease

in northern Europe. Historical data analysed. Malaria Journal, 4(1), 19.

13. Jorge F. K., Se, Y., Schaecher, K., Smith, B. L., Socheat, D., & Fukuda, M. M.,

(2008). Evidence of artemisinin-resistant malaria in western Cambodia. New England

Journal of Medicine, 359(24), 2619-2620.

28

14. Killeen G.F., Smith T.A., Ferguson H.M., Mshinda H., Abdulla S., Lengeler

C.,Kachur S.P., (2007). Preventing childhood malaria in Africa by protecting

adultsfrom mosquitoes with insecticide-treated nets. 4:e229.

15. Kudom, A. A., & Mensah, B. A., (2010). The potential role of the educational system

in addressing the effect of inadequate knowledge of mosquitoes on use of insecticide-

treated nets in Ghana. 9, 256.

16. Lengeler C., (2004). Insecticide-treated bed nets and curtains for preventing malaria.

17. Littrell, M., Gatakaa, H., Phok, S., Allen, H., Yeung, S., Chuor, Chavasse. M., ...&

O’Connell, K. A., (2011). Case management of malaria fever in Cambodia: results

from national anti-malarial outlet and household surveys. 10, 328.

18. Malaria, R. B., & World Health Organization. (2013). New perspectives: malaria

diagnosis: report of a joint WHO/USAID informal consultation, 25-27 October 2009.

19. Murray, C. J., Rosenfeld, L. C., Lim, S. S., Andrews, K. G., Foreman, K. J., Haring,

D., ... & Lopez, A. D., (2012). Global malaria mortality between 1980 and 2010: a

systematic analysis. The Lancet, 379(9814), 413-431.

20. Nyandigisi, A., Memusi, D., Mbithi, A., Ang'wa, N., Shieshia, M., Muturi, A.,…&

Zurovac, D. (2011). Malaria case-management following change of policy to

universal parasitological diagnosis and targeted artemisinin-based combination

therapy in Kenya. 6(9).

21. Okello, P. E., Van Bortel, W., Byaruhanga, A. M., Correwyn, A., Roelants, P.,

Sirima, S. B., ... & Akogbeto, M., (2006). Variation in malaria transmission intensity

in seven sites throughout Uganda. American Journal of Tropical Medicine and

Hygiene, 75(2), 219-225.

22. Okonofua, F., & Snow, R. C. (2010). Maternal mortality in Nigeria: the real issues.

African Journal of Reproductive Health, 7-13.

23. Pettifor, A., Taylor, E., Nku, D., Duvall, S., Tabala, M., Mwandagalirwa, K.,

...&Behets, F. (2009). Free distribution of insecticide treated bed nets to pregnant

mothers in Kinshasa: an effective way to achieve 80% use by mothers and their

newborns. Tropical Medicine & International Health, 14(1), 20-28.

24. Pulford, J., Hetzel, M. W., Bryant, M., Siba, P. M., & Mueller, I., (2011). Reported

reasons for not using a mosquito net when one is available: a review of the published

literature. 10(10).

29

25. Ranson, H., N’Guessan, R., Lines, J., Moiroux, N., Nkuni, Z., & Corbel, V. (2011).

Pyrethroid resistance in African anopheline mosquitoes: what are the implications for

malaria control? Trends in parasitology, 27(2), 91-98.

26. Salaam-Blyther, T., (2011). Global Fund to Fight AIDS, Tuberculosis, and Malaria:

US Contributions and Issues for Congress. DIANE Publishing.

27. Wallon, M., Roman, E., Brieger, W., Rawlins, B., Agarwal, S., Dickerson, A., ...&

Cowan, F. M., (2012). A malaria in pregnancy case study: Zambia’s successes and

remaining challenges for malaria in pregnancy programming. Health Policy and

Planning, 27(3), 245-55.

30

APPENDICES

APPENDIX I: QUESTIONNAIRE

CHALLENGES FACINGTHE UTILIZATION OF ITNs AMONG MOTHERS OF

CHILD BEARING AGE .

General Instructions

i. The information to be obtained is purely for academic purposes and will be treated

with confidentiality.

ii. Tick or fill where appropriate.

iii. Do not indicate the name of the respondent.

QUESTIONNAIRE NO ----------------------------------------

DATE OF INTERVIEW ---------------------------------------

CONSENT FORM.

I am a fourth year student from Moi University seeking to investigate the challenges facing

the utilization of ITNs among mothers of child-bearing age. The research is purely for

educational purposes though the findings can be used to better the maternal and child health. I

therefore invite you to take part in it.

There will be no incentives offered in exchange for your cooperation. However, the findings

of the research will enable health care providers to assist you more in curbing malaria

through the use of ITNs. Be informed that the information obtained is confidential and that no

outside party will access it for malicious intentions.

I finally wish to let you know that you reserve the rights to either give or relent form giving

the requested information. You will not be coerced into doing it, nor will you be punished for

refusing to give the information.

If you have any questions you may ask them now or even later after the study has started.

May we start the interview now?

Yes [ ]

No [ ]

31

DEMOGRAPHICS

NNNO. QUQUESTION RERESPONSE CODE

101101 How old are you? 18-27

28-37

38-47

48 and above

01

02

03

04

102102 Level of Education None

Primary

Secondary

Tertiary

01

02

03

04

103103 Marital Status Single

Married

Separated

Widowed

Divorced

01

02

03

04

05

104 Religion Christian

Hindu

Muslim

01

02

03

105 Occupation Employed

Self-employed

Not employed

01

02

03

KNOWLEDGE

NO. QUQUESTION RERESPONSE CCCODE

201 Have you ever heard of Malaria? Yes

No

01

02

202 If YES, where did you get the information? Media

Friends

Health facility

CHW

School

N/A

01

02

03

04

05

06

203 What do you think causes the malaria? Witchcraft

Mosquito bite

Being rained on

Eating fatty foods

Drinking dirty water

01

02

03

04

05

32

ATTITUDE AND PRACTICE

NO. QUESTION RESPONSE CODE

301 What is your perception towards mosquito nets? They smell bad

Comfortable

I don’t know

Others (specify)………….

N/A

01

02

03

00

06

302 How important do you think it is for young

children to sleep under a treated net?

Extremely important

Important

Nto important at all

01

02

03

303 Treated nets are safe to sleep under. Strongly agree

Agree

Disagree

Strongly disagree

Don’t know

01

02

03

04

05

305 Most people in this community sleep under

insecticide-treated nets every night

Strongly agree

Agree

Disagree

Strongly disagree

Don’t know

01

02

03

04

05

306 People are at risk of getting malaria only during

the rainy season.

Strongly agree

Agree

Disagree

Strongly disagree

Don’t know

01

02

03

04

05

307 Do you have mosquito nets in your home? Yes

No

01

02

308 If YES, are they treated? Yes

No

Don’t know

N/A

01

02

05

06

309 If YES, how often do you normally treat your

nets?

After six months

After one year

It’s long lasting

Never

Don’t know

N/A

01

02

03

04

05

06

33

SOCIO-ECONOMIC FACTORS

NO. QUESTION RESPONSE CODE

401 What are some of the ways you’ve observed

that most people abuse mosquito nets

Selling to get income

Beautifying houses

Nursery beds

Sheds for poultry

Others (specify)…………

01

02

03

04

00

402 What measures apart from sleeping under ITNs

do you use to prevent mosquito bites?

Burning mosquito coils

Applying ointments

Environmental hygiene

Others (specify)…………

01

02

03

00

403 Where do you get your mosquito net? Given free at health facility

Buy from chemist /pharmacy

Buy from supermarkets

Others (specify)………..

N/A

01

02

03

00

06

404 In your opinion what hinders the use of

mosquito nets in this area?

Not available

Very expensive to buy

It’s not necessary

Don’t know

Others (specify)…………..

01

02

03

05

00

34

APPENDIX II: KERICHO COUNTY MAP

35

APPENDIX III: RESEARCH BUDGET

ITEM DESCRIPTION QUANTITY UNIT COST TOTAL COST(Ksh)

1. Computer program SPSS purchase 1 1,000

2. Printing services 1,000

3. Internet charges 1,500

4. Pens 6 20 120

5. Rulers 3 20 60

6. Rubber 6 10 60

7. Pencils 6 20 120

8. Printing papers 3 400 1,200

9. Office glue 1 100 100

10. Binding 150

11. Research assistant 6 200 1200

12. Lunch 6 70 420

13. Miscellaneous 1000

14 Contingencies 10% of total 793

TOTAL

8,723

36

APPENDIX IV: TIME FRAME

ACTIVITY

.

WEEK

Week 1 Week 2 Week 3 Week 4 Week 5

Reconnaissance to identify

community health problems

Identification of study topic.

Presentation and Approval of

Topic

Identification of supervisors

Literature review and

Questionnaire development

Pilot study

Data analysis and presentation

(pilot study)

Main study

Data analysis and presentation

(Main study)

Presentation of study findings/

Feedback.