Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05 625 Knowledge and Compliance with the Use of Insecticide-treated Nets in Manalu of North

Chandrayani Simanjorang1,2, Nasrin Kodim3, Umar Fahmi Achmadi4, Tri Yunis Miko5

1Lecturer at Department of Health, State Polytechnic of Nusa Utara, 2Doctoral Studentat Department of Epidemiology, Public Health Faculty of Universitas Indonesia, 3Professor at Department of Epidemiology, Public Health Faculty of Universitas Indonesia, 4Professor at Department of Environmental Health Universitas Indonesia, 5Lecturer at Department of Epidemiology, Public Health Faculty of Universitas Indonesia

Abstract Background: Insecticide-treated nets is essential in prevention of malaria parasite transmission and morbidity. Almost in every year, malaria cases always increase. At least in the last 5 years, malaria morbidity rate is so high, with the Annual Parasite Incidence (API) of more than 5 per 1,000 populations; with the highest number of cases occur at the Public Health Center of Manalu Sub-district of South Tabukan, with 226 positive cases. Based on these data, this region has become one of the target areas of netting intervention. Since 2011, insecticide-treated nets have been distributed at Manalu Public Health Center whichas the category of malaria endemic. Each household gets 1 or 2 insecticide-treated nets. If there are pregnant women or infants, they will get extra insecticide-treated nets.

Method: This study aims to determine the level of knowledge and compliance of the use of Long lasting insecticidal nets by people who have received the distribution since 2011. This observational study was conducted in Manalu Public Health Center of Sangihe Islands Regency from April to June 2017. Then, an interview was made towards 103 household heads who received insecticide-treated nets.

Result: Results of study found that most respondents (98%) had a good knowledge of insecticide-treated nets and were compliant in using of insecticide-treated nets when they slept (83.1%); approximately 96.1% of respondents installed the nets correctly; approximately 85.7% of respondents took care and washed the nets and approximately 93.9% of respondents dried the nets in the sun. Currently, communities in the area own insecticide-treated nets (96.8%) and ordinary insecticide-treated nets (3.2%).

Conclusion: Although they have good knowledge of and compliance with the use of insecticide-treated nets, in fact, up to now there are still relatively high cases of malaria endemics (API> 5). Therefore, we need to look for other factors, such as geographical conditions, social conditions, and the age of insecticide- treated nets. Geographical areas in this regency are mostly in form of swamps and beaches (98.1%). This condition can affect many breeding places because most people work as fishermen with activities outside of their homes, from dawn until evening. Age of nets is now about 6 years so it needs a replacement program of insecticide-treated nets by the government to optimally prevent mosquito bites while sleeping at night.

Keywords: Knowledge, compliance, insecticide-treated nets, malaria.

Introduction population have a high risk of malaria with the highest number is in Africa (47%) and followed by south- Insecticide-treated nets is essential in prevention east Asia (37%). The malaria cases have reached 216 of malaria parasite transmission and morbidity.[1] million cases and 81% of them occurred in Africa with It is estimated that around 1.2 billion of the world’s the mortality rate reaches 655,000 cases (86%).[2] Based 626 Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05 on the Indonesian Ministry of Health’s malaria program who are assumed to have more authority in the family. report, in Province, especially in There’s92 people as male subjects (89.5%), 85 families Sangihe Islands Regency is one of the malaria-endemic have members generally 1-4 members (82.5%). areas that almost every year it experiences cases of Geographical condition of those who live at beach are malaria. In 2013, a report shows that malaria morbidity 101 households (98.1%), families who have children rate (Annual Parasite Incidence) was 5.44 per 1,000 under five are 18 families (17.5%) as well as families populations. At least, number of positive malaria cases who have pregnant women consist of 6 households (6%). that were reported as many as 686 cases. The number of P.falciparum and P.vivax cases is almost the same. Most Table 1. Respondents Distribution Based on of those cases occurred at Manganitu Public Health Characteristics Center (220 cases) and Enemawira Public Health Center Variables n % (174 cases). In 2014 the incidence of malaria dropped to 4.75 per 1,000 populations, with the number of cases Age Group coming from Manalu Public Health Center. Thus, this 15-24 years 4 3,9 district has become one of pockets of endemic malaria 25-44 years 36 35,0 in Sangihe. 45-64 years 51 49,5 In an effort to lower endemic malariaat Manalu 65-78 years 12 11,7 Public Health Center the insecticide-treated nets are distributed with free of charge to all households. Based Number of family members on data from the Health Department, each household 1-4 members 85 82,5 gets one or two insecticide-treated nets in 2011. The 5-8 members 18 17,5 Health Department also conducted an awareness drive through public health centers on the procedure Gender and the installation of nets inside the house. Since the Male 92 89,3 distribution and socialization was done, it has not been Female 11 183,3 known regarding the knowledge and compliance of public in the use of insecticide-treated nets to prevent Village Name malaria. This fact is very important to know, considering Lesabe 42 40,8 the fact that up to 2015, status of a public health center Bentung 31 30,1 with API> 5 /% population relatively has high endemic. Batuwingkung 30 29,1

Method Geographical Condition

This study uses descriptive cross-sectional study Beach 52 50,5 design with a structured interview and observation Paddy field 1 1,0 method. This study was conducted at Manalu Public Health Center of South Tabukan Sub-District. The Forest 1 1,0 study was conducted in April-June 2016. Population Swamp 49 47,6 of the study is all households at Manalu Public Health Children under five Center, covering 792 households. Samples are heads of household who obtained insecticide-treated nets. The Exist 18 17,5 number of samples is calculated using the proportion of Not exist 85 82,5 sample 1 of which a sample of 96 households has been Pregnant Women obtained.[12] Exist 6 5,8

Result Not exist 97 94,2 Most of respondents (95.1%) are in the age group of initial elderly category and final elderly category. The majority of respondents understand well and Research subjects in this study are the heads of family install insecticide-treated nets correctly (80%) (Table 2). Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05 627

Table 2. Respondents Distribution Based on the Variable N % Usage Method of Insecticide-treated nets Knowledge Variable N % Good 101 98 Use and install a insecticide-treated net Moderate 2 2 74 80 correctly Lack 0 0 Use a insecticide-treated net but done it 3 3 Use of Insecticide-treated net inccorectly Yes 74 83 Do not use insecticide-treated net 16 17 No 15 17 Total 93 100

Based on netting maintenance procedures, most Discussion of people do the washing method. Meanwhile, drying Proportion of respondents who comply in using is done in the direct sunlight where drying is supposed of insecticide-treated nets while sleeping (slept under to be done in the areas that are not exposed to direct insecticide-treated nets the previous night) is around sunlight. This occurs because in general, people have a 83.1%. This is one of the fives indicators of insecticide- clothesline outside the home. treated nets use based on WHO indicators.[5] These results are not much different from previous study Table 3. Respondents Distribution Based on the in Brazil, India, Ghana that used insecticide-treated Method of Washing of Insecticide-treated nets nets which the proportion was 85.7%, 70%, 91.9% in [6,7,8] Variables N % Vijayakumar’s study and 91.9% in. But Findings made by Farchanny in Sikka regency was lower, Washing of net proportion of respondents who comply in using of Yes 66 85,7 insecticide-treated nets while they sleep is only 40%.[9] No 11 14,3 A high proportion of respondents who comply in using Place of net washing of insecticide-treated nets can be used as an indicator River 15 22,7 of the success of malaria control programs. Compliance in using of insecticide-treated nets is associated with a Gutter 39 59,1 decreased risk of malaria incidence. Residents in Sikka Fish pool 0 0,0 district of NTT province who do not comply in using of Sewer 9 13,6 insecticide-treated nets are risky to suffer malaria 6.16 Other places 3 4,5 times greater.[8] Frequency of usage Knowledge of the community about the insecticide- Every month 13 19,7 treated nets is also noted. Knowledge will affect a Every 2 months 4 6,1 person’s behaviour.[9] People who know insecticide- Every 3 months 45 68,2 treated nets will protect themselves against mosquito Every 4 months 1 1,5 bites malaria and will tend to use insecticide-treated nets while sleeping. This study finds that people that have Every 5 months 0 0,0 been studied have a good knowledge about the use of Every 6 months 3 4,5 insecticide-treated net (98%). Therefore in this study Method of net drying knowledge and attitudes are in line. Another study in Drying in the direct sunlight 62 93,9 Nigeria found that majority of sample had adequate Drying not in the direct sunlight 4 6,1 knowledge (90,6%) but only 54,1% adhered to daily use.[9] Program of insecticide-treated nets has been There’s 98% of respondents have good knowledge implemented by the Ministry of Health since 2011. It’s about the method of insecticide-treated nets and 83% of output is that each household has insecticide-treated them have complied in using of insecticide-treated nets. nets and those nets are used and installed properly during sleeping at night. Then what is needed to do is to Table 4. Respondents Distribution Based on Level of measure the impact of prevention that has been already Knowledge and Compliance in the Usage of Insecticide- treated nets. 628 Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05 done through insecticide-treated net program. One of its of malaria cases owned by the Public Health Center over effects is the decrease of number of malaria cases. In the last 5 years. this study, further assessment of trend is based on data

Based on Figure 1 the number of cases and endemic to avoid mosquito bites when performing activities level (API) show a decline trend in 2011-2015. However, outside the home. Another intervention areincectiside this decline cannot change the status of the red zone outdoor space spraying, and indoor residualinsectiside (API=5) into the yellow zone (API = 1-4) or the green spraying that are considered as quite expensive. Third zone (API <1) of endemic malaria. In 2015 the API the age of insecticide-treated nets has enteredthe 6th status at Public Health Center working area=10, which year. According to the Health Ministry the resilience it means that it is still categorized as highly endemic. of insecticide-treated nets will last only up to 5 years API is the Annual Parasite Incidence – the number of old, with appropriate washing and drying. Thus the nets positive cases of malaria per 1000 population per year. are used by the people today do not meet the criteria Endemic status of malaria in the Manalu Public Health for optimal prevention of mosquito bites. Secondly the Center must be watched because there is a tendency to geographical conditions of the working area of Manalu increase. Health Centers. The result show that geographically majority of ManaluHealth Centers (98.1%) arein areas There are facts that need to be considered by the of beaches and marshes. Geographical conditions such policy makers in malaria control. First the geographical as these will increase the number of breeding places condition of Manalu Public Health Center, which so that if it is not intervened properly the anopeheles geographical conditions of most of the region (98.1%) mosquito will continue to proliferate. are beaches and marshes of which the number of mosquito breeding places are considered as high. Conclusion Without any intervention the environmental conditions like this will make anopheles mosquitoes continue to Most of respondents (98%) have a good knowledge proliferate. The WHO recommendation is to modify about the use of insecticide-treated nets. Most of the environmental, chemical and biological larvicides. respondents (83.1%) also comply in using of insecticide- [5] Secondly, activities or employment of most people treated nets at night. This condition is different from in the region are fishermen. It means that activities the status of endemic malaria at Manalu Public Health outside the home at night or at dawn, exposed to high Center which there are decreasing of malaria cases risk of being bitten by malaria mosquitoes. Thus, it is during the last 5 years, but the area is still in a red zone necessary for the socialization program about how (endemic) with API> 5. Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05 629 On malaria control programs the factors of 4. Ministry of Health: Annual Program Reports. knowledge and usage of insecticide-treated nets in Jakarta: endemic areas have become important factors to be 5. WHO: Household survey indicators for malaria assessed. If these factors are already controlled but high control. Geneva: WHO press 2013. endemic cases still high then it is important to assess 6. Jessica de Oliveira Sousa, Bernardino Claudio de other factors to be controlled and cared for by the policy Albuquerque, José Rodrigues Coura & Martha makers. For example the factor of net age is associated Cecilia Suárez-Mutis: Use and retention of long- with the effectiveness of insecticide-treated nets, lasting insecticidal nets (LLINs) in a malaria risk environmental factors, and socioeconomic factors. area in the Brazilian Amazon: a 5-year follow-up Suggestion: There are some efforts that can be made intervention. Malaria Journal 2019; 18:125. to optimize malaria control at Manalu Public Health 7. K.N.VijayakumarK.GunasekaranS.S.Sahu Center. Firstly, it is important to assess the possibilities P.Jambulingam: Knowledge, attitude and practice of other factors that may be the cause of high endemic on malaria: A study in a tribal belt of Orissa state, malaria, nowadays. Among others, factor ofusage age of India with reference to use of long lasting treated insecticide-treated nets, environmental factors such as mosquito nets: Acta Tropica 2009; Vol.112: 137- geographical conditions that affect mosquito breeding 142. places, and employment factors with respect to activities 8. Dakwah IA, Nyarko KB: Knowledge of malaria outside the home. For all three of these factors the policy prevention and control in a sub-urban community makers can perform replacement of insecticide-treated in Accra Ghana. Int J Trop Med 2011; 6:61-69. bed nets that are already 5 years of usage, conducting 9. FarchannyAchmad Tri Adryanto: Relationship public awareness about the importance of preventing of compliance using insecticide nets with malaria mosquito bites when performing activities outside the in sikkaregency, East Nusa Tenggara Province: home, as well as controlling a vector with modification Jakarta: UI press 2010. of the environment through community empowerment. 10. Godpower C. Michael, Ibrahim Aliyu, BukarA. Conflict of Interest: The authors declare that there Grema: Knowledge of malaria and adherence to is no conflic of interest. its preventive measures among adults attending out-patient clinics of Nigerian tertiary hospital: Source of Funding: This study supported by State has anything changes?.Afr J Med Health Sci 2017; Polytechnic Health of North Nusa Utara, Indonesia 16:43-51 Ethical Clearance: The ethical committee of 11. Notoatmodjo, Soekidjo: Health behavioral sciences. Department of Health State Polytechnic of Nusa Jakarta: PT. RinekaCipta 2010. Utara. Patients were informed of the study purpose and 12. Stanley Lemeshow, David W Hosmer Jr, Janelle provided written consent before participating. Klar, and Stephen K. Lwanga: Adequacy of sample size in health studies: WHO press 1990. References 13. Kodim Nasrin: Insecticide-treated nets: useful but 1. Arinze Onyia Susan, Edmund Ndibuagu, Samuel neglacted. Medical Journal Indonesia 2014; No.3 Robsam Ohayi: Knowledge and Utilization of Vol. XL. Insecticide Treated Nets in a Rural Community in 14. Ministry of Health: Guidelines for the management Southeast Nigeria. Africa: International Journal of of malaria cases. Ditjen PP & PL Jakarta 2009. Health Sciences & Research 2016;Vol.6 15. World Health Organization. World malaria report 2. WHO: Epidemiological apporoach for malaria 2013. WHO press 2013. control. Geneva: WHO press 2013; 2nd ed.2v. 3. WHO: Larval Source Management: a supplementary measure for malaria vector control. Geneva: WHO press 2013.