Conducting Focus Group Discussions On Causes, Prevention And Treatment Of Malaria In Anambra, Bauchi And Rivers States, Nigeria

Focus Group Discussions on Causes, Prevention and Treatment of malaria in Anambra, Bauchi and Rivers States, Nigeria

Report Submitted to Jumana Qamruddin The World Bank

Nkechi Genevieve ONYENEHO, PhD Dept. of Sociology/Anthropology University of Nigeria, Nsukka Enugu State, NIGERIA [email protected] +234 803 6869451 Acknowledgement

The World Bank provided the funds and logistic supports for this study. We therefore owe the success of this exercise to the cooperation received from The World Bank staff here in Nigeria and Washington as well as their partners in the Malaria Control Programmes in the States visited. We would like to thank specifically the following persons for their contributions and assistance towards the successful execution of this assignment.

 Jumana Qamruddin, for making the necessary logistics for the success of this assignment. She initiated the process that led to the full blown study  Janet Adebo gave the necessary administrative assistance  Drs. Joe Aranumba, Babuga Umar Abubukar, and Justina. Jombo, Roll Back Malaria programmes managers in Anambra, Bauchi and Rivers States respectively. They ensured smooth operation of the team in their respective states.  The cooperation of members of the communities visited is also acknowledged here

ii List of Acronyms

CDI Community Directed Intervention

DFID Department for International Development

FGD Focus Group Discussion

FGN Federal Government of Nigeria

FMoH Federal Ministry of Health

GPZ Geopolitical Zone

HBM Health Belief Model

ISR Implementation Status Report

ITN Insecticide Treated Net

LGA Local Government Area

NDHS Nigeria Demographic and Health Survey

NGO Non Governmental Organization

NMCP Nigerian Malaria Control Programme

NPC National Population Commission

iii PIU Project implementation Unit

RBM Roll Back Malaria

SPSS Statistical Package for Social Science

UN United Nations

iv Executive Summary

As its new approach to project implementation, the World Bank has designed an implementation status report (ISR) system that would allow the disclosure of information on implementation as well as enhance results and accountability, through a methodical approach to elicit feedback on project performance from end users. In pursuit of this process, the World Bank is piloting the ISR Plus concept in a few countries to test the best set of mechanisms for obtaining data from end users.

In Nigeria, the focus group discussion method was used in obtaining information from end users of the ITN campaign in three world booster states drawn from three geopolitical zones (GPZs) of Nigeria. These are Anambra, Bauchi and Rivers in the Southeast, Northeast and South-south GPZs respectively. FGD sessions were held with adult males, adult females and youth from communities selected through multi-staged sampling.

The results revealed the following:

 The people recognize malaria as very worrisome condition, which they have been conditioned to live with. This is the same in all the states.  Beneficiaries recognize the usefulness of the nets and they are willing to use it to protect themselves from mosquito bites.  Although they expressed gratitude for the number of nets so far distributed, a good number of people, especially the unmarried, youth and those who were absent when the registration and distribution of net cards were undertaken.  They are pockets of people with poor knowledge of malaria and mosquito bites, which also result in some cases wrong perception as well as wrong usage of the nets. Some use the nets as door and window blinds to “protect everybody in the house” since only two nets were give per household that sometime number close to twenty.  Suggestions were made to use community structures such traditional leaders/village heads, youth and community institution like churches and mosque. It is believed that involvement of such community structure will ensure effective distribution of the nets as well as sensitization and monitoring of net use in the communities.  There is urgent need for health education, which will help to dispel rumours and misconceptions about mosquitoes and malaria conditions as well as nets. Some of such misconceptions include fear that ITNs could kill; curtail human fertility; taking local gin (Kai Kai) will induce one to sleep and be oblivious of mosquito nuisance; among others

v Table of Contents

Acknowledgement...... ii

List of Acronyms...... iii

Executive Summary...... v

Table of Contents...... vi

1.0 Introduction...... 1 1.1 Background to the Study...... 1 1.2 Research Questions...... 3 1.3 Objectives of the FGDs...... 3

2.0 Methods...... 4 2.1 Study Design...... 4 2.2 Study sites and population...... 4 2.3 Sampling...... 6 2.4 Instrument and Method of Data Collection...... 7 2.5 Method of Data Analysis...... 7

3.0 Results...... 9 3.1 Current Status of Malaria Control in the Study States...... 9 3.2 Social Demographic Characteristics of the Respondents...... 10 3.3 Common Health Problems...... 13 3.4 Knowledge of Malaria in the Communities...... 16 3.5 Management of Malaria...... 19 3.6 Treatment of Malaria...... 20 3.7 Prevention of Malaria...... 21 3.8 Sources of ITNs and Costs...... 22 3.9 Perceptions on ITNs...... 23 3.10 Use of ITNs in the Communities...... 25 3.11 Number of Participants who own ITNs...... 27 3.12 Number of Participants who Slept under Net the Previous Night...... 28 3.13 Suggestion on Ways of Preventing Malaria in the Communities...... 29 3.14 Suggestions on Ways of Improving Distribution of ITNs in the Communities...... 30 3.15 Suggestions on Ways of Making People Use ITN in the Communities...... 30

4.0 Discussion Conclusions and Recommendations...... 32 4.1 Discussion...... 32 4.2 Conclusion...... 34 4.3 Recommendations...... 34

vi References...... 36

Appendix...... 38 1. FOCUS GROUP DISCUSSION GUIDE...... 38

vii 1.0 Introduction

1.1 Background to the Study

Malaria remains a disease of public health concern in Africa. One of the hardest hit countries is Nigeria, where the disease accounts for 11% of maternal mortality and 12-30% of mortality in children under 5 years of age (FMoH and NMCP, 2009). Malaria is endemic throughout Nigeria. Over 140 million people are at risk of malaria in Nigeria. While 50% of the adult population experience at least one malaria episode annually, children less than five years may experience up to four episodes leading to 55% mortality rate among the latter. The disease currently accounts for nearly 110 million clinically diagnosed cases per year, 60 percent of outpatient visits, and 30 percent hospitalizations (NPC and ICF Macro, 2009).

Houggenhegen, et al (2003) noted that pregnant women and children are most at risk of malaria transmission and it effects. An estimated 300,000 children die of malaria each year and it threatens over thirty million pregnancies in endemic countries throughout Africa (WHO, 2003). The hardest hit of the countries in Africa is Nigeria, where the disease accounts for 11% of maternal mortality and 12-30% of mortality in children below 5 years (FMoH and NMCP, 2009). Malaria infection in pregnant women is the major risk factor for death in the first month of life (Steketee et al, 2001).

Pregnant women are more susceptible to complications from malaria (Shane, 2001). Cerebral malaria, renal failure and hemolysis (the destruction of red blood cells) are some of the complications of malaria. This increased risk continues into early postpartum period. Malaria has severe negative effects on maternal health and birth outcomes in Nigeria. It causes maternal anemia and increases the incidence of miscarriage and low birth weights. Malaria causes up to 15% of maternal anemia and about 35% of preventable low birth weight, which is a leading cause of neonatal mortality (CDC, 2007). It is also estimated that globally 75,000 to 200,000 infants’ deaths each year are associated with malaria infection during pregnancy.

The prevalence of malaria among pregnant women in Nigeria estimated at 48 percent in 2000 and 2001 (FMOH, 2004). From a study of two hospitals and a traditional birth home (TBH) in Abeokuta, Nigeria, Idowu, et al, (2006) reported MIP prevalence in the first, second and third trimesters of 37.5 percent, 47.3 percent and 47.5 percent respectively.

In addition to the direct health impact of malaria, there are also severe social and economic burdens on communities and the country as a whole, with about 132 billion Naira lost to malaria annually in the form of treatment costs, prevention, loss of work time, etc. (FMoH and NMCP, 2009). The remarkable burden of malaria notwithstanding, malaria prevention and control remains a challenge. Ironically, effective strategies for prevention and control of malaria have been developed and shown to have remarkable impact on the health of the people (WHO/UNICEF, 2003).

Efforts to control malaria-associated morbidity and mortality include the National Malaria Control Programme promotion of effective treatment with antimalarial drugs and the distribution and promotion of the use of insecticide-treated nets (ITNs) and other malaria control commodities. However, the use of ITN in Nigeria, as in other African countries, falls short of global targets (UN, 2008). The 2008 NDHS results indicate that 17 percent of households in Nigeria own a mosquito net (treated or untreated), and 8 percent of households own more than one mosquito net. Sixteen percent of households own at least one ever-treated mosquito net, and 7 percent own more than one ever treated mosquito net. The percentage of households that own at least one ITN is 8, while 3 percent own more than one ITN. The average number of ITNs per household is less than one (NPC and ICF Macro, 2009). This is against the target of at least two treated nets per household, despite the tremendous progress in net production and availability in Nigeria. This could be attributed to a weak supply and distribution mechanism.

The National Programme is built around a strong public-private partnership that ensures that commodities are available and accessible to the 36 States and the Federal Capital Territory (FCT, Abuja). Implementation is actively supported by nationally recognized non-governmental organizations (NGOs). State programme managers and, to a limited extent, local government desk officers are regularly engaged in capacity development activities, information and communication for malaria control through partnerships. All the same, net distribution in recent years, has often been epileptic with only a few LGAs targeted in various States. This has made it impossible to attain full saturation of any one area. This also complicates net replacement strategies. The approach since 2009 has been to start afresh with a coordinated strategy to deliver 2 nets to every household across the country through a series of stand-alone campaigns to achieve universal coverage. The World Bank Booster supported states (Kano, Jigawa, Bauchi, Gombe, Anambra, Akwa Ibom and Rivers) have completed their net campaigns. The nets will now contribute to a broader partner effort to achieve national coverage of nets distribution under the new scheme.

However, effective involvement of communities in malaria control raises several complex questions, amongst them:

 What are the people's perceptions of malaria, its causes, prevention and control?  What are their views/experience on net distribution and access to nets?  What are the experience on use of nets

Answers to these complex questions reside in the people, who are the end users and the heart beat of all efforts to control malaria through the promotion of ITN use. Oftentimes, the views of the people are missing from so-called “people centred” malaria intervention discussions. The study outlined here focuses on listening to the people. It will provide information on current malaria control practices, from the point of view of the end users, and identify gaps and strategies for effective net distribution and use. .

2 By seeking the views of the end users it is hoped that the information gathered will identify immediate-impact solutions that take into account the limitations of the existing organizational weaknesses in net distribution/campaign. The outcome of the study will provide suggestions originating from the people themselves and not from global thinking trying to find solutions for the local level. It will be an opportunity to link global and local approaches to improve net distribution/campaign.

1.2 Research Questions

 What is the current status of malaria control in Anambra, Bauchi and Rivers States, Nigeria?

 What are the perceived causes of malaria among the end-users of ITNs distributed in Anambra, Bauchi and Rivers States, Nigeria?

 How do the end users perceive bednet campaign in the States?

1.3 Objectives of the FGDs

The objectives of the End-user Consultation are:  To elicit views among three different types of ‘end-user’ (youth, women and men) on o the causes of malaria and the prevention and treatment measures to control the disease; o the bednet campaign in their respective states; and o the current status of malaria control in the States.  Analyze the FGD data  To feed the results to the Bank’s ISR Plus pilot phase

3 2.0 Methods

2.1 Study Design This study is designed to allow a description and analysis of community perceptions/views of net distribution and malaria control in Nigeria The study will employ qualitative inquiry, which will be based on focused group discussion methods. This will contribute to an in-depth understanding of end user perceptions/views.

2.2 Study sites and population The study was carried out in three states in Nigeria. These are Anambra, Bauchi and Rivers, drawn from the Southeast, Northeast and South-south geopolitical zones of Nigeria. They are part of the seven World Bank Booster supported States.

Anambra, with 21 local government areas (LGAs) is a state in south-eastern Nigeria. It is located between 6o20’N and 7o00’E with a land mass of 4,844Km2. The Capital and the Seat of Government is Awka. Onitsha and Nnewi are the biggest commercial and industrial cities, respectively. Boundaries are formed by Delta State to the west, Imo State and Rivers State to the south, Enugu State to the east and Kogi State to the north. The origin of the name is derived from the Anambra River (Omambala) which is a tributary of the famous River Niger.

The indigenous ethnic groups in Anambra state are the Igbo (98% of population) and a small population of Igala (2% of the population) who live in the western part of the state. With a population of 4,182,032 persons recorded in the 2006 Nigerian population and housing census, Anambra is the eight most populated states in the Federal Republic of Nigeria and the second most densely populated state in Nigeria after Lagos State. The population density is 863/km2. The stretch of more than 45 km between Oba and Amorka contains a cluster of numerous thickly populated villages and small towns giving the area an estimated density of 1,500–2,000 persons living within every square kilometer of the area.

With an annual population growth rate of 2.21 percent per annum, Anambra State has over 60% of its people living in urban areas making it one of the most urbanized places in Nigeria. The major urban centres of Anambra state are Onitsha including Okpoko, Nnewi, and Awka. Awka

4 and Onitsha developed as pre-colonial urban centres with Awka as the craft industrial centre of the Nri hegemony; and Onitsha the city on the Niger and a river port and commercial centre.

Malaria is a major health problem here. Transmission through mosquito bites is all year round. The major strategy for prevention is through ITN use. In last one, the State malaria programme received 1,791,200 nets but distributed 1,613,140 nets through net campaign. The nets came from the World Bank, which 1,106,200 nets and DFID which contributed the rest.

Bauchi State is a state in Northeastern Nigeria. Its capital is Bauchi. The state is divided into 20 Local Government Areas (LGAs). Bauchi state occupies a total land area of 549,260 km² representing about 5.3% of Nigeria’s total land mass and is located between latitudes 9° 3' and 12° 3' north of the equator. Longitudinally, the state lies between 8° 50' and 11° east of the Greenwich meridian. The state is bordered by seven states, Kano and Jigawa to the north, Taraba and Plateau to the south, Gombe and Yobe to the east and Kaduna to the west.

Bauchi State has a total of 55 tribal groups in which Hausa, Fulani, Gerawa, Sayawa, Jarawa, Bolewa, Karekare, Kanuri, Fa'awa, Butawa, Warjawa, Zulawa, and Badawa are the main tribes. This means that they have backgrounds, occupational patterns, beliefs and many other things that form part of the existence of the people of the state. There are cultural similarities in the people's language, occupational practices, festivals, dress and there is a high degree of ethnic interaction especially in marriage and economic existence. Some of the ethnic groups have joking relationships that exist between them, e.g. Fulani and Kanuri, Jarawa and Sayawa. The 2006 population and housing census put the population of Bauchi State at 4,67.465 people with a landmass of 45,657 Km2.

Malaria is also constitutes health problem. Transmission is all year round and the major preventive is the promotion of net use to avoid mosquito bites. In 2010, the PIU embarked on net campaign with target of giving two nets per household. According the PIU manager, the total number of nets required 100 percent coverage is 2,067,946. The number supplied however, is 2,049,499, and all these came from the World Bank Booster programme. Of this 2,026, 889 nets have been distributed. Five thousand, six hundred and ninety six nets are yet to be distributed. On the whole, the State PIU spent one hundred and forty-three million, one seventy one thousand, five hundred twelve Naira on the entire campaign for the year 2010.

Rivers State is one of the 36 states of Nigeria. Its capital is Port Harcourt. It is bounded on the South by the Atlantic Ocean, to the North by Imo, Abia and Anambra States, to the East by Akwa Ibom State and to the West by Bayelsa and Delta states. Rivers state is predominantly Ikwere in population and land mass and small amounts of Ijaw, Ogoni etc in its coastal areas.

Rivers State is divided into twenty-three Local Government Areas (LGAs), with a total population of 4,185,400 persons (NPC, 2006). It occupies a landmass of 11,077Km2 and is located between latitude 4o45’N and longitude 6o50’E.

Rivers state, named after the many rivers that border its territory was part of the Oil Rivers Protectorate from 1885 till 1893, when it became part of the Niger Coast Protectorate. In 1900

5 the region was merged with the chartered territories of the Royal Niger Company to form the colony of Southern Nigeria.

Malaria is endemic in all the LGAs in the three States and transmission is all year round due to the high population density and other population activities such as the creation of refuse dumps and open water collections. The State Ministry of Health has an RBM PIU which plans and implements malaria implementation activities, including net campaigns.

The state got 2.246 nets, all from the World Bank booster programme. All have been distributed except 4,010,540 pieces. These will be distributed during the mop up that scheduled to come up later in 2010.

2.3 Sampling Sampling in qualitative studies is usually theoretical. That is the researcher continues to conduct FGDs until new ideas stop coming out. However, for this study, the number of FGDs conducted in each State is contained in Table 1 below.

Table 1: Distribution of LGA 1 LGA 2 LGA 3 Groups Total Urban Rural Urban Rural Urban Rural Adult Males 1 1 1 3 Adult Females 1 1 1 3 Youth 1 1 1 3 Total 1 2 2 1 2 1 9

In each state, one LGA was randomly selected from each of the three senatorial zones in the state, given three LGAs per state and nine LGAs for the study. The communities in each selected LGA were clustered into rural and urban. One community each was sampled from the rural and urban clusters of communities in each LGA. This gave a total of six communities in three LGAs of one State, and 18 communities in nine LGAs of three States. The FGDs were however staggered across each state to cover 3 groups of adults, females and youth respectively. This gave a total of 27 FGDs in the entire study. See Table 2 for the senatorial zones, LGAs and communities visited in each State.

Table 2: Communities, LGAs and Senatorial Zones visited in each of the Study States by Locality State Senatorial Zone LGA Communities Locality Anambra Anambra Central Awka South Ukwu Orji Urban Nibo Rural Anambra North Oyi Oyi Urban Nteje Rural Anambra South Nnewi North Okpuno Egbo Urban Umudim Rural Bauchi Bauchi Central Ganjuwa Ganjuwa Urban Miya Rural

6 State Senatorial Zone LGA Communities Locality Bauchi North Katargum Azare Urban Bidir Rural Bauchi South Bauchi Kofan Madaki Urban Dumi Rural Rivers Rivers East Ikwere Isiokpo Urban Elele Rural Rivers West Bonny Bonny Island Urban Light House Rural Rivers Southeast Khana Bori Urban Bua Khani Rural

2.4 Instrument and Method of Data Collection

The instrument for data collection is an FGD guide, which ensured data on the people’s perceptions of malaria, its causes, prevention and treatment as well as the people’s access to, and use of ITNs. The participants’ demographics were also collected at the end of each discussion.

Discussions were held with groups of adult males, adult females and youth. The adult groups were homogenous and contained 6-12 persons per group. The youth group was however composed of both male and female and with 6-12 per group. The consultant, who is a PhD holder in Medical Sociology/Anthropology, facilitated each group discussion, and was assisted by other academics from the Department of Sociology/Anthropology, University of Nigeria, Nsukka. A member of the academic staff of the Department of Sociology/Anthropology served as note taker for each discussion. The discussions were tape recorded and, photographed, where permission was granted.

To ensure smooth discussion, a local guide was recruited to mobilize participants to the discussion sessions. The discussion sessions were made informal with light refreshment served to the participants during discussion. The team spent approximately one week in a state for activities which included mobilization of the groups, actual discussion and cross checking to ensure the discussion data are in good condition.

2.5 Method of Data Analysis

Data editing and validation were done on a daily basis, starting from the field and on return from field. This was aimed at ensuring that problems were detected as early as possible when it would still be possible to apply corrective measures.

Analysis of the data placed emphasis on the interpretation, description and recording/writing of what was actually said. The transcription was done in English. In going through the transcriptions, phrases with contextual or special connotations were noted and pulled out as

7 illustrative quotes in developing the ethnographic summaries. To do this, relevant themes were developed for the coding and sorting of the qualitative data and Atlas.ti version 5.0 software was used in managing the qualitative data. To do this, the transcripts were first processed with MSWord and converted to an ASCII file by saving it in a rich text format (.rtf) and later transferred to the Atlas.ti software for coding and analysis.

However, the Statistical Package for the Social Sciences (SPSS) software for data management was employed in the characterization of the respondents on the basis of the demographic characteristics. Descriptive statistics, such and means, percentages and a frequency table were employed in the presentation of the demographics of the respondents.

8 3.0 Results

3.1 Current Status of Malaria Control in the Study States

As is the case with other states in Nigeria, Anambra, Bauchi and Rivers States all have well established Roll Back Malaria (RBM) programmes with a mandate to control malaria transmission and eliminate malaria in the respective states. The states are also supported by the World Bank under the World Bank Malaria Booster programmes. Malaria control activities in these States are guided, but not limited by the National Programmes on Malaria Control in Nigeria, with Headquarters in Abuja. Each State creatively and innovatively plans its programme within a project implementation plan to address the malaria scourge.

One of the key strategies for controlling malaria in these states is the distribution and promotion of ITN use in households, especially among pregnant women and children under five years. The States recently conducted campaigns aimed at ensuring wider coverage in ITN ownership. There are also plans under way to launch the community directed intervention (CDI) strategies for ITN distribution and use in the communities.

With the CDI approach, it is hoped that communities will be effectively empowered and engaged to ensure greater coverage and sustainability of the ITN distribution mechanisms in the States. The communities will not only be involved in the implementation of malaria control through distribution of intervention commodities, they will also take charge of the implementation process. The communities will take major decisions on the mode, timing as well as distributors of the communities. They will also be empowered to monitor use of the intervention commodities to ensure compliance. According to the programme managers in the respective states visited, this strategy will promote effectiveness, ownership and sustainability of the programmes in malaria control. They however, noted that they were yet to be fully trained on the CDI strategy.

All the same, steps are on to prepare the grounds for the launching of the CDI strategy for malaria control in the states. For instance, the programme managers hinted that on various occasions they were invited to Abuja office of the World Bank to develop work plan for the CDI strategy. Meanwhile the process for the listing of the kindreds in the communities is on because the community directed distributors (CDDs) will be selected at the kindred levels in the communities.

Presently, the distribution of ITNs through campaigns in the communities has been successfully implemented, while waiting for the launching of the CDI model of malaria control intervention. FGDs were conducted to document the perceptions of the end users of these ITNs about the distribution process as well as the ITNs in the control of malaria.

9 3.2 Social Demographic Characteristics of the Respondents

A total of two hundred and thirty six persons were enlisted in the study and participated in the discussions. Approximately one-third of this was drawn from each of the participating States. Similar proportions are noticed in the different groups of discussions. That is approximately a third of the participants fell into the three categories of focus group discussion participants, namely adult female, adult male and youth (see Table 3).

Table 3: Distribution of Participants by Socio-Demographic Characteristics

Socio-Demographic Characteristics Frequency Percentage States Anambra 75 31.8 Bauchi 88 37.3 Rivers 73 30.9 LGAs Awka South 25 10.6 Bauchi 21 8.9 Boni 22 9.3 Ganjuwa 35 14.8 Ikwere 25 10.6 Katargum 32 13.6 Khana 26 11.0 Nnewi North 23 9.7 Oyi 27 11.4 Groups Adult Female 80 33.9 Adult Male 75 31.8 Youth 81 34.3 Sex Female 122 51.7 Male 114 48.3 Marital Status Married 156 66.1 Married Before 5 2.1 Never Married 75 31.8 Educational Level No Formal Education/Arabic 29 12.3 Primary 49 20.8 Secondary 116 49.2 Post Secondary 42 17.8 Occupation Student/Unemployed 51 21.6 Civil Servant/Health worker 56 23.7 Farmer/Fisher/Cattle-rearer 24 10.2 Trader 65 27.5

10 Socio-Demographic Characteristics Frequency Percentage Artisan 40 16.9 Age Group <19 years 15 6.4 19-24 37 15.7 25-29 29 12.3 30-34 14 5.9 35-39 23 9.7 40-44 34 14.4 45-49 25 10.6 50+ 59 25.0 Number of Children None 76 32.2 1-2 19 8.1 3-4 51 21.6 5+ 90 38.1 Under Five Children None 127 53.8 1-2 72 30.5 3-4 28 11.9 5+ 9 3.8

Slightly more than half (51.7%) of the participants were females. Over fifty percent (66.1%) of the respondents were married. Slightly less than a third (31.8%) was single while 2.1 percent were married before and currently widows. At least one in every ten (12.3%) participants in the FGD sessions had no formal education. About five in every ten participants (49.2%) had secondary education while approximately two in every ten had post secondary 80 Fig. 1: Age of Participants in the Three States (17.8%) and primary (20.8%) education respectively. 70 S

R The FGD participants were drawn from A

Y various occupational categories and were

N I fairly evenly distributed. For instance, 21.6 S

T 50 N percent were unemployed or students while A P I 23.7 percent were civil servants and health C I

R workers. Others include farmers/fishermen A P

and women/cattle rearers (10.2%), traders F

O 30 (27.5 percent and artisans (16.9%). The E G

A income levels of the participants ranged 20 from zero (0) to sixty thousand Naira per month with an average of N10,718.82 per 10 month (N10,718.82± N13,381.16SD).

ANAMBRA BAUCHI RIVERS STATE

The ages of the FGD participants ranged from 15 to 80 years with a mean age of 38.9 years (38.9±14.99SD). The ages of the participants were categorized into five year intervals. Though the age groups seemed fairly evenly distributed those aged 50 years and above appeared to have dominated the sample with 25.0 percent. This could be attributed to the lumping of many ages in that group. Otherwise, the young people aged 19-24 years led the sample with 15.7 percent. Those aged 40-44 years followed with 14.4 percent. The ages of the participants in the three states did not differ significantly. Figure 1 revealed that the ages of the participants ranged from slightly less than 20 years to 70 years and above. More importantly the median ages of the participants in all three States fell around 40 years.

About a third (32.2%) of the respondents had no children. However, slightly more than a third of the respondents had 5 or more children. On the average the participants had 3.76 children (3.76±3.79SD). Table 3 also revealed that in 25 Fig. 2: No. of Children and Children U-5 in slightly less than half Household of Participants in the Study States (46.2%) of the households 159 of the participants had 20 children less than five years old. The number of children less than five 15 years in the participants 15 households ranged from 1 to 10 with an average of 10 159 1.13 (1.13±1.57SD). 228 85 161 Figure 2 revealed some 5 differences between childbearing in Bauchi on the one hand and the other 0 two states on the other ANAMBRA BAUCHI RIVERS hand. With respect to STATE No. of Children in Participant's HH No. of U5 Children in Participant's HH number of children in the households of the participants, Figure 2 revealed that in Bauchi State, it ranged from 0 to more than 15 with a median of 5. On the other hand, Anambra and Rivers States had a range of 0 and somewhere around 10 children with a median of 3 children. Similarly, in terms of children under five in the households, Bauchi State differed from the other two States with a median of 0 child.

Figure 3 revealed that the participant were fairly balanced across the different states included in this study. Differences were only observed in the sex composition (p=0.026) and levels of education p<0.001).

12 The observed difference in the sex composition of the participants was mainly from the contributions of the Anambra sample, where the females (64.0%) far outnumbered the males (36.0%). Beyond that, the sex distributions of the sample in Bauchi and Rivers States were similar.

Understandably, the States differed by levels of educational attainments. More of the participants from Bauchi State had no formal education. This compares with the very small proportions of participants from Anambra and Rivers States. Bauchi is a predominantly muslim state, where Arabic education is common.

13 3.3 Common Health Problems

The discussions opened with a review of the common health problems in the communities. The participants were invited to mention the common health problems without prompting for any particular health problem. A variety of health problems were mentioned, including malaria. However, the health problems mentioned varied from State to State, even within and among LGAs in the States.

In Anambra State, for instance, the common health problems mentioned in Nnewi North LGA were limbs and waist pain, rheumatism, stroke and high blood pressure. However, malaria and typhoid had the highest occurrence as the major health problem. On the other hand, while, malaria and typhoid were mostly mentioned as the commonest health problems in Awka South LGA, eye problems, arthritis, stroke, diabetes were the other health problems mentioned here. Oyi LGA of Anambra State presented a slightly different picture as skin diseases like onchocerciasis, stoke and rheumatism featured prominently on the list of common health problems in the communities, and were actually mentioned before malaria, which is still seen as the commonest health problem. Below are samples of the quotes to illustrate the findings

The sickness we have in this community… are waist pain and leg pain [Participant: FGD, Female Adult, Awka South LGA, Anambra]

I will say the most common sickness among we women is leg pain. There is nobody that you will see now without either walking stick or struggle with her leg [Participant: FGD, Female Adult, Urban, Anambra]

We have something like rashes on the body, onchocerciasis, malaria and eye problem, which is too much in our community…. [Participant: FGD, Male Adult; Oyi LGA, Anambra State]

Malaria is one of the sicknesses that give a lot of problem [Participant: FGD, Male Adult, Rural, Anambra]

Malaria is more because it can come in different ways until that person goes for test and they confirm it to be malaria while that person must have been taking

14 treatment for another sickness. So there are different malaria [Participant, FGD, Female Adult, Urban Anambra]

Malaria is the highest among other diseases we suffer from now in our community Awka South and even in all Igbo land, malaria is the highest [Participant: FGD, Male Adult, Urban Anambra]

We have many health problems in our community like malaria because it is the most common sickness we have that disturbs a lot of people. [Participant: FGD, Male Adult, Urban Anambra]

Malaria should not be referred to as a common disease because it is not common. it is actually a very strong sickness that can kill somebody. [Participant: FGD, Youth, Urban Anambra]

Old people have the disease that is peculiar to them while young people have their own. But the one that is general is malaria and typhoid [Participant: FGD, Youth, Urban Anambra]

However, youth in Oyi LGA believed that malaria is on the downward trend due to government commitment to its eradication.

In this our community, malaria is common but from my own view, malaria is reducing gradually because the government is making effort to eradicate it. [Participant: FGD, Youth, Urban Anambra].

The Anambra situation appears typical of the other LGAs and groups from the other States in the study

Cough and malaria, waist pain, stomach bite, poison are the sickness we have here in light house [Participant: FGD, Youth, Rural Rivers]

Malaria is the type of sickness that people suffer too much here and typhoid too. [Participant: FGD, Male, Adult, Urban Rivers]

Actually, the sickness we have in this place at the moment is malaria because if you watch, if we are 100 in number here over 50 is sick with malaria. This shows that malaria is very here [Participant: FGD, Male Adult, Urban, Rivers]

There are diseases that affect us here in this community. That disease is polio. In fact, there is a child that is suffering from polio as I am talking to you now. Before there were 5 to 6 children that suffered this polio [Participant: FGD, Youth, Rural Bauchi]

Our main health problem here is malaria [Participant: FGD, Female Adult, Urban, Bauchi]

15 Our main health problem is malaria because it has been killing our children so much. Both men, women and children, our main health problem in this community is malaria [Participant: FGD, Male Adult, Urban, Bauchi]

As is the perception in Anambra, people in Bauchi and Rivers believe that malaria is on the downward trend. For example, see some quotes from Bauchi for illustration

Before malaria was so much but now the level has gone down [Participant: FGD, Female Adult, Rural Bauchi]

The level of malaria now is low from what it used to be [Participant: FGD, Male, Adult, Urban Bauchi]

3.4 Knowledge of Malaria in the Communities

All participants were well aware of malaria as a major health problem. This is reflected in the misconceptions about malaria captured in some quotes. In relation to other health problems, malaria was described as a ‘big’ sickness because it has the tendency of coming with other health problems and may occur several times in one month. Below are some quotes that illustrate the magnitude of malaria as a problem in the communities.

Malaria is very big sickness in this community. If you go to the hospital, most children that are brought to the hospital is because of malaria. If there are five children on admission in the hospital, three of them are suffering from malaria…. [Participant: FGD, Youth, Rural Bauchi]

Malaria is very rampant here in Oyi and even in other places. It is not a new thing. People always have it and that is why it is well known here [Participant: FGD, Youth, Rural Anambra]

Knowledge of the cause of malaria was however mixed, and appeared generally low. While some of the FGD participants knew that the malaria parasite is transmitted through mosquito bites, others mentioned factors like eating too much oily food, working too hard and exposure to sun, dirty environments, water bearing plants like plantain, coco-yam, and water leaf, around the home.

Some even believe the problem with mosquito is limited to the troublesome bite and disturbance from sleeping. Thus, once they are able to sleep, the mosquito bites will constitute no major source of concern. For instance, a male participant in an FGD session in rural River State had this to say

….I don’t think malaria is the problem because once you drink enough kaikai (local gin) you will sleep and will not know if mosquito is biting you [Participant: FGD, Male Adult, Rural Rivers] 16 Other participants in different FGD sessions however noted that malaria incidences could be attributed to multiple factors. See quotes below

Malaria is associated with many factors. It is not caused by a single factor. The environment in which people are living can cause malaria. Stagnant water and the kind of water we are drinking all cause malaria… [Participant: FGD, Male Adult, Rural Rivers]

The cause of malaria in this village is from us. You see most of the women in this village have not washed their wrapper for the past three months. So dirtiness causes malaria. If we clean our environment we are going to be safe from malaria [Participant: FGD, Male Adult, Rural Rivers]

Another cause of malaria is refusal to sleep under net. The nets they shared to use in quantum is bastardized by some people who use it to do windows and door blinds instead of sleeping under it. Eating of soured garri (cassava flour) also causes malaria [Participant: FGD, Male Adult, Rural Rivers]

A few however know that mosquitoes transmit malaria parasite when they bite people. For example a female participant in an FGD session in urban Rivers noted that …what causes malaria is when you are bitten by mosquito…”. Another female participant in an FGD session in the urban area said, “…what I know is that it is anopheles mosquito, that female mosquito that bites. When it is infected and it bites another person that person will be sick…”.

In Bauchi, like the situation in Rivers and Anambra state, malaria is attributed to environmental factors. According to a participant in a female FGD session in the urban area,

…the main cause is stagnant water and bad drainages everywhere, poor hygiene and filthy environment. Formally government used to fumigate and spray the gutters with chemicals that kill mosquitoes. But now they have stopped and the mosquitoes breed in these gutters and stagnant water and so spread malaria in the community

In this community we do a lot of farm work and working under this harsh sun causes malaria, and not keeping our environment clean… [Participant: FGD, Youth, Rural Anambra]

What causes malaria in our community is bush. There are so many bushes here in our community which causes malaria and bad stagnant water in the gutters and in our different homes. Collection of dirty water causes malaria. We do not get malaria only from bad water but also from uncovered drinking water and after mosquito will enter inside it. When we drink it the person contacts malaria [Participant: FGD, Youth, Rural Anambra]

17 While such environmental factors like stagnant water, bushes and dirt around the homes may have some bearing on the transmission of malaria, because of the suitable breeding site they provide for mosquitoes, the plasmodium parasite vector, the relationship the people tended to draw between these factors and malaria transmission tend to demonstrate their ignorance. All the same, it is important to note that within the youth groups in the three States mosquito bite was mostly mentioned as the major cause of malaria and its transmission.

… the causes of malaria are mosquito and poor nutrition [Participant: Youth, Urban Bauchi]

… it is mosquito, when they transfer their plasmodium to somebody’s body [Participant: Youth, Rural Rivers]

It is caused by mosquito and also the way you keep your environment [Participant: FGD, Youth, Urban Rivers]

What causes malaria from my view is mosquito and too much sun…. [Participant: FGD, Youth, Rural Anambra]

What causes malaria is nothing but mosquito and too much work. In this our community old women do a lot of farm work which increases the rate of malaria because of the mosquito that bites them in the bush [Participant: FGD, Youth, Rural Anambra]

Knowledge of the cause of malaria appeared higher among the youth. In Rivers State however, the youth stressed such environmental factors like stagnant water, water bearing plants, exposure to sunlight, activities of oil companies like gas flaring, oil exploration, bad drinking water as the major causes of malaria, as their older counterparts did.

… one of the causes of this malaria is our water. We do not have borehole or any kind of pipe borne water so it is affecting the community with high fever and any other kind of fever you know…. [Participant: Male Adult, Rural Rivers]

This may be attributed to the peculiar nature of the environment in Rivers State, with much of gas flaring, oil spillage among other oil related realities in the State.

All the participants recognized that there is no age segregation in susceptibility to mosquito bites and malaria attacks. According to a youth in Bori, Rivers State, “mosquito does not know age and bites every body”. In Anambra, the youth in Nnewi North stressed that “mosquito will not ask for your age before biting you…”.

There is no particular people because if mosquito wants to bite you, it will not ask if you are pregnant or not and if it bites you it will give you malaria. [Participant: FGD, Youth, Rural Anambra]

18 All the same, pregnant women and children under five years were recognized as the group most affected by malaria. This is true of all the groups and study sites. Most participants mentioned low immunity as the reason for this. According to a participant in an FGD session with adult females in Anambra State, “ the blood of the pregnant women is being shared with the foetus while the under five child’s blood is not yet strong”. Below also are some illustrative quotes from other FGD sessions in the study sites on this.

The most affected are the children, then women, then pregnant women [Participant: FGD, Female Adult, Urban Bauchi]

Children and pregnant women are affected most. [Participant: FGD, Male Adult, Rural Bauchi]

It is the children that suffer malaria most [Participant: FGD, Male Adult, Rural Rivers]

I see that babies and pregnant women suffer malaria most… [Participant: FGD, Female Adult, Urban Rivers]

There were some participants who did not believe in any differences in malaria impact on any group. According a male FGD participant in Rivers, “…malaria does not know age…”.

3.5 Management of Malaria

Generally, there is evidence of prompt management but not necessarily appropriate treatment of malaria at the onset of signs and symptoms. Participants’ first action is to visit the nearest chemist to “mix” drugs. Only when this fails do participants visit health centre or hospital. Although a few mentioned going for laboratory test but this depended largely on the financial buoyancy of the concerned person or the carers. According to a male FGD participant in rural Rivers State,

In this our community we do not have a health centre. So any time we have fever we just go to the chemist and ask for drugs but we do not even know what is exactly wrong because we do not go for tests

We rush to any nearby chemist to purchase all these drugs. We do not know the one that is adulterated and the one that is real. As villagers we just take them like that [Participant: FGD, Youth, Rural Rivers]

What I observe people do when they have malaria is to go to the nearby chemist. Some people will go their farm and get some roots and herbs and boil it and drink [Participant: FGD, Youth, Rural Rivers]

It depends on availability of money. If you have money you go to hospital if not you go and boil leaves [Participant: FGD, Female Adult, Urban Anambra] 19 There was also large resort to traditional medications as participants in Anambra State, particularly mentioned that current malaria drugs in the market were no longer effective. Some participants in the youth group in Anambra State would only use traditional medication for the treatment of malaria. Below are some illustrative quotes.

In this community, anybody that has malaria; there is a native way we do it which our ancestors thought us. But now the person will go to hospital. But there are native herbs and there is one whereby you get some leaves and cook it and cover yourself with wrapper or mat and the heat from those cooked leaves (local steam bath) will cause you to sweat very well. After that you bathe with the water, drink the water and it cures malaria very well [Participant: FGD, Male Adult, Rural Anambra]

The same opinion was expressed by women in Bauchi and Rivers State as well as men in Nnewi North, who felt that the native medicines were natural and unadulterated.

Our people have medicine for malaria. There are some people that know how to prepare the malaria medicine locally in this our community to cure malaria before orthodox drugs now came. But after the people are told to go to hospital [Participant: FGD, Male Adult, Urban Anambra]

Some women also apply traditional treatment. They will collect the leaves and roots of some plants like dogon yaro and boil it and give the child to drink [Participant: FGD, Female Adult, Rural Bauchi]

In our community, people do not believe in taking orthodox drugs when one has malaria. They believe that traditional medicine is more effective and it cures malaria very well. There is a place they get traditional medicine and they give birth in that place. It is a maternity and that is the place people always go to get this traditional medicine to cure malaria [Participant: FGD, Youth, Rural Anambra]

Agreeing, another youth in an FGD session in Anambra State said,

What this brother said is true because some people believe in traditional medicine. Even me I believe that traditional medicine is better for treatment of malaria and that is what I take always [Participant: FGD, Youth, Rural Anambra]

However, there were a few dissenting opinion who did not believe in the traditional medication because it has no standard dosage. A female adult in an FGD session in Anambra rural argued that the sick person goes to hospital for treatment.

3.6 Treatment of Malaria

20 Different ways of treating malaria as mentioned by participants include, boiling of roots and herbs of lemon grass and lipton tea. Others include the use of dogonyaro for drinking and for steam bath. Some other participants preferred to go to chemist to purchase drugs which are recognized to be largely ineffective, however reasons for use of this method of treatment for malaria was its relative cheapness and nearness to the participants. Participants also mentioned going to the health centre but drugs in the health centre are free only for pregnant women and children under the age of five. However drugs from the health centres are recognized for their superiority and effectiveness over the ones available in the chemists. Although majority of the participant mentioned that people first went to chemists, there is indication that on a personal level, most participants from the rural areas preferred to take traditional medication and only visited chemist or health centre when the malaria is viewed as “stubborn malaria”.

3.7 Prevention of Malaria

Malaria is seen by all participants as very serious ailment. According to participants, malaria is so serious that “it can make somebody to go mad”. “It kills a lot of people”. “It makes people to be very weak”. For them “nobody sees malaria as cough or catarrh because malaria is very serious”. Other typical quotes include:

Malaria is a big sickness that even causes people to become mad. It can damage one’s brain… [Participant: FGD, Male Adult, Urban Anambra] …malaria is very serious it has killed many people… [Participant: FGD, Male Adult, Rural Rivers] Malaria is so serious that it makes people to be weak, lean and even make some to be blind [Participant: FGD, Male Adult, Rural Rivers]

Most of the deaths we record are caused by malaria… [Participant: FGD, Male Adult, Rural Rivers]

Malaria is a very serious sickness and is very common. It is one of the sicknesses that disturb our people. It is part of the household properties we have due to its commonness in the community. But it is unfortunate that it is a sickness. It is very common [Participant: FGD, Male Adult, Urban Anambra]

The participants belief that dirty environment is haven for mosquitoes makes keeping the environment clean a top priority in the effort to protect themselves from malarial attack. Apart from environmental cleanliness, some participants do little or 21 nothing because there is very little you can do to protect yourself since you cannot carry net around. For the participants in Anambra, net can only protect one inside the room but not in the farms and other places. In the word of an Anambra rural youth in an FGD session, “we prevent malaria by using that net but we cannot carry the net to the farm or market. Other solutions need to be found”.

In Rivers state, participants are of the view that the ITN is good but that it is very inadequate especially as the youth are excluded in the distribution. According to a participant in the youth group, “my father uses one and my mother uses one” so children and youth do not have protection from malaria. In an FGD session with Anambra rural youth, it was advised that in sharing the nets, “they should share house to house and if they share it they should give to youth that is boys and girls because they have a place they sleep in so that everybody will get it”. Other participants in FGD session noted that

Well the net they brought has helped to reduce mosquito bite. That is how people have managed. But for those that do not have it I don’t know how they manage [Participant: FGD, Female Adult, Urban Rivers]

The ITN that the World Bank gave to us is what we are using in this community [Participant: FGD, Male Adult, Rural Bauchi]

Participants in all the states agree that the net works well for malaria prevention but all also insist that the net is grossly inadequate for the number of people requiring and needing it. Mainly participants from Anambra state mentioned the use of mosquito coil and shelltox for protection from malaria, those from the rural setting used the burning of certain leaves, the smoke of which has the ability to drive away mosquito as the way of protecting themselves from malaria. In Rivers however, there were participants who took drugs to protect themselves from malaria. In the words of a female participant in an FGD session,

…what I know is coartem and you should clear the bush around your house and do not allow stagnant water remain around your house because if there is stagnant water mosquito will breed there and will enter the house and bite. And if you have net, you should get your family to sleep inside

22 3.8 Sources of ITNs and Costs

In Anambra state, all participanys got their net through the health centres nearest to them while those in Rivers state got from either the health centre or the house of the village head, where there are no health centres, or primary school or church close to the people. Interestingly none of the participants claimed to have paid any money before getting the ITNs. Below are illustrative quote on the sources and cost of ITN in the different communities visited.

We got it (ITN) from government through our Mai Angwa (community head) [Participant: FGD, Female Adult, Urban Bauchi]

We get net from the hospitals or designated distribution points [Participant: FGD, Female Adult, Rural Bauchi]

I got my net from health centre [Participant: FGD, Male Adult, Urban Anambra]

I got net the time they shared net in Nteje health centre and they gave two to a family [Participant: FGD, Male Adult, Rural Anambra]

I collected from the hospital that is near our ward [Participant: FGD, Female Adult, Urban Anambra]

They brought the net to the chief’s house and people went there to collect them with their cards [Participant: FGD, Male Adult, Urban Rivers]

We get the net through the health centre in Bonny [Participant: FGD, Male Adult, Urban River]

The time I gave birth is the time they gave me net which I will use with my kid in the hospital [Participant: FGD, Female Adult, Rural Rivers]

3.9 Perceptions on ITNs

In all three states visited, the ITNs are viewed as very good by all participants. The nets are accepted by the people as capable of preventing malaria. Majority of participants have nets and

23 use them accordingly. However, the nets are not easily available or accessible. The quotes below buttress the people’s perception of accessibility of the nets.

It is not easy to get nets [Participant: FGD, Youth, Rural Rivers]

It is not easy, which everybody knows. It is not easy [Participant: FGD, Male Adult, Urban Anambra]

… it is not easy to get nets. Many people suffered for a long time before they could get the net [Participant: FGD, Youth, Rural Anambra]

… actually it is not available because it only 40 percent of us that got the net and sixty percent did not get and they need it seriously [Participant: FGD, Male Adult, Urban Bauchi]

This is because a good number of the participants who did not get the net when it was distributed have not been able to access the nets. There is general agreement among the participants that although the nets are good, they are not enough. All participants agreed that the nets are “free gifts from the government, so we all got it free of charge without paying even one naira”.

Desirability of the net is obvious but this is marred by wrong perceptions that emanate from inadequate sensitization. Although a good number of the participants who have the nets claim to use them, there are others who do not use them for various reasons. For instance, there are mothers who reserve the net for their unborn grand children whom they expect from their currently teenage daughters. There are also those who cut up the nets and use them as door and window blinds because the two nets given to each family is not adequate for the needs of very large families. So in order to “protect” everyone the nets are fixed to the windows and doors. Deserving of mention here too, are those who do not use the net because of wrong perceptions. In Anambra and Rivers states, there are people who do not use the net because “I heard that one man slept in the net and vomited blood” and because, “I heard that it causes skin irritation because the chemical is too much”. In the same vein, in Bauchi state there are people who think that the nets are laced “with birth control chemicals”. Generally the nets are still in very high demand. Below are some quotes that support the people’s appreciation and demand for more nets, irrespective of study sites and groups.

Everybody is happy about the net. We like it and we want it. [Participant: FGD, Male Adult, Rural Rivers]

With the use ITNs malaria has reduced a lot and we are grateful for this [Participant: FGD, Male Adult, Rural Bauchi]

With the use of mosquito nets given to us we do not have malaria again. The mosquito net (ITN) has reduced malaria so much in this community [Participant: FGD, Male Adult, Rural Bauchi]

24 The ITN that they have distributed to us, people are very happy about it [Participant: FGD, Male Adult, Urban Bauchi]

Truly, this ITN was distributed in this community. There are some people who did not get the ITN. This ITN has been of immense benefit to us. Before mosquito disturb us so much but now it does not disturb us so much again. We put one ITN inside the room. We put one in the veranda (balcony). When we enter the room without children we are inside one. If we come out to stay in the veranda we are inside the ITN. So we are now saying bye-bye to mosquito [Participant: FGD, Female Adult, Urban Bauchi]

Before they have this perception that the net is meant for family planning (control of child birth) and that the net can kill. But having gotten the net those people with that perception have seen that their perception is wrong. Now they want to use it also. [Participant: FGD, Male Adult, Urban Bauchi]

Since after sharing of this net, those that got it said malaria has reduced. [Participant: FGD, Male Adult, Urban Anambra]

I see people’s acceptance of the net and they are happy about the net [Participant: FGD, Male Adult, Urban Anambra]

Within my compound, we are one of the beneficiaries. My mother benefited and she is using her own. My own family benefited and we are using it. My late senior brother’s family benefited and they are using it [Participant: FGD, Male Adult, Urban Anambra]

… . Yes, but not everybody collected. There are people who did not collect [Participant: FGD, Female Adult, Rural Rivers]

Some of us that got our nets are very happy. We appreciate government and World Bank for providing us with ITNs [Participant: FGD, Male Adult, Urban Bauchi]

People that want it are many. There are people that will like to sleep in it with heat provided mosquitoes did not bite him/her. It depends on the person’s body [Participant: FGD, Male Adult, Urban Anambra]

3.10 Use of ITNs in the Communities

The success of any programme depends not only on the efficacy of the intervention provided, under ideal and controlled conditions but also on achieving optimal use by the target population. In the opinion of participants, those who got the nets are using it because they want to protect themselves from malaria. According a youth in an FGD session in Rivers Rural community, “I 25 believe people are using it. In another FGD session with urban females in Rivers State, a participant said, “…yes some people sleep under net. Some do not because they complain of heat”. This is only one of the reasons for low usage of the nets, as participants attest to the comfort they feel under the warmth of the night on cold nights. Countering the of the net induced heat, a participant in an FGD session with female adults in Khana LGA, Rivers State, a female participant said she enjoys the warmth from the nets particularly during the rainy season. In her words,

you know that you can never please the world. There is nothing you do that people will praise you…. As rain falling, if you sleep under this net you will enjoy sleep. I like this net very much … and I sleep very well in it and I will like government to bring more another participant in the same discussion session said,

I like the net because during rainy season there is cold. But when you sleep under the net it is no longer cold

Reasons for low usage also include inadequacy of the net for the number of people in the home, ignorance regarding instruction for use, fear of the unknown as well as spousal disagreement. Some keep it for their grand children. Below are sample quote that illustrate these points.

Mosquito is no problem because of the net they gave. Some people use it (ITN) as window blind and door blind. They don’t use it the way they should. [Participant: FGD, Male Adult, Rural River]

We use the ITN to cover the windows with nails and everywhere through which mosquito can enter the room [Participant: FGD, Female Adult, Rural Anambra]

Some people are using it but some are not because in some families they are ten in number and there are only two nets so only two people will use. Our own, my mother is using one and my father is using one so the children are not using. [Participant: FGD, Youth, Urban Rivers]

Wrong usage of the net was also reported. Some of those who use the net wrongly live with the illusion that they use it often. One way they use wrongly is to fix it to the doors and windows as a way of making every member of the household benefit from the net. According to a participant in an FGD session with youth in rural Anambra,

…some people use it for the real purpose of preventing mosquito bites. In short, I will say people wish to use it to protect themselves against mosquito bite but the problem is the wrong usage. Some simply use it as window and door blinds still with the purpose of warding off mosquitoes but this is the wrong approach

26 Some people are selling the net. I swear to God, I bought it for two hundred naria. I am using it to sieve sand. [Participant: FGD, Male Adult, Rural Rivers]

Typically, participants in some of the FGD sessions, who received the nets but fix them on their windows and doors argued that they use their nets everyday. For instance, a participant in an FGD session with youth in rural Anambra, said

… some hang their own on the bed and there are some that put their own on windows and doors. So people are using their own. Like me I put my own at the window so I use my own everyday

I use ITN and cover the windows and doors [Participant: FGD, Female Adult, Rural Anambra]

I use the ITN to cover our bed, and doors and window [Participant: FGD, Female Adult, Rural Anambra]

Let me first thank the government for the net they shared to us and also condemn what our fathers and mothers did. I heard that some of them registered twice as they were giving two nets per person. They packed it so his/her grand children will use it in the next five years without knowing that it has expiry date. But if they make use of it and also share among the people that did not receive because the government may tomorrow bring better ones for our children. But they don’t understand [Participant: FGD, Youth Rural Anambra]

3.11 Number of Participants who own ITNs

Majority of the participants had ITNs although they all maintain that it is not adequate for their needs. Those who did not have nets expressed the desire to get their own nets. When questioned on the reasons why they did not get their own net during the distribution period, many said they were not at home when the net cards were distributed. Below are some quotes on why people do not own ITNs

…many did not get it because when they came for registration many people were not around… [Participant: FGD, Male Adult, Rural Rivers]

I don’t have net. I was not at home when they shared the card…[Participant: FGD, Female Adult, Urban Rivers]

They did not give me because I am single [Participant: FGD, Youth, Urban Rivers]

During the distribution of the cards, it was only the housewives that they gave the nets…. We were told that we will not be given the card, that we were not married [Participant: FGD, Youth, Rural Bauchi] 27 When the ITN was distributed to us, we collected and benefited from it. But some people refused to collect it because they said if one sleeps under the ITN it will cause itching and even death. But with mobilization and enlightenment on how to use the ITN we are told that ITN has some medicine in it, so we should put it outside for 24 hours before use. We followed the instruction and started using it, when they saw that it does not harm anybody they changed their minds. [Participant: FGD, Youth, Rural Bauchi]

3.12 Number of Participants who Slept under Net the Previous Night

Majority of the participants in all the states visited did not sleep under their nets last night. Reasons for not sleeping under net ranged from being too tired to tuck in the nets to too much heat. The participants complained that they experienced too much heat when they used the net so on particularly hot nights the nets were deliberately avoided while they enjoyed the nets on cold nights. However there are participants who claimed to use their nets in spite of weather and temperature.

… No I did not sleep there because my husband and I were quarrelling so I refused to sleep there I went and slept somewhere else [Participant: FGD, Female Adult, Urban Rivers]

Participants’ Opinion on Distribution of ITNs in the Communities

In Anambra state, participants were satisfied with the way the distribution was done, but in order to ensure wider coverage, participants were of the opinion that there should be an announcement so as to make people stay home to collect their net cards. This is because most people who did nor get the net, were not at home to collect net card when it was distributed. Participants were particularly pleased with innovation of tearing the nets out of the packets and giving the bare nets to the people to encourage them to use it instead of storing or selling them. In Rivers urban communities, the distribution was also applauded but in the rural communities, participants who are predominantly farmers suggested that the distribution should be done on Sundays and in their various churches. The same is the situation in Bauchi. See quotes below.

Before they gave us ITN, they first collected our names according to the number of wives we have…. They now gave us cards. On the day of the distribution we gave them the cards and the ITN was given to us for free at the hospital. If you do not have card you are not given ITN [Participant: FGD, Male Adult, Rural Bauchi]

The only problem is that when they came to register people they came when people had already gone to farm. So next time they should come when people are at home. That is the only problem [Participant: FGD, Male Adult, Rural Rivers] 28 They only gave to those who registered. So those who went to farm that day did not get net. I don’t think I like the way they shared it because too many people did not get. [Participant: FGD, Male Adult, Rural Rivers]

This time was different from last time because before they will just give you like that. But this time around they will tear the packet off and give you the net naked. They tore it because they found that people were storing the nets and not using it or even selling it. So they tore off the packet in order to free people to use the nets [Participant: FGD, Female Adult, Urban Rivers]

… the reason is that people expected to get as many nets as the number of people in their household. When they got the first net and it was shared and it finished, they were not happy. The problem we have is that people wrote their names and the names of their wives and the number of children they have and they expected to get the number of nets that is equal to the number they have in the household and they felt disappointed when they were given only two nets while there are households that were twelve in number [Participant: FGD, Male Adult, Urban Anambra]

3.13 Suggestion on Ways of Preventing Malaria in the Communities

Majority of the participants would like government to help clean their environments in order to prevent malaria. They also suggest the supply of more net and adequate drug supply in the health centres. However one participant noted that one sure way of preventing malaria is by teaching the people preventive methods like the use of net because according to him, the people believe so much in treatment instead of prevention and that is why they keep asking government to bring in more drugs. Participants in Anambra State suggested that instead of giving two nets to families that may require eight nets, it may be more economical to convert the nets to window and door nets. Generally more nets are demanded because more children are being born everyday and the old nets continue to need replacement. Below are quotes that support the claims above

One sure way of eradicating malaria is by educating the people more about prevention and why it is necessary to prevent malaria. Our people only trust treatment not prevention. From my observation, many people have cut up their nets and are using it as curtains. There is need for proper sensitization and training on why they must use net and prevent malaria [Participant: FGD, Male Adult, Rural Rivers]

…. Government used to send public health official who go round to inspect the homes and compounds of people. If that can be done now, it will make people to keep their environments clean and remove stagnant water and water bearing plants from their homes [Participant: FGD, Male Adult, Rural Rivers]

29 … they should bring more nets and let the nets go round both married and unmarried people, children and adults. If it reaches everybody it will help us prevent malaria since mosquito does not know who is married or not. Again, if it reaches everybody, no one will need to buy it from anybody [Participant: FGD, Female Adult, Urban Rivers]

We suggest, if your group could embark on something like during rainy season, during that time mosquito is at its high rate, if there is something they can produce and spray within villages and areas that encourage them, something that cannot be harmful to human life and kill mosquito, it will help to reduce this malaria. If they can produce anything, they can distribute within homes or spray through automobile vehicles or spray in the air once mosquito breathe in it will die that will reduce mosquito population because we are told right from infancy that if mosquito bites you, maybe after some days you will develop malaria [Participant: FGD, Male Adult, Urban Anambra]

First is to clean our environment so that we don’t allow mosquito to breed. Also the government should add more mosquito nets for those who did not collect [Participant: FGD, Male Adult, Urban Bauchi]

3.14 Suggestions on Ways of Improving Distribution of ITNs in the Communities

While participants in Bauchi appreciate the current distribution method, they also suggest that using the heads of the communities will make for wider coverage because the community heads know each person in the community and will ensure that no one collects more than is due him. In Rivers, the churches are believed to be better points of distribution because as farmers and fishermen and women, the only day they are found at home is Sunday. Anambra is in support of using community leaders. See typical quotes that support these.

The proper way to share these nets is to encourage the health people to be sharing very well. But it is better to change and share it through the churches. Let the pastors share it to their members [Participant: FGD, Male Adult, Rural Rivers]

The method was that they spend seven days distributing cards to various households. After the seven days we came to Saraki’s house and spent another four days indicating when to give each person his/her net. So if they can use the same method it will work [Participant: FGD, Male Adult, Urban Bauchi]

What can be done so that the net can reach everybody is that in each street there are leaders of that street and these nets should be given to them to share to their people. If they bring it to the health centre not everybody will know about it [Participant: FGD, Male Adult, Urban Anambra]

30 3.15 Suggestions on Ways of Making People Use ITN in the Communities

Health education is suggested to be the remedy to making people use ITN. A participant in Khana, adult males captured this clearly when he said...... ”many people have net but they are not using it

I think the solution is to do what we It is true that people have listed. Let the nets get to the complain of heat, but giving youth, who will then demonstrate the them health education either use of the nets to the older people then through church, school, educate the people on the uses. Involve market etc will make them the local community groups in the see that enduring that heat distribution and enlightenment of the is better than having people because if the people hear it malaria. Then the net from our own people they will believe should be shared through fast. Right now people think the net can the community leaders. kill and as such are afraid to use the nets There should also be [Participant: FGD, Youth; Rural community sanitation to remove stagnant water which attracts mosquito. [Participant: FGD, Male Adult, Rural Rivers]

After distributing the net the community leader should call all the leaders of various quarters and tell them that everybody should be using the net. [Participant: FGD, Male Adult, Rural Bauchi]

…explaining very well how we should use it so that we don’t have double mind on it [Participant: FGD, Youth, Rural Anambra]

…there is nothing I can say because I cannot even guarantee you I will use the net. It is very harsh from what other people have said. Maybe when I am convinced I will use it. I know it protects the user against mosquito bite but what of the itching and heat it causes the users. These issues must be addressed if people will use the nets. [Participant: FGD, Youth, Rural Anambra]

31 4.0 Discussion Conclusions and Recommendations

4.1 Discussion

Malaria is a major health problem in the three states under review. The magnitude of the malaria is easily noticeable in the sentiments with which the people expressed their concerns about malaria. In relation to other health problems, the people consider other health problems no match to malaria because according to them malaria could come with other illnesses, it has killed many people in their communities and even made some go mad (cerebral malaria). Effort to control malaria is thus very easily recognized and appreciated.

However, knowledge on the causes of malaria is mixed. Some believe malaria is caused by multiple factors like failure to wash wrappers, eating oily food, exposure to sunlight, and working too hard as well as drinking mosquito infested water. Others blamed the transmission of malaria on environmental factors like oil spillage and gas flaring, water bodies such gutters, water bearing plants, dirt. Another factor that was mentioned by some of the participants in the FGD sessions is mosquito. While the environmental factors may be considered correct, some of the participants listing the environment factors did not however draw a correct link between the environment and mosquito breeding on the one hand, and malaria transmission on the other hand. In Rivers States, where the malaria situation was blamed seriously on environment, the commonest link they made is that the oil exploration activities of the oil companies are responsible for the malaria situation. Attempt to blame malaria on everything could be appreciated for the overwhelming impact of malaria on the people’s existence and the desperate search for solution.

To prevent, treat and/or manage malaria, the people resort to all sorts or practices like taking anything bitter such as dogon yaro, bitter leaf, unripe pawpaw and its leave, among others. Some even relied of drinking kai-kai (local gin) and local steam bath. Others use local herbs and roots while a few use orthodox medication. This is akin to the argument of the health belief model (HBM) (Rosenstock, 1974). HBM argues that the perceived severity of any problem as well as the perceived effectiveness of available solutions influence the adoption of intervention. However, it is pertinent to note here that reliance on the orthodox drugs is very low, as these drug are considered adulterated and ineffective.

Recently, however, the people are beginning to appreciate the effectiveness of insecticide treated nets in the prevention of mosquito bites and malaria transmission. Some even attest to the fact that with the nets, malaria is now on the downward trend. They endeavour to collect their free nets for this purpose. Albeit, those who succeeded in collecting the nets, which were given free under the World Bank Malaria Booster programme, put it into different uses. While some, in appreciation of the efficacy of the nets reserved it for their grand children, yet unborn, others use them as door and window blinds in the hope that all in the household will be protected, since only two nets were given to household that may be as large as twelve or more. Some, unfortunately put it to the most absurd use, such as sieving sand for plastering houses.

32 All the same, some community members indicated that they were not given the nets either because they were not at home when the net cards were distributed or for being unmarried. The youth in particular were not targeted in the net campaigns and were not given the nets.

Some however complained about severe adverse effects of the nets. In some extreme cases it is alleged that the nets could cause cough, catarrh, skin irritation and even death. Further discussions showed that none of the participants had actually seen anyone who died after sleeping in the net. The fear of the net is largely due to rumours. Other speculations that limit the acceptability and use of the nets, is the fear that it is meant to control population growth. Some even discouraged the use of net and recommend reliance on kai-kai instead. For this category of persons, sufficient consumption of kai-kai will put one to sleep and make the person oblivious of the biting menace of mosquito, implying that the only problem with mosquito is the disturbing “ring tone”. These rumours and misconceptions of the nets could be blamed on poor health education and sensitization on the nets. The health workers are often in a hurry to share the nets without taking time to educate the people on appropriate net usage. The people are left to speculate on the nets. For instance some argued that since they were asked to keep the nets out for 24 hours, it means there must be something dangerous about the nets. Speculations such as these spread fast and have lasting consequences for net use. This consequently leads us to very vital and practical suggestions made during the discussions on how best to promote net use in the communities.

A very pertinent suggestion made in many of the FGD session was the need to involve the community in net distribution. In all the States, the involvement of community leadership structure and local organizations like churches, community heads and the youth was strongly advocated. Their suggestion was informed by the need to promote acceptance and compliance. They argued that the benefits of involving the communities are many fold. One is that it removes rumour and misconception, because they believe their own people who tell them to use the nets. Another is that it will remove the current problem of inadequate supply and distribution because the community will do an accurate registration of themselves and will be there to notice those who were absent as they return. More important, the community resource persons will also educate the people on proper usage, monitor and encourage same. This will eliminate situations such as the current use of the net as window and door blinds, for instance.

The promotion of ITN use is one of the key strategies for the control of malaria in the three States under review. In 2010, campaigns were undertaken in these states to distribute nets and create awareness on the use of nets as a way of controlling malaria. The target of the campaigns was to ensure that each household in the states gets at least two nets. This target was to a large extent met in the three states. All the same some households complained that they were not given nets because they were absent when the registration of households and issuance of net cards were undertaken, preparatory to the net distribution.

33 4.2 Conclusion

 Malaria remains a major problem in the communities. It is considered the worse health problem in the communities.  People are keen on controlling malaria, and would use anything they perceive as effective in malaria control

 ITN is widely accepted but unfortunately put into many wrong uses due to ignorance. Some use it as window and door blind. Some use it to sieve sand some prefer to preserve it for their unborn grand children

 Moreover, there are still misconceptions and fears about the nets, as the nets are believed to be capable of inflicting pain and death on the users

 The nets did not get to all households for many reasons, including being absent during the registration and issuance of net cards, which were preparatory to the net campaigns, being unmarried etc.

 The malaria control programmes in the States under review endeavour to undertake net campaign as their major strategy for controlling malaria. This however achieved only modest successes because, the nets did not reach all that should have nets and usage is largely unmonitored.

 The people made suggestions on ways of ensuring greater coverage and utilization of net in future.

4.3 Recommendations

Following from the foregoing the following recommendations are made to ensure greater success in future ITN campaigns and distribution in the communities.

 Efforts should be made to address the current gap in knowledge about the causes of malaria and the impact of mosquitoes in the communities.

 The people should be made to appreciate the need to prevent malaria in the communities, using the ITNs

 There is an urgent need to re-strategize the net distribution process. As was suggested in the discussions, communities should be involved in all the processes of prevention that is built on net use. This is important because access to nets alone do not translate into proper utilization of the nets. Community members and their leaders are better positioned to dispel rumours and misconceptions about ITNs as well as convince their members to use nets. They are also in a position to install the nets correctly and monitor 34 net use. This is in line with the community directed intervention (CDI) strategy that has been widely acknowledged as successful in the delivery of other health interventions in many African communities including the hard to reach (Okeibunor, et al, 2004; Remme, 2004; Amazigo, et al, 2007, The CDI Group, Forthcoming).

35 References

Amazigo_U, Okeibunor J, Matovu V, Zoure´ H, Bump J, Seketeli A. (2007). Performance of predictors: Evaluating sustainability in community-directed treatment projects of the African programme for onchocerciasis control. Social Science & Medicine 64:2070–2082

Centers for Disease Control and Prevention (2007). “Alternatives for Pregnant Women and Treatment: Severe Malaria”. Atlanta, USA.

Federal Ministry of Health (FMOH) (2004). “Malaria Situation Analysis Document”, Federal Ministry of Health, Nigeria, pp 14.

Federal Ministry of Health (FMoH) [Nigeria], and National Malaria Control Programme (NMCP). (2009). Strategic Plan 2009-2013 “A Road Map for Malaria Control in Nigeria” Abridged Version –2009. Abuja, Nigeria: Yaliam Press Ltd.

Heggenhougen, H.K., V. Hackenthal & P. Vivek (2003). The Behavioural and Social Aspects of Malaria and its Control: An Introduction and Annotated Bibliography. Geneva, WHO/TDR.

Idowu OA, Mafiana CF, Dapo S. (2006). Malaria among pregnant women in Abeokuta, Nigeria. Tanzan Health Res Bull. 8(1):28-31.

NPC and ICF Macro (2009). Nigeria Demographic and Health Survey 2008. NPC and ICF Macro

Okeibunor, J. C., Ogungbemi, M. K., Sama, M., Gbeleou, S. C., Oyene, U., & Remme, J. H. F. (2004). Additional health and development activities for community-directed distributors of ivermectin: Threat or opportunity for onchocerciasis control? Tropical Medicine and International Health, 9(8), 887d–896d.

Remme, J. H. F. (2004). Research for control: The onchocerciasis experience. Tropical Medicine and International Health, 9(2), 243–254.

Rosenstock, I.M. (1974), Historical Origin of the Health Belief Model. Health Education Monograph, 2.

Shane B, (2001). “Malaria Continues to Threaten Pregnant Women and Children”. Population Reference Bureau (PRB), Washington DC. USA.

Steketee RW, Wirima JJ, Campbell CC, (1996). “Developing Effective Strategies for Malaria Prevention Program for Pregnant African Women”. Am. J. Trop. Med. And Hygiene. 55(1 suppl). 95-100.

The CDI Study Group, (Forthcoming). Community-Directed Interventions for Priority Health Problems in Africa: Results of a Multi-country Study. WHO Bulletin.

36 United Nations (2009). The Millennium Development Goals Report for 2008. New York

WHO/UNICEF (2003). “Lives at Risk: Malaria in Pregnancy”. Africa Malaria Report.

World Health Organization. (2003). Report on the review of primary health care policy in the African region. Brazzaville: WHO, Regional Office for Africa.

37 Appendix

1. FOCUS GROUP DISCUSSION GUIDE Types of Participants  Adult males  Adult females  Youth

Number of Participants: 8-10 per group

Introductory Remarks Good day, my name is ...... (moderator) and my colleague is…………(note taker). We are conducting a study on the malaria in this LGA. The information we are collecting will help in advising donors and programme implementers on better ways of designing malaria interventions. You have been selected to participate in this Focus Group Discussion (FGD) because we feel your views will help in understanding the real issues in malaria in this community. We therefore, kindly request you to share your honest experiences/opinions on these issues. Participation in this discussion is voluntary. You are free not to contribute to any issues you feel uncomfortable with. However, we wish to assure you that the information you give us shall be kept confidential and will only be used for purposes of this study. The information will not be linked to any participant. Our discussion will last approximately 45-60 minutes during which everybody will have an opportunity to contribute. So please, if you agree to participate you will be required to speak one at time and feel free to express your views even if you feel that they are different from what other participants think.

I also wish to kindly request you to allow me tape record this discussion so that I can capture everything we discuss.

Do you have any questions or comments before we proceed?

Instruction to the Moderator:  In case of any questions, please try to address them before proceeding.  In case participants refuse to be tape-recorded, ignore the recorder and proceed with the discussion as the note-taker writes down verbatim as much as she/he can.

IDENTIFIERS State LGA Community Total Number of participants Group Category Highest educational qualification of the group Least educational qualification of the group Language of discussion

38 TOPIC MAJOR QUESTIONS 1 Health Q: Warm up: What are the main health problems in this community? (Probe for problems in malaria, if not mentioned) the community 2 Knowledge of Q: What can you tell us about malaria in this community? Malaria (Probe for perception of malaria in relation to other health problems) Q: What are the causes of malaria? Q: How do people manage malaria? Q: Who are the most affected and why? 3 Prevention of Q: How serious is the problem of malaria in this community? malaria Q: How are people in this community protected from getting malaria? (Probe for ITN)? Q: Where do you get ITN in this community? (Probe for the cost) 4 Perceptions on Q: What are the general feelings of people in this community about ITN? ITN (Probe for acceptability, availability, affordability, accessibility and desirability of ITN) 5 Use of ITN Q: How often do you think people in this community use ITN? (Probe for reason for low usage and high usage) Q: How many of you here have ITNs in your houses? (Ask those without IT N the reason they do not have ITN) Q: How many of you here slept under ITN last night? 5 Distribution of Q: Where do people get ITN in this community? ITN Q: What can you tell about distribution of ITN in this community? 6 Treatment of Q: How do people treat malaria in this community? (probe for different types of malaria treatment and reasons) Demographics Collect the following information on each participant of Participants Age: Occupation: Income level: Education: Marital status: Number of children Number of children under five in your household:

END OF THE DISCUSSION

THANK YOU VERY MUCH FOR YOUR PARTICIPATION