Garley et al. Malaria Journal 2013, 12:119 http://www.malariajournal.com/content/12/1/119 RESEARCH Open Access Gender differences in the use of insecticide- treated nets after a universal free distribution campaign in Kano State, Nigeria: post-campaign survey results Ashley E Garley1*, Elizabeth Ivanovich1, Erin Eckert2, Svetlana Negroustoueva3 and Yazoume Ye1 Abstract Background: Recent expansion in insecticide-treated net (ITN) distribution strategies range from targeting pregnant women and children under five and distributing ITN at antenatal care and immunization programmes, to providing free distribution campaigns to cover an entire population. These changes in strategy raise issues of disparities, such as equity of access and equality in ITN use among different groups, including females and males. Analysis is needed to assess the effects of gender on uptake of key malaria control interventions. A recent post- universal free ITN distribution campaign survey in Kano State, Nigeria offered an opportunity to look at gender effects on ITN use. Methods: A post-campaign survey was conducted three to five months after the campaign in Kano State, Nigeria from 19 October to 4 November, 2009, on a random sample of 4,602 individuals. The survey was carried out using a questionnaire adapted from the Malaria Indicator Survey. Using binary logistic regression, controlling for several covariates, the authors assessed gender effects on ITN use among individuals living in households with at least one ITN. Results: The survey showed that household ITN ownership increased more than 10-fold, from 6% before to 71% after the campaign. There was no significant difference between the proportion of females and males living in households with at least one ITN. However, a higher percentage of females used ITNs compared to males (57.2% vs 48.8%). After controlling for several covariates, females remained more likely to use ITNs compared to males (OR: 1.5, 95% CI: 1.3-1.7). Adolescent boys remained the least likely group to use an ITN. Conclusions: This study reveals gender disparity in ITN use, with males less likely to use ITNs particularly among ages 15–25 years. The uptake of the intervention among the most at-risk group (females) is higher than males, which may be reflective of earlier strategies for malaria interventions. Further research is needed to identify whether gender disparities in ITN use are related to traditional targeting of pregnant women and children with malaria interventions; however, results provide evidence to design gender-sensitive messaging for universal ITN distribution campaigns to ensure that males benefit equally from such communications and activities. Keywords: Long-lasting insecticidal net, Insecticide-treated net, Net use, Gender, Universal coverage, Health disparities, Survey, Free distribution campaign, Kano State, Nigeria * Correspondence: [email protected] 1ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA Full list of author information is available at the end of the article © 2013 Garley et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Garley et al. Malaria Journal 2013, 12:119 Page 2 of 7 http://www.malariajournal.com/content/12/1/119 Background potential reservoirs for malaria transmission; therefore, Universal coverage through free insecticide-treated net it is essential to prevent all cases among both women (ITN) distribution campaigns is the current agreed-upon and men. strategy to improve coverage in ownership of ITNs; how- Close attention needs to be paid to how inequalities ever, traditional strategies such as social marketing and facilitate the spread of disease, affecting the ability of free distribution through antenatal care (ANC) and immu- both genders to access health care and other services nization campaigns are still recommended to reach preg- equitably and in a manner that does not exacerbate gen- nant women and children under five years. This universal der inequalities that exist in society. Donors, including coverage strategy has been facilitated by an increase in the Global Fund to Fight AIDS, Tuberculosis and Malaria funding levels during recent years that have led to im- and the President’s Malaria Initiative (PMI), assert that proved access to ITNs by allowing country programmes gender inequalities are a strong driver of malaria and that to provide the entire population with ITNs instead of success in reducing malaria-related deaths can only be limiting nets to high-risk groups [1]. Today, countries achieved through gender-sensitive programming [10,11]. are rolling out these campaigns in an effort to achieve Therefore, as countries strive for universal ITN ownership universal coverage, which is defined as one net per two and use, it is important to assess gender dimensions to household members, by 2015 [2]. Directed to the entire better inform programme implementation. However, there population, particularly in high-transmission settings, free is limited evidence on the effects of gender, as a contextual ITN distribution campaigns have the advantage of rapidly and social determinant, on ITN uptake and its subsequent achieving high community-level coverage, benefiting all use, particularly after a free distribution campaign. Using community members rather than just those who own nets data from the Kano post-campaign survey [7,12], the [3]. As shown by a number of studies in various settings, authors investigated the outcomes of the free mass ITN this strategy has the potential to achieve equity in owner- distribution campaign on ITN uptake and use through ship of mosquito nets and their use [4-7]. However, the a gender lens, using sex-disaggregated data. level of its achievement depends largely on being context specific, i.e. using effective distribution strategies that address specific contextual determinants, such as gender. Methods Gender roles, norms, cultural practices, and behaviours Study population can strongly influence disease prevention, care seeking, The post-campaign evaluation survey took place at the and access to treatment. These influences highlight the end of 2009 in Kano State, in the northwest region of importance of addressing gender and other social determi- Nigeria, and included 24 local government areas (LGA), nants of health in policies and interventions to achieve which were covered by two independent campaign waves. gender equal returns from health programmes. Although During Wave 1, which took place in May 2009, the cam- men and women are both affected by malaria, social and paign covered 21 LGAs, while Wave 2 (July 2009) covered biological factors contribute to the different impact mal- 23 LGAs. aria has on each. For instance, socially determined gender This study was a cross-sectional household survey norms mean that women most often carry the extra bur- with a stratified two-stage cluster sampling design. The den of caring for sick family members, so malaria would strata were the two areas covered in the different cam- affect their ability to work and provide care for young paign waves and each stratum was considered a survey children and other members of the family. Women are domain. The size of the sample was estimated based on also more susceptible to developing malaria due to a de- confidence intervals (alpha-error) of 95%, statistical power creased immunity during pregnancy and an inequitable (1-beta-error) of 80%, and a design effect of 1.75. It was economic status that often results in delays to access assumed an anticipated nonresponse of 5% and an average health interventions [8]. household size of 5 people. Children under 5 constituted On the other hand, men are less likely to use ITNs, an estimated 20% of the population, while 3.5% of the which are traditionally distributed to pregnant women female population was currently pregnant. and children. In many cultures, men do not use health Stage one included the selection of clusters using sys- care routinely, leading to delays in seeking medical care tematic sampling with probability proportionate to size when needed and, subsequently, omission of their cases (PPS). Stage two included the selection of households by in medical records. Moreover, in many malaria-endemic field team mapping small villages, randomly selecting 17 areas, certain gender-specific occupations may increase households and using the same household definition used exposure to malaria vectors: men are more vulnerable to in the distribution campaign, which was "a wife with her contracting malaria through occupational exposure (e.g. direct dependents". A compound was divided into several working in gold mines or forest logging and working at households depending on the number of wives and the night) [9,10]. Men with untreated malaria infections are husband was assigned to the first wife's household. Larger Garley et al. Malaria Journal 2013, 12:119 Page 3 of 7 http://www.malariajournal.com/content/12/1/119 communities (more than 120 compounds) used the equal of household was considered. The polygamous household size section-approach. variable was also measured since the ITN distribution Clusters were defined as urban or rural, based on their strategy during the campaign considered every wife as a categorization in the 2006 census, not their urban/rural household unit; however, in the analysis, the official defin- stratification. A sample of 30 clusters, with an estimated ition of a household was used in order to be comparable 17 households per stratum, resulted in a total sample of to those used as demographic health survey indicators. 1,020 households in the campaign area, including 4,602 Finally, previous studies have shown that more nets in a individuals. Data collection took place from 19 October household lead to better net usage, thus analysing the to 4 November, 2009 and involved a questionnaire adapted ratio of ITNs to household members was essential.