|BRIEF RESEARCH ARTICLE
|Year : 2013 | Volume
| Issue : 4 | Page : 276-279
Use of insecticide-treated bednets in an urban coastal area of Puducherry, India: A cross-sectional study
Suman Saurabh1, S Ganesh Kumar2, Swaroop Kumar Sahu2, Suresh Thapaliya3, S Sudharsanan4, T Vasanthan5
1 Junior Resident, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Assistant Professor, Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Junior Resident, Department of Psychiatry, AIIMS, New Delhi, India
4 Junior Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
5 Junior Resident, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||18-Dec-2013|
Junior Resident, Department of Preventive and Social Medicine, 4th Floor, Administrative Block, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Use of Insecticide-Treated Bednets (ITNs) has been shown to reduce the incidence of mosquito-borne diseases. However, the impact of ITNs depends on its community acceptance. We studied the ITN usage and factors influencing it, following the distribution of one ITN to each family in an urban area of Puducherry. Around 93.6% of the 157 respondents surveyed were aware of mosquito-borne diseases. Coils and vaporizers were used in 91.1% of the families. Around two-fifths (41.3%) of the 116 families who received the ITNs used it regularly with another 5.1% using it irregularly. Majority of the users (85%) reported reduced mosquito bites and pleasant sleep after use. Small size of ITNs was the most common reason for non-use (46.3%). Families not using normal bed nets at the time of distribution of ITNs were unlikely to use ITNs at present (odds ratio = 5.22, P < 0.001). Therefore, ITN size should be increased and distribution in urban settings should accompany behavior change communication.
Keywords: Acceptability, Bed nets, Coastal area, Education, Insecticide-treated bednets, Malaria
|How to cite this article:|
Saurabh S, Kumar S G, Sahu SK, Thapaliya S, Sudharsanan S, Vasanthan T. Use of insecticide-treated bednets in an urban coastal area of Puducherry, India: A cross-sectional study. Indian J Public Health 2013;57:276-9
|How to cite this URL:|
Saurabh S, Kumar S G, Sahu SK, Thapaliya S, Sudharsanan S, Vasanthan T. Use of insecticide-treated bednets in an urban coastal area of Puducherry, India: A cross-sectional study. Indian J Public Health [serial online] 2013 [cited 2020 Dec 5];57:276-9. Available from: https://www.ijph.in/text.asp?2013/57/4/276/123269
Mosquito-borne diseases are a major cause of morbidity and mortality. Globally, malaria alone has been estimated to cause 219 million cases and 660,000 deaths in 2010.  It has been estimated to cause 205,000 deaths in India in 2002-2003.  Puducherry has long been known to be a high prevalence area of filariasis, but recently there has been a rise of malaria and dengue cases also.  In the past decade, global malaria action plan has included Insecticide-Treated bednets (ITNs) as a key vector control strategy in addition to indoor residual spraying.  Currently, ITN distribution has been taken up in highly endemic areas including coastal and tribal areas as a part of National Vector Borne Disease Control Program.  In the earlier trials in Africa, use of ITNs not only reduced the malaria-attributable mortality in under-fives, but also the overall mortality.  However, studies have shown that the overall impact of ITNs depends not only on its insecticidal activity but also on various social and operational factors, which in turn determine its acceptance in community. ,, Our objective was to study the community acceptance of ITNs in an urban setting. The knowledge and awareness of the community regarding mosquito-borne diseases and their control measures were also assessed as factors likely to influence ITN use.
This cross-sectional analytical study was done in November 2011, which is the rainy season in Puducherry and a peak time for vector breeding. We studied Kurusukuppam and Vazhakulam areas of Puducherry, which are served by our Institute Urban Health Center. This is an urban locality with sizeable fishing population along the coast with apartments toward the west of the coastal area. Total population of our study area was 4584 with 1185 families. One ITN per family was supplied to those residents of the area who came to collect the ITNs at the Urban Health Center in the months of October 2010 and May-June 2011.
A sample size of 201 among 1185 families was calculated based on 80.5% of regular ITN use in the rainy season with absolute precision and alpha value of 5%.  However, we could cover only 157 families due to unavoidable constraints. This was found sufficient if we recalculated our sample size using the absolute precision of 6%. Systematic random sampling was used to select the households.
A structured questionnaire was designed covering socio-demographic data, awareness about mosquito-borne diseases and ITNs, perception of mosquito problem and use of ITNs. The questionnaire was pre-tested and standardized in Tamil and administered to an adult respondent who was available in each family. As only one ITN was distributed to each family, we did not expect all members to be using the ITN. Thus, use of ITN on all seven nights of the preceding week, even by one member of the family was considered as regular use. ITN use for 1-6 nights in the preceding week was taken as irregular use. All other families were considered as non-users. Reasons for non-use and irregular use or any beneficial effects due to the use of ITNs were recorded. The data were collected by MBBS interns who were adequately trained for ensuring uniform data collection.
Chi-square test was used to analyze categorical data with P value of 0.05 considered to be significant. Odds ratios were calculated for each plausible risk factor such as overcrowding, low socio-economic status and non-use of a normal bed net at the time of receiving ITNs. There were no families in the lower socio-economic class (Class V) and only four families were in the upper socio-economic class (Class I) as per Kuppuswamy classification. Therefore, we combined Classes IV and V as low socio-economic class, Class III was taken as middle class and Classes I and II were combined as upper class.
Demographic details of 598 family members were collected by interviewing one respondent each from 157 families. Literacy rate was high at 89.3% for this surveyed population. Out of the 157 families surveyed, 41 didn't collect the ITNs from the Health Center, thereby yielding the ITN distribution coverage of 73.9%. Out of the remaining 116 families who collected the ITNs, 48 (41.3%) were regular ITN users. Another 8 families (5.1%) were irregular users. The remaining 60 families were found to be non-users.
Awareness of at least one mosquito-borne disease among respondents was high at 93.6%. About 96.2% of the respondents reported that mosquitoes were a problem in their area. When asked to list the methods of prevention of mosquito-borne diseases, nearly 91.1%, 81.5%, and 75.8% of respondents mentioned mosquito coils and vaporizers, mosquito nets and peridomestic sanitation respectively. On the other hand, the awareness of spraying or fogging, personal protection and screening of the house was low at 26.8%, 11.5% and 8.9% respectively. The awareness regarding ITNs as a method of prevention was found to be low at 8.3% when the respondents were asked to list the methods. However, a majority (91.7%) of them told yes when a separate question, "Have you heard about ITNs" was asked.
Mosquito coils and vaporizers were used by a majority of community members [Figure 1]. Although mosquito nets were the second most used method of control, their use was relatively low as they were used by less than half of those aware of them ([Figure 1], P < 0.001 on Chi-square test). The practice of surrounding sanitation and spraying as a method of control were also low as they were used by less than one-third of those aware of them ([Figure 1], P < 0.001 on Chi-square test). On the other hand, the relative practice of mosquito coils and vaporisers corresponded closely to their awareness in the community [Figure 1]. This showed that there are barriers in translation of mosquito nets, sanitation and spraying from known methods to used methods in the community.
Around 41.4% of the ITN users reported reduced mosquito bites during sleep and another 32.8% reported pleasant sleep. Only 11.2% perceived reduced number of mosquitoes in their house. Another 12.9% of users did not report any specific benefit from ITNs.
Small size of the ITNs emerged as a problem in both feedback by the users (46.3%) and as a reason for non-use or irregular use (28.0%). Other reasons for non-use or irregular use of ITNs were their poor quality (14.8%) and lack of space in the house for tying them (8.2%). However overcrowding did not emerge as a risk factor for non-use or irregular use of ITNs [Table 1].
|Table 1: Association of plausible risk factors with ITN non-use or irregular use among 116 families receiving ITNs|
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Around 38.4% of families were washing the ITNs provided to them once a week. Majority (56.9%) were found to be washing them at least once monthly. The 116 families who collected the ITNs consisted of 465 individuals. ITN use in this population did not show any gender difference with 19.6% of males and 15.7% of females having used the ITN the previous night (P = 0.28 on Chi-square test). However, use was higher at 32.0% in the younger age-group of up to 15 years compared to 12.3%, 16.7% and 20.0% use in 16-45 years, 46-60 years and more than 60 years age groups respectively (P < 0.001 on Chi-square test).
Coverage in our study was lower than that found in studies done in rural area of north-east India and in a tribal area of Odisha. , This might be explained by the fact that door to door distribution was not done in our study area. Instead, people collected the ITNs at the Health Center, which was located 100 m to 2 km from their residence.
Both the awareness about mosquito-borne diseases and perception of these diseases as a problem were more than that found in a Puducherry rural study by Boratne et al and a Tanzanian study by Mboera et al. , This is a positive finding, and might be explained by high literacy and awareness of this urban community.
Overall the ITN usage in our study was found lower than that of the study done in north-east India and the study done in tribal area of Odisha. , This can be explained by the small size and perception of low quality of ITNs and competing use of mosquito coils and vaporisers.
We found that families not using the normal bed nets earlier were around 5 times more likely not to be regularly using the ITNs at present compared with those using normal bed nets at the time of ITN distribution [Table 1]. This highlights the fact that habit formation is essential for the practice of mosquito-control measures, especially those associated with daily routine. Furthermore, unacceptably frequent washing of ITNs points to low awareness regarding maintenance of ITNs. Therefore, behavior change communication of the community should be incorporated in the ITN distribution process. Door-to-door delivery of ITNs is preferable as it helps in one-to-one communication of instructions for use. The small size of bed nets and inadequate numbers meant that the families had to select the members using the ITNs. This process of selective use was found in this study in favour of the children. Therefore, distribution of ITNs on a large scale alone might not guarantee their appropriate use in the community. Urgent attention should be given to ensure larger and better quality ITNs along with health education at the time of distribution. Also, number of ITNs distributed per family should take in account the size of the family, so that all the family members can be protected against vector-borne diseases.
As the study was cross-sectional in nature, the ITN users could not be followed-up for the reduction in confirmed cases of mosquito-borne diseases. The impact of ITNs in terms of disease events was not measured. Overall the study supports the growing evidence that the success of health interventions is rooted in human behavior.
| Acknowledgments|| |
We would like to acknowledge the help of MBBS graduates Dr. Mohammed Akmal Haq, Dr. Kundan Kumar, Dr. Khrustoe Khiki and Dr. Ramavath Devender Naik for their help in data collection.
| References|| |
|1.||Global Malaria Report 2012. Geneva: WHO; 2012. Available from: http://www.who.int/entity/malaria/publications/world_malaria_report_2012/en. [Last accessed on 2013 May 04]. |
|2.||Dhingra N, Jha P, Sharma VP, Cohen AA, Jotkar RM, Rodriguez PS, et al. Adult and child malaria mortality in India: A nationally representative mortality survey. Lancet 2010;376:1768-74. |
|3.||Puducherry State Health Report 2010. p. 19. Available from: http://www.mohfw.nic.in/NRHM/Documents/UT_Reports/Puducherry_Report.pdf. [Last accessed on 2013 May 04]. |
|4.||Global Malaria Action Plan. Roll Back Malaria Partnership 2008. Available from: http://www.rollbackmalaria.org/gmap/gmap.pdf. [Last accessed on 2013 May 04]. |
|5.||Scaling up of malaria control interventions with a focus on high burden area. In: Strategic Action Plan for Malaria Control in India 2007-2012. New Delhi: NVBDCP, DGHS, Ministry of Health and Family Welfare; 2010. Available from: http://www.nvbdcp.gov.in/Doc/Strategic-Action-Plan-2007-12.pdf. [Last accessed on 2013 May 04]. |
|6.||Alonso PL, Lindsay SW, Armstrong JR, Conteh M, Hill AG, David PH, et al. The effect of insecticide-treated bed nets on mortality of Gambian children. Lancet 1991;337:1499-502. |
|7.||Gunasekaran K, Sahu SS, Vijayakumar KN, Jambulingam P. Acceptability, willing to purchase and use long lasting insecticide treated mosquito nets in Orissa State, India. Acta Trop 2009;112:149-55. |
|8.||Prakash A, Bhattacharyya DR, Mohapatra PK, Goswami BK, Mahanta J. Community practices of using bed nets & acceptance & prospects of scaling up insecticide treated nets in north-east India. Indian J Med Res 2008;128:623-9. |
|9.||Jambulingam P, Gunasekaran K, Sahu S, Vijayakumar T. Insecticide treated mosquito nets for malaria control in India-experience from a tribal area on operational feasibility and uptake. Mem Inst Oswaldo Cruz 2008;103:165-71. |
|10.||Boratne AV, Jayanthi V, Datta SS, Singh Z, Senthilvel V, Joice YS. Predictors of knowledge of selected mosquito-borne diseases among adults of selected peri- urban areas of Puducherry. J Vector Borne Dis 2010;47:249-56. |
|11.||Mboera LE, Shayo EH, Senkoro KP, Rumisha SF, Mlozi MR, Mayala BK. Knowledge, perceptions and practices of farming communities on linkages between malaria and agriculture in Mvomero District, Tanzania. Acta Trop 2010;113:139-44. |