Socio-demographics characteristics of participants
The age of the respondents ranged from 18-72 years with a mean age of 36 years and a modal age of 40 years. The majority of respondents, 221(56.5%) were males. Majority had primary education level 195 (49.9%), most participants were involoved in agriculture 291 (74.4) and the majority were Iteso 303(77.5) as showed table 1.
Table 1
Socio-demographic characteristics of respondents (N=391)
Variable
|
Frequency, N
|
Percentage (%)
|
Age group of respondents (Years)
|
31-40
|
142
|
36.3
|
21-30
|
129
|
33.0
|
41-50
|
62
|
15.9
|
51-60
|
30
|
7.7
|
18-20
|
19
|
4.9
|
61+
|
9
|
2.3
|
Gender
|
Male
|
221
|
56.5
|
Female
|
170
|
43.5
|
Education Level
|
Primary (1-7)
|
195
|
49.9
|
Ordinary level (S1-S4)
|
119
|
30.4
|
None
|
43
|
11.0
|
Advanced level (S5-S6)
|
27
|
6.9
|
Tertiary
|
7
|
1.8
|
Occupation
|
Agriculture
|
291
|
74.4
|
Un-skilled manual
|
28
|
7.2
|
Skilled manual (Vocational)
|
26
|
6.6
|
Sales services
|
17
|
4.3
|
Professional office work
|
15
|
3.8
|
Domestic service
|
9
|
2.3
|
Others
|
4
|
1.0
|
None
|
1
|
0.3
|
Ethnicity
|
Iteso
|
303
|
77.5
|
Kumam
|
84
|
21.5
|
*Others
|
4
|
1.1
|
*Others = Acholi, Baganda & Basoga. Data source - field findings from respondents
Malaria control measures by children under five years
A total of 779 children under five years who were resident in the households were included in the study. About half of them 400 (51.3%) were aged 3-4 years, with a mean age of 2.5 years (sd 1.2) and range of 3 years. A majority of the children 712 (91.4%) were using atleast one malaria preventive measure. The commonest malaria preventive measure used was bed nets 690 (96.9%) as in Additionl file 2. This was confirmed by one Key Informant (KI) from DHO’s office who said, “The commonest and most effective preventive measure against malaria used by children under five years is sleeping under bed nets whether treated or untreated, although other measures such as closing doors or going to bed early and slashing bushes around homes exist”.
Most children 617 (89.4%) were reported to have slept under bed nets the previous night to the survey, however only 392 (56.8%) slept under bed nets consistently (slept daily for the previous 12 months). A key informant from the DHO’s office noted that not all children were sleeping under bed nets consistently because of various reasons. He explained this saying, “For example people in rural areas have few houses which are multi-purpose. The same house is a sitting room, store and sleeping room. People find it difficult to tie and un-tie bed nets on a daily basis, especially on nights visitors come and stay upto late. This defeats consistency in bed net use”. A key informant from Stop Malaria Project agreed with the previous KI and said, “We recently carried out a rapid assessment on bed net use in one nursery school in the Municipality and more than half of the children in Baby class said they never slept under the bed net the previous night”.
A majority of these children 633 (91.3%) still used bed nets even if they slept on the floor/mat.
Most of the bed nets were obtained from NGOs (92.5%). Other sources of bed nets were government hospital, church/friend/relative, private hospital/clinic and from the VHT/Community leaders (Additional file 2).
A key informant from DHO’s office confirmed this and said, “Community members get bed nets from malaria control partners (NGOs) distributed through Ante-natal clinics in health centers as well as from the open market”.
Predisposing factors of respondents (Knowledge about malaria)
A majority of the respondents 372/391 (95.1%) mentioned that malaria is transmitted by mosquitoes. However, some of the respondents among those who mentioned mosquitoes also had other incorrect views on malaria transmission including beliefs that malaria is transmitted by getting soaked in rain, eating bad/contaminated food and by drinking unboiled water (Additionl file 3). The respondents had a fairly good knowledge about malaria control measures. The majority of them 364/391 (93.1%) correctly mentioned that malaria can be prevented by sleeping under a mosquito net. Other malaria preventive measures mentioned were clearing bushes around the home, destroying mosquito breeding sites, chemoprophylaxis, spraying with insecticides, use of mosquito repellants and closing door/windows early in the evening (Additional file 3).
Most respondents 307 (78.5%) reported that they had been sensitized about malaria transmission and control. The most common source of information was from radio programs 197 (64.2%). Other sources of information mentioned were the church, community leaders and friends.
Other respondent predisposing factors about consistent use of bed nets assessed
Most respondent 332/391 (84.8%) were aware of the fact that they were at risk of getting malaria and the majority 381 (97.4%) believed that consistent use of bed nets is beneficial because it prevents the user from getting malaria. Most respondents 298 (82.5%) had a positive attitude about using bed nets if they lacked raised beds or had their beddings on the floor.
Respondents acknowledged that their chances of getting malaria were fairly high and only 64 (19.3%) believed that their chances of getting malaria were very low. Although a majority said bed nets were worth buying if not provided free of charge by government or NGOs, a few 56 (14.3%) believed that bed nets were harmful (Additional file 4).
A number of benefits of consistent use of bed nets were cited by respondents. These included reducing chances of getting malaria 287/391(75.1%), reducing medical expenses 266 (69.6%) and relief from mosquito nuisances/painful bites 218 (57.1%).
Some respondents believed bed nets were harmful because they cause side effects including the itching and burning of the skin following use (ITNs). Furthermore, they believed that a bed net makes one feel stuffy and causes excessive heat/disconfort at night when one sleeps under it. A respondent from Gweri said, “Much as most of us use bed nets, these nets sometimes cause itching of the skin/cancer, a lot of heat at night especially during dry season and they can even suffocate people at night”.
Most respondents 336/391 (85.9%) acknowledged that mosquitoes are ever present in their sleeping rooms at night. A good number of them accordingly employ measures to protect themselves from mosquito bites. The most common protective measure used was sleeping under bed nets (94.8%) followed by burning mosquito coils and spraying houses with insecticide. This was confirmed by a Key Informant from World Vision who said, “Most people are nowadays using bed nets as the main malaria control measure since bed nets are distributed freely through ANC services and maternities by malaria control partners, especially if a household has more than one woman conceiving in a year”.
Other malaria prevention measures employed were smoking the house by burning rubbish/dung, using local herbs and going to bed early. Most respondents (79.5%) said they slept under the bed net the previous night although only 44.3% slept under bed nets consistently (additional file 4).
Perceived enabling factors to consistent bed net use by under fives
A small proportion of children 89 (11.4%) were not sleeping under bed nets to protect them from getting malaria. Reasons for not sleeping under bed nets advanced by their caretakers included the high cost 71/89 (79.3%), fear that the children would suffocate 41 (46.6%) and to avoid heat and discomfort experienced when sleeping under bed nets 11 (12.1%).
The parents/caretakers of children often shared beds with children and their attitude towards bed nets influenced use of the bed nets by children. Respondents said the bed nets could be widely used consistently if they they were adequately availed free of charge; while the colour, shape and size also affected consistent use. A few respondents 64/391 (17.7%) said the size of the bed nets was inappropriate and that they preferred very large bed nets. Another group 107 (29.6%) said the shape of the bed nets was inappropriate and they preferred conical bed nets that are easy to hang up their round houses.
This was confirmed by most key informants who said, “The size, shape and multi-purpose nature of houses in rural areas can not facilitatye use of common rectangular bed nets. It is difficult and tiresome to hang/unhang those bed nets on a daily basis; thus conical bed nets should be provided to rural residents if consistent use is to be enhanced”.
Nearly half of respondents 196 (54.3%) disliked white bed nets and prefered mostly blue coloured bed nets. The need to use of bed nets was more during the rainy season when mosquito population was high. Most respondents 221 (38.8%) reported that they mainly used bed nets during rainy season when mosquitoes are many (Additional file 5). Most key informants agreed with this line of aguement as one commented that, “Many people quite believe that bed nets are used more during rainy season because that is when there are many mosquitoes because of much water within the homesteads”.
Results from key informant interviews
Most key informants mentioned bed nets as the main malaria control strategy in Soroti, followed by slashing compounds and closing doors early. Other methods used included spraying houses with insecticides and destroying broken containers where mosquitoes could breed.
Regarding source of bed nets for the people, most of them mentioned NGOs, followed by government health centres and open market.
Majority of key informants said the major draw backs for consistent use of bed nets by the children under five years were the nature of sleeping rooms, nature of bed nets and cost of buying if not provided free of charge. Others factors given were season of the year (dry) and presence of few mosquitoes in houses (Additional file 6).
Factors influencing consistent use of bed nets among children under five years
Socio-demographic characteristics of respondents and children
Table 2 shows the association between socio-demographics characteristics of respondents and children and consistent use of bed nets by the children.
Consistent use of bed nets was significantly higher among children whose caretakers did professional office work than their counterparts (OR: 0.25, 95% CI: 0.10-0.67, p= 0.006).
The age of children was a significant predictor of consistent bed net use in that the odds of consistent bed net use were 3 times higher among children aged 1-2 years than among those aged 3-4 years (Crude OR 2.945, 95% CI: 1.321-3.559).
The tribe of the respondent showed a significant association with consistent use of bed nets by children under five years in that the odds of consistent bed net use were higher among children of the Iteso than those of Kumam, Acholi, Baganda and Basoga combined (Crude OR=1.81, 95% CI :1.26-2.60) but the difference was marginal.
However, age, gender and education level of respondents did not show any statistically significant relationship with consistent use of bed nets by children under five years.
Table 2
Influence of socio-demographic characteristics of respondents & children on consistent use of bed nets by children under five years(N=690)
|
Consistent use of bed nets (n)
|
Variable/Question
|
Yes(n=392)
n(%)
|
No(n=298)
n(%)
|
Un-adjusted OR (95% CI)
|
Age of respondent
|
31-40
|
151(57.6)
|
111(42.4)
|
1.20 (0.48-98)
|
21-30
|
141(60.5)
|
92 (39.5)
|
1.06 (0.42-2.66)
|
41-50
|
44 (42.3)
|
60 (57.7)
|
2.22 (0.85-5.80)
|
51-60
|
32 (59.3)
|
22 (40.7)
|
1.12 (0.40-3.14)
|
18-20
|
13 (61.9)
|
8 (38.1)
|
1.0
|
61+
|
11 (68.8)
|
5 (31.2)
|
0.74 (0.19-2.92)
|
Gender
|
Male
|
223 (59.0)
|
155 (41.0)
|
1.22 (0.90-1.65)
|
Female
|
169 (54.2)
|
143 (45.8)
|
|
Education level
|
Primary (1-7)
|
191 (56.7)
|
146 (43.3)
|
0.76 (0.46-1.26)
|
O’ level
|
120 (56.6)
|
92 (43.4)
|
0.77 (0.45-1.30)
|
None
|
38 (50.0)
|
38 (50.0)
|
1.0
|
A’ level
|
33 (63.5)
|
19 (36.5)
|
0.58 (0.28-1.19)
|
Tertiary
|
10 (76.9)
|
3 (23.1)
|
0.30 (0.08-1.18)
|
Occupation
|
Agriculture
|
276 (55.8)
|
219 (44.2)
|
1.0
|
Un-skilled manual
|
31 (55.4)
|
25 (44.6)
|
1.02 (0.58-1.77)
|
Skilled manual (Vocational)
|
27 (52.9)
|
24 (47.1)
|
1.07 (0.60-1.93)
|
Sales services
|
19 (57.6)
|
14 (42.4)
|
0.93 (0.46-1.89)
|
Professional office work
|
25 (83.3)
|
5 (16.7)
|
0.25 (0.10-0.67)**
|
Domestic service
|
10 (58.8)
|
7 (41.2)
|
0.88 (0.33-2.36)
|
Others
|
4 (50.0)
|
4 (50.0)
|
1.58 (0.42-5.94)
|
Ethnicity
|
Iteso
|
323 (60.0)
|
215 (40.0)
|
1.81(1.26-2.60)**
|
Others
|
69 (45.4)
|
83 (54.6)
|
|
Age of the children
|
1-2 years
3-4 years
|
240 (69.8)
152 (43.9)
|
104 (30.2)
194 (56.1)
|
2.95 (2.15- 4.03)**
|
*P<0.1; **P<0.05:
Influence of predisposing factors on children’ consistent use of bed nets
Table 3 shows the relationship between respondents’ predisposing factors and consistent use of bed nets by children under five years.
The results show that there was no statistically significant relationship between knowledge about malaria transmission and control, perceived risk of malaria, having been sensitized about malaria control measures before, perceived benefits of bed nets, perceived harm and considering bed nets worth buying if not provided freely and consistent use by children under five years.
Table 3
Influence of respondents’ predisposing factors on consistent use of bed nets by children under five years (N=690)
|
Consistent use of bed nets (n)
|
Variable/Question
|
Yes/392 (%)
|
No/298 (%)
|
Un-adjusted OR (95%CI)
|
Knowledge on malaria transmission
|
Knowledgeable (Mosquitoes alone)
|
205 (58.2)
|
147 (41.8)
|
1.0
|
Less knowledgeable(also wrong ways of transmission mentioned)
|
170 (55.2)
|
138 (44.8)
|
1.13 (0.83-1.54)
|
No knowledge (Don’t know)
|
17 (56.7)
|
13 (43.3)
|
1.07 (0.50-2.26)
|
Knowledge on malaria prevention
|
Knowledgeable (>2 correct responses)
Less knowledgeable(<2 correct responses)
|
169 (54.2)
223 (59.0)
|
143 (45.8)
155 (41.0)
|
0.82 (0.61-1.11)
|
Ever been sensitized about malaria control?
|
Yes
|
315 (56.4)
|
244 (43.6)
|
0.91 (0.62-1.33)
|
No
|
77 (58.8)
|
54 (41.2)
|
|
Think you are at risk of getting malaria?
|
Yes
No
|
326 (55.5)
66 (64.1)
|
261 (44.5)
37 (35.9)
|
0.70 (0.45-1.08)
|
Think consistent use of bed nets is beneficial?
|
Yes
No
|
384 (57.1)
8 (47.1)
|
289 (42.9)
9 (52.9)
|
1.5 (0.57- 3.92)
|
Think bed nets are harmful in any way?
|
Yes
No
|
55 (51.9)
337 (57.7)
|
51 (48.1)
247 (42.3)
|
0.79 (0.52-1.20)
|
Think bed nets are worth buying if you had resources?
|
Yes
No
|
374 (57.1)
18 (51.4)
|
281 (42.9)
17 (48.6)
|
1.26 (0.64-2.48)
|
Influence of respondents’ enabling and need factors on children’s consistent bed net use
Table 4 shows the relationship between respondents’ enabling & need factors and consistent use of bed nets by the children.
The results show that respondents’ consistent use of bed nets promoted consistent use of bed nets by their children by upto 37% (Crude OR 1.37, 95% CI: 1.01-1.87).
Likewise, children’s use of bed nets the previous night promoted consistent use of bed nets among them by 2 times (Crude OR 2.17, 95% CI: 1.32-3.55).
Respondents’ concern about the size of bed nets (that they preferred very large bed nets) promoted consistent use of bed nets by the children by 37% (Crude OR 1.373, 95% CI 0.929-2.028).
Furthermore, there was no association between respondents’ perceived susceptibility, opinion about the shape, colour and season bed nets were used more and consistent use of bed nets by the children under five years.
Table 4
Influence of respondents’ enabling and need factors on children’s consistent use of bed nets (N=690)
|
Consistent use of bed nets (n)
|
Variable/Question
|
Yes: n(%)
|
No: n(%)
|
Un-adj. OR (95%CI)
|
Presence of mosquitoes in houses
|
Many
Some
|
336 (55.7)
56 (64.4)
|
267 (44.3)
31 (35.6)
|
0.70 (0.44-1.11)
|
Respondents’ use of bed nets the previous night
|
Yes
|
315 (58.0)
|
228 (42.0)
|
1.28 (0.87 – 1.88)
|
No
|
66 (52.0)
|
61 (480
|
|
Respondent’s consistent use of bed nets
|
Yes
No
|
188 (61.0)
193 (53.3)
|
120 (39.0)
169 (46.7)
|
1.37 (1.01- 1.87)**
|
Child’s use of bed net the previous night
|
Yes
|
363 (58.8)
|
254 (41.2)
|
2.17 (1.32- 3.56)**
|
No
|
29 (39.7)
|
44 (60.3)
|
|
Respondent’s opinion regarding the size of bed net (n=684)
|
Inappropriate
Appropriate
|
84 (63.2)
306 (55.5)
|
49 (36.8)
245 (44.5)
|
1.37 (0.93-2.03)
|
Opinion about the shape of bed nets
|
Inappropriate
Appropriate
|
110 (53.4)
280 (58.6)
|
96 (46.6)
198 (41.4)
|
0.81 (0.58- 1.13)
|
Opinion about the colour of bed nets
|
Inappropriate
Appropriate
|
205 (55.0)
185 (59.5)
|
168 (45.0)
126 (40.5)
|
0.83 (0.61-1.13)
|
Season when the child uses the bed net
|
Always
Rainy season
|
159 (56.6)
231 (57.3)
|
122 (43.4)
172 (42.7)
|
0.97(0.71-1.32)
|
*P≤0.1, **p<0.05
Independent predisposing, enabling & need factors associated with consistent use of bed nets by children under five years
Table 5 shows the independent factors associated with consistent use of bed nets by children under five years. This formed the final model of the study, determined by Hosmer-Lemeshow-fitness test, with a p-value of 0.578 and -2loglikelihood of 830.808.
The final logistic regression model used was;
Logit P (Child used bed net consistently) = -1.6 + 1.14Age of child + 0.7Child’s use of bed net previous night + 0.7Opinion on size of bed net - (1.4Occupation-professionals + 0.6perceived susceptibility + 0.5 no perceived risk of getting malaria+0.5Opinion on rectangular shape of bed net).
The independent factors associated with consistent use of bed nets by children under five years were categorized under predisposing, enabling and need factors.
Pre-disposing factors:
In the final model, consistent use of bed nets was influenced by occupation of respondent, age of children, childrens’ use of bed nets the previous night to the survey, respondent’s perceptions that mosquitoes were few in sleeping rooms and being at risk of getting malaria.
The results show that the odds of consistent use of bed nets were 79% higher among children of professionals than among children of respondents who practiced agriculture (Adj OR: 0.21, 95% CI: 0.08-0.58, p=0.003). On the other hand, the odds of consistent bed net use were 3 times higher among children aged 1-2 years than among the older children (Adj OR: 3.15; 95% CI: 2.26-4.39, P=0.000). As expected, children who used bed nets the previous night to the survey were more likely to use them consistently (Adj OR; 1.93 95%CI: 1.11-3.36, P=0.02).
Furthermore, respondent’s perceived risk of getting malaria influenced their children’s consistent use of bed nets in that the odds of consistent use of bed nets were 43% lower among children of pespondents who said they were not at risk of getting malaria than among those of their counter parts (Adj OR: 0.57, 95% CI: 0.35-0.92, P=0.02).
Enabling factors:
The final model shows that respondents’opinions about bed net size and shape influenced consistent use of bed nets by the children.
The results show that children of respondents who preferred very large bed nets were more likely to use bed nets consistently than those of respondents who preferred medium sized bed nets (Adj OR: 1.87, 95% CI: 1.07-3.28, p=0.03). Likewise, children of respondents who said they preferred conical bed nets were more likely to use bed nets consistently than children of respondents who said they preferred rectangular bed nets (Adj OR 0.58; 95%CI: 0.36-0.94, p=0.03).
Need factors:
The final model shows that children of respondents who were aware that many mosquitoes are ever present in houses were more likely to use bed nets consistently than those of their counter parts. The results show that the odds of consistent use of bed nets were 45% lower among children whose caretakers said the mosquitoes were few in houses than among those of their counter parts (Adj OR: 0.55, 95% CI: 0.33-0.93, p=0.02).
Table 5
Final logistic regression model for factors influencing consistent use of bed nets by under fives in Soroti district, North Esatern Uganda
Variable
|
Consistentbednetuse (n=670) (N=670) (N=670)
|
Unadjusted OR/95%CI
|
Adjusted OR 95% CI
|
Yes/381(%)
|
No/289(%)
|
Occupation
|
Agriculture
|
276 (72.4)
|
219 (75.8)
|
1.0
|
1.0
|
Domestic service
|
10 (02.6)
|
07 (02.4)
|
0.88 (0.33-2.36)
|
0.70 (0.24-2.02)
|
Un-skilled manual
|
31 (08.1)
|
25 (08.7)
|
1.02 (0.58-1.77)
|
0.86 (0.45-1.60)
|
Skilled manual
|
27 (07.1)
|
23 (08.0)
|
1.07 (0.60-1.93)
|
1.38 (0.74-2.59)
|
Sales services
|
19 (05.0)
|
14 (04.8)
|
0.93 (0.46-1.89)
|
0.94 (0.43-2.02)
|
Professional office work
|
25 (06.6)
|
05 (01.7)
|
0.25(0.10-0.67) **
|
0.21(0.08-0.58)**
|
Others
|
04 (01.0)
|
04 (01.4)
|
1.58 (0.42-5.94)
|
1.38 (0.34-5.59)
|
Knowledge on malaria prevention
|
169 (44.4)
|
143 (49.5)
|
0.82 (0.61-1.11)
|
0.78 (0.55-1.11)
|
Age of children (1-2 years)
|
240 (63.0)
|
104 (36.0)
|
2.95(2.15-4.03)***
|
3.15(2.26-4.39)***
|
Child’s use of bed net previous night
|
363 (95.3)
|
254 (87.9)
|
2.17(1.32-0.56)**
|
1.93 (1.11-3.36)**
|
Respondent’ consistent bed net use
|
188 (49.3)
|
120 (41.5)
|
1.37(1.01-1.87)**
|
1.17 (0.84-1.63)
|
Perceived susceptibility (many)
|
336 (88.2)
|
267 (92.4)
|
0.7(0.44-1.11)
|
0.55 (0.33-0.93)**
|
Perceived risk of getting malaria
|
326 (85.6)
|
261 (90.3)
|
0.70 (0.45-1.08)
|
0.57 (0.35-0.92)**
|
Opinion on bed net size
|
84 (22.0)
|
49 (17.0)
|
1.37 (0.93-2.03)
|
1.87 (1.07-3.28)**
|
Opinion about Shape of bed net
|
110 (28.9)
|
96 (33.2)
|
0.81(0.58- 1.13)
|
0.58 (0.36-0.94)**
|
***P<0.001, **P<0.05, *P≤0.1