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					                        Malaria, poverty and health:
               Baseline results from the ITN-Oriade Initiative

                                          Working Draft
                                      (Circulation restricted)

Prepared By:
Center for Health Sciences Training,
Research and Development (CHESTRAD) International
29, Aare Avenue
New Bodija Estate
UIPO Box 21633
Ibadan, Oyo State
                                                                 September 2000
                                     Outline of contents


1. Introduction
2. ITN-Oriade
3. Activities of ITN-Oriade
4. Materials Developed
5.   Comparative findings from 4 States
     5.1    Background characteristics of respondents
     5.2    Knowledge of cause of, and of malaria prevention methods
     5.3    Malaria experience
     5.4    Community based management of malaria
     5.5    Use of nets and ITNs
     5.6    Malaria and income
6. Conclusions and Recommendations
7.   Contact Information


     1. Introduction

Malaria causes more than one million deaths each year. The majority who die are the children of Africa.
Deaths linked to malaria in Africa are on the increase due to changes in climate, population movements,
resistance of malaria parasites to the inexpensive front-line drugs and limitations in national health ser-
vices. In the past decade, African leaders have called for action to address the impact of malaria on their
people. IN response, the World Health Organization launched the Africa Initiative on Malaria in 1996 and
in 1997; African Heads of State signed the Harare declaration on Malaria. Since then, partners and donors
in Africa have responded with many other strategies and initiative to combat the scourge of malaria. This
culminated in the launch of the Roll Back Malaria (RBM) initiative by WHO, UNICEF, WB and the
UNDP in 1998.

The global goals of the RBM initiative is to adopt ………… In recognition of the crucial role of African
governments and people in this renewed effort against malaria, as well as the need to effectively engage
all partners including the private sector and other components of the civil society in this effort, a Summit
of African Heads of State was held in Nigeria in April, 2000. The action plan for this summit proposes a
global strategy for malaria control including activities in research, community/home based prevention in-
cluding early diagnosis and treatment and the use of prophylaxis, community engagement and participa-
tion, surveillance, vector control and promotion of the use of insecticide treated materials.

2.      ITN-Oriade

In 1999, CHESTRAD devised and implemented a project for the community-based management of sim-
ple malaria and promotion of the use of insecticide treated materials (ITN-Oriade). ITN-Oriade is imple-
mented within the wider context of a health and poverty reduction project, the Oriade initiative. The initi-
ative is currently active in four states in the south-western health zone of Nigeria.

ITN-Oriade was designed with the broad goals of reducing the mortality and morbidity due to malaria in
communities (with a focus on women and children) participating in the Oriade Initiative in South West
Nigeria adopting a multi-method approach incorporating applied research, home-based management of
simple malaria, strengthen of referral systems for malaria control, education on the use of insecticide
treated materials and community engagement in all processes for malaria control. This component of the
initiative is implemented in 12 local governments in Oyo, Osun, Ekiti and Ogun States.

ITN-Oriade aims to:
        i.      improve the ability of village based agents to identify and treat cases of simple malaria,
                recognize the symptoms of impending complications/severity and refer such cases to des-
                ignated local health facilities,
        ii.     build the capacity of these facilities to manage referred cases; and
        iii.    Implement community-managed activities of vector control and personal protection using
                insecticide treated materials.

A secondary goal is to establish local capacity to produce, treat and re-treat insecticide treated
materials for local sustainability of malaria control efforts. All activities are community owned
through programs of co-financing, co-management and local monitoring for impact assessment/evaluation
with technical assistance provided to the community and the local government by the Center for Health
Sciences Training, Research and Development (CHESTRAD). The B zone of the United Nations Chil-
dren’s Fund (UNICEF) has supported implementation of the ITN-Oriade initiative.

3.      Activities of ITN-Oriade

Implementation of ITN-Oriade is based on a composite of the following activities
        1.      Community advocacy and consensus building dialogues to understand local perceptions,
                current management practices for simple malaria and local issues in the promotion of in-
                secticide treated materials
        2.      Survey of local health facilities to assess existing infrastructure and manpower capacity
                for the management of complicated and severe malaria
        3.      Annual yearly cross-sectional survey of malaria prevalence and use of Insecticide treated
                materials. A baseline survey has been conducted in participating sites. This survey was
                implemented during the peak of the malaria transmission season between June – August,
                the period of the rainy season. This is based on findings that highest prevalence of simple
                malaria is reported at this time, and acceptability of insecticide treated materials is most
                favored during this period of high transmissibility (Personal Communication, National
                Vector and Malaria Control Program)
        4.      Selection and training of village based agents to recognize, treat simple malaria, identify
                signs of danger, refer cases of simple and other forms of malaria as appropriate and mobi-
                lize the local community for control activities

         5.     Identification and strengthening of focal referral facilities to provide support to local
                communities by the management of referred cases
         6.     Strengthen and/or establish public sector-local community partnership for primary health
                care using malaria as a focal disease
         7.     Promote sustainability via income generation activities based on local production of in-
                secticide treated materials

The guiding principle of implementation is to build communal capacity to direct the control of simple ma-

4.       Materials developed

Based on the findings from the community advocacy and consensus building dialogues, various IEC and
training materials have been developed. These include:

         i.     Radio Jingle titled ‘Ala re re’ (Sweet dreams) to communicate the ability of the bed nets
                not only to prevent mosquito bites but also to reduce their nocturnal nuisance value and
                ensure sound sleep

         ii.    A six-episode video based radio drama series also titled ‘Ala re re’ showing different as-
                pects of the management of simple malaria and its control. These video series are played
                during community advocacy dialogues and have been very useful in passing on key mes-
                sages on the use of insecticide treated bed nets and the role of local households and fami-
                lies in community directed management of simple malaria. Issues presented in the epi-
                sodes are as follows:

                        -        Environmental Sanitation
                        -        Insecticide treated bed nets for the control the nuisance of mosquitoes
                        -        Malaria in pregnancy
                        -        Drug abuse for the treatment of simple malaria
                        -        Malaria among children
                        -        Insecticide treated bed nets for the control of malaria

        iii.    An illustrated instructional booklet on malaria and insecticide treated bed nets ‘Myths
                and facts about malaria and insecticide treated bed nets’ has been produced and is be-
                ing widely circulated in the participating communities.

                                        Insert cover page here

        iv.     An illustrated instructional guide ‘Community Directed Management of Simple Ma-
                laria and Promotion of the Use of Insecticide Treated Bed Nets: Manual for Com-
                munity Orientation and Advocacy Dialogues’. The instructional guide is presented in
                two parts. Part One deals with community based management of simple malaria and pro-
                vides information on types of malaria, symptoms and signs of simple malaria and of dan-
                ger, methods of control and organizing public education activities for malaria control.
                The second part of the guide focuses on community based promotion of insecticide treat-
                ed materials with modules on record keeping and community organization for malaria
                control activities. This guide has been used for the training of village based agents, mem-
                bers of local development committees and the local health authorities on community-
                directed malaria control programs.

                                       Insert picture of cover page here

5.      Baseline findings from four states

A total of 4,309 respondents participated in a community based survey. Participants were identified across
12 local governments in Ekiti, Oyo, Osun and Ogun States.

Figure 1:          Distribution of respondents by State

                     Osun              Ekiti                    Ogun          Oyo

The highest number of participants were from Ekiti State where there are communities participating in the
complete complement of activities of the Oriade initiative.

        5.1        Background Characteristics of the Respondents

        Figure 2: Distribution by Sex
              70                      64.4                   62.1
                                                                           51.4 48.6
              40                               35.6                 37.9
                       Osun             Ekiti                   Ogun        Oyo

                                                Male   Female

In all sites, more male respondents were identified with the highest percentage (69.9%) of male respond-
ents from Osun State. Gender composition of the sample from Oyo State was almost equal. The state also
reported the highest percentage of female respondents (48.6%).

Figure 3:        Distribution of respondents by Literacy Status

            70                                                                          67.9
            60                             55.4          55.5              54.8
            30                                                   29.7
                                              22.4 2.3
                                                 2                            25.7
            20                                                                   19.6      17.5
                                                             14.8                             14.6
                                             Osun            Ekiti          Ogun          Oyo

                            Reads easily    Reads with difficulty       Cannot read

The distribution of respondents by literacy status is presented in Figure three above. The highest literacy
level of 67.9% was also reported in Oyo State while the greatest percentage of non-literate respondents
were reported from Ekiti State. This level of literacy has implications for the forms of health education
and information materials produced and the medium for its dissemination. While States with higher pro-
portion of literate populations may benefit from printed materials and posters, those with less literate pop-
ulations will be better targeted using electronic media including radio/televisions drama and jingles.

Table 1:          Socio-economic characteristics by State

Characteristics            State                                                                Total
                           Osun             Ekiti           Ogun               Oyo
Age Group
0 – 18 years               0.4              0.8             1.4                5.2              1.8
19 – 65 years              91.6             88.1            94.5               93.5             91.1
> 65 years                 8.0              11.1            4.1                1.3              7.2
Educational Status
No formal Education        26.1             32.6            22.7               13.5             25.5
Basic Education            35.1             38.6            40.5               55.5             41.8
Vocational Training        7.1              2.2             6.9                1.5              3.8
Higher Education           31.7             26.6            29.9               29.5             28.9
Community Status
Indigene                   70.3             74.2            77.8               55.5             69.8
Non-indigene               29.7             25.8            22.2               44.5             30.2
Residency Status
Fully resident             73.5             79.4            72.2               72.2             75.6
Partially resident         24.1             19.3            26.7               26.7             22.6
Non-resident               2.4              1.2             2.7                2.7              1.8
Monthly income
0 – 1199                   33.4             33.9            21.1               25.8             30.0
1200 – 2999                17.4             14.0            21.9               11.0             15.8
3000 – 5000                34.7             27.9            34.6               27.4             30.5
> 5000                     14.5             24.3            22.4               35.7             23.7

The distribution of other social and economic characteristics by state is presented in the table above. In all
States combined, 45.8% earn less than =N= 3,000.00 (Three thousand naira) which is the approved mini-
mum wage at the time of the survey and represents an income of less than $1 (one dollar) a day at the
prevailing exchange rate. The lowest proportion of the poor, 36.8% was reported in Oyo State while the
highest percentage of 47.9% was reported in Ekiti State. The implication of poverty for malaria control is
discussed in section 5.6 of this report.

        5.2       Knowledge of cause and methods of prevention of malaria

Knowledge of the cause of a disease often determines the ability to take preventive methods for its control
at both personal and communal level. This section presents the disaggregated figures of basic knowledge
of the cause of malaria in all participating States.

Figure 4:           Knowledge of cause of malaria by State

              80                                   73.1                                     75

              20   21.1
                                          9.3              10.9 11.4                9.59.2
                      5.84.9         3.7                      7.2 4.2            5.5
              0             0.6              1.2                                          0.8
                       Osun                Ekiti                  Ogun                Oyo

                                    Dirt    Sun      Hard labor          Curse     Mosquito

Across all States, there is a high percentage identification of mosquitoes as the cause of malaria. Malaria
was also often associated with dirt and hard labor. A few proportion of the respondents also identified ma-
laria as being a curse from the gods, more so when it progresses to complicated and severe forms of the
disease. The global identification of mosquitoes as the cause of malaria assisted in the identification of
entry points for information presented in the communication materials produced by the study.

Figure 5:           Knowledge of malaria prevention methods by State

                           Osun                           Ekiti                      Ogun                 Oyo

                                  Sprays     Coils        Nets      Sanitation      Cover pots   Others

Knowledge of the methods of prevention of malaria is displayed in Table 5 above. Coils, sprays and en-
vironmental sanitation rank high amongst the known methods of prevention. The use of nets, both as bed
and window nets ranked 4th amongst all the methods of prevention investigated. Other methods reported
include the use of fruit peels and burning of local herbs were also reported as methods for the manage-
ment of the nuisance caused by mosquitoes and reduction in the number of mosquitoes in the community.

        5.3         Malaria experience

In addition of knowledge of the cause and methods of prevention of malaria, the baseline survey also in-
vestigated the experience of malaria.

Figure 6:            Malaria1 Experience By State

                    47 48.6
               40             35.6
               30                                                                           Osun
                                                    17.2                                    Ekiti
                                                        7.3                                 Ogun
               10                                                                           Oyo
                      Suffering                 Malaria > 3X
                    from malaria                 a month

Respondents from Ekiti State reported the highest level (48.6%) of current experience of malaria, closely
followed by Osun State at 47%. The lowest level of current experience of malaria of 33.7% was reported
from Ogun State. Respondents were asked if they experienced malaria more than three times a month.
The distribution of their responses is also presented in the figure 6 above with more than a quarter of the
respondents from Osun State reporting experience of malaria more than 3 times of a month. It is worthy
of note that all forms of fever are often treated as malaria. An important activity in the on-going data col-
lection is the validation of clinical reports of malaria, including a documentation of the differential diag-
nosis of a fever.

    Malaria was defined by the survey as a fever that has responded, or is responding, to the use of anti-malaria drugs

           5.4 Community based management of malaria

It is the goal of ITN-Oriade to promote home/community-based management of malaria. The success of
the program in this regard would depend largely on the ability of carers and members of the local com-
munity including the village-based agent of identify the symptoms and signs of malaria. Table Two pre-
sents existing ability to recognize the symptoms and signs of malaria, drug use and place of treatment for
the last episode of malaria.

           Table Two: Management Practices for Simple Malaria

Management Practice                                        Osun       Ekiti       Ogun   Oyo       Total

Ability to recognize symptoms and signs of ma-

Fever                                                      86.8       80.9        90.8   82.8     84.2
Rigors                                                     36.8       64.1        65.5   38.2     52.6
Headaches                                                  89.4       82.1        64.1   86.8     82.0
Joint Pains                                                65.4       70.9        55.2   65.1     66.0
Tiredness                                                  62.7       63.5        68.8   78.1     67.3
Itching                                                    13.2       8.8         17.6   19.8     13.5
Malaria drug used for last episode of malaria

Choloroquine                                               67.8       70.6        43.6   54.4     62.4
Fansidar                                                   16.2       8.3         10.3   10.9     10.9
Metakelfin                                                 7.8        5.5         10.6   5.3      6.7
Local Herbs                                                8.3        15.6        35.5   29.3     20.0
Place of treatment of last episode of malaria

At home with drugs                                         19.8       25.7        25.5   43.9     28.3
At home with herbs                                         12.4       14.9        42.9   20.1     20.1
At a health facility                                       66.5       56.5        29.9   32.6     49.5
At other facility                                          1.2        2.9         1.7    1.7      2.1

Fever was commonly identified as a symptom and sign of malaria. Other frequently identified signs and
symptoms and signs of malaria include headache and joint pains. Overall, more than half of the respond-
ents identified rigors with lower levels of identification in Oyo and Osun States. Choloroquine remains
the first identified drug for the treatment of malaria followed by the use of Fansidar and local herbs. For

    Note that responses are independent and column percentages do not add up to 100%

most of the respondents, a public health facility is the first port of call for the treatment of malaria with
48.4% treating malaria at home with either drugs or herbs (Table Two).

        5.5 Use of nets and ITNs

A major objective of the project is to create demand for insecticide treated bed nets and promote its use
for the prevention of malaria. The distribution of ever use of nets and the effectiveness of nets by State is
displayed as figure 7.

Figure 7:       Use of nets

         70                                          64.5
                              47.2       49.5
                Osun       Ekiti      Ogun        Oyo

                          Ever use nets         Nets effective?

Respondents from Ekiti State reported the lowest figure of ever use of nets even though almost 50% be-
lieve that nets are effective. The latter proportion is highest proportion of over 60% was reported from
Oyo State. This high level of belief in the efficacy of bed nets is of crucial import to the project goals of
promotion of the appropriate use of insecticide treated bed nets and materials.

Figure 8: Use of ITN

                 30    26.2
                 20                         15.6
                       Osun       Ekiti      Ogun          Oyo

                                    Ever heard ITN?   Sleep under ITN?

Just above 25% of respondents in Osun State have heard about ITNs and in Ekiti State, less than 10% had
heard of ITNs. However, the proportion of respondents who had anyone sleep under ITNs in their house-
hold was less than 5% across all States. On-going project targets is to increase this number by about 50%
over the next two years with specific emphasis on use by children and women in the reproductive age
group, particularly pregnant females.

           5.6        Malaria and income

It is estimated that malaria causes over a million deaths in Africa each year and that the majority of those
who die are children and pregnant women. It has been estimated that malaria contributes about 30% to
child mortality in Nigeria (UNICEF key social indicators). Malaria keeps Africa’ people poor. It prevents
adults from working and is the greatest reason for sickness absence of children from school. ITN-Oriade
in its baseline survey examined the relationship between income and experience of malaria. Findings
from the survey are presented in this sub-section. Table two displays the relationship between income and

Table Three: Income and malaria

Malaria Experience       Monthly Income                                                     Total
                         < =N= 3000                            >=N= 3000
Is not malaria preventa- 13.2%                                 6.5%                         10.2%
Are you currently suf- 45.7%                                   40.0%                        43.2%
fering from malaria?
Suffer from malaria > 3 20.1%                                  12.7%                        16.8%
times a month?3
X2 = 10.51, df=1, p=0.001

It was identified that persons with a mean income of less than $1 per day are less able to perceive malaria
as a preventable disease, more likely to report current malaria fever and many more episodes a month
than persons who earn above =N= 3,000 per month. It was also observed that 14.2% of the poor and
18.5% of the non-poor had ever heard of insecticide treated bed nets, a level that suggests that income
may also be related to access to health promotion and knowledge. Controlling for age and sex, there is a
48% greater likelihood of ever use ITV with each one-step increase in educational status. Similarly,
women are 31% more likely to report ever use of the bed net than men when age and education are con-
trolled. Controlling for age, sex and education, income was associated with ever use of the bed net with a
9% greater likelihood of ever use of the bed nets at higher income levels (Figure Nine).

Figure Nine:        Average monthly income and ever heard of insecticide treated bed nets



                                              <=N= 3000        >=N= 3000

X2 = 10.51, df = 1, p=0.001

Figure Ten presents the relationship between income and choice of anti-malarial drugs for the last episode
of illness. For both the poor and non-poor, choloroquine is reported as the most frequently used drug for

    All types of fever responsive to treatment with choloroquine is identified as malaria

the treatment of simple malaria. However, the non-poor are two times more likely to use the more expen-
sive drugs that are effective against resistant forms of the disease. This disparity in access to the more ex-
pensive frontline drugs has implications for the access of the poor to the treatment of choloroquine re-
sistant forms of malaria with a potential for increase in the morbidity and mortality due to sever forms of
the infection.

Figure Ten:      Average Monthly Income and the use of anti-malaria drugs for last episode of ma-

           70                          62.3                                       62.2

           30                                 24.5
           20                                                                                 13.8
                                                 8.4                                                 9
           10                                          4.8
                                       < =N= 3000                                  > =N= 3000

                             Chloroquine      Local Herbs         Fansidar   Metakelfin

X2 = 74.02, df = 4, p=0.00

6.      Conclusions and recommendations

The findings of this baseline survey reaffirm that communities perceive malaria as a disease of import that
affects their productivity and longevity. They are also able to recognize the symptoms and signs of the
disease, and correctly identify its vector and it major clinical signs and symptoms. Although the level of
use of insecticide bed nets is low, many believe that bed nets are effective, creating an easy in route for
the promotion of treatment of the nets. Many members of the communities who participated in this survey
are also able to identify other methods of control besides the use of insecticide treated materials. Public
health facilities and home-based treatment are commonly utilized for the management of malaria. It is this
of import to build on this existing willingness to management of simple malaria in home or community
based situations while building the capacity for referral of complicated and severe malaria in primary and
secondary care facilities.


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