Knowledge, Attitude and Practices Among Mothers Towards Insecticide-Treated Nets in Abuharira Village -Um Remta Locality- The White Nile State -2015

Malaria is the most prevalent parasitic endemic disease in North Sudan, 75% of the total population is at risk. WHO recommends the use of insecticide-treated nets (ITNs) an effective malaria control strategy. This study was aimed to assess the knowledge, attitudes and practices of mother’s about Insecticide-Treated Nets as one of the preventive measures against malaria. This is a descriptive community based study of (295) mothers living in Abo Harira village in North Sudan. The pre-tested structured questionnaire was used for data collection. Multivariate logistic regression was used to study association between the dependent and independent variables, using Spss version 20. The study showed that more than half (55.9%) of mothers had good knowledge regarding ITNs, In spite of good knowledge about ITNs, (66.8 %) of mothers still had negative attitude and only (27.8%) reported always sleeping under it. Multivariate analysis suggested that mothers aged ≤31 years were more likely to have good knowledge about ITNs compared with mother with age ≥ 32 years [OR; 0.5174 (95% CI: 0.2974-0.9001)]. Similarly, mothers who had formal education were more likely to have knowledge about ITNs, two time higher than those with informal education [OR; 2.2 (95% CI: 1.274-3.788)]. We observed that mothers with age ≤31 years had positive attitudes towards ITNs [OR=0.461; 95%CI= (0.2578-0.8232)]. In addition, mothers with formal education were more likely to have positive attitude toward ITNs two time higher than those with informal education [OR; 1.99 (95% CI: 1.11823.5731)]. Only association between income and practice is evident. Higher income group is more likely to practice preventive activities two time higher than those with low income group [OR; 1.69 (95% CI: 1.0158-2.8214)]. We Conclude that the attitude and practice of mothers to ITNs in this study was poor. Multivariate analysis revealed that knowledge of mothers about ITNs has significant association with age and education, also illustrate that mothers attitude towards ITNs has significant association with age, mother’s work, education and monthly income. Therefore, Education System and the Malaria Control Programme in North Sudan should work closely, especially on malaria education for behaviour change as a key element for increasing utilization of ITNs.


Introduction
Worldwide, an estimated half of world populations are at risk of malaria [1]. Malaria is endemic in Africa, with an estimated 80% of cases are almost exclusively due to P. falciparum [2], and 91% of deaths occurred, amongst children and pregnant women. Children under-five years of age most at risk of infection and adverse outcomes [1], [3].
In Northern Sudan, malaria is a major public health problem [4]. It is a leading cause of morbidity and mortality, nearly 75% of the total population is at risk of malaria, 30% of inpatient admissions and 16% of hospital deaths are attributed to malaria [5]. Overall parasite prevalence has doubled in 2012 compared to 2009 (increased from 1.8% in 2009 to 3.3% in 2012) [4]. Interventions strategies to control malaria in North Sudan the use of insecticide treated net is one of them, between 2012 and 2014 national malaria control programme distribute sufficient ITNs to protect 54% of highrisk populations [2]. Even though, the Abuja declaration targets agreed upon by African heads of state in 2000 aims to provide at least 80% of pregnant women with ITNs by the year 2005, only 54% of high-risk populations presently make use of an ITN in Sudan which hindered the effectiveness of ITNs.
Among other preventive interventions, WHO recommends the use of insecticide-treated nets (ITNs), particularly longlasting insecticidal nets, which have been shown, reduce malaria episodes among children < 5 years of age by approximately 50% and all-cause mortality by 17% [6] Universal coverage with ITNs is defined as use by > 80% of individuals in populations at risk [7].
Moreover regarding the effectiveness of ITNs a number of studies have confirmed that the use of insecticide-treated nets (ITNs) reducing clinical malaria episodes by 48 to 50% and malaria-related morbidity mortality [5], [8]. A 25% reduction in all-cause mortality for children one to nine years of age was detected during the first year of the Gambian National Bednet Program [9]. In Kenya, 33% reduction in mortality and also were found that 44% reduction in hospital admissions for severe malaria and reduce malaria transmission by at least 60% and child deaths by 20% [10].
These findings approved that ITNs are an effective malaria control strategy, even though, there have been many challenges to ITNs coverage, misconceptions concerning ITNs utilization and poor knowledge when trying to implement large-scale ITN programs.
Um Remta Locality is one of the White Nile State localities. This state is known as malarious zone with recorded cases of malaria throughout the year [31]. The major malaria vector control strategy is the usage of Insecticide Treated Nets. However, the monitoring and evaluation about usage of ITNs was not adequate. Also there were no recent data on the knowledge, attitudes and practice (KAP) of mothers about use of ITNs, Therefore, this study was conducted to assess the level of knowledge, attitudes and practices among mothers about Insecticide-Treated Nets as one of the preventive measures against malaria.

Study Design
A descriptive community based study was conducted in Um Remta locality -White Nile State with an objective, to assess the level of knowledge, attitudes and practices among mothers about Insecticide-Treated Nets as one of preventive measures against malaria.

Study Area
The study was conducted in Abo Harira village, Um Remta, which is one of the eight localities that form White The heavy rainy season in the area is between June and September, during which crop cultivation takes place. The total annual rainfall ranges between ‫001ـــ009(‬ mm). The climate in general is hot with relative humidity varies from ‫.%07ـ05‬ The mean maximum temperature is 40°C, occurred during summer season; while the mean minimum temperature is 18.0°C occurred during winter seasons. The common source of water supply in the area is River Nile and arteizian wells. The locality has 4 hospitals, 12 health centers also has 18 higher secondary schools and 52 primary schools. The main malaria prevention and control strategies being undertaken in the study area include ITNs, IRS, use of pesticides to control larvae, adult mosquitoes, environmental intervention and case management.

Study Population
The study population included all the mothers living in Abo Harira village, Um Remta locality-White Nile State, who were freely provided by insecticide treated nets (ITN).

Sampling Technique
The study areas were purposively selected to represent the rains malarias areas of the Um Remta locality, White Nile state. It's characterized by year round transmission with seasonal peaks following the heavy rains. Abo Harira village was randomly selected from the list of Um Remta locality villages. All mothers (295) living in Abo harrira village were freely provided with ITN were considered as sample size.

Data Collection
A close-ended, pre-tested and structured questionnaire was administered by interview method to all mothers visited at their homes. The questionnaire consist of four sections: Socio-demographic data includes age, educational level of mothers, monthly income family size and occupation. The variables include knowledge, attitude towards insecticidetreated nets and practice of preventives measures likes ownership and use of insecticide-treated bed nets. The data was collected by public health officers during January 2015.
Determination of knowledge, attitude and practice regarding insecticide-treated nets: Based on the previous studies conducted in different part of malaria endemic areas the average mean of overall knowledge, attitude and practice score has been considered as the cutoff point [3], [27], [28], [30].
Mothers knowledge assessment: A composite variable was generate an overall knowledge score was calculated by adding up the scores for each mothers across all (11) questions and the total score was (15), zero point was given for an incorrect answer and one point was given for correct answer. Those whose score are equal to mean (8.2) or above were taken as having good knowledge while those with score of less than the mean (<8.2) were considered as having poor knowledge about insecticidetreated bed nets.
Mothers attitude assessment: An overall attitude score was determined for each participants by adding up the scores across the six attitude questions and the total score was (6). Participants with score of greater than or equal to the mean score (3.04) were considered as having positive attitude whereas those with score of less than the mean score were taken as having negative attitude towards ITNs.
Mothers practices assessment: Was assessed based on the participants answers to the practices questions, if mothers always performed a good practice i.e., owning and sleeping under a mosquito net, she was given a score of one points, if on the other hand, she never performed a good practice, she was given a score of zero. An overall practices score was calculated by adding up the scores across the (7) ITNs practices questions and the total score was (7) mothers with score of greater than or equal to the mean score (3.2) were considered as having good practice while those with score of less than the mean score were taken as having poor practice in relation to ITNs.

Data Analysis
The data obtained from the participants through research tool was analyzed. Depending on the types of the variables, descriptive statistics were used to tabulate and describe the data, and inferential statistics was used to examine association between variables. While Odds ratio (OR) with 95% confidence interval was calculated to study check statistical association between the dependent and independent variables using the binary logistic regression. The data was analyzed through Statistical software Package for Social Sciences (SPSS) version 20. The tests were carried out at 95% confidence interval, p-values less than 0.05 were considered significant.

Ethical Considerations
The study was reviewed and approved by the Ethical Committee of the Medical and Health Studies Board at University of Khartoum. Moreover, during training of the interviewers, emphasis was placed on the importance of obtaining informed oral consent before every session of the interview. Two hundred ninety five (295) mothers participated in the study and were interviewed during the period of study. Their mean age was 30.8 ±12.1 years, with about 50.8% aged between 32 and 45 years. However majority of the mothers had formal education (69.3%). Number of children alive ranged between up to 6 members and more than 6 members. Related to the occupational status of the participants, majority of mothers non-employed (83.7%), while (85.4%) of the household were engaged in work and (51.5%) of those household had monthly income <450 Sudan Pound. (Table1). Knowledge about ITNs was considerably higher among mothers.  The main reason that they were not using ITNs was ITN cause allergic(48.2%), ITN caused thermal stress(26.3%), using repellents (18.4%), and difficulties in collecting and hanging ITNs every day (4.4%), (2.6%) respectively. (Figure 1) Overall Knowledge about ITN was calculated by adding up the score for each other across all (11) questions and the total score was (15). Poor Knowledge with score of less than the mean (<8.2) and Good Knowledge with the score equal to mean (8.2) or above. Overall attitude score was determined for each participants by adding up the scores across the (6) attitude questions and the total score was (6). Participants with score of greater than or equal to the mean score (3.04) were considered as having positive attitude whereas those with score of less than the mean score were taken as having negative attitude towards ITNs. Overall practices score was calculated by adding up the scores across the (7) ITNs practices questions and the total score was (7) mothers with score of greater than or equal to the mean score (3.2) were considered as having good practice while those with score of less than the mean score were taken as having poor practice in relation to ITNs Figure 2. Showed that overall level of knowledge of mothers about ITNs was categorized as good or poor. Consequently, almost more than half (55.9%) of them had good knowledge regarding ITNs, while the remaining 44.1% of the mothers possessed poor knowledge. With regard to the attitude more than half of the mothers (66.8%) had negative attitude towards ITNs, while the remaining (33.2%) of the mother's possessed positive attitudes. However mothers who owned ITNs (57.3%) had good practice while 42.7% mothers had poor practice. While no significant association was found between mothers knowledge and mother work, family size, and monthly income (p>0.05), Further details of analysis are presented in Table 3. Multivariate analysis illustrate that mothers attitude towards ITNs has significant association with age, mother work, household work, education and monthly income. We observed that mothers with age <31 years had positive attitudes towards ITNs [OR=0.461; 95%CI= (0.2578-0.8232)]. In addition, mothers with formal education were more likely had positive attitude toward ITNs two time higher than those with informal education [OR; 1.99 (95% CI: 1.1182-3.5731)]. As well mother with up to 450 SDG household monthly income more likely have a positive attitudes towards ITNs[OR; 0.503 (95% CI: (0.2922-0.8663)] than mother with monthly income (451-1450 SDG). While no significant association was observed between mothers attitude and family size [OR=1.485 CI= (0.8474-2.6019)].

Association Between Socio-demographic Variables and Mother's Knowledge Attitude and Practice About ITNs
With regard to mothers practices the results showed significant association with (451-1450 SDG) household monthly income were more likely to practice activities likes owing ITN, sleeping under a net, hang up the net before sun set, use ITN all over the year, use ITN for all family members, washing ITN periodically and re-treat the net two time higher than those with Up to 450 SDG household monthly income [OR; 1.69 (95% CI: 1.0158-2.8214)]. While no significant association was observed between mothers practices regarding ITNs and age, mother work, household work, family size and education (p>0.05). More details of analysis are presented in Table 4.

Discussion
This study showed that more than half (55.9%) of mothers had good knowledge regarding ITNs, which may motivate them to use ITNs more effectively [11]. In spite of fairly good knowledge about ITNs, the attitude and practice of mothers to ITNs was still poor. The 66.8% of mothers had negative attitude was recorded in this study which is slightly lesser than reported in Nigeria (70%) [12].
The probable reasons for the poor attitude toward ITNs could be misunderstanding of its importance and lack of cultural exposure to the use of mosquito nets.
Regarding disparities between household possession of ITN and ITN use, this study showed that proportion of net use among mothers (27.8%) and ownership (66.0%) of households owning at least one net. Assessment surveys conducted in Africa showed similar disparities between household possession of ITN and ITN use [17]. Likewise, recent data showed that households owning an ITN increased up to 65% in one study, the use of ITNs among women was only 23% [18]. Despite a high coverage of ITN users remains less than that of ITN owners. These disparities might be due to many reasons hindering ITNS use likes lack of cultural exposure to the use of mosquito nets, negative perception such as ITN cause allergic, thermal stress, and difficulties in collecting and hanging ITNs every day.
Multivariate analysis revealed that knowledge of mothers about ITNs has significant association with age and education. The analysis suggested that younger mothers <31 years were more likely to have knowledge about ITNs than the others (>32 years). The majority of younger mothers (67.3%) had formal education. This might have lead to an increased level of knowledge about ITNs, because the formal school curriculum might have sensitized them with many health education messages about prevention of diseases.
As well, mothers had formal education were more likely to have knowledge about ITNs two time higher than those with informal education. This finding is in agreement with recent study conducted in Iran by Hanafi et al., in 2011 who found that educational level is positively associated with knowledge of malaria [19]. Whereas in contrary with a previous study conducted in Nigeria by Charles et al., in 2017 who found that female education were not significantly associated with ITN knowledge, and usage [20].
Related to association between socio-demographic and mothers practices regarding ITNs, only association between income and practice is evident. Higher income group is more likely to practice than low income group. Previous study conducted by  in Mali how found that cost was the main factor. Similar results have been found in other studies [21], [22]. Moreover other study reported those who have better income were 1.8 times more likely utilize ITN than have less income [23]. This might be people with low income concerns about the cost of ITNs and absence of a sustainable mechanism for the distribution of ITNS. While no significant association was observed between mother's practices regarding ITNs and education. Njoroge et al., in 2009 highlighted the fact that high level of knowledge does not necessarily translate to use of appropriate interventions [24]. This is also similar with the findings of the studies in Kenya and Northern Ethiopia [25], [26]. Other studies showed that good knowledge is associated with poor practice [12]. Which is concordant with the findings of the study conducted by Tarfi et al. 2015 in Ethiopia who found that level of education was significant predictor of ITNs use. Another study in Iran showed that bed net use rate was positively associated with educational level of respondents [3], [19].

Conclusions
We conclude that the attitude and practice of mothers to ITNs in this study was poor. In spite of fairly good knowledge of the benefits of ITNs. (66.0%) mothers owned an ITN, only (27.8%) reported always sleeping under it. This explain the disparities between mothers possession of ITN and ITN use. Multivariate analysis suggested that younger mothers <31 years were more likely to have knowledge about ITNs than the others (>32 years). As well, mothers had formal education were more likely to have knowledge about ITNs, two time higher than those with informal education. However only association between income and practice is evident. Higher income group is more likely to practice than low income group. While no significant association was observed between mother's practices regarding ITNs and education.

Recommendation
The study reveals that mothers have adequate knowledge about ITNs and of the link between the use of ITN and malaria control. While attitude of mothers towards the use of ITNs was poor, so creating only the awareness is not enough. People should be motivated to create a culture and enhance their understanding towards practicing preventive measures against malaria, like use of ITN, environmental intervention and insecticide spray. This can be achieved through formal education. Involvement of formal education in malaria control has a critical role to play. Education System and the Malaria Control Programme in North Sudan should work closely, especially on malaria education for behavioural change. Furthermore the Health authority should enhance training of volunteers and local leaders towards proper utilization of ITNs.