Community practices of using bed nets & acceptance & prospects of scaling up insecticide treated nets in north-east India

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1 Indian J Med Res 128, vember 2008, pp Community practices of using bed nets & acceptance & prospects of scaling up insecticide treated nets in north-east India Anil Prakash, D.R. Bhattacharyya, P.K. Mohapatra, B.K. Goswami & J. Mahanta Regional Medical Research Centre, NE (Indian Council of Medical Research), Dibrugarh, Assam, India Received August 21, 2007 Background & objectives: The National Vector Borne Disease Control Programme (NVBDCP), India has been promoting and scaling up the use of insecticide-treated nets (ITNs) in the tribal dominated malarious areas of north-east India. But, information on sleeping habits, bed net ownership and use practices, and feedback of communities in ITN - targeted areas is needed for formulating a strategic framework for upscaling the coverage of ITNs. We carried out a community-based cross-sectional survey in select areas of Nagaland and Mizoram (where ITNs were introduced) along with Assam (where ITNs were not introduced) to know the response of community. Methods: Following large scale introduction of ITNs during in the north-eastern States of Nagaland and Mizoram by NVBDCP, India, a cross-sectional community-based survey was undertaken in April-May, 2003 covering 435 households of Nagaland and 464 households in Mizoram, using a structured questionnaire, to assess the demographic variables relevant to bed net use, bed net washing practices and acceptability of ITNs etc., for upscaling the coverage of ITNs in the surveyed communities. A total of 448 households in 8 villages in a non-itn PHC area of Assam were served as the control area. Results: The average bet net usage per family (2.01 to 2.65). Bed net use was mostly seasonal in Nagaland where a majority ( %) used bed nets only during summers and monsoon as compared to the year round use in Mizoram (83.5%) and Assam (78.9%). Frequent washing of nets was most common in Assamese communities with 77 per cent households washing their nets at least once in a month. More than two third users favoured use of ITNs over the conventional indoor residual spray of DDT for malaria control. Interpretation & conclusion: ITNs are widely acceptable in the user communities and a demand for ITNs is evident in the non-user communities of north-east India. Approach of treating community owned nets through an efficient service delivery mechanism will be a viable option for upscaling the ITN coverage. Key words Community nets impregnation - insecticide treated nets - malaria - north-east India Insecticide-treated bed nets (ITNs) have emerged as a potent and effective weapon in the armory of vector control options for the prevention of morbidity and mortality caused by malaria 1. Besides providing personal protection to the users against mosquito bites, ITNs also produce mass effect, if comprehensive 623 coverage by ITNs of the community is ensured by killing a large number of malaria vectors, substantially reducing their longevity and entomological inoculation rate 2. Curtis 3 equated the beneficial combination of personal protection and community wide mass effect of ITNs to the benefit derived from vaccination

2 624 INDIAN J MED RES, NOVEMBER 2008 against measles. It is no wonder that many malaria endemic countries in the world have included ITNs in their national malaria control programmes 4,5 and promotion of use of ITNs has become a key malaria control strategy globally 6. In India, ITNs showed efficacy in trials carried out in diverse eco-epidemiological settings for controlling malaria transmitted by Anopheles culicifacies 7, An. fluviatilis 8, An. minimus 9 and An. dirus 10 complex mosquitoes. Members of An. minimus and An. dirus complex are the main vectors of malaria in the northeastern region of India 11. On the basis of vector behaviour, especially the An. dirus complex, and the experimental successes, the use of ITNs was regarded as the suitable and effective intervention measure for malaria control in the north-eastern region of India 12. Therefore, National Vector Borne Disease Control Programme (NVBDCP), India, is promoting the use of ITNs in the tribal dominated malarious areas of north-eastern States and peninsular India with plans to scale up the coverage. However, except one published account on practices related to bed net use among a few communities of Nagaland and Arunachal Pradesh 13 practically there is no or scanty information available on the sleeping habits, bed net use practices of various ethnic communities inhabiting the NE States which is crucial, for implementing this alternate vector control strategy. Moreover, feedback from the communities on the acceptability of ITNs is vital to formulate a strategic framework for scaling up the coverage of ITNs. We report here the results of a community-based crosssectional survey done in select areas of Nagaland and Mizoram (where ITNs were introduced during ) along with Assam State (where ITNs were not introduced) to elicit the bed net use practices, response of the communities on the use of ITNs and the prospect of up scaling the coverage of ITNs in north-east India. Material & Methods For promoting ITN use in north-east India, NVBDCP, India, during 2001 and 2002 supplied 1,40,000 single and double sized bed nets and adequate quantities of deltamethrin flow insecticide to the north-eastern States of Nagaland (27,000 nets) and Mizoram (1,13,000 nets) for gratis distribution to the communities. Health departments of these States impregnated and distributed the treated nets in the targeted malarious areas. Accordingly, in Nagaland, 27,400 ITNs (17,400 single and 10,000 double), including 400 nets of old stock, were distributed during July-August, 2002 in 126 villages in all the 8 districts. In Mizoram, 1,13,000 ITNs (63,000 single and 50,000 double) were distributed during May-October, 2001 in 888 villages in all the 9 districts. We carried out a cross-sectional community-based evaluation of ITN programme in these States during April-May, Survey methodology: Study protocol envisaged to cover 2 districts, at least 2 Primary Health Centres (PHCs) in each district and at least 1 village in each PHC with a total sample size of about 450 households in each State. Operational considerations such as disturbed field conditions and resource constraints restricted the sample size of surveyed households to about 450 per State in the study. The list of beneficiary villages was obtained from the Medical Officer-in-charge of the selected PHCs and villages were randomly chosen for the study. Every 4 th household in a village was included in the survey, however, in thinly populated villages sampling was doubled (every 2 nd household) to achieve the target. Two experienced investigators administered a pre-tested and structured questionnaire to the head of the surveyed households. Help of the local health workers was solicited for communication, wherever required. In order to have a comparative picture from an area not covered under the ITN programme until then, nearly equal numbers of households were surveyed in district Tinsukia of Assam. Study villages: The study was carried out in district Kohima and Mokokchung in Nagaland; and Aizawl (West) and Kolasib in Mizoram. In Nagaland, five villages under PHC Jaluki (inhabited by Zeiliang tribe) of district Kohima and two villages each under PHCs Sabangya and Tuli (inhabited by Ao tribe) of district Mokokchung, were surveyed covering 435 households. In Aizawl (West) district one village each under PHCs Sairang and Lengpui and 2 villages each under PHCs Kolasib and Kawnpui (inhabited by Mizo tribe) of district Kolasib were surveyed covering 464 households in Mizoram State. Among non-itn areas, a total of 448 households in 8 villages under PHC Ketektong of Tinsukia district, Assam (inhabited predominantly by Kachari-Ahom ethnic groups) were surveyed. Thus, the present study encompassed a total of 1,347 families residing in 23 villages spread across 8 PHCs in 5 districts of 3 north-eastern States covering 4 major tribes. Results Bed nets use practices: Surveyed villages topographically were either hilly (district Mokokchung, Nagaland;

3 PRAKASH et al: OPERATIOLIZATION OF ITNs IN NORTH-EAST INDIA 625 Mizoram) or plain (district Kohima, Nagaland; Assam). Most of the villages were inhabited exclusively by one tribe/community. However, in some villages of Kolasib district in Mizoram and Tinsukia district in Assam about 20 per cent population was relatively new settlers like Nepalis and ex-tea garden labourers. Among the four tribes, covered in the present study, the average family size varied from 4.6 to 7.3, highest in Zeiliang and lowest in Ao, both in Nagaland. Study population was exclusively indoor sleeper in all the communities. In a household, people seldom slept singly and sharing of bed by members of the family was a common feature. On an average, 2.09 family members among Mizos shared a bed in contrast to 1.52 among Ao. Large sized cots were more commonly used in Naga communities. Use of bed nets was common in all the communities. Majority of community owned nylon nets. Average bed net ownership was highest among Kachari-Ahoms (2.65 bed nets/household) followed by Zeliangs (2.44), Mizos (2.34) and Aos (2.01). Use of bigger sized nets was more popular and per cent of community owned nets were of double size. Majority (ranging 86.3% in Zeliangs to 95.6% in Mizos) in a family used bed nets on a regular basis (every night). Among the regular bed nets users, each bed net on an average was shared by more than 2 persons in Naga and Mizo communities whereas in Assamese communities less than 2 persons shared a net. Seasonal pattern of bed net use was noticeably different in Naga tribes. While majority of Mizos (83.5%) and Kachari-Ahoms (79%) used the bed nets round the year, a large number of Zeliangs (65%) and Aos (79%) people in Nagaland used bed nets only during summers and monsoon months. Nearly all households ( %) in Nagaland and Mizoram left their nets hung over the beds/cots during the day time in comparison to only 63 per cent in Assam. A wide variation in the bed net washing frequencies was noted among the surveyed tribes. The practice of washing of bed nets was more prevalent in Assamese communities where 77 per cent families washed their bed nets at least once in a month in comparison to only 10 per cent Mizo, 4.4 per cent Zeliang and 11.8 per cent Ao doing so (Table I). Table I. Bed net use pattern and practices in select tribes of north-east India Areas with ITNs Areas without ITNs Characteristics Nagaland Mizoram Assam Zeliang Ao Mizo Kachari-Ahom. villages surveyed households surveyed Average family size (mean + SD) Sleeping and bed net use pattern: Average no. of beds / household Average no. of members sharing a bed bed nets owned / family (mean + SD) Single sized Double sized of regular bed net users /household 6.3 (86.3%) (90.2%) (95.6%) (88.8%). of regular bed net users sharing a bed net/household Bed net usage practices: % households using bed net during Summers only Whole year How bed nets are stored during day time (% households) Remain hung over the bed Remove & fold Frequency of washing of bed nets (% households) Once or more in a month Once in 2-3 months Once in 4-6 months Once in >6 months

4 626 INDIAN J MED RES, NOVEMBER 2008 Response of communities to ITNs: Though ITN use rates were not quantified in this study, actual ITN usage by the people was qualitatively assessed through physical verification of the presence and use of ITNs in a few randomly selected households in each surveyed village. Almost in every house, thus, checked ITNs were found in use and majority of ITN users in Mizoram and Nagaland gave a positive feedback about their benefits. More than 80 per cent users liked the use of ITNs and favoured it over the conventional indoor residual spraying with DDT for malaria control (Table II). While about 82 per cent Zeliang people experienced the protective effect of ITNs not only against the mosquito bites but also against other household insects, besides the malaria disease, only 24 per cent Aos and 44 per cent Mizos felt so and the rest felt that ITNs provided protection against mosquito bites alone. One or more members in about 18 per cent Mizo families experienced mild skin irritation and burning sensation initially for a few days after using ITNs in comparison to about 5 to 7 per cent Naga families. In spite of that, more than 95 per cent families in the surveyed communities expressed their willingness to buy the treated nets, if available in the open market, instead of ordinary nets because of the perceived benefits of ITNs. Further, they were also ready to pay INR per net, if asked for, towards the cost of impregnation in the village by an agency. In Assam, surveyed communities had no prior experience of using ITNs themselves and only 6.8 per cent people had heard about ITNs through various channels, still about 90 per cent households expressed their willingness to spend money to get their own nets impregnated in the village, as and when arranged (Table II). Characteristics Table II. Communities response on insecticide treated nets (ITNs) in select tribes of north-east India Areas with ITNs Whether liked using ITNs (% households) Side effects experienced by any family member after using ITNs (% households) Skin irritation/burning sensation Sneezing Nil Whether ITNs provided protection against (% households) Mosquito bites only Malaria only Other insects All the above Would you prefer using ITNs over DDT spray for malaria control (% households) Are you willing to buy treated bed nets from the market, if available (% households) Are you willing to pay the cost of pyrethroid insecticide (INR per net) for impregnating own bed nets, if it is made available in the village (% households), not applicable Areas without ITNs Nagaland Mizoram Assam Zeliang Ao Mizo Kachari-Ahom

5 PRAKASH et al: OPERATIOLIZATION OF ITNs IN NORTH-EAST INDIA 627 ITN service delivery mechanism: State Health Department in Nagaland used the well established and functional agency of `Village Councils for impregnating and distributing ITNs in the identified villages. Select volunteers from every village council were trained in bed net impregnation in the concerned PHC who subsequently carried out impregnation in their villages in the Council Hall and distributed ITNs to the beneficiaries, identified before hand by the village council. Efforts were made to provide at least one ITN to each family in the identified villages and communities were encouraged to get their own nets impregnated. Apparently the mechanism worked well with little problem. However, in Mizoram, the State Health Department was the main service provider for introducing treated nets with sundry help from the `Young Mizo Association (YMA), and the village councils. PHC staff enumerated and identified the beneficiaries (families involved in Jhum cultivation and those below the poverty line), carried out the impregnation of nets mainly in the health sub-centres and subsequently distributed in the identified villages. During survey in Assam the views of the people were elicited on the potential service delivery agency for introducing ITNs in their area. A majority (77%) opined that the task of impregnation of bed nets should be undertaken within the village at a common place such as school building or Namghar (a religious place) through either any community-based organization (44%) or the village headman (40%). Surprisingly only 2 per cent respondents favoured handling of the task by the State Health Functionaries (Data not shown). Discussion A strong tradition of bed net use in north-eastern region of India has earlier been reported 13. The present study noted the wide acceptance and popularity of insecticide treated nets in select tribal communities of Mizoram and Nagaland. A positive feedback by the ITN users and a demand for ITNs in the nonusers was evident in the surveyed areas. The response of the communities from different areas of NE India, where ITNs were introduced in a pilot study during 1995, was also reported to be very enthusiastic 14. This shows that the use of ITNs is an appropriate vector control strategy for north-east India considering unique transmission features of malaria 11 and is largely accepted by the communities. However, establishing a suitable mechanism for introducing and upscaling the coverage of ITNs is a challenging task. A single blanket approach for this task may not work with equal success in all areas of northeast India because of the diversity of ethnic groups, practices, sleeping pattern and other factors influencing the use of ITNs and, therefore, necessary flexibility may be required to have State specific or area specific approach in sync with the preferences and practices of the local communities. Net washing is an important determinant of the effectiveness of ITNs, targeted efforts have to be made through behaviour change communication to modify the net washing practices of the communities while introducing ITNs in an area. In Dares-Salaam in a study it was found unrealistic to prevent people from washing their nets and it was suggested to opt for a low-dose frequent-treatment strategy of treated bed nets 16. This approach may technically be fit but organizing frequent (re)treatment may pose organizational and operational difficulties in an area like north-east India. Therefore, a suitable alternative could be the introduction of long-lasting insecticidal nets (LLINs) instead of conventionally treated nets. LLINs, a new technological advancement, are wash resistant and reported to retain their insecticidal efficacy for its entire life span (3-4 years) in spite of repeated washings 17. Another big advantage with LLINs is that these are factory treated at the time of manufacturing and need no re-treatment for up to 20 washings or about 3 years of its field use 18. This feature makes LLINs operationally very convenient, cheaper in long run and suitable for far flung inaccessible areas. In Nagaland and Mizoram about per cent ITN users reported to have suffered from skin irritation/burning sensation of short durations which prompted them to stop their children, especially infants and toddlers, from sleeping under ITNs. These temporary adverse reactions were experienced mostly by those who used the treated nets on the same day of its impregnation without giving sufficient time for drying. This emphasizes the importance of giving proper and clear instructions by the service providers to the ITN users on the precautions to be observed. In spite of occurrences of such minor problems, overall acceptance of ITNs has been high in all areas. Insecticidal impregnation of community owned nets may be a viable option for up-scaling the ITN coverage. High ownership of the bed nets in various communities of Nagaland and Arunachal Pradesh has already been reported 13. Present study also noted a high average ownership of bed nets. Therefore, a suitable and sustainable strategy need to be formulated to impregnate the community owned nets. We found

6 628 INDIAN J MED RES, NOVEMBER 2008 willingness in surveyed communities to bear the cost of treating their nets suggestive of feasibility of having a cost-sharing mechanism for community nets impregnation. In a pilot study based on public-privatecommunity partnership, conducted in a few districts in north-eastern States of Assam, Arunachal Pradesh, Meghalaya and Mizoram, the communities were asked to pay for the cost of insecticide for impregnating their nets. A variable but reasonably satisfactory response was obtained from the communities in this experiment. Success was relatively more evident in Mizoram and Assam where 72 and 56 per cent of the set targets respectively could be achieved (RMRC Dibrugarh, unpublished observations). w-a-days, social marketing of ITNs is being emphasized with a stress to educate communities to become accustomed to pay for ITNs because agencies of government, non-governmental organizations cannot be expected to continue supplying free nets for all time due to resource crunch 19. Scaling up ITN coverage via social marketing was attempted in Tanzania 19,20 where it was found to work well in urban areas but performed poorly in villages 21. Experience gathered so far points out that social marketing of ITNs/insecticide can perhaps be a potential option in north-east India. Effectiveness of a community-based ITN programme would greatly depend on the efficiency and strategic framework of the service delivery mechanism. Adequate sensitization of the communities on ITN use prior to the introduction mechanism of impregnation, distribution of treated nets, and re-treatment are important and integral components of the ITN service delivery process. In Mizoram, Health Department relied mainly on its own infrastructure and manpower for ITN introduction which further strained the already burdened health personnel and communities were also less motivated. In comparison, in Nagaland the agency of Village Councils was utilized for this purpose which seemingly worked well perhaps due to the direct involvement of the communities through village councils. Nagaland experience showed that community involvement did not only lessen the load of the health department but also brought in a sense of ownership which made the difference. In surveyed villages of Assam, the desire of communities to involve suitable community based organization(s) for implementing ITN programme is also a pointer to this fact. In those north-eastern States where an established system of village councils is non existent or organized community based organizations are scarce, bed net introduction can be attempted with the help of social and religious leaders as was done successfully in tribal areas of Orissa 22. Place of community nets impregnation also seems to affect the extent of coverage. It emerged from the present study that people favoured a common place and a place closer to their households for impregnating their nets. Similar observations were made in Burkina Faso 23. In conclusion, our findings showed that ITNs may be the ultimate answer to the problem of malaria in remote, inaccessible areas of the NE region provided a suitable and optimal service delivery mechanism is in place for treatment; distribution of ITNs and more importantly timely re-treatment is ensured. Acknowledgment Authors acknowledge the National Vector Borne Disease Control Programme, Delhi for funding the study. 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