FACTORS CONTRIBUTING TO PREVALENCE MALARIA AMONG

WOMEN ATTENDING ANC SERVICES IN BUSIA COUNTY

REFERRAL HOSPITAL

BY
AUMA ELIZABETH ODERO.
ADMISSION NO.; D/NURS/19064/2374

A RESEARCH REPORT SUBMITTED IN PARTIAL FULFILLMENT

OF THE REQUIREMENT FOR THE AWARD OF DIPLOMA IN
COMMUNITY HEALTH NURSING OF KMTC
BUSIA CAMPUS

MAY, 2022

1
Contents
CERTIFICATION................................................................................................................................ 4
DECLARATION................................................................................................................................... 5
ACKNOWLEDGEMENT.................................................................................................................... 6
DEDICATION....................................................................................................................................... 7
Abstract.................................................................................................................................................. 8
Abbreviations ........................................................................................................................................ 9
CHAPTER ONE ................................................................................................................................. 10
1.1 Introduction............................................................................................................................... 10
1.2 Problem Statement.................................................................................................................... 11
1.3 Justification ............................................................................................................................... 12
1.4 Research Questions................................................................................................................... 12
1.4.1 Study Objectives..................................................................................................................... 12
1.4.2 Main Objective:.................................................................................................................. 12
1.4.3 Specific objectives .............................................................................................................. 12
CHAPTER TWO ................................................................................................................................ 13
2.0 Literature Review ..................................................................................................................... 13
2.1 Introductions ............................................................................................................................. 13
2.3 Assessing the Level of Knowledge of Mother/Women and Caretaker On Malaria Injection 15
2.4 Utilization of Insecticide Treated Nets .................................................................................... 16
CHAPTER THREE ............................................................................................................................ 17
3.0 Research Methodology ............................................................................................................. 17
3.1 Study Area ................................................................................................................................. 17
3.2 Sample Population .................................................................................................................... 17
3.3 Sample Size ................................................................................................................................ 17
3.4 Permission Obtainment ............................................................................................................ 17
3.5 Research Design ........................................................................................................................ 18
3.5.1 Method for Investigating the Prevalence Of Malaria In Pregnancy ................................. 18
3.5.2 Observations on Knowledge and Attitude of Caregivers to Malaria Diagnosis............... 18
3.6 Data Analysis............................................................................................................................. 18
3.7 Data Collection Process ............................................................................................................ 18
3.7.1Training of Research Assistants ................................................................................................ 19
3.8 Data management and analysis ............................................................................................... 19
3.8.2 Analysis of Data Variables Dependent Variable ................................................................. 19
3.10 Ethical consideration .............................................................................................................. 19

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 3.11 Research Instrument .............................................................................................................. 20
CHAPTER FOUR............................................................................................................................... 21
4.1 Research Finding ...................................................................................................................... 21
4.1.1 Social Demographic Characteristics .................................................................................... 21
4.1.2 Coverage of IPT in Identified Health Facilities................................................................... 21
4.1.3 Knowledge of Pregnant Women on IPT .............................................................................. 22
4.2 Level of Education ReSPondent .............................................................................................. 22
4.2.2 Distribution of Respondents Based On Their Occupation ................................................. 23
4.2.3 Attitude of Health Care Workers on IPT Services. ............................................................ 23
4.2.3.1 Malaria as a Threat To Pregnant Women........................................................................ 23
4.2.3.2 Opinion on Prevention Of Malaria In Pregnancy............................................................ 23
4.2.3.3 Opinion on The Provision Of IPT By Other Healthcare Providers ............................... 23
4.2.3.4 Acceptance of SP by the Clients......................................................................................... 24
4.2.4 Practice of IPT........................................................................................................................ 24
4.3 Religion of Respondents ........................................................................................................... 24
4.4 Availability of Drug and Clean Water for IPT Administration ........................................... 24
CHAPTER FIVE ................................................................................................................................ 26
5.1 Discussion................................................................................................................................... 26
5.1.1 Finding .................................................................................................................................... 26
5.2 Knowledge about IPT ................................................................................................................... 26
5.3 Attitude on the Use of SP.......................................................................................................... 27
5.4 IPT Practice............................................................................................................................... 27
5.5 Monitoring of IPT Services. ..................................................................................................... 27
5.6: Conclusion ................................................................................................................................ 27
5.7 Recommendations ..................................................................................................................... 27
Reference ......................................................................................................................................... 29
APPENDIX I ....................................................................................................................................... 31
TIME SCHEDULE 2021 -2022...................................................................................................... 31
APPENDIX II..................................................................................................................................... 32
BUDGET.............................................................................................................................................. 32
APPENDIX III: STUDY AREA ........................................................................................................ 33

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CERTIFICATION

The undersigned certifies that she has read and hereby recommend for acceptance by the BUSIA
Medical Training College a dissertation entitled Factors Contributing To Prevalence Malaria
Among Women Attending ANC Services In BUSIA County And Referral Hospital By
Elizabeth Auma Odero, in partial fulfillment of the requirements for the award of Diploma In
Heath Registered Nurse.
I hereby certify that this dissertation has been submitted for examination for approval.

Supervisor: Mr. KEN SITUMA

Designation:
Signature:
Date:

4
DECLARATION

I, AUMA ELIZABETH ODERO, declare that this dissertation is my own original work and that
it has not been presented and will not be presented to any other University for a similar or any
other award.

Signature

5
ACKNOWLEDGEMENT

I am very thankful to the Almighty God for his mercy, protection and guidance during the whole
period of my study, many thanks to all those who helped with the completion of this dissertation.
My heartfelt appreciation to my parents for her valuable advice and guidance in the design and
conduct of this study together with devotion of taking the pain of going through the manuscript
several times before the final production

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DEDICATION
This study is dedicated to my lecture Mr. KEN SITUMA, my parents and all women and
families that have experienced the fate of Malaria during pregnancy.

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Abstract
Background; BUSIA adapted the World Health Organization (WHO) policy of giving two
doses of Sulphadoxine- Pyrimethamine (SP) to pregnant women attending Antenatal clinics
(ANCs) in order to control malaria in pregnancy. Implementation of IPT policy has been
observed to face various challenges making the targeted coverage of 80% too far from being
achieved. The main objective of this study was to identify factors affecting the uptake of
Intermittent Preventive Treatment of Malaria among pregnant women attending ANCs.
Methodology; A cross sectional study was carried out where interviewer guided questionnaires
was administered to 302 pregnant women and 25 healthcare workers. The Reproductive and
Child Health (RCH) cards of the pregnant women were also inspected for additional information.
Focus Group Discussions (FGD) were conducted to the ANC staff and non-participatory ANC
observations were made using a standardized checklist.
Results; The IPT program in public health facilities has successfully achieved higher coverage
for both IPT 1 and IPT 2, (90% and 79.5% respectively).Gestation age appeared to have an
influence on knowledge of pregnant women in IPT (p=0.04) and knowledge seem to have a
significant relationship with IPT coverage (p= 0.03). Generally, there was high knowledge
among health care workers and availability of drug for IPT administration was good (92%), the
probable reason for high coverage.
Conclusion; The IPT program has successfully achieved higher coverage for both IPT 1 and IPT
2. Factors that were observed to influence coverage include knowledge of both healthcare
workers and pregnant women, availability of SP and monitoring of IPT services. Knowledge of
the pregnant women was found to be generally high and had an influence on the coverage of IPT.
Health worker knowledge and attitude on IPTp was found to be high. Improved monitoring of
IPT services will enhance copying of the best practice from one health facility to others.
Recommendations; There should be continuous efforts that the health care workers are now
practicing, probably by providing them with refresher training. More advocacies are needed
including creation of clear IEC messages to help the healthcare workers in implementing the
program. The IPT program should provide standardized improved IEC messages that will
provide well understood information. The study also recommends that a similar study should be
conducted in private health facilities to find out if they contribute significantly

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Abbreviations

ANC Antenatal Care

BCRH Busia County Referral Hospital
CHMT Council Health Management Team
DOT Direct Observation Therapy
FANC Focused Antenatal Care
GDP Gross Domestic Product
IPT Intermittent Preventive Treatment
IPTp Intermittent Preventive treatment in Pregnancy
IPT 1 The first dose of Intermittent Preventive Treatment
IPT2 The second dose of Intermittent Preventive Treatment
IPT 3 The third dose of Intermittent Preventive Treatment
ITN Insecticide treated net
MDG Millennium Development Goals
MIP Malaria in Pregnancy
PMTCT Prevention of mother to child transmission
RCH Reproductive and child health
SP Sulphadoxine -Pyrimethamine
USAID United States Agent for International Development
WHO World Health Organization

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 CHAPTER ONE

1.1 Introduction
Malaria is a parasite disease caused by a bite of infected anopheles’ mosquito, malaria occurs in
poor tropical and subtropical areas of the world.in many of the affected countries, it is a leading
cause of death.in area with high transmission, the most valuable groups are young children who
have developed immunity to malaria, pregnant women also at risk due to reduced immunity.
According to world malaria report, these were 229 real causes of malaria in 2019compared to
228real cases of malaria in 2018.the estimated number of malaria death stood at 409,000 in 2019
compared with 400000 death cases in 2018. Children under the age of five years were the most
vulnerable.
Globally estimated 125 million pregnant women residing areas where there are at risk of
contracting malaria during pregnancy (MIP), and MIP remains an important precaution causes of
adverse birth outcomes. This poses pregnant women are at the following risks; preterm
deliveries, giving birth to low weight babies, anemia in pregnancy, parental loss of life at birth.
In Kenya malaria is the leading cause of mortality accounting to 1/3 of now cases reported and
about 80% is at risk of malaria, transmission is dependent on rainfall patterns, vector Species,
intensity of biting and altitude. The malaria cases accounts to 19% outpatient consultation
nationally and 6% of outpatient consultation in 8 focus countries supported by the U.S President
Malaria Initiative (PMI).
In western Kenya ,malaria is a major cause of mortality and mortality with more than 70% of
the population at risk, with BUSIA being one of the most affected county.in 2017,age group
between (15-30) females were affected at BUSIA referral hospital that is a total 194192.the
purpose of the study was to provide relevant information for the stakeholders in health sectors on
gap that they have not implemented by providing answers so that they may initiate integrated
education on external visits, use of tested insecticide nets, consumption of intermitted
presumption, treatment with SP. They may also provide outreach services to ensure all pregnant
women get care they need during pregnancy and how malaria is prevented and treated to present
its compilation in pregnancy.
Malaria is a parasite disease caused by a bite of an infected anopheles’ mosquito. Malaria occurs
in poor and sub-tropical areas of the world.in many of the countries affected by malaria, it is a
leading cause of death.in areas with high transmission, the most vulnerable groups are young
children, who have not developed immunity to the disease, pregnant women, whose immunity to
malaria has been reduced by pregnancy.
Malaria in pregnancy remain a notable cause of maternal and parental mortality and morbidity
often associated with maternal illness, maternal anemia, low birth weight, preterm deliveries and
parental loss especially in primigravidae.

1
 In a study from Maqui, Papua new giving the peak prevalence in primigravidae studied reached
55%to compared to 86% in other study for Kenya (Fleming,1998) studies have also suggested
nd
that the highest prevalence of this infection occurs in 2 trimester.
Based on this chose to study on contributing factors to malaria in pregnancy like none use or
improper use of treated insecticide nets, failure to go for routine checkup, traditional belief on
the disease, illiteracy and lack of information about utilization of intermittent preventive
treatment.
The purpose of the study was to identify gaps in previous studies on the same and find answers
to those gaps, despite all the measures put in place to ensure eradication, preservation and control
of malaria in those at risk. You find not every pregnant mother have accessibility to health
centers, some prefer seeking medication from traditional herbalists.

1.2 Problem Statement

Globally, about 3.2 billion of people, at most half of the population is at risk of malaria.
Expectant mothers/women, young children and non-immune from malaria free areas are
particularly vulnerable to the disease.it is also estimated that at least 2 pregnant women are
infected with malaria are at highest risk for mortality and morbidity in the gravida, adolescent
and those co-infected with HIV/aids. Twenty-five million pregnant women are currently at risk
for malaria in over 10000 maternal and 200000 parental per year (iwho,2014)
An estimated 125 million pregnancies per year are at risk of malaria around the world. For both
pregnant mothers and children is potentially life threat and common risk factor are; maternal
anemia, pregnancy and poor birth outcome such as low birth which is associated with a negative
impact childhood development. (who), reported that in 2014 11 million pregnancies were
exposed to malaria. The high levels of maternal anemia and the delivery around 872000 children
with low birth weight.
A large population in Africa especially cote ’d Ivore , Burkina Faso, Angola are at serious risk
.in 2013,an estimate of million cases of malaria occurred outside Africa most raw medicines
including anti-malaria drugs ,the women are actively excluded from trials and injections.
Data to support the use of medicine during pregnancy is typically collected only after the product
is marketed efficiency established. In order to balance potential use in pregnancy .data on drug
exposure in women is also collected in a post -approval setting.in the content of malaria endemic
countries, there is always a long delay in access to medicine by pregnant and lactating mothers.
The lack of accept treatment for pregnant women limits the scope of effectiveness of preventive
treatment or mass drug administrations (malaria elimination) campaigns aimed at preventing,
infecting and reducing malaria.
In additional, the few cases where there are recommended therapeutic options for pregnant
women drug supply. The pregnant mothers are illustrated with the example of pyrimethamine
(SP), which is recommended to be used in pregnant women at a curative dose, each treatment
beginning as early as possible during the first test of pregnancy. This is therefore referred to as
intermitted preventive treatment (IPT) for malaria.

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Latest data from (2019) who world malaria report shows that in 10 countries with the highest
burden of the percentage of pregnant women who received ended in 3 doses of IPT remains a
major public concern.

1.3 Justification
It is estimated that 309-509 million malaria episodes and over 1 million death occurs globally
Given the differences that exist between some rural and urban settings, it will be of interest to
find out whether the same factors affect IPT uptake in an urban setting. This study was therefore
designed to assess IPT use among pregnant women attending public health care facilities for
antenatal services in an urban area. Their knowledge, attitude towards IPTp use, compliance with
IPTp and factors influencing IPTp coverage were determined.

1.4 Research Questions

1. What is the level of awareness of pregnant women on IPT use for prevention of malaria in
pregnancy? 2. What do pregnant women know on the effects of malaria in pregnancy? 3. What
is the level of clients acceptance of the drug used in IPT? 4. What do health care workers know
about IPT? 5. How do health care workers institute IPT? 6. What challenges do health care
workers face in IPT provision? 7. What is the level of availability of the drug and clean water
used in IPT?

1.4.1 Study Objectives

1.4.2 Main Objective:

To identify factors affecting the uptake of intermittent preventive treatment of malaria among
pregnant women in BUSIA

1.4.3 Specific objectives:

1. To assess the level of mothers knowledge on malaria spread, prevention and control in BCRH.
2. To assess utilization of health services by mothers during expectancy period in BCRH
3. To assess utilization of ITN among mothers in BCRH.

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 CHAPTER TWO

2.0 Literature Review

2.1 Introduction
Trends in prevalence of malaria in pregnancy plasmodium falciparum infection is the major
cause of morbidity and mortality particularly among the vulnerable groups (war same et al.,
2005). Pregnant women constitute the main adult risk group for malaria. In NIGERIA, the
national malaria control programmed (NMCP) reported 4.3 million suspected malaria cases in
2009; 42% increase compared to 2000 (who, 2010). In areas of high p. Falciparum transmission
in Africa, anemia is the most common form of severe malaria (Aribodor et al., 2003) and there is
a seasonal drop in hemoglobin concentration in children during the high transmission season,
probably due to increased malaria transmission (Diadier et al., 2007). Generally, there is slow
acquisition of active immunity to malaria (Perlmann and Troye-blomberg, 2000). The very low
prevalence in young infants is consistent with maternal immunity, but the possibility that social
practices reduce the exposure of very young infants to mosquitoes cannot be excluded (Plebanski
and hill, 2000). Children born to immune mothers are protected against the disease during their
first half year of life by maternal antibodies. As they grow older, after continued exposure from
multiple infections with malaria parasites over time, they build up an acquired immunity and
become relatively protected against disease and blood stage parasites (Plebanski and hill, 2000),
6 hence lower prevalence of malaria among the older age groups (Olasehinde, 2010). The age
distribution of parasite prevalence and parasitaemia density provide suggestive information about
the level of naturally acquired immunity to malaria and, indirectly, about the long-term intensity
and stability of malaria transmission (Perlmann and Troye-blomberg, 2000).
Malaria in pregnancy is a significant health problem in sub - Saharan Africa where 90% of the
global malaria burden occurs. Malaria disease is more hazardous especially an infection with p.
Falciparum during pregnancy. P. Falciparum malaria can run a turbulent and dramatic course in
pregnant women. Pregnancy appears to interfere with the immune processes in malaria, a disease
which itself alters immune reactivity (Perlmann and Troye-blomberg, 2000). The physiological
changes of pregnancy and the pathological changes due to malaria have synergistic effect on
each other, thus making life difficult for both the mother and the child (Steketee et al., 2001). In
pregnancy, malaria tends to be more atypical in presentation. At pregnancy, immunity has been
altered; hence, with malaria 70- 7 80% of pregnant women in malaria’s areas are susceptible to
anemia (Brabin, 1996).
Falciparum infection is higher during pregnancy, more so in primigravidae and is usually
associated with anaemia or reduced haemoglobin levels (Mockenhaupt et al; 2000). Anaemia is
the trademark of malaria, especially with p. Falciparum infection. The mean haematocrit level is
lower in primigravidae when compared with secundigravidae and multigravidae in malaria
endemic areas (Nosten et al., 1991). Cell-mediated immune responses to malaria antigens are
more markedly suppressed in first than in subsequent pregnancies (Brabin, 1996).

1
The multigravidae are presumably less affected because immunological memory from first
pregnancy is retained (Brabin, 1996). Younger maternal age is also an independent risk factor for
malaria in pregnancy (Espinoza et al., 2005). Young primigravidae and multigravidae are at
greater risk of malaria and its adverse effects than older primigravidae and multigravidae
respectively because of continuous development of malaria immunity in older women. (Dicko et
al.,2003). Human immunodeficiency virus (HIV) infection increases susceptibility to malaria,
resulting in more prevalent and higher infection, and a relative loss of gravid-dependent
immunity (Cohen et al., 2005). Cerebral malaria was a common complication of severe p.
Falciparum infection, with a high mortality rate during pregnancy (Brabin, 2000). Akinboro,
2010, recorded 88% predominance of p. Falciparum with highest prevalence (59.4%) in first
trimester irrespective of parity status. P. Falciparum infection during pregnancy increases the
likelihood of maternal anaemia, abortion, still birth, prematurity, intrauterine growth retardation
8 and low birth weight (Mockenhaupt et al., 2000). Uko et al., 1998 documented about 3%
abortions, 3.7% stillbirths and 2.2% neonatal deaths in p. Falciparum infected women. The
presence of malaria parasites in the blood of newborns may be as a result of congenital malaria
as reported by Oduwole et al., 2011.
Congenital malaria, defined as the presence of malaria parasites in the erythrocytes of newborns
aged less than 7 days, was considered rare in endemic areas until recent studies started reporting
high prevalence rates (Oduwole et al., 2011). Though has been documented for many years, it
was previously thought to be uncommon especially in indigenous populations; more recent
studies, however, suggest that incidence has increased, and values between 0.30 to 33.00% have
been observed from both endemic and non-endemic areas . An. Arabinoses appear to be a good
vector of malaria, especially in the savannah-forest. Malaria vectorial system in Nigeria is more
complex than expected, looking at the combined contribution of these mosquito Species to
malaria transmission. It is therefore very important to 10 understand the dynamics of the
transmission of malaria in a large country like Nigeria with different ecological zones through a
regular assessment of each country's malaria situation which is worthwhile since control
measures can only be effective if the abundance, behavior and proportion of the Species are
known. Incidence of malaria varies by weather, which affects the ability of the main carrier of
malaria parasites, anopheles mosquitoes, to survive or otherwise.
Tropical areas including Nigeria have the best combination of adequate rainfall, temperature and
humidity allowing for breeding and survival of anopheles mosquitoes; Onyabe and conn, 2001).
Malaria transmission in Nigeria takes place all year round in the south but is more seasonal in the
northern regions (who, 2010). Malaria transmission, based on climatic parameters occurred
between April and october in anambra state (Ayanlade et al., 2010), which shows that rainfall
plays an important role in the distribution of breeding sites for the mosquito vector thereby
influencing malaria transmission. The peak malaria transmission coincides with the appearance
of stagnant water collections just after the rainy season. In an area of much higher rates of
transmission, chronic placental infection was associated with both mechanisms, and low birth
weight resulting from premature birth was more common than usually thought (Menendez et al.,
2000). 2.4 immune response to malaria during pregnancy women develops increasing resistance
to malaria infection over successive pregnancies.

1
This pattern of parity-Specific resistance has been associated with the acquisition of antibodies to
the surface of placental parasitized erythrocytes. Early in the pregnancies, women generally lack
antibodies that react with the surface of placental binding parasitized erythrocytes, which
suggests these express novel surface variants.
However, by the second trimester (~ 20 weeks) many prim gravid women possess antibodies that
react to laboratory-adapted chondroitin sulphate a binding lines, suggesting they have been
exposed to placental adherent parasitized erythrocytes (rickets et al., 2003). Consistent with this
interpretation, the blood circulation opens up to the placenta about 10 weeks into pregnancy; and
biochemical evidence demonstrates that low sulphate chondroitin proteoglycans are present in
the placenta and intervillous blood Spaces by the end of the first trimester and can support
parasitized erythrocytes binding in vitro (Agbor- enoh et al., 2003). Binding phenotype suggests
that most placental parasites do not undergo a full cycles of replication in the placenta but 15
circulate and sequester during the later developmental stages. Therefore, women are susceptible
to placental infections early in pregnancy, beginning at approximately 10- 12 weeks. Mixed
infections of p. Falciparum with the non-falciparum Species cannot be differentiated from pure
p. Falciparum infections. However, with regard to the pldh test, it is claimed that in the presence
of P. vivax infection, the genus Specific line is much darker and more intense than the Species
Specific line due to the presence of all the stages of the parasite in the blood.

2.3 Assessing the Level of Knowledge of Mother/Women and Caretaker On Malaria Injection
During this research it was realized that majority of women lacks knowledge about the causes
and effects of malaria at pregnancy period. Access to medical care is limited in many malaria-
endemic areas and where medical services exist, they commonly lack facilities for laboratory
diagnosis, and as a result, malaria treatment is mostly given on the basis of clinical or self-
diagnosis (Chiodini, 1998). Determination of a patient's clinical history and symptoms is an
acceptable basis for the management of malaria disease (WHO,2000). Although the signs and
symptoms of malaria, such as fever, chills, headache and anorexia, are generally nonspecific,
some signs and symptoms, especially in combination, have diagnostic value in Specific
epidemiological and operational situations (Redd et al., 1996). However, it is not possible to
apply any one set of clinical criteria to the diagnosis of all types of malaria in all patient
populations. Experience has shown that the appropriateness of particular clinical diagnostic
criteria vary from area to area according to the intensity of transmission, the prevalent malaria
Species, the incidence of other causes of fever, the qualifications of the health care staff and the
health service infrastructure (who, 2000a). This may not apply if parasite prevalence is very
high, in which case the additional costs of improved diagnosis may provide little benefit in terms
of savings on drug costs. On the other hand, where prevalence (and host immunity) is high, RDT
test results may erroneously suggest a positive diagnosis in patients with parasitaemia incidental
to another illness (who, 2003). RDT detect antigens and not parasites, results may therefore
reflect recent and not current parasitemia. . The limited knowledge of signs of severe malaria,
including convulsions, indicates an area that requires strengthening largely through health
education and communication. Malaria still remains major threat to health sector in Kenya.

1
2.4 Utilization of Insecticide Treated Nets

The world health organization (who) recommends that in malaria endemic areas, all pregnant
women should receive malaria chemoprophylaxis and sleep under ITNs [9].

Roll back malaria initiation in African countries increased access to chemoprophylaxis and use
of ITNs by pregnant women and children under five years [10] that have become an integral part
of malaria control strategies in Ghana and Africa at large.
The 2015 goals of the world health organization’s (who’s) roll back malaria partnership are to
reduce global malaria cases by 75% and to reduce malaria deaths to near zero through universal
coverage by effective prevention and treatment interventions. Among other preventive
interventions, who recommends the use of insecticide treated nets (ITNs), particularly long-
lasting insecticide nets, which have been shown to be cost-effective, to reduce malaria episodes
among children less than 5 years of age by approximately 50% and all-cause mortality by 17%
.universal coverage with ITNs is defined as use by > 80% of individuals in populations at risk.

The use of ITNs is largely affected by the knowledge of people. Behavioral patterns of people-
utilization of the ITN are dependent on their knowledge on the consequence of nonuse [12].
Researchers give varied indications on the use of the ITN and peoples level of knowledge. Toe et
al., 2009, reported that despite evidence that the use of ITNs decreases malaria-related morbidity
and mortality, the use of ITNs in Africa remains relatively low. Estimates suggest that in 2005,
only 3% of children less than five years of age slept under ITNs, while up to ten times as many
are thought to sleep under any bed net. This shows that the fact that ITNs are very effective in
malaria prevention does not necessarily mean that people will use them after they have received
them. While the evidence based on the effectiveness of ITNs in reducing malaria transmission
has grown rapidly in recent years, utilization rates of ITNs in most African countries have been
very low.
Programmer managers place Specific emphasis on children under five and pregnant women
because of the increased susceptibility to the disease. Most people rather use traditional malaria
control strategies, including drinking of herbs and avoiding sweets which have no direct effect in
controlling malaria. However, in a study conducted in the municipality of the Volta region of
Ghana, ITN use among respondents was 76.6% [15].

Despite the measures to curb malaria, the disease still remains one of the leading causes of death,
especially among children under five years of age in Kenya.
It is for this reason that this study sought to describe the use of ITNs among caregivers of
children under five years in the ho municipality. The finding of this study is a source of
information to the district health management team (DHMT), NGOs, government, and private
enterprises who are involved in the promotion of ITNs in the fight against malaria among
children. This study can be useful to the policy makers, the ministry of health (MOH)
Specifically in the department of malaria control.

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 CHAPTER THREE

3.0 Research Methodology

This deals with the following, study area, study design, study population, sample side
determination, data collection, quality control and ethic consideration.

3.1 Study Area

The study was conducted in BUSIA county, Marachi community in Kenya. This most populated
community among the four communities that make up the Marachi. The community is
predominantly rural with a population of approximately 22032 (12012males and 10020 female)
and a population density of up to 600/km2. It experiences two distinct seasons - a wet season of
abundant rainfall which begins in April and ends in October or early November, and a dry season
which lasts from November to march. There are two rainfall peaks, one in July and the other in
September, and annual precipitation is in excess of 2000mm .temperature is high throughout the
year with day time range of 230c - 350c. Malaria is endemic in these areas and occurs throughout
the year with peaks during the rainy season.

3.2 Sample Population

The sample population for prevalence of malaria was pregnant women that attended ante-natal
clinic in hospitals in BUSIA. For knowledge and attitude to malaria diagnosis, the sample
population was caregivers from selected households in the community.

3.3 Sample Size

A total of 243 pregnant women were sampled for prevalence of malaria. To arrive at the sample
size, the annual 3% growth rate for the female population was determined as at 2011. The
population of women of reproductive age, which is 49% of all female population, was
determined. Also determined was the population of pregnant women; who constitute 5% of
women of reproductive age in NIGERIA.
The figure obtained was substituted in the formula for determining sample size:
n = n/1+n
where n = minimum sample size, n = total population to be sampled, e = error term at 5% (95%
confidence interval) . For knowledge and attitude to diagnosis, a total of 393 caregivers were
sampled. To arrive at the sample size, the annual 3% growth rate for the total population was
determined as at 2011. The adult population, which is 45% of total population, was also
determined. The figure obtained was substituted in the formula for determining sample size.

3.4 Permission Obtainment

A letter of identification from the department of parasitology and entomology was used in pre-
40 survey visits made to the hospitals to obtain permission from the hospitals’ authorities.
During the visits, the management, health workers in charge of antenatal services and laboratory
scientists were informed on the nature and objectives of the study. They later organized and
informed the pregnant women about the study. The informed consent of both management and
the pregnant women were sought and obtained before the commencement of the study.

1
3.5 Research Design
The research consists of two parts. The first part was on prevalence of malaria in pregnant
women attending antenatal clinic. The second part was on knowledge and attitude of community
members on diagnosis of malaria.

3.5.1 Method for Investigating the Prevalence of Malaria In Pregnancy

The study was a hospital based cross-sectional survey conducted between November 2011 and
January 2022. Maternity was selected out of a total of seven hospitals in this community using
simple random sampling. The 243 pregnant women selected were women of reproductive age
(15 – 45 years). Peripheral blood samples were 41 collected from pregnant women in each of the
hospitals once a week, during the antenatal visits. This lasted for three months. The consent of
the patients was taken before commencing the study. Questionnaires concerning age, gravidity,
pregnancy stage, level of education and occupation were distributed to the sampled pregnant
women, and with my assistance and that of some of the nurses, the questionnaires were
completed by the sampled pregnant women. Blood samples collected were preserved with acid
(EDTA) before being transported to the laboratory of parasitology and entomology.

3.5.2 Observations on Knowledge and Attitude of Caregivers to Malaria Diagnosis

The study was a community based cross-sectional survey conducted between November 2021
and January 2022. First of all, names of all kindred’s in each village were listed and five
kindred’s from each village were selected using simple random sampling, making a total of
twenty kindred’s. In the second stage, twenty households were selected from each kindred using
systematic random sampling to obtain three hundred and ninety three caregivers/interviewees.
Data were collected using a pre-tested structured questionnaire Specifically developed for
determining knowledge; attitude of community members to diagnosis of malaria. this structured
questionnaire comprises 10 questions. The questionnaire included two sections. The second part
investigated their knowledge and attitude to malaria and its diagnosis. The questionnaire was
pre-tested in Simba chai village before the final draft was made. Respondents were interviewed
in their homes. It took approximately 15 minutes to administer a questionnaire per person. All
participants gave their verbal consent. I used both English and Igbo languages in explaining the
content before administering the questionnaire.

3.6 Data Analysis

The data generated on prevalence was analyzed using statistical programmer for service solution
(SPSS) 17.0 window versions. The statistical significance of variables was estimated using chi-
square test. Pearson correlation analysis was used to establish possible correlation of prevalence
with parity, age, trimester as shown in appendix iii. P-values of equal to or less than 0.05 was
taken as measures of significance. Data on knowledge and attitude was analyzed also using SPSS
version 17.0 for window. Cross tabulations of important variables were done and the

3.7 Data Collection Process

An introduction letter was sought to introduce the exercise to the municipals, permission letters
were obtained from the three municipals’ offices; these were used as introduction letters to the
facilities.

1
The data collection exercise went for a period of 13 working days; some facilities were only
visited once, however due to clients workload, some facilities had to be visited twice to obtain
information from the health care workers.
3.7.1Training of Research Assistants
Two data collectors were involved in the study, these were given a one day orientation then
pretesting was done as on the job training. Each data collector was given a list of facilities to be
visited in her municipal, a set of data collection instruments and a copy of permission letter to
conduct the study in health facilities.

3.8 Data management and analysis

3.8.1 Management of the Data
Data cleaning was done after data collection, entry, storage and analysis was also done by the
principal investigator with the help of a statistician.
3.8.2 Analysis of Data Variables Dependent Variable
Uptake of IPT independent variable: socio demographic characteristics (age, gravidity, parity,
marital status, level of education), knowledge of IPT, perception of IPT, availability of drugs,
availability of clean water, supervision and monitoring of IPT. Data was analyzed using
Microsoft office excel 2007 and SPSS computer software. Data was then summarized using
frequency tables, graphs, means and standard deviations. Chi-square test analyses were used to
test the association between categorical variables. The p-value of less than 0.05 was taken to be
significant at a confidence interval of 95%. The socio-demographic characteristics like education
and marital status were categorized and chi square test was used to test their association with the
IPT uptake. The perception of healthcare providers was analyzed manually.

3.9 Study
limitations
The sampling process used to sample pregnant women from health facilities was based on
convenient process; this could have affected the results especially in terms of both dependent and
independent variables.

3.10 Ethical consideration

Ethical clearance (appendix 11) was sought from the office of the director of research and before
the study was conducted. An introduction letter (appendix 12) was obtained to introduce data
collectors to the municipals. The municipal officers for health and the heads of the ANC’s were
informed of the study and their permission to conduct the study was sought. During the study
period, informed consent (appendix 9) was sought from all eligible participants before the
interviews were held. The study however does not constitute any issues of ethical concern, study
participants were assured of anonymity in data collection and processing.

1
3.11 Research Instrument
The tools were pretested before the actual data collection exercise began; necessary amendments
and corrections were done to ensure that all the important information required from the field
was captured. These included changing section four of appendix one into a groups interview, this
helped to avoid multiple responses from the same facility. There were also several questions
where the ‘other’ option needed to be added. Of variable was obtained.

2
 CHAPTER FOUR

4.1 Research Finding

The results chapter first summarizes results of the antenatal clients (pregnant women) then
results of health care workers and health facility factors influencing IPT implementation. For
pregnant women the results are divided into three sections; socio demographic characteristics,
knowledge on IPT and attitude on IPT. For the health care workers the results are divided into
knowledge, attitude and practice of IPT, availability of drug and clean water for IPT
administration was assessed using a standardized checklist. 4.1 part one: a total of 302 pregnant
women were interviewed, this was 93% of the estimated sample size.

4.1.1 Social Demographic Characteristics

The mean age of pregnant women was found to be 25.8years (SD 5.6) and the age range was 15
to 42 years for pregnant women. The majority of pregnant women who were interviewed were
married 234(77.5%), 124 (41.1%) of the interviewed women were in their first pregnancy, 168
(55.6%) were in gestation age 20 to 32 week, of which 122 (73%) were in the week of 28 and
above. The mean parity was 1.8 (SD 1.1) ranging from zero to five. 186 (61.6%) women had
primary education, 89 (29.5%) had above primary education, only 27(8.9%) did not have a
formal education. Table 1 summarizes the social demographic characteristics of the pregnant
women.
Range of age in years No. Of respondent Percentage
18-20 3 13.6364
21-30 10 45.4546
31-40 15 22.7273
41-50 4 18.18182
50 and above 0 0
Total 22 100

Figure 4.1 showing number of people, age and percentage

4.1.2 Coverage of IPT in Identified Health Facilities.

The coverage of IPT was obtained by observing the client (MCH cards), this showed that out of
the 302 pregnant interviewed, 186 pregnant women were above 20 weeks of gestation and were
eligible to be given SP. The coverage of SP for a woman who got at least one dose was found to
be 90%(168), and out of 122 pregnant women who were eligible to get the second dose
97(79.5%) received SP. Table 2 shows that 186 pregnant women were eligible to receive SP, out
of these; 87(47%) got one dose and 81(44%) got two doses. Not all women who received second
dose were also given the first dose, this was found in the MCH cards of four women where two
of them had refused to take the first dose, and the other two did not find the drugs at the facility
by the time they were supposed to get one.

2
Table 3 shows the gestation age at which pregnant women were given both first and second
doses, from the table it can be seen that out of 164 pregnant women who got the first dose,
150(91%) got their SP at the recommended gestation age of 20-24 weeks, likewise out of 97
pregnant women who got the second dose 85(87%) were given at the right recommended age of
28-32 weeks.

4.1.3 Knowledge of Pregnant Women on IPT

There were eleven responses assessing the knowledge of pregnant women on IPT, a client who
was not able to provide any of the correct responses was considered with low knowledge. For the
purpose of this study and considering the mode of knowledge transfer from healthcare workers to
their clients, pregnant women who were able to provide up to 60% of the correct responses were
considered as having adequate knowledge, likewise those who scored above 60% were
considered as having high knowledge. Table 4 shows the components of IPT knowledge among
all pregnant women interviewed, about 81.8% of the pregnant women knew that the drug of
choice for IPT is SP. However, only 38.7% knew that SP can be taken for malaria prevention and
60.6% knew that SP should be taken twice during pregnancy. 23 generally there was low
knowledge on the effects of malaria in pregnancy as it can be seen in table 4 the most frequent
response was death (51%) while anemia, Spontaneous abortion, low birth weight and premature
births were mentioned by less than 50% of the clients interviewed.

4.2 Level of Education Respondent

The findings were that most of the respondent were not educated while the least were fortunate
enough to have reached college level of education as shown in below in column graph

Education level of respondent

70
60
50
Level of education in

40
30
20
10
0
1 2 3 4
Not educated Primary level Secondary
College
level
level

4.2.1figure shows level of education of the respondent

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4.2.2 Distribution of Respondents Based On Their Occupation
Occupation Frequency Percentage
Employed 4 18.18
Unemployed 7 31.82
Self employed 9 40.90
Others 2 9.09
Total 22 100

Above table shows analysis of data based on occupation, and 36.54% of the respondent were
unemployed, 36.29% employed with others standing at7.94%.

4.2.3 Attitude of Health Care Workers on IPT Services.

Attitude of health care workers was assessed using focus group discussion in the sampled health
facilities, the FGDS ceased when no new data emerged, a total of 11 focus group discussions
were conducted, the discussions were translated and then transcribed, below are the summary of
the findings under each theme.

4.2.3.1 Malaria as a Threat to Pregnant Women.

All the groups that were interviewed agreed about malaria being a threatening disease and hence
the reason for continuous efforts to fight the disease. It was heard from one of the dispensaries
that ‘since the introduction of SP they experience fewer cases of fever and fatigue from pregnant
women, sometimes pregnant women even ask for the SP themselves since they know that it helps
them’.

4.2.3.2 Opinion on Prevention of Malaria In Pregnancy

It pointed out that early attendance, health education and measures of prevention before 20
weeks of gestation should be emphasized; it was also pointed out that the responsibility of
preventing malaria in pregnancy should be multi sectorial. This was further explained that IPT
and ITNs are given only to pregnant women, but these women live in the community that has
malaria and the extent to which the community is sensitized against malaria is still questionable.
One of the health care workers mentioned that ‘the majority of the communities are on busy
lifestyle which does not give them enough time and money to afford proper diet; this lowers their
immunity and hence make them prone diseases including malaria.

4.2.3.3 Opinion on the Provision Of IPT By Other Healthcare Providers

This was controversial as many health care workers were not ready to point out their
weaknesses. However, it was mentioned in one of the groups that staff motivation like focused
antenatal care (FANC) training encourages staff to provide required services, at health facility
how experience clients from outside their service area who have not received not only SP but
other essential services (such as iron tablets and ITNs) that they were supposed to receive from
their nearby facilities. This shows that there are probably other facilities where providers do not
provide these services.

2
 An observation at a dispensary showed a provider did not issue SP to a client who was eligible
just because the medicine had just gotten finished from her dispensing table and at that time, she
was too tired to go and request more from the pharmacy. However, this provider mentioned that
a client will get SP when she comes to the clinic for the upcoming visits.

4.2.3.4 Acceptance of SP by the Clients

It was not easy to predict client acceptance in larger health facilities like the three district
hospitals where they give SP to clients to go and drink it at home. In smaller health facilities
where dot was observed, client acceptance was almost 100%, facilities reported that very few
clients refuse and however with additional counseling they end up taking the medication. This
was also noted when interviewing the clients where most of them seem to accept the medicines
that they are given from the health facilities, claiming that ‘these are government medicines and
the government cannot give out something that will harm its people.

4.2.4 Practice of IPT

Practice of health care workers on IPT provision was assessed through an observation checklist
as well as in the focus group discussion. The results from table 12 showed that 20(80%) of health
facilities provided health education early in the morning before the start of services and also do
provide a separate session that includes counseling and testing those who attend ANC for the
first time. Despite having malaria mentioned in health education in 18(72%) health facilities,
only 9(36%) talked about IPT. Table 14 shows the different aspects of practice that were
observed on the day of visit. Request forms that include SP were found in all the 25 health
facilities, SP was available in (92%) facilities, dot was observed in 14 (56%) facilities, of which
9 facilities were providing free water for dot, one facility was providing water for sale and clients
were observed to take dot with their own water from 4 facilities.

4.3 Religion of Respondents

The respondents were asked to include their religion as in the table.
Religion Frequency Percentage
Catholic 15 68.18182%
Protestant 5 22.7273%
Others 2 9.09091%
Total 22 100%

4.4 Availability of Drug and Clean Water for IPT Administration

SP availability has shown to be a basis of IPT uptake, as out of 46 healthcare workers who said
they have experienced a stock out in the last three months, 34(73.9%) mentioned that they do not
provide any IPT services when there is no SP. During this study SP was not available in 23(92%)
of the health facilities. Water availability did not seem to be challenge to IPT provision as most
pregnant women have been informed that they should be carrying water when they come to the
clinic, however practice of dot was observed in 14 (56%) of the facilities of which 9(36%)
facilities indicated that they do provide safe and clean water, of these 9; only one facility buys
commercial water (Uhai) and provides it for free while other eight facilities boil water and store
it in the bucket.

2
In all the nine facilities the cups provided for taking drugs are of reusable types so they also set
aside cleaning facilities for those cups. Appendix 3 shows water for IPT administration at
hospital. It was mentioned at health center that out 34 of 30 clients, only about three are ready to
drink the water that is provided at the clinic for free, the rest purchase water from the nearby
shop outside the facility.

2
 CHAPTER FIVE

5.1 Discussion
This study assessed the factors influencing the implementation of IPT in public health facilities
located in urban and semi urban settings of BUSIA County. The factors assessed were
knowledge attitude and practice of both pregnant women and health care workers in relation to
IPT coverage and services.

5.1.1 Finding
The study found that at least 90% of pregnant women received at least one dose, and 79.5%
received the second dose this figure of 90% pregnant women got at least one dose is higher than
the one in the 2010 TDHS (63.9%) for urban areas. The number of pregnant women who are
attending the ANC for the first time during their most recent pregnancy in a particular year as the
denominator and the number of pregnant women receiving one, two or three doses of SP under
observation by a health worker as the numerator.
Studies done indicated that coverage of IPT is influenced more by the availability of SP, in this
study; SP was available in 92% of the facilities, the probable reason for the high coverage. Some
of the health care workers in the health facilities that do provide delivery services like hospitals
and health centers have confirmed that there is a marked decrease of cases of complications due
to malaria in pregnancy as a result of increased uptake. The approach that was used to record
coverage would have been more accurate if all the facilities were practicing dot; in this study
only 14 (56%) facilities were giving SP as dot. The other health facilities would either issue a
prescription or give the medicine to the client to go and take at home and make a note in the mch
cards as it was observed in the many of the facilities, this method would not guarantee that the
client will really take the medicine. The recommended approach by who to measuring IPT.

5.2 Knowledge about IPT

The study showed that there was a general high knowledge on IPT among pregnant women and
it has shown that higher knowledge correlates well with and IPT coverage (p= 0.03). However,
having knowledge alone is not enough as transferring knowledge into practice is another issue to
be considered, a gap was observed when clients were interviewed about the drug of choice for
IPT, more than 80% knew that the drug is SP but only 38.7% could mention SP as one of the
methods used in malaria prevention and only 60% knew that SP has to be taken twice during
pregnancy. A study done showed that there was inadequate recognition that SP prescribed at the
ANC facilities was for malaria preventive purposes, these findings are corroborated by the
current status which clearly demonstrate a knowledge gap among the ANC clients.
Knowledge of healthcare workers was also generally high, according to the knowledge scale, no
one had low knowledge. Knowledge of health care workers has probably contributed to the high
knowledge of pregnant women.

2
5.3 Attitude on the Use of SP
The majority of pregnant women 275(91.1%) showed a positive attitude towards the
effectiveness of SP, when probed to explain more why they think is effective, the response was
‘any medicine that is issued by the government facility is safe to take’ this could have resulted
from the health talk that these clients are given as they are threatened from buying medicines
from private outlets without consulting a health practitioner. Given the fact that more than 50%
of the clients interviewed had an education level of primary school and below, the only trust they
could have is from the healthcare practitioner who is attending them. A similar study conducted
in NIGERIA showed respondents’ belief in the effectiveness of SP for IPT was low and
suggested the cause as being poor delivery mechanism for the intervention or a poor educational
program delivered to pregnant women at the antenatal clinic.

5.4 IPT Practice

This study observed that even when there was one healthcare worker on duty that day as it was
observed at some dispensaries and one hospital, the health care worker would ensure to give the
required services like issuing of SP without ensuring that the client has got enough information
about the drug. This suggests a reason as to why a few respondents mentioned SP as one of the
methods of malaria prevention and a few who would resist taking the drug. However, in case of
resistance to taking the drugs healthcare workers would cohesive the clients to take the drug by
threatening to withhold services if they got any problem.

5.5 Monitoring of IPT Services.

This study observed that monitoring and supervision activities received by the health facilities
could have contributed to the staff commitment to IPT provision and hence high coverage of
IPT. Similar findings were found in a study in whereby supervisory visits contributed to the high
staff commitment to IPT. However there is still room for improvement as the results have shown
that only 17(68%) have received supervision.

5.6: Conclusion
IPT program has successfully achieved higher coverage for both IPT 1 and IPT 2, (90% and 87%
respectively). The knowledge of the pregnant woman in IPT highly depends on the health worker
knowledge and attitude. Knowledge of the pregnant women on SP for IPT was found to be
generally good and had an influence on the coverage of IPT. Health workers knowledge and
attitude on IPTp was found to be good. Improved monitoring of IPT services will enhance
copying of the best practice from one health facility to others, this will include setting aside
budget for purchasing water for dot and drugs in case of stock outs.

5.7 Recommendations
Since it was observed that there is health care education in many facilities, there should be
continuous efforts for continuing education for health care workers, probably by providing them
with refresher training. This will enable a constant high uptake as the clients will be constantly
informed.

2
However, the health education that is provided at the clinics should be for the whole group and
not for those attending for the first time only, in this way clients will get a better chance to
understand and ask questions concerning IPT and other antenatal services.
While the IEC messages observed were facility generated, the IPT program should ensure
provision of standardized improved IEC messages that contain clear and well understood
information. This information should show not only the benefits of IPT, but also the number of
doses and gestation age at which pregnant women should take this dose. A good example can be
taken from the tetanus vaccine messages that were also observed in this study. More advocacies
is also needed to help the healthcare workers in implementing the program.
Monitoring of IPT services should also be emphasized to ensure constant availability of drug and
clean water for IPT administration. Health facilities should copy the best practice from other
facilities that have a budget for provision of safe and clean water; this information can be
transferred by the supervision team within the districts. Improved monitoring should also ensure
that healthcare workers are constantly gaining updated knowledge for better provision of their
services.

2
 Reference
Gross K, Alba S, Schellenberg J. Kessy F, Mayumana I and Obrist B,(2011). ‘The combined
effect of determinants on coverage of intermittent preventive treatment of malaria during
pregnancy. Malaria journal 2011, 10:140
Marcia Caldas De Castro, Yoichi Yamagata, Deo Mtasiwa, Marcel Tanner, Ju Rg Utzinger,
Jennifer Keiser, And Burton H. Singer (2004) ‘integrated urban malaria control: a case
study in Dar es salaam, Tanzania’. Am. J. Trop. Med. Hyg., 71(suppl 2), pp. 103–117
Maternal and child health: integrating to save lives. Factsheet September 2011.
Marchant T, Nathan R, Jones C, Mponda H, Bruce J, Sedekia Y, Schellenberg J, Mshinda H
And Hanson K, (2008). ‘Individual, facility and policy level influences on national
coverage estimates for intermittent preventive treatment of malaria in pregnancy in
Tanzania.’
Malaria journal 7:260
Mboera E G L, Makundi E A, And Kitua Ay. (2007) ‘Uncertainty in malaria control in Tanzania:
crossroads and challenges for future interventions’ am. J. Trop. Med. Hyg., 77(6): 112–
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Mubyazi Gm, Bygbjerg I C, Magnussen P, Olsen O, Byskov J, Hansen K S, And Blochp, (2008.)
‘ProSPects, achievements, challenges and agenda for research’. Open trop med j., 1: 92–
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Mubyazi G, Bloch P, Kamugisha M, Kitua A And Ijumba J, (2005). ‘Intermittent preventive
treatment of malaria during pregnancy: a qualitative study of knowledge, attitudes and
practices of district health managers, antenatal care staff and pregnant women in
korogwe district, north-eastern Tanzania.’ malaria journal, 4:31 doi:10.1186/1475-
2875-4-31
National Bureau of Statistics. Measure DHS, ICF Macro Calverton. ‘Tanzania demographic and
health survey, preliminary report 2010’, 36-37.
Pell C, Straus L, Andrew Evw, Men˜ Aca A, Pool R (2011). ‘Social and cultural factors affecting
uptake of interventions for malaria in pregnancy in Africa: a systematic review of the
qualitative research.’ in plos one 2011, 6 (7)
Roll Back Malaria/WHO. (2000) ‘the Abuja declaration and the plan of action. An extract from
the African summit on roll back malaria’, Abuja, 25 April, Geneva, who, 2000
(WHO/CDS/RBM/FRRLV2000.1 ;)
Roll back malaria partnership: malaria in pregnancy info sheet 4, rbm 2008.
Tarimo S D. (2007) ‘appraisal on the prevalence of malaria and anemia in pregnancy and
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United Republic of Tanzania, Ministry of Health and Social Welfare: national guidelines for
malaria diagnosis and treatment 2006. Malaria control series 11.
Van Eijk A M, Hill J, Alegana V A, Kirui V, Gething P W, Kuile F O, Snow R W, (2011).
‘Coverage of malaria protection in pregnant women in Sub Saharan Africa: a synthesis
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World health organization: global malaria report. 2008

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APPENDIX I: TIME SCHEDULE 2021 -2022
ACTIVITY TIME
NOV DEC JAN FEB MAR APR MAY

Identification
Of research
topic
Writing of the
research
Proposal

Corrections

Data collection

Data analysis

Discussion and
interpretation

Conclusion and
recommendation

31
APPENDIX II: BUDGET
ITEM QUANTITY UNIT COST (KSHS)
FULLSCAPS 1 30
TYPING 1 600
PRINTING PAPER 1 1000
PHOTOCOPYING 70 280
HB PENCILS 2 40
BINDING 2 100
PRINTING 600
FILE 2 100
TRANSPORT 500
LUNCH 500
MISCELLENEOUS 600

TOTAL COST 4350

32
APPENDIX III: STUDY AREA

33
THE RESEARCH QUESTIONNAIRE
Instruction: (Tick where appropriate)
SECTION A: BIODATA
1. Age of respondents
a) 15-20 [ ] (b) 21-25 [ ] (c) 26-30 [ ] (d) 31-35 [ ]
2. Marital status
a) Single [ ] (b) Married [ ] (c) Divorced [ ] (d) Separated [ ]
3. What is your occupation?
a) Employed [ ] (b) House help [ ] (c) Farmer [ ] (d) Business [ ]
4. What is your sex?
a) Male [ ] (b) Female [ ]
5. What is your religion?
a) Christian [ ] (b) Muslim [ ] (c) Hindus [ ] (d) Others [ ]

SECTION B: LEVEL OF KNOWLEDGE OF MOTHER ON MALARIA

1. What is malaria?
a) Worms [ ] (b) Poor sanitation [ ] (c) Animal [ ] (d) Disease [ ]
2. What are risk factors of malaria?
a) Poor diet [ ] (b) Lack of water supply [ ] (c) Not using treated nets [ ]
(d) Poor sanitation [ ]
3. What are the causes of malaria?
a) Eating raw food [ ] (b) Poor hygiene [ ] (c) bite of anopheles mosquito [ ]
b) (d) Rain[ ]

3
 SECTION C: UTLIZATION OF INSECTICIDE TREATED NETS
1. What factors led not to use of ITNS?
a) Uncomfortability [ ] (b) Unavailability [ ] (c) Unaffordability [ ]
(d) Numbers one to use [ ]
2. Are there any important of using ITNS?
a) Yes [ ] (b) No [ ] (c) None of the above [ ] (d) All of the above [ ]

SECTION D: UTILIZATION OF HEALTH SERVICES

1. Are the health facilities far from the house hold?
a) Yes [ ] (b) No [ ] (c) None [ ]
2. How do the health works relate with you in health facilities?
a) Arrogant [ ] (b) Harsh [ ] (c) Rude [ ] (d) Welcoming [ ]
3. Do you get satisfaction on health services?
a) Yes [ ] (b) No [ ]

SECTION E: OBSERVATION CHECKLIST

1. Availability of mosquito nets
a) Yes [ ] (b) No [ ]
2. Antenatal attendance
a) Not available [ ] (b) Complete immunization [ ] (c) Defaulter [ ]
(d) Ongoing [ ]
3. Condition of the compound
a) Littered [ ] (b) Good [ ] (c) Water logged [ ] (d) Slashed [ ]
4. Provision of toilets/pit latrines
a) Provided [ ] b) Not Provided [ ]