AN EVALUATION OF HEALTH

PROMOTION AND
INTERVENTION ON MALARIA
PREVENTION THROUGH
DISTRIBUTION OF INSECTICIDE-
TREATED NETs (ITNs) IN
OBUBRA, IKOM AND OGOJA LGAs
OF CROSS-RIVER STATE NIGERIA

TABLE OF CONTENT
ABSTRACT...................................................................................................................1

INTRODUCTION..........................................................................................................3

BACKGROUND............................................................................................................4

CONCEPT OF HEALTH...............................................................................................5

HEALTH PROMOTION...............................................................................................6

SOCIAL DETERMINANTS OF HEALTH..................................................................7

HEALTH PROMOTION MODEL AND STRATEGY................................................8

INTERVENTION PLANNING...................................................................................10

PARTNERSHIP WORKING.......................................................................................12

EVALUATION............................................................................................................13

CONCLUSION............................................................................................................14

RECOMMENDATION...............................................................................................15

REFERENCE...............................................................................................................16
ABSTRACT

Malaria parasite remains a threatening pathogen in Africa. Nigeria ranks as world

most malaria endemic region according to the World Malaria Report, 2022. Cross-

River records one of the highest cases in the country being a riverine area. The health

promotion and intervention is a school-based distribution of ITNs in 3 local

government areas that has not been captured in the state’s health ministry ITNs

distribution program that happened a year earlier. Choice of grade levels were 1 to 3

years apart to ensure most households with children could receive at least 1 ITN every

2 to 3 years. Social health determinants that contribute to the continous exposure of

participating localities to malaria vector despite the efforts of the primary health care

center were highlighted. The health need assesment was properly done using

NetCALC to evaluate the effectiveness of the mass campaign and the percentage of

household not covered. State and local government health and education officials,

head teacher, school teachers, parents (through the parent/techer association) and

community leaders were stakeholders in the intervention. Ealuation and monitroing

was carried out by analysing data received from survey on the no. of ITNs distributed,

students within identified grades that received one ITN each, no. of household that

obtained at least 1 ITN, no. of household that used the ITN.

1
2
INTRODUCTION

Malaria is an acute life-threatening disease that is spread through the bite of infected

female Anopheles mosquito, which is responsible for the transmission of the parasitic

protozoon, Plasmodium, into the body of humans. (Aguia et al., 2021). According to

the WHO World Malaria Report, 2022, Nigeria globally accounts for 27% of world

Malaria cases, followed by Congo (12%), Uganda (5%) and Mozambique (4%).

Proven effective options to reduce morbidity and mortality include early diagnosis,

combined with prompt effective therapy and malaria prevention through reduction of

human-vector contact, emphasizing the use of insecticide-treated nets (ITNs). This

report will examine the effectiveness of ITN(s) school distribution programme as a

means of ameliorating the havoc caused by Malaria in 3 local governments (Obubra,

Ogoja and Ikom) in Cross-river state Nigeria. A critical approach will be taken into

the health promotion and intervention along with the health model and partnership

working used in implementing this health programme. The headings- health

intervention, planning and implementation, social determinants of health, evaluation

and monitoring we will grossly discuss contrasting the approach of this intervention to

approaches and standards used in similar works.

Design, Implementation, and Evaluation of a School Insecticide-

Treated Net Distribution Program in Cross River State, Nigeria |

Global Health: Science and Practice (ghspjournal.org)

3
BACKGROUND

Death toll from malaria in Nigeria is still of great concern as there are up to 100

million malaria cases and up to 300,000 malaria-related mortalities annually (Singh et

al., 2014). The most vulnerable population are pregnant women, infant and under-five

children. Malaria is a cause of pregnancy loss, stillbirth, low birth weight, and

neonatal mortality. Individuals with sickle cell and other low immune groups are also

at higher risk (Roll Back Malaria Partnership, 2007). Several socio-economic factors

have contributed to the slow progress achieved in the prevention/eradication of

Malaria in Nigeria (Ogbonna et al., 2016). The recommended preventive interventions

are the use of ITNs, and indoor residual house spraying and other preventive

interventions where appropriate and effective (Okumu and Moore, 2011).

This intervention which doubles as a research work is a school-based distribution of

ITN(s) in 3 local government areas of Cross-river (Obubra, Ogoja, Ikom) is the

intervention program to combat malaria spread in households. Ikom served as the

control community while Obubra and Ogoja served as test. Social determinants of

health like education, environment and wealth index was put into consideration. The

stakeholders/partners included the Cross-river state Ministry of Education and Health,

the community heads, the head-teachers and teachers. Planning and implemetation

began with a need accessment following the data obtained from the first phase of

ITN(s) distribution by the state health ministry.The NetCALC was used to acsertain

the determinate outcome of the previous distribution and the remaining population

uncovered. A before-after assessment of intervention areas with a comparison area

using cross-sectional household surveys was carried out. The survey report from the

4
earlier distribution by the Cross-river State health ministry served as a baseline while

the report from the continuous distribution program served as the end-line evaluation.

CONCEPT OF HEALTH

‘Hael’, is the Old English word for ‘Heal’, from which the word ‘health’ was derived

meaning- ‘whole’ (Ajima and Ubana, 2018) .The state of total mental, physical and

social well-being as against the absence of infirmity or disease is known as Health

(Bauer, 2014). The WHO goes further to define health as the degree to which a person

or group of persons goals/objectives and satisfy need and to change or adapt with the

environment (McKenzie, Neiger and Thackeray, 2022). However, a number of

stakeholders in the health education and practicing industry have identified some

lacunae in the WHO definition of health as the adjective “Complete” preceding the

definition of health is arguably inaccurate (Morse and McNamara, 2013). The

argument is based on the detriorative nature of man and the gradual nature of disease

process (Woodall et al., 2015). For instance, terming a person having malaria parasite

plasmodium in his blood without any physical symptom of headache, fever, nausea or

vomiting can be deceptive as continous exposure and delayed dignosis and treatment

under suitable condition can result to sudden occurrence of acute malaria which can

rapidly lead to the death of the person (Woodall et al., 2015). The ITN(s) intervention

is based on the deteriorative nature of man and the incompleteness of stating that a

man that hasn’t been diagnosed of malaria illness is healthy in a malaria endemic

society (Babiker, Gadalla and Ranford-Cartwright, 2013).

5
HEALTH PROMOTION

The great medical historian, Henry E. Sigerist, in 1945 coined the term “Health

Promotion”, defining the major tasks of medicine as four including promotion of

health, prevention of illness, restoration of the sick and rehabilitation (Kumar and

Preetha, 2012). Sometimes Health education is used interchangeably with Health

promotion. The provision of knowledge on health and health-related information to

persons and communities and empowering individuals to adopt heath behaviour

voluntarily is termed Health Education (Abdulraheem, 2012). It involves a coherent

learning experience created to foster improved health through increase in knowledge

or influence on attitude and health seeking behaviour of the persons and their

communities (Hale et al., 2011). On the other hand, Health Promotion is more

elaborate approach to advancing health by involving key players and stakeholders in a

multisectoral approach. Health promotion is broader and it is geared towards handling

developments that impact health directly or indirectly, such factors include inequity,

change in the pattern of consumption, environment, cultural beliefs. The health

promotion strategy used in this intervention involved key players in health, education

and community levels. It also considered socio-economic factors that could hamper

the aim of the program either by directly impeding the approval or collaboration from

stakeholders or indirectly preventing the outcome from succeeding in the household

level.

6
SOCIAL DETERMINANTS OF HEALTH

To achieve an effective health promotion intervention, social determinants of health

should be put to consideration (Bambra, 2010). Social determinants of health (SDOH)

are the conditions in the environments where people are born, live, learn, work, play,

worship, and age that affect a wide range of health, functioning, and quality-of-life

outcomes and risks (Friedman, 2021). WHO further defines SDOH as the non-

medical factors that influence health outcomes. They are the conditions in which

people are born, grow, work, live, and age, and the wider set of forces and systems

shaping the conditions of daily life (DeVoe et al., 2016). These forces and systems

include economic policies and systems, development agendas, social norms, social

policies and political systems (DeVoe et al., 2016). Socioeconomic factors such as

education, wealth index, environment, occupation and religion have been setbacks to

the eradication advances of government and non-governmental agaencies to combat

malaria in Nigeria (Metu and Kalu, 2020).

HEALTH LITERACY

The degree to which a person can locate, comprehend, and use information and

services to support health-related decisions and actions for themselves and others is

known as their level of health literacy (Bröder et al., 2017). A significant obstacle to

eliminating malaria in Nigeria is illiteracy. This may help to explain why efforts

centered on the free distribution of insecticide-treated nets (ITNs) or medications

haven't actually had the expected impact. The incentive to protect children from bites

of mosquito or take prompt action to treat malaria in children would remain low

unless malaria is recognized by all parties involved as a dangerous illness brought on

7
by mosquito bites. As a result, there is a significant and rising prevalence of malaria

among youngsters (Nsikanabas, 2014). However, ITNs (insecticide-treated bednets)

are in short supply (Isola, 2013). In Nigeria, certain states are wealthier than others,

hence the extent to which the government would provide for its residents via a healthy

subsidy will differ from that in other states. For instance, in Rivers State, the

government distributes insecticide-treated bednets as part of a massive yearly

budgetary commitment to the elimination of malaria.

HEALTH NEED ASSESSMENT

Health need assessment is a thorough process that assess the extent to which an

intervention or project is needed by a community or a people (Fernandez et al., 2019).

Health needs assessment is essential as it helps to ensure that the right intervention is

carried out and resources are adequately managed and efficiently used (Wang et al.,

2022). This intervention carried out the health need assessment by going through the

records of earlier distribution performed by the cross-river state government. This

effort help them to discover the communities in the need of the intervention more.

Obubra, Ikom and Ogoja communities didn’t benefit in the second distribution

program championed by the Cross-River state health ministry leaving them as part of

most vulnerable population.

8
HEALTH PROMOTION MODEL AND STRATEGY

The Health Promotion Model (HPM) provides a framework to explain and predict

specific health behaviors (McEwen, 2011). The HPM shows that each person is a

biopsychosocial creature that is partially shaped by the environment, but also seeks to

create an environment in which inherent and acquired human potential can be fully

expressed (Pender, 2011). The HPM was originally developed to target individuals;

however the framework can be used to target families, groups, or communities.

Moreover, the HPM incorporates elements of the change process, including a

commitment to a plan of action and acknowledgement of competing demands. The

final outcome is engagement in health promotion behaviors.

Health Belief Model was used in this intervention. The Health Belief Model is a

theoretical model that can be used to guide health promotion and disease prevention

programs. It is used to explain and predict individual changes in health behaviors. It is

one of the most widely used models for understanding health behaviors. It focus on

individual beliefs about health conditions, which predict individual health-related

behaviors. The model identifies the key factors that influence health behaviors as an

individual's perceived threat to sickness or disease (perceived susceptibility), belief of

consequence (perceived severity), potential positive benefits of action (perceived

benefits), perceived barriers to action, exposure to factors that prompt action (cues to

action), and confidence in ability to succeed (self-efficacy).

Three strategies have been identified in carrying out a health promotion program. This

includes health communication, health education and policy, system and

environmental changes. This ITN(s) intervention employed the health education

9
strategy by organizing training for the teachers who are expected to pass the

knowledge to the grades that have been selected to be beneficiaries of the distribution.

The limitation of the health education model used in this intervention program is that

it’s effectiveness in student/teacher knowledge of the use of ITN(s) does not

guarantee proper use in households. A health communication approach that involves

demonstration of usage to households and use of visual communication modes such as

handbills, bill boards and pamphlets that describe the use of the ITN(s) would have

yielded a more successful intervention.

INTERVENTION PLANNING

Effective implementation of health promotion interventions also requires sound

planning, good management, systematic monitoring and evaluation, and partnership

building among multiple development sectors including health, civil society, the

private sector, households and communities (Rantala, Bortz and Armada 2014).

The health protagonist's part in the first stage of community assessment and problem

analysis is to more understand the problem and the community's means, including the

degree to which the problem is conceded by the community, its compass and

distribution across a community or population, its cause, and the environment of the

community in which it occurs.

This intervention ensured planning based on the recommendation of the continuous

distribution toolkit. The ITN(s) intervention, research, and evaluation activities were

guided by a set of school-based participatory research principles, as outlined by Kate

Kolaczinski (2016). Schools in Obubra and Ogoja local government were selected as

distribution channels. Choice of grade levels were 1 to 3 years apart to ensure most

10
households with children could receive at least 1 ITN every 2 to 3 years: primary year

1, primary year 4, junior secondary school year 1 (7th year of education), and senior

secondary school year 1 (10th year of education).

All partners share influence, control, and decision-making power through their

participation, and the intervention activities. Planning began with the evaluation of the

extent and coverage of earlier distribution of ITN(s) by the state government in order

to ascertain the need among the unreached population. The model of cascade training

was applied. For an orientation on distribution, form completion, supervision, and

social and behavior change communication (SBCC) messages, heads of schools

traveled to the LGA level. After that, school administrators went back to teach their

staff. The nets were distributed nets to schools and grades using enrollment data that

heads of schools presented to trainings. During these sessions, microplans for ITN

storage and transportation were also developed. a personal transportation service to

deliver ITNs from the state warehouse (to which they were directly shipped after

arrival at port) to the LGA warehouse once school microplanning data were verified,

and then from the LGA warehouse to schools. Obubra and Ogoja communities served

as the test. Ikom was the control. The school- based distribution of ITNs was to the

test communities, Ikom was not supplied the nets. for conducting human subject

research, the team obtained ethical clearance from the Johns Hopkins Bloomberg

School of Public Health Institutional Review Board as well as from the National

Health Research Ethics Committee of Nigeria. The consent of all participants were

also sought.

11
PARTNERSHIP WORKING

A collaborative partnership is an alliance among people and organizations from

multiple sectors, such as schools and businesses, working together to achieve a

common purpose (Green and Johnson 2015). In public health, collaborative

partnerships attempt to improve conditions and outcomes related to the health and

well being of entire communities (Jagosh et al., 2015). When the focus is a

community, those affected may include people who share a common place, such as a

rural community or an urban neighborhood, or an experience, such as being a child or

living in poverty (Sharkey, 2013). In public health, collaborative partnerships take

many forms, including coalitions of community members and groups, alliances

among service agencies, consortia of health care providers, and grassroots and

broader advocacy efforts and initiative (Minkler, Wallerstein and Wilson, 2012). Up

to six (6) partners were identified in this intervention execution which includes the

state and local government health authorities, education officials, NGO

representatives, local consultants, community heads and private transport company.

This state and local health bodies ensured that intervention was channeled to the most

vulnerable population who had little or no access to ITNs in the initial phase of Cross-

river state mass distribution. Education officials secured the intervention an approval

to use the school-based approach. NGOs partenered in ensuring quality delivery of

12
ITNs, community leaders verified that participants we’re indigenous or resident in the

selected population. The teachers through the parent/teachers association

communicated the health implication of not using or improper use of the ITNs to

parents. Parents were not directly involved as stakeholders in the intervention and this

might have affected their attitude to the acceptance and use of the ITNs for the control

of mosquitoes in their homes.

EVALUATION

Health promotion interventions must be evaluated to determine their efficacy, justify

resource usage, identify unexpected outcomes, and inform and improve future

practice (Vedung, 2017). The WHO (2013) describes avaluation as an assessment that

is systematic and impartial as possible, of an activity, project, programme, strategy,

policy, topic, theme, sector, operational area, institutional performance. It focuses on

expected and achieved accomplishments, examining the results chain, processes,

contextual factors and causality, in order to understand achievements or the lack

thereof. Regardless of these definitions, a standard approach to the evaluation of

public health interventions remains elusive due to the complexity inherent in these

interventions.

Activities that may be useful to routinely monitor and evaluate a school-based ITN

distribution include:

• Collation of ITN audit trail documentation.

13
• Supervision of activities against specific criteria including adherence to

communications activities and quality of training. Supervision reports should be

collated and findings used to inform planning of subsequent rounds.

• Collation and analysis of distribution data to determine:

- Number of ITNs delivered.

- Efficiency of the distribution (i.e., what proportion of targeted students are

recorded as receiving nets).

• Net tracking study following distribution to estimate:

- The proportion of ITNs received by students that were taken to their households.

- The proportion of ITNs received that were slept under the previous night. Data

on other ITNs and the household structure will depend on understanding.

- The extent to which messages about ITNs delivered as part of school programs

are recalled by students and household members.

This intervention collected and analysed data with respect to - ITN ownership

(proportion of households that owned at least 1 ITN), Proportion of households with

at least 1 ITN for every 2 people, Proportion of the population with access to an ITN

within their household (the proportion of the population that could be protected by an

ITN, assuming that each ITN in a household can be used by 2 people), Net use (the

percentage of a given population group that slept under an ITN the night before the

survey) and Equity (access to any ITNs across economic quintiles). There was no

evualtion for the effectiveness of the training conducted to the teachers.

This intervention doubles as a research work and so little emphasis was placed on the

use or replacement of the ITNs. The life span of ITNs is 3 year. World Health

Organization (WHO, 2017) recommends that undamaged ITNs should be treated with

14
insectiside at an interval of 2-3years. This intervention failed to address the

significance of the WHO recommended maintenance and effectiveness standard.

CONCLUSION

This report has evaluated the effetiveness of a school-based ITNs distribution as an

intervention for Malaria-related illnesses in 3 local governments in Cross-river state,

Nigeria. The intervention considered all the necessary areas of health promotion,

using appropriate model, strategy, implementation plan and evaluation. However,

being a school-based intervention, there was no report on how households that has no

student in the schools with these communities were included in the program. The

definition of household according to this report is - ‘persons who eat from the same

pot’. The assumption that every household have a child in school is lessening to the

aim of the studies. Partnership was evenly distributed amongst community, regional,

governmental and non-governmental authorities which ensured a more organized,

targeted, effective distribution and efficient use of resources.

RECOMMENDATION

 In order to minimize mosquito bites use of ITNs is effective but more

enlightenment through health communication should be employed. Accessibility

doesn’t negate non-usage or improper use and this gap can be filled by

demonstrative or visual communication.

 Collaboration between government and non-governmental health agencies to

tackle the endemicity of Malaria in Nigeria and other African countries should be

intensified.

15
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