CHAPTER ONE

INTRODUCTION

1.1 Background To the study

The vast majority of malaria deaths occur in Africa, south of the Sahara, where malaria also presents major obstacles to social and economic development. Malaria has been estimated to cost Africa more than US$ 12 billion every year in lost GDP, even though it could be controlled for a fraction of that sum.

There are at least 300 million acute cases of malaria each year globally resulting in more than a million deaths. Around 90% of these deaths occur in Africa, mostly in young children. Malaria is Africa's leading cause of under-five mortality (20%) and constitutes 10% of the continent's overall disease burden. It accounts for 40% of public health expenditure, 30-50% of in-patient admissions, and up to 50% of outpatient visits in areas with high malaria transmission. Malaria accounts for over 60% of outpatient visit in Nigeria and other sub-Saharan African countries. Prompt access to effective anti- malarial treatment is one of the major strategies for reducing the burden of malaria. Prompt access means having treatment available as near to home as possible so that it is given within 24hrs of onset of symptoms.

Malaria is the leading cause of death for both adults and children in Tanzania, killing 100,000-125,000 people annually (CDC, 2005). Environmental conditions play an important role in the transmission of malaria, as macro-environmental factors, such as climatic conditions (temperature and rainfall), microenvironmental factors, such as local topography, and human land use and management greatly influence vector abundance. Environmental management is an underutilized but promising technique for vector control, because it decreases the available breeding habitat for mosquitoes by removing or modifying stagnant or slow-moving water sources (Ault, 1994).  It is estimated that 42% of the malaria burden in Sub-Saharan Africa could be prevented through environmental management (Pruss-Ustun and Corvalan, 2006).

Human activities play an important role in influencing the transmission of infectious diseases, including malaria (Patz et al 2004; Sattenspiel 2000; Weiss & McMichael 2004). Human-induced micro-environmental changes, such as the construction of irrigation schemes and dams, have been shown to dramatically increase mosquito populations in an area by creating new breeding habitat (Ijumba et al 2002; Mutero et al 2004). Malaria is thus a particular problem in agricultural areas, as land use changes implemented to improve crop yields often result in an increased presence of surface water. Environmental management is an important component of malaria control, as it can be used to regulate these micro-environmental conditions, reducing the amount of slow-moving water present in an area, and thus creating land less suitable for sustaining mosquito populations. This method has been successful in reducing the malaria burden in many different ecological, socioeconomic, and epidemiological conditions (Utzinger et al 2001). Environmental management was first used on a large- scale basis in the early 1900’s, fell out of practice in the 1940’s with the onset of DDT spraying, and only began to be implemented again for malaria in the 1980’s (Ault 1994).

Environmental management consists of installing and maintaining drains, removing pools of stagnant water, managing vegetation, irrigating intermittently, and altering rivers to create faster flowing water (Keiser et al., 2005). Additional techniques include filling holes and larviciding (Lindsay et al., 2004; Walker 2002; Yohannes et al., 2005). Multiple studies have shown that the reduction of mosquito-breeding habitat through environmental management has significantly decreased mosquito abundance in surrounding areas (Ault, 1994; Okech et al., 2008; Yasuoka et al., 2006a; Yohannes et al., 2005). Additionally, in Nepal, community-based environmental management  consisting of clearing vegetation in ponds, draining and filling areas that collect water, and repairing irrigation canals resulted in a reduction in malaria cases by 35% in the intervention villages in 1983 versus the baseline year (1982) (Ault, 1994). This form of malaria control is relatively inexpensive, simple for local communities to implement and maintain, and not harmful to humans or the local environment (Keiser et al., 2005). Therefore, community-level environ- mental management, if implemented as part of an integrated vector-management program and paired  with control strategies, such as mosquito nets, could prove effective at reducing malaria burden.

Whereas environmental management activities often are performed by a central authority or a set of volunteers/ workers (Lindsay et al., 2004; Utzinger et al., 2001; Yohannes et al., 2005), there is increasing emphasis on the need to enlist local communities in ongoing, decentralized malaria control activities. Yet household-level environmental management relies on sufficient community participation to achieve efficacy in reducing mosquito populations. An accurate understanding of mosquito biology and habitat requirements is likely to play a role in one’s participation in controlling these habitats to reduce mosquito populations. Studies have illustrated that a lack of understanding of mosquito biology is prevalent in African communities. For example, in a survey of 1,451 households in Kenya, 65% of respondents stated that they did not know what mosquito larvae look like (Opiyo et al., 2007). Educational programs have been used to increase community understanding and participation in malaria control through activities such as identifying breeding habitat, observing larval mosquitoes, and teaching techniques for suppression of mosquito breeding (Mukabana et al., 2006; van den Berg and Knols, 2006; Yasuoka et al., 2006b).

1.2 Statement of the problem

During the last 40 years, the population of sub-Saharan Africa (SSA) has almost trebled, growing by more than 15 million people each year, to the present level of over 600 million (www.fao.org).

As the population continues to grow, people move away from the countryside to the cities, attracted by the hope of a better life. At present, one third of Africans in SSA live in cities, and this proportion is likely to grow in the future. In fact, it is estimated that more than half of all Africans will live in cities by 2022. Thus the urban environment will become an increasingly important feature of African life.

Although malaria is primarily a rural disease, it can also be a considerable drain on populations living on the fringes of urban settlements, causing significant morbidity and mortality while also reducing productivity (Trape 1987, Bouganalih et al. 1993, Baujat et al. 1997, Beier et al. 2003).

Following observation from the study area, it was clear that malaria was a significant public health problem in the cities.

This problem is likely to grow as a result of the increase in parasite strains resistant to chloroquine (Babirye et al. 2000).

At present the major foci of malaria control include the case management of clinical episodes of malaria, the promotion of insecticide-treated nets (ITNs), focal indoor residual insecticide spraying (IRS), presumptive treatment of malaria in pregnant women and environmental management (EM). EM, through a process of social mobilization and community participation, is being encouraged by the Ministry of Health and includes filling small water collections, clearing bushes around homes and closing windows early in the evening. With a growing focus on community-level environ- mental management as a component of malaria control, it becomes crucial to determine existing beliefs regarding the link between malaria and the environment, and how these beliefs relate to environmental management practices.

1.3 Objective of the study

The main objective of this study is to explore community knowledge and practices on environmental  management for malaria control. Specifically, our goal is to:

1. Assess the environmental management practices used by community members.

2. evaluate the relationships among knowledge, beliefs, and environmental management practices.

3. Identify key challenges and opportunities for improving the effectiveness of environmental management in this region as well as in a larger context.

1.4 Significance of the study

It is now widely acknowledged that access to appropriate and effective treatment for malaria should be provided within 24 hours of onset of symptoms. A strategy to provide such access should take into account poor rural populations in malaria-endemic countries who are particularly inadequately served by the health system.

Evidence from Nigeria shows that most episodes of fever are initially self-treated and over 70% of cases rely exclusively on it. However of this proportion only 15% of the actions taken were adjudged as appropriate. This pattern has been consistent across the Country as documented in several other reports.8 A study of health seeking behavior for childhood illnesses in 3 rural Nigerian communities showed that the most common form of first line treatment was drugs from a patent medicine vendor (49.6%), while only 3.6% did nothing. In a study conducted at Igbo Etiti and Ibarapa North in Nigeria on 105 preschool children, Brieger et al found that 74% of parents took treatment action under 8 hours of onset of illness, while nearly 96% acted within 24 hours. Unfortunately only 14.3% of these actions were judged to have been appropriate. Studies in rural areas have shown the feasibility of home management and its positive impact on the burden of malaria. There is also paucity of data on environmental management in Nigeria.

1.5 Research Question

Following the objective of the study, the study will answer the following questions

1. What are the environmental management practices used by community members ?

2. What is the relationships among knowledge, beliefs, and environmental management practices?

3. What are the key challenges and opportunities for improving the effectiveness of environmental management in this region as well as in a larger context?

1.6 Hypothesis of the study

The following hypotheses were formulated and tested by the study

Ho: There is no relationship between some demographic/socioeconomic factors and environmental management practices

H1: There is relationship between some demographic/socioeconomic factors and environmental management practices

1.7 Scope/Limitation of the study

This study will focus on the awareness of the use environmental management in the control and prevention of malaria. It will explore the important role played by environment in the transmission prevention and control of malaria. It will be carried out in Ifako-Ijaiye Local Government. A local government in Lagos state Nigeria.

The limitation faced by the researcher include how to get the data necessary for the study and also the availability of literature, considering the recent and limited studies  in this area.  

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