Presented by Ashley Garley at the 2012 ASTMH Annual Meeting.

1. Gender Difference in Use of Insecticide Treated Nets After a Universal Free Distribution Campaign in Kano State in Nigeria
Ashley Garley1, Elizabeth Ivanovich1, Erin Eckert2, Svetlana Negroustoueva3, Yazoume Ye1
1
ICF International, 2US Agency for International Development, 3Independent Consultant
Background
Although malaria affects men and women, their vulnerability and access to treatment is influenced by gender roles and affected by equity in society. A recent shift in
insecticide treated net (ITN) distribution strategy from targeting pregnant women and children under five to aiming for universal coverage among the general population,
raises issues associated with equity of access and equality in the use of ITN. There is a need for analysis to assess the effects of gender on the uptake of this key intervention
for malaria control. The recent post-campaign survey in Northern Nigeria offers an opportunity to examine gender differences in ITN use, by using sex-disaggregated data.
Realities in Nigeria: Current ITN distribution strategy in Nigeria :
Low ITN coverage Mass ITN distribution campaigns for all population groups increase ITN coverage
• 8% ITN ownership (DHS 2008) •63 million new Long lasting Insecticide Treated Net (LLIN) to be distributed
• 6% ITN use among children under five years (DHS 2008) by the end of 2010
Photo source: Arne Hoel / World Bank • 5% ITN use among pregnant women (DHS 2008) •At least 80% of LLINs distributed put in use
Methods Sampling
Location of the study site-Nigeria Data Collection
•Sample Size=4,602 individuals •Household survey took place Oct 19 –Nov 4, 2009
Kano State •Beta=80%, alpha=5%, design effect= 1.75 •5 months after campaign 1
•Accounting for non-response rate: 5% •3 months after campaign 2
•Average size of household=5 people •Structured questionnaire was used
•Children under 5 years=20% of population •Head of Household was primary respondent
Warawa
•Pregnant females=3.5% of female population •Verbal informed consent obtained before interview
•Power to detect 50% point change in household net ownership
Statistical Analysis
Sampling Procedure •Analysis was restricted to only individuals living in households with at least 1 ITN (3,056)
•Sampling frame: Questionnaire adapted from the •Descriptive Analysis-described gender difference in ITN use by background characteristics
Wave 1 May 2009
Malaria Indicator Survey •Logistic regression (binary response)-assessed ITN use difference between male and female
Wave 2 July 2009 •Selection of 30 clusters - wards controlling for several covariates (campaign Waves, age, place of residence, education of the
•List of community-villages compiled in each ward head of households, polygamous households [yes/no] and ratio of ITNS to household
Source: Ye et al, 2012 •Selection of 17 households per community members
Results
Individual Living in Household with ITN ITN Use Sex as a Predictor for ITN Use
Number of # individual using
Table 1: Percentage of individuals living in households with ITNs by gender and background Factors individuals ITN (%) Odd Ratios (95% CI) p value
Total number of individuals 3,056 1622 (53.1)
characteristics.
Explanatory variable
Background Female Male Total Gender
characteristic Male 1,494 729 (48.8) 1
Percentage N Percentage n Percentage N Female 1,562 893 (57.2) 1.46 (1.25-1.70) 0.000
Covariates
Total 66.7 2,342 66.1 2,260 66.4 4,602 Wealth quintiles
Lowest 521 273 (52.4) 0.80 (0.61-1.05) 0.104
Campaign Waves Second 610 307 (50.3) 0.82 (0.64-1.06) 0.128
Third 640 359 (56.1) 1.09 (0.86-1.39) 0.479
Wave 1 63.8 1,169 63.3 1,175 63.6 2,344 Fourth 653 341 (52.2) 0.89 (0.70-1.13) 0.334
Wave 2 69.6 1,173 69.1 1,085 69.4 2,258 Highest 632 342 (54.1) 1
Wave
Place of residence Wave 1 1,490 735 (49.3) 1
Wave 2 1,566 887 (56.6) 1.38 (1.18-1.61) 0.000
Urban 69.5 791 68.5 774 69.0 1,565 Age
Under 5 year 639 397 (62.1) 1.41 (1.14-1.75) 0.002
Rural 65.3 1,551 64.9 1,486 65.1 3,037
5-15 years 971 471 (48.5) 0.88 (0.73-1.06) 0.169
Wealth quintiles 15-25 years 467 203 (43.5) 0.57 (0.45-0.73) 0.000
25 years and plus 979 551 (56.3) 1
Lowest 62.3 453 65.7 364 64.0 817 Place of residence
Urban 1080 538 (49.8) 1
Second 70.0 466 71.4 398 70.7 864 Rural 1976 1,084 (54.9) 1.15 (0.98-1.35) 0.098
Middle 69.3 452 66.2 494 67.7 946 Education head of household
None 1,880 965 (51.3) 1
Fourth 70.6 472 69.0 464 69.8 936 Primary 636 374 (58.8) 1.38 (1.13-1.67) 0.001
Secondary 382 185 (48.4) 0.87 (0.68-1.12) 0.288
Highest 61.7 499 60.0 540 60.9 1,039 Overall, ITN use among individuals living in households with at least one Higher 115 75 (65.2) 1.80 (1.16-2.78) 0.009
ITN was 53%; however, there was a significant difference in use Missing 43
Of the 4,602 individuals in the survey samples, 66% lived in households between females and males (57% vs. 53%, p<0000.1). Consistently,
Polygamous household
Yes 1,291 666 (51.6) 1
which owned at least one ITN with no difference between females (67%) females reported significantly higher ITN use than males in Wave 1 (52%
No 1,765 956 (54.2) 0.88 (0.76-1.03) 0.114
Ratio 1 net for 2 person met
and males (66%). The percentage of individuals living in households with vs. 46%, p=0.017) and Wave 2 (62% vs. 51%, p<0.0001). Similar patterns No 2,268 1,077 (47.5) 1
at least one ITN increased by 5.8 points between Wave 1 (May 2009) and were observed by residence. Furthermore, females had significantly
Yes 788 545 (69.2) 2.53 (2.11-3.04)
Model fit: LR chi2(18)=238.45; p value=0.0000; Pseudo R2=0.057; Log likelihood = -1963.54
0.000
Wave 2 (July 2009) for both sexes . There was no difference by sex in the higher use of ITNs compared to males when analyzed by household
proportion of individuals living in households which owned at least one Logistic regression showed females are more likely to use ITNs compared to males
wealth: quintiles except the second (53% vs 47%, p=0.147) and middle
ITN in either rural or urban areas. Individuals in the households in the after controlling for potential confounders, (OR:1.5, 95% CI: 1.3-1.7). Age showed a
(60% vs.53%, p=0.069). significant effect on ITN use; children under five had higher odds of using an ITN,
second and fourth wealth quintiles were the most likely to own at least
one ITN ( 71% and 70%, respectively). while individuals age 15-25 years were less likely to use an ITN. Individuals living in
households with a head that had no formal education were less likely to use an ITN.
Individuals living in households with at least one ITN for every two members were 2.5
times more likely to use an ITN compared to individuals living in households with less
than one ITN for every two members.
Conclusions Acknowledgments
The results from this analysis in Kano state showed that household ITN ownership increased more than tenfold, This study was the result of a collective effort with several partners including USAID Nigeria, SuNMAP, Malaria Consortium,
from 6% before to 71% after the campaigns. There was no significant difference between the proportion of RMS and MEASURE Evaluation. The authors would like to thank all the institutions and individuals who contributed to the
females and males living in households with at least one ITN. However, a higher percentage of females used design and implementation of the post-campaign survey. In particular, the team would like to acknowledge Albert Killian, the
ITNs compared to males , even after controlling for several covariates, females remained more likely to use Research Marketing Service (RMS) team. Special thanks to Emmanuel Adegbe and Olatunde Oladimeji from SuNMap for
overseeing the field activities and data processing. The team is also grateful to all the people who reviewed and gave
ITNs compared to males . comments on the initial draft. This study was made possible by support from the U.S. Agency for International Development
This study reveals gender disparity in ITN use, with men less likely to use ITNs . Notably, the uptake of the (USAID) under the terms of Cooperative Agreement GPO-A-00-03-00003-00. The opinions expressed are those of the authors
intervention among the most-at-risk group (females) is higher than males. Further research is needed to and do not necessarily reflect the views of USAID, or the United States Government.
identify whether gender disparities in ITN use is related to the traditional targeting of women with malaria
interventions; however, results provide enough evidence to design gender-sensitive messaging for ITN
distribution to ensure that males equally use ITNs.