臺灣博碩士論文加值系統

ABSTRACT
Studies conducted in late 80s and early 90s in The Gambia by The Ministry of Health and
Medical Research Council (MRC), and in many other African countries showed that regular
use of Insecticides Treated Nets (ITNs) can protect children from frequent malaria episodes and
reduce mortality by more than 30%. Since then, promotion of ITNs has been one of the major
malaria control strategies in The Gambia. The aim of the study was to identify important
factors associated with beliefs, preference and utilization of ITNs among mothers as protective
measure against malaria for their children under the age of five years. A cross-sectional survey
was carried out in July and August 2008 in Jokadou District, The Gambia. The important
factors derived from the Classification and Regression Tree (CART) model were: most of
mothers aged >22 years preferred big size bednets, younger mothers (<22 years) whose malaria
awareness obtained from health workers were more likely to have high belief of ITN, mothers
of different ethnicities would prefer different colored bednets, mothers having >2 LLNs and
whose ITNs were treated by health workers are more likely to have children<5 years sleep
under ITNs. 64.3% of Mandinka and Bambara mothers preferring colored bednets compared
with 69.0% of Wolof, Fula and Sarere mothers preferring white nets. In conclusion, the
potential correlates identified in this study are likely to have important implication for public
health policy making and malaria prevention among African countries.

ABSTRACT
Studies conducted in late 80s and early 90s in The Gambia by The Ministry of Health and
Medical Research Council (MRC), and in many other African countries showed that regular
use of Insecticides Treated Nets (ITNs) can protect children from frequent malaria episodes and
reduce mortality by more than 30%. Since then, promotion of ITNs has been one of the major
malaria control strategies in The Gambia. The aim of the study was to identify important
factors associated with beliefs, preference and utilization of ITNs among mothers as protective
measure against malaria for their children under the age of five years. A cross-sectional survey
was carried out in July and August 2008 in Jokadou District, The Gambia. The important
factors derived from the Classification and Regression Tree (CART) model were: most of
mothers aged >22 years preferred big size bednets, younger mothers (<22 years) whose malaria
awareness obtained from health workers were more likely to have high belief of ITN, mothers
of different ethnicities would prefer different colored bednets, mothers having >2 LLNs and
whose ITNs were treated by health workers are more likely to have children<5 years sleep
under ITNs. 64.3% of Mandinka and Bambara mothers preferring colored bednets compared
with 69.0% of Wolof, Fula and Sarere mothers preferring white nets. In conclusion, the
potential correlates identified in this study are likely to have important implication for public
health policy making and malaria prevention among African countries.

TABLE OF CONTENTS
ABSTRACT 6
CHAPTER l Introduction ............................................................................................................. 7
1.1 Background .................................................................................................................... 7
1.2 The purpose of the study ............................................................................................... 11
1.3 Objectives of the study ................................................................................................. 12
1.4 Research Questions ...................................................................................................... 12
CHAPTER II LITERATURE REVIEW AND CONCEPTUAL FRAMWORK ....................... 13
2.1 Overview of Malaria .................................................................................................... 13
2.2 Malaria burden in children under five years of age ..................................................... 14
2.3 Economic impact of malaria ......................................................................................... 15
2.4 Malaria Prevention and Control Strategies ................................................................... 15
2.5 Insecticides Treated nets (ITNs): modes of action ...................................................... 16
2.6 ITNs Benefits (effectiveness trials) .............................................................................. 17
2.7 ITN Use in The Gambia ................................................................................................ 18
2.8 Studies on factors influencing the use of ITNs ............................................................. 19
2.8.2 Beliefs about ITNs .................................................................................................... 21
2.8.3. Insecticides Treated nets (ITNs) Preference for Color, Size and Shape .................. 21
2.8.4. Insecticides Treated Nets (ITNs) utilization. ............................................................ 22
2.9 Summary ....................................................................................................................... 24
2.10 Definition of Concepts ................................................................................................. 26
2.11 Terminology .................................................................................................................. 28
2.12 Abbreviations ................................................................................................................ 30
Beliefs, Preference and Utilization of ITN 4
CHAPTER III METHODOLOGY ........................................................................................... 31
3.1 Study Design ................................................................................................................ 31
3.2 Setting .......................................................................................................................... 31
3.3 Sampling and sample size determination ..................................................................... 32
3.4 Survey instrument ......................................................................................................... 33
3.5 Data Collection ............................................................................................................. 35
3.6 Data process and analysis ............................................................................................. 36
3.7 Ethical consideration ..................................................................................................... 38
CHAPTER IV RESULTS ........................................................................................................ 39
4.1 Background characteristics of Sample Respondents .................................................... 39
4.2 Beliefs about Insecticide Treated Nets ......................................................................... 40
4.3 ITNs Preference in Respect to Colour, Size and Shape ............................................... 41
4.4 Insecticides Treated Nets (ITNs) Ownership and Utilization ...................................... 42
4.5 Summary of Results ...................................................................................................... 44
Figure 2: Classification and Regression Tree on ITN Beliefs .................................................. 50
Figure 3: Classification and Regression Tree of ITN preference ............................................. 51
Figure 4: Classification and Regression Tree (CART) for ITN Utilization ............................. 52
CHAPTER V DISCUSSION ..................................................................................................... 53
5.1 Beliefs about ITNs ....................................................................................................... 53
5.2 Insecticides Treatednets (ITNs) Preference .................................................................. 55
5.3 ITN Utilization ............................................................................................................. 57
CHAPTER VI CONCLUSION AND SUGGESTIONS .......................................................... 60
6.1 Conclusion and Policy Implication .............................................................................. 60
Beliefs, Preference and Utilization of ITN 5
6.2 Recommendation for future studies .............................................................................. 62
6.3 Limitations .................................................................................................................... 63
REFERENCES ............................................................................................................................. 64
Appendix Informed Consent ..................................................................................................... 73
Appendix B Questionnaires ....................................................................................................... 75
Appendix C Expert Validation of Questionnaires .................................................................... 84
Appendix D Map of The Gambia ............................................................................................... 96
List of Figures
Figure 1 Conceptual Framework …………………………………………………………25
Figure 2 Classification and Regression Tree on ITN Beliefs ……………………………50
Figure 3 Classification and Regression Tree on ITN Preference ………………………...51
Figure 4 Classification and Regression Tree on ITN Utilization ………………………...52
List of Tables
Table 1 Demographic Characteristics of Mothers ……………………………………..45
Table 2 Beliefs, Preference and Utilization of ITNs …………………………………..47
Table 3 Correlation Matrix table……………………………………………………….59

REFERENCES
Aikins MK, Pickering H, Alonso PL, D’Alessandro U, Lindsay SW, Todd J, Greenwood
BM, (1993). A malaria control trial using insecticide-treated bed nets and targeted
chemoprophylaxis in a rural area of The Gambia, west Africa. Trans R Soc Trop Med
Hyg 87 (Suppl 2): 25–30
Aikins, M. K., Pickering, H. and Greenwood, B.M. (1994) J. Trop.Med. Hyg., 97,81-86.
Ajzen I, 1991. The theory of planned behaviour. Org Beh Hum Dec Proc 50: 179–211
Alaii J., van den Borne H., & Kachur S. (2003a). Community reactions to the
introduction of permethrin-treated bed nets 24 Anthony K Mbonye et al.for malaria
control during a randomised controlled trial in western Kenya. American Journal of
Tropical Medicine and Hygiene 68 (Suppl. 4): 128–36.
Alonso, P. L., Lindsay, S. W., Armstrong Schellenberg, J. R. M.,Konteh, M., Keita, K. Marshall,
C, Phillips, A., Cham, K.and Greenwood, B. M. (1993). A malaria control trial using
insecticide-treated bed nets and targeted chemoprophylaxis in a rural area of the Gambia,
West Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene, 87
(Suppl.2), 31-36.
Alonso, P. L., Lindsay, S. W., Armstrong, J.R.M., Conteh, M., & Sondorp, E. (1997). Bull World
Health Org, 75, 23-29.
Alonso, P. L., Lindsay, S.W.,Armstrong, J.R.M., Conteh, M., Hill,A.G., David, P.H., Fegan, G.,
de Francisco,A., Hall,A.J., Shenton, F.C., Cham, K., & Greenwood, B.M. (1991). The
effect of insecticide-treated bednets on mortality of Gambian children. Lancet. 337, 1449-
1502.
Beliefs, Preference and Utilization of ITN 65
Ballou, W. R., Arevalo-Herrera, M., Carucci, D., Richie, L. T.,Corradin, G., Diggs, C., Druilhe,
P., birgitte, K. B., saul, A. D.,gray Heppner, D. G., kester, E. K., Lanar, D. E., Lyon, J.,
Hill, A.V. S., Pan, W., and Cohen, D. J. Am. J. (2004). Trop. Med. Hyg, 71, 239-247.
Bates, I., C. Fenton and J. Gruber (2004). Vulnerability to Malaria,Tuberculosis, and HIV/AIDS
Infection and Disease:Determinants Operating at Individual a Household Level. The
Lancet Infectious Diseases, 4(5), 271–272.
Beach RF, T. & Sexton J. (1993). Effectiveness of permethrin-impregnated bed nets and curtains
for malaria control in a holoendemic area of western Kenya. American Journal of
Tropical Medicine and Hygiene, 49, 290–300.
Bermejo A. & Veeken H. (1992). Insecticide-impregnated bed nets for malaria control: a review
of the field trials. Bulletin of the World Health Organization, 70, 293–296.
Binka FN. & Adongo P. (1997). Acceptability and use of insecticide impregnated bednets in
northern Ghana. Trop Med Int Health 2, 499–507.
Binka, F. N., Indome, F. and Smith, T. (1998). Am. J. Trop. Med. Hyg, 59, 80-85.
Binka FN, Kubaje, A., Adjuik M, Williams LA, Lengeler C, Maude GH, Armah GE, Kajihara B,
Adiamah JH, & Smith PG, . (1996). Impact of permethrin impregnated bednets on child
mortality in Kassena-Nankana district, Ghana: a randomized controlled trial. Trop Med
Int Health, 1, 147–154.
Bloland PB, Ruebush T., & McCormick JB (1999). Longitudinal cohort study of the
epidemiology of malaria infections in an area of intense malaria transmission
I.Description of study site,general methodology, and study population. American Journal
of Tropical Medicine and Hygiene, 60, 635–640.
Beliefs, Preference and Utilization of ITN 66
Bradley, A. K., Greenwood, B. M., Greenwood, A. M., March, JC, Bypass, P., Tulloch, S. &
Hayes, R. (1986). Bed-nets (mosquito-nets) and morbidity from malaria. The Lancet
Infectious Diseases, 204-207.
Bradley, A. K., Greenwood, B.M., Greenwood, A.M., & Marsh, K. (1997). Health Policy Plan.
12, 240-247.
Breiman L, Friedman JH, Olsen RA., & Stone CJ. (1984).Classification and regression trees. The
Wadsworth Statistics/Probability Series, Belmont, California
Bryce, J. (2005). WHO estimates of the causes of death in children. Lancet, 365, 1147-1152.
Choi, H. W., Breman, J. G., Teutsch, S. M., Liu, S., Hightower, A. W., & Sexton, J. D. (1995).
The effectiveness of insecticide-impregnated bed nets in reducing cases of malaria
infection: a meta-analysis of published results. Am J Trop Med Hyg, 52(5), 377-382.
Curtis, C. F. (1991). Control of Disease Vectors in the Community. Wolfe, London.
Curtis CF (1992) Personal protection methods against vectors of disease. Review of
Medical and Veterinary Entomology 80, 543–553.
Curtis, C., Maxwell, C., & Lemnge M. (2003) Scaling-up coverage with insecticide-treated nets
against malaria in Africa: who should pay? Lancet Infectious Diseases 3, 304–307.
D’Alessandro U, A. M., Langerock P, Bennett S., & Greenwood BM. (1994). Nationwide survey
of bednet use in rural Gambia. Bull World Health Org, 72, 391–394.
D'Alessandro U. Olaleye BO, McGuire W, Langerock P, Bennett S et al. (1995).
Mortality and morbidity from malaria in Gambian children after introduction of an
impregnated bednet programme. Lancet 354: 479-83.
Daniel, W.W. (1999). Biostatistics: A Foundation for Analysis in the Health Sciences. 7th edition.
New York: John Wiley & Sons
Beliefs, Preference and Utilization of ITN 67
Dictionary of mathematics and statistics - Sci:Q Ref QA/5/DJ216, Sci:Ref QA/276.15/EX52
Gallup J. (2001). The economic burden of malaria. Am J Trop Med Hyg, 64, 85–96.
Global Forum for Health Research Research (2000). The 10/90 Report on Health Research.
Published by the Global Forum for Health Research, ISBN 2-940286-01-9.
Goodman CA, & Mills AJ, (1999). The evidence base on the cost-effectiveness of malaria
control measures in Africa. Health Policy Plann. 14, 301–312.
Green, S. T., Small, M. J., & Casman, E. A. (2009). Determinants of national diarrheal disease
burden. Environ Sci Technol, 43(4), 993-999.
Hawley, W. A., Howard, P. A., ter Kuile, F. O., Terlouw, D. J., Vulule, J. M., Ombok, M.,
Nahlen, Gimnig, Kariuki, Kolczak, and Hightower 2003). Community-wide effects of
permethrin-treated bed nets on child mortality and malaria morbidity in western Kenya.
Am J Trop Med Hyg, 68(4 Suppl), 121-127.
Killeen G. (2007). Mortality and morbidity from malaria in Gambian children after introduction
of an impregnated bednet programme. Lancet 354, 479-483
Kok G., Schaalma H., De Vries H., Parcel G., Paulussen T. (1996). Social psychology and health
education. Eur Rev Social Psychol, 7, 241–282.
Lemmon, C. R., Ludwig, D. A., Howe, C. A., Ferguson-Smith, A., & Barbeau, P. (2007).
Correlates of adherence to a physical activity program in young African-American girls.
Obesity (Silver Spring), 15(3), 695-703.
Lengeler C. & Sharp (2004),Insecticide-treated bednets and curtains for preventing malaria.
Cochrane Database of Systematic Reviews, (2000), (2):CD000363 (update Cochrane
Database of Systematic Reviews
Beliefs, Preference and Utilization of ITN 68
Lwanga SK and Lemeshow S. (1991). Sample Size Determination in Health Studies: A Practical
Manual. Geneva: World Health Organization
MacCormack, C. P., and Snow, R. W. (1986) Gambian cultural preferences in the use of
insecticide-impregnated bed nets. Journal of Tropical Medicine and Hygiene, S9, 295-
302.
Macintyre, K., Keating, J., Okbaldt, Y. B., Zerom, M., Sosler, S., Ghebremeskel, T., et al. (2006).
Rolling out insecticide treated nets in Eritrea: examining the determinants of possession
and use in malarious zones during the rainy season. Trop Med Int Health, 11(6), 824-833.
Makemba AM, Kamazima SR, Makame VR, Sengo F., Lubega PB, Minjas JN, & Shiff CJ,
(1995). Community based sale distribution and insecticide impregnation of mosquito nets
in Bagamoyo district Tanzania. Health Policy Plan, 10:50–59.
Mann, J. J., Ellis, S. P., Waternaux, C. M., Liu, X., Oquendo, M. A., Malone, K. M., et al. (2008).
Classification trees distinguish suicide attempters in major psychiatric disorders: a model
of clinical decision making. J Clin Psychiatry, 69(1), 23-31.
Marchant, T., Armstrong S., Nathan, R.,Abdulla, S., Mukasa, O., Mshinda, H., & Lengeler, C.
(2004). Trop.DALY = Disability Life Years. Med. Int. Health, 9, 262-266.
Merriam-Webster Medical Dictionary. Springfield, Mass. : Merriam-Webster, Inc., c2003
Mbonye, A., Neema, S., & Magnussen, P. (2006). Preventing malaria in pregnancy: a study of
perceptions and policy implications in Mukono district, Uganda. Health Policy Plan,
21(1), 17-26.
McElroy PD, Lal A.A., & Hawley W.A.(1999). Analysis of repeated haemoglobin measures in
full-term, normal birth weight Kenyan children between birth and four years of age. The
Beliefs, Preference and Utilization of ITN 69
Asemobo Bay Cohort Project. American Journal of Tropical Medicine and Hygiene,
61(932–940.9), 295-302.
Meltzer MI, Terlouw DJ, Kolczak MS, Odhacha A., ter Kuile FO, Vulule JM, Alaii JA, Nahlen
BL, Hawley WA, & Phillips-Howard PA, (2003). The household-level economics of usin
permethrin-treated bed nets to prevent malaria in children less than five years of age. Am
J Trop Med Hyg, 68 (Suppl 4), 149–160.
NetMark, (2001): Baseline Survey on Insecticide Treated Materials (ITM) in Uganda. NetMark
Project, Academy for Educational Development
NetMark. ( 2004). NetMark 2004 survey on insecticide-treated nets (ITNs) in Senegal.
Washington, DC: AED/NetMark. http:// www.netmarkafrica.org/research. accessed 8th
April 2008
Njunwa, K. J., Lines, J. D., Magesa, S. M., Mnzava, A. E., Wilkes, T. J., Alilio, M., et al. (1991).
Trial of pyrethroid impregnated bednets in an area of Tanzania holoendemic for malaria.
Part 1. Operational methods and acceptability. Acta Trop, 49(2), 87-96.
Nuwaha, F. (2001). Factors influencing the use of bed nets in Mbarara municipality of Uganda.
Am J Trop Med Hyg, 65(6), 877-882.
Nuwaha F. (2002). People’s perceptions of malaria in Mbarara, Uganda. Tropical Medicine and
International Health 7: 462–70
Okeyo AP, (1979). Women in the household economy: managing multiple roles. Stud Fam
Plann 10: 337–343
Phillips-Howard, P. A., Nahlen, B. L., Alaii, J. A., ter Kuile, F. O., Gimnig, J. E., Terlouw, D. J.,
et al. (2003). The efficacy of permethrin-treated bed nets on child mortality and
Beliefs, Preference and Utilization of ITN 70
morbidity in western Kenya I. Development of infrastructure and description of study site.
Am J Trop Med Hyg, 68(4 Suppl), 3-9.
Rashed, S., Johnson, H., Dongier, P., Moreau, R., Lee C., Crépeau, R., Lambert, J., Jefremovas,
V., & Schaffer, C. (1999). Determinants of the permethrin impregnated bednets (PIB) in
the Republic of Benin: the role of women in the acquisition and utilization of PIBs. Soc
Sci Med, 49, 993-1005.
Redd, SC, Wirima JJ, & Steketee RW, (1994). Risk factors for anemia in young children in rural
Malawi. American Journal of Tropical Medicine and Hygiene, 51, 170–174.
Roll Back Malaria, WHO (World Health Organization), and UNICEF (United Nations
Children’s Fund). ( 2006).“Guidelines for Core Population Coverage Indicators for Roll
Back Malaria: To Be Obtained from Household Surveys.” MEASURE Evaluation:
Calverton, Md.
Roll Back Malaria (2000). Scaling up insecticide-treated netting (ITN) programmes in Africa: a
strategic framework for coordinated national action. Geneva: Roll Back Malaria,
Technical Support Network for Insecticide-Treated Materials
Sachs, J., & Malaney, P. (2002). The economic and social burden of malaria. Nature, 415(6872),
680-685.
Schellenberg, J. R., Abdulla, S., Nathan, R., Mukasa, O., Marchant, T. J., Kikumbih, N., et al.
(2001). Effect of large-scale social marketing of insecticide-treated nets on child survival
in rural Tanzania. Lancet, 357(9264), 1241-1247.
Sexton, J. D., Ruebush, T.K. II, Brandling-Bennett, A.D., Breman,J.G., Roberts, J.M. and Odera,
J.S. (1990). Ann. Trop. Med. Parasitol., 43, 11-8.
Beliefs, Preference and Utilization of ITN 71
Slutsker L., Khoromana CO, & Hightower A.W.(1996).Malaria infection in infancy in rural
Malawi. American Journal of Tropical Medicine and Hygiene, 55,, 71–76.
Snow, R. W., Lindsay. S. W.. Hayes, R. J. and Greenwood.B. M. (1988b). Permethrin-treated
bed nets (mosquito nets) prevent malaria in Gambian children. Transactions of the Royal
Society of Tropical Medicine and Hygiene,, 82, 838-842.
Tanner M., & Vlassoff C. (1998). Treatment-seeking behaviour for malaria: a typology based on
endemicity and gender. Soc Sci Med 46: 523–532.
ter Kuile, F. O., Terlouw, D. J., Phillips-Howard, P. A., Hawley, W. A., Friedman, J. F., Kolczak,
M. S., et al. (2003). Impact of permethrin-treated bed nets on malaria and all-cause
morbidity in young children in an area of intense perennial malaria transmission in
western Kenya: cross-sectional survey. Am J Trop Med Hyg, 68(4 Suppl), 100-107.
The Gambia Malaria Situational Analysis (2000). Malaria Situational Analysis. Ministry of
Health and Social Welfare (DOSH, The Gambia, Banjul
Waltz, C., &Bausell, R. B. . (1983). Nursing research: Design, statistics, and computer analysis.
Philadelphia: F. A. Davis
Warner MW, Al-Hassan RM, & Kydd JG, (1996).Beyond gender roles? Conceptualising the
social and economic lives of rural people in sub-Saharan Africa. Some evidence from
Northern Ghana. Series in Empirical Agricultural Economics and Econometrics.Wye,
United Kingdom: Wye College Press.
Whitty CJM, Rowland M, Sanderson F & Mutabingwa TK (2002) Science, medicine, and
the future – malaria. British Medical Journal 325, 1221–1224
World Health Organization (1999). World Health Report. World Health Organization.Geneva,
Switzerland.
Beliefs, Preference and Utilization of ITN 72
World Health Organization (2000). The African summit on Roll Back Malaria, Abuja, 25 April
2000. . Geneva: WHO. Available:http://www.rbm.who.int/docs/abuja_declaration.pdf.
Accessed 12th March 2008
World Health Organization (2003). Malaria. Fact Sheet No. 94. Geneva, Switzerland: World.
Health Organization; http://www.who.int/mediacentre/factsheets/fs094/en.accessed.
Accessed 15th March 2008
World Health Organization (2005).htt://www.who.int/countries/eth/news/speeches/2005/html.
Accessed 15th March 2008
Wiseman, V., Hawley, W., ter Kuile, FO, Phillips-Howard P.,Vulule J., Nahlen BL, & Mills AJ.
(2003). The cost-effectiveness of permethrin-treated bednets in an area of intense malaria
transmission in western Kenya. Am J Trop Med Hyg, 68, 61–67.
Wiseman, V., Scot, A., McElroy, B., Conteh, L., Stevens W. (2007). Determinants of Bed Net
Use in the Gambia: Implications for MalariaContro. Am J Trop Med Hyg, 76(5), 830-836.