Concern about women’s and girl’s education in Nigeria and worldwide has peaked with the abduction of around 300 female secondary school school students in northeastern Nigeria. Normally we see many positive benefits of women’s education in various health indicators, but it appears that bednet use does not follow that trend neatly.
Analysis of bednet use in the Nigeria Malaria Indicator Survey (MIS) of 2010 found that ironically net use of all kinds, including ordinary nets, insecticide treated nets and long lasting insecticide-treated nets actually decreased as educational level of women increased.
Interestingly the same picture is painted for levels of wealth with 41% in the lowest quintile using any kind of net the night before the survey versus 16% for the highest quintile. Also of note, 19% of urban women reported using any kind of net versus 34% in the rural areas.
In contrast the 2010 Nigerian MIS found that only 22% of women without education had received any antenatal care (ANC) during a recent pregnancy compared to 89% with greater than secondary education. Getting at least two doses of intermittent preventive treatment (IPTp) during ANC was only 7% for those without formal education, but 24% for those with higher than secondary education. Why does bednet use show a reverse trend here?
One factor may be the delivery mechanism. ANC and IPTp require utilization of a service with all the economic and intra-family dynamics that this implies. Nets have so far been mainly provided during outreach campaigns. Is there an element of equity going on here with an effort to reach the less educated and poorer segment of society with nets?
Also educated people and those with relatively greater wealth may have better housing conditions that are less likely to encourage mosquito entry. Such families may perceive that they have less need for nets if they actually have ceilings and windows with netting.
Just by way of comparison, a similar picture of net use was was seen in the Malawi MIS of 2012. That survey only recorded three levels of education and the contrast between highest and lowest use was only about 10% points compared to 25% difference in Nigeria.
Colleagues have recently documented gaps in net access and use across many countries. We need to ensure not only that nets reach a house, but that adequate numbers of nets are available for universal coverage (UC = at least one for every two residents – though this adequacy calculation depends on cultural sleeping patterns).
Malaria control efforts since 2009 have been aiming at UC, but various surveys have shown this goal to be elusive, let alone sustainable, since nets need to be replaced every 2-3 years. It is encouraging if some element of equity might underlie net distribution, but we still need to learn more about why people get and use nets or alternatives to ensure that all women and other household members are truly protected from malaria.