Long-lasting Insecticide-Treated Mosquito Nets in the Democratic Republic of the Congo: Knowledge, Attitudes and Practices among households in Bonzola Health Zone in Mbuji-Mayi.

Malaria is the most widespread parasitic disease in the world. It is a major risk of morbidity and mortality for more than two billion human beings worldwide. In the Democratic Republic of the Congo (DRC), it is one of the three leading causes of death among the most vulnerable groups children under five and pregnant women. The impregnated mosquito net is currently one of the best ways to prevent malaria. The purpose of this study is to assess the knowledge, attitudes and practices of households related to the use of long-lasting insecticide-treated net in Bonzola Health Zone in the City of Mbuji-Mayi . This is a cross-sectional descriptive study conducted with 360 households. Our statistical unit was the household. The interview technique was used to collect data that were encoded, processed and analyzed using Excel 2007 software. In our statistical analyses, we used the calculation of frequencies, mean, standard deviation and proportions. The Chi-square test was used for association research.


INTRODUCTION 1. Background
Malaria is the most widespread parasitic disease in the world. It is caused by a protozoan of the genus Plasmodium transmitted to humans through the bite of an infected female Anopheles mosquito. With 207 million episodes and 627 thousand deaths reported in 2012 according to the WHO report, Malaria is a major risk of morbidity and mortality for more than two billion people. Sub-Saharan Africa, which has only 8% of the world's population, accounts for 85 to 90% of Malaria cases (90% of which are due to Plasmodium falciparum). Children under five years of age and pregnant women are the first victims because of their vulnerability (18). Malaria kills 1.5 to 2.7 million people each year, including one million children under five years of age (22).
Malaria is rife in more than 100 tropical and subtropical countries, particularly in Sub-Saharan Africa, Asia, the Pacific and Latin America. It was estimated that there were 216 million malaria episodes in 2010, with a wide range of uncertainty from 194 to 274 million cases. Nearly 81%, or 174 million cases (between 113 and 239 million), occurred in the Africa region and 13% in South-East Asia (22).
In recognition of the value and effectiveness of LLITNs, the Abuja Summit on "Roll Back Malaria" in April 2000 endorsed a series of Malaria control measures, including making insecticide-treated nets (ITNs) readily available to the public. As a result, ITNs have become a central part of the malaria control strategy.
In DRC, according to the results of the thick smear, the prevalence of malaria (23% for all children aged 6-59 months) increases with age, rising from a minimum of 12% at 6-8 months to a maximum of 27% at 48-59 months. Estimated prevalence varies greatly according to province (see map below): the highest proportion of malaria positive children is found in the Kasai Provinces (29% in Kasai-Oriental and 32% in Kasai-Occidental), Katanga (32%), Maniema (34%) and especially in Province Orientale (38%). These proportions decrease considerably with the improvement in the educational level of mothers after primary school. In fact, while 26% of children of mothers with primary education level are positive, this proportion is only 8% when the mother has a higher level of education (18).

According to the directory of Health Statistics published by the Directorate for Disease and Major
Endemics Control of the DRC Ministry of Public Health, malaria remains the major endemic and the first cause of morbidity. It is also one of the three leading causes of mortality among the most vulnerable group, namely children under five years of age and pregnant women (24).
To date, the DRC has made progress as hoped. Figures providing reliable and comparable estimates on LLITN use testify to this; for example, the rate of ITNs use by children has increased significantly, from 6% in 2007, 38% in 2010 (MICS-DRC) and to 56% in 2013, and the proportion of pregnant women sleeping under an ITN has also increased significantly, from 7% in 2007, 43% in 2010 (MICS-DRC) and to 60% in 2013(18).

Justification
The impregnated mosquito net currently remains one of the means of malaria prevention. Its study provides information not only on its effectiveness on mosquitoes and its impact on malaria prevalence, but also on the problems that block its use and its popularization among populations.
The Consortium MSH, OSC and IRC had implemented in the DRC the project called "Projet de Santé Intégré" (PROSANI), targeting primarily children under the age of five and pregnant women and secondarily the entire population. This project ensured a free distribution of nearly 26,000 LLITNs in the period from October 2013 to September 2014 in order to contribute to the reduction of at least 50% of morbidity and mortality attributable to malaria by the end of 2015 in DRC in 68 health zones -including the health zones of Kasai Oriental (20). During the month of August 2015, the DR Congolese Government, through the National Malaria Control Programme, in partnership with the ASF/PSI, conducted a campaign for free distribution of LLITNs in Mbuji-Mayi with the aim of increasing the fight against the pandemic. Several LLITNs were distributed to households in Mbuji-Mayi. (20) While studies abound on malaria control, few report on household knowledge, attitudes and practices in this area; and overall, knowledge is estimated at only 58%, good attitudes at 71% and good practices in LLITN use at 28% according to the study conducted in June 2010 in Kisanga Health Zone in Lubumbashi by Davos D. Sangba, University of Lubumbashi (5). What about households in the city of Mbuji-Mayi?
In light of the above, the questions that this study has endeavoured to answer are as follows:  What is the prevalence of LLITN availability and use?
 Are LLITNs accepted and used in households in Mbuji-Mayi in Bonzola Health Zone?
 What factors are associated with the use or non-use of LLITNs?

Objectives of the study
The overall objective of this study was to assess household knowledge, attitudes and practices

I. INSECTICIDE-TREATED MOSQUITO NET
According to WHO, the Insecticide-Treated Mosquito Net is a net that repels, inactivates or kills mosquitoes that come into contact with the insecticide impregnated in the net (21).
The application of the long-lasting insecticide to fabrics to prevent vector-borne diseases such as malaria and leishmaniasis began during World War II, when warring forces used insecticide-treated nets and clothing (4). In the late 1970s, synthetic pyrethroids were shown to be effective for this purpose.
Early studies on insecticide-treated nets demonstrated the safety of pyrethroids and their impact on various entomological parameters, including the number of times the vector was able to feed, vectorial capacity and the number of bites inflicted on humans. These studies have also helped to better define the active mechanism (mosquito repellency and suppression) and the optimal dosages for various combinations of nets and insecticide (3).
Insecticides used for impregnation must meet WHO specifications. In addition, they must be registered and accepted by the country. The choice of insecticide type depends on vector sensitivity, efficacy, availability, cost and resources.
In terms of product types, the most suitable types for net treatment are synthetic pyrethroids and pseudo-pyrethroids and ofenprox, which have the advantage of being easily absorbed by the tissues and have a rapid action. Examples include permethrin, deltamethrin, lambdacyhabothrin, and ofenprox. (16) ITNs are a product intended for household consumption and therefore, like any product, they must be renewed. This raises the question of the lifespan of an ITN. A long-lasting insecticidal net (LLITN) is a mosquito net pre-treated at the factory with an insecticide that has a duration of action of more than three years and does not require treatment (18); it has a lifespan of about 3 years or 20 washes (minimum), and does not need to be re-treated (washing is sufficient to reactivate it). The insecticide molecules give the net an exit-repellent effect (which keeps mosquitoes and other insects away) and a "KD: Knock Down" effect that stuns and kills the mosquito that comes into contact with the impregnated surface. LLITNs also have a known impact on other nuisance species: fleas, lice, cockroaches, bugs, bark beetles.
It appears that LLITNs are used to protect against nuisance and mosquito bites. It is now established that LLITNs provide effective protection against several vector-borne diseases such as leishmaniasis, human African trypanosomiasis, filariasis and malaria; in malaria-endemic areas, they can reduce overall child mortality by about 20% (25).
Some houses are not suitable for the installation of mosquito nets; they are very small and are used for cooking but also for sleeping. The use of LLITNs is applied on beds, but it is, however, conditioned by the type of housing the user lives in.

Use of LLITN
A survey of 420 households in Yaoundé, Cameroon, indicated that nets were used in only 14.  (Table I).

Impact of LLITN use in Africa
In recent years, insecticide-treated mosquito nets have emerged as an effective means of stemming the rising tide of malaria around the world (22). Several trials in Africa and elsewhere in the world confirm the efficacy of ITNs in highly endemic settings.
Indeed, four large-scale studies have been conducted to measure the effects of ITNs on overall child mortality rates in various malaria-endemic regions of Africa (Burkina Faso, The Gambia, Ghana and Kenya). The results of these four trials, now published, indicate that the child mortality rate decreased significantly (between 15% and 33%) in each of the sites (22).

Factors influencing the use of LLITN
Although the effectiveness of ITN use is particularly well established in modern medicine, there are certain factors that limit its use, namely (14):  Sociological burdens (illiteracy and very low education level of the population); housing types; lifestyle and recreation;  Anthropological factors (belief in particular rites, presence of traditional medicines...);  Economic burdens (very low income level of most people) and finally  Burdens related to the health care system (accessibility and equipment of Health Centres; insufficient supply of ITNs, which at times leads to long-term stock-outs or total unavailability of LLITNs).

i. People's knowledge of mosquito nets
In general, the majority of the population has an idea about ITNs; however, level of knowledge, lack of information, beliefs and education level show a significant influence on this knowledge. Some people who perceive no link between mosquitoes and malaria believe that the net is used to reduce the nuisance of mosquitoes rather than to protect against malaria. This has led to the perception of ITNs as a prestige item or as a way to get a good night's sleep for those who want to buy them.
In a study conducted in Brazzaville in two neighbourhoods after an awareness day, 56.7% of households surveyed in the sensitized neighbourhood said they were aware of the existence of ITNs and 30.6% in the control (non-sensitized) neighbourhood (2).
The lack of information and population's ignorance about the role of mosquitoes in malaria transmission raise concerns that have led some people to think that perhaps more emphasis should be placed on reducing the nuisance associated with bites to motivate the use of ITNs. This proposition is reinforced by the fact that net use is associated with high mosquito densities; when people are asked about the benefits of ITNs, they talk much more about reducing mosquito nuisance than they do about reducing malaria (15).
Education level is a variable that has been extensively studied to explain health behaviours. Education implies changes in behaviour, attitudes and thinking, resulting in better use of modern health services and better health practices in the household (10). An individual's education level reflects the acquisition of knowledge. An individual with a high level of education is more likely to know the real cause of malaria than an individual with no education. Thus, this variable accounts somewhat for knowledge because it remains highly correlated with knowledge. Indeed, education allows for progress in the standard of living.
It should also be noted that almost the majority of the population has no knowledge of the role or protection of ITNs against other vector-borne diseases such as leishmaniasis, human African trypanosomiasis and filariasis (25).

ii. Attitudes of populations towards mosquito nets.
Reduction of discomfort is, without doubt, the most immediate, frequent and best perceived result of using an ITN. However, this desire to avoid nuisance is not a sufficient reason to use a treated net all year round. It is quite common, in this context, not to use ITNs during the season when mosquitoes are less numerous.
Ecological factors are particularly important in determining whether or not to use the net:  Mosquito proliferation causes a very considerable culicidal nuisance. As a result, these conditions can lead households to purchase nets. In Côte d'Ivoire, according to studies conducted in 2008 (7), almost half of households preferred insecticide-treated nets as a means of controlling mosquito nuisance.
 Cleanliness and drying of stagnant water near the houses are hygiene techniques that can prevent mosquitoes from multiplying. This can therefore limit the use of nets even in hyperendemic areas, as the nuisance of mosquitoes will be less in places that are sanitized and maintained.
Although some people are indifferent to or reject the use of LLITNs because of suffocation, warmth during sleep, -assumed -allergies, or tightness of housing, a large proportion of the population communicates a positive attitude towards LLITNs not only as a means of reducing mosquito nuisance, but especially as a means of preventive malaria control.
iii. Population's practices with regard to mosquito nets As mentioned above, there are a number of factors that justify the use or non-use of LLINs, including: ownership of an LLITN; accessibility and equipment of LLITN distribution points; types of housing...
To use an LLITN, you must first have one! The geographical accessibility of LLITN distribution points is an important factor determining LLITN ownership. It is measured by the proportion of the population living within a given radius of a distribution point (8). This is because access to these distribution points requires a travel and their remoteness makes this access much more difficult as it requires means of transport and time. However, door-to-door distribution makes it possible to circumvent this constraint.
In DRC, the Demographic and Health Survey II estimated that 72% of households had a treated net or an LLITN. However, the proportion of the population who spent the night before the interview under an ITN in a household with two ITNs was 25% and 21% in households with three ITNs (18).
This is sufficient evidence that acceptance of LLITNs by the population is not complete, although the population is aware and/or willing to accept it.
Household size and sleeping habits (2,26) are variables that influence net use/practice of the net to the extent that they influence the number of nets to be acquired. This is because large households require a relatively high number of nets. In Kasai Oriental, 64% of households own at least one LLITN; the average number of LLITNs per household is 1.1 and the percentage of households with at least one LLITN for every two people is 18.6% (18).
The adaptation of these nets to the organization of the domestic space greatly influences the daily use of nets. The small size of houses makes it impossible to leave these impregnated nets stretched over the sleeping berths during the day, so for one reason or another, LLITN use is no longer permanent (9).
Gender significantly influences the use of malaria preventive measures because women are more likely to encourage the use of malaria control measures than men.
Although the LLITN is designed to be a means of preventive control against malaria and other vectorborne diseases, this is not always the case in communities: some use it as curtains, some use it as a football net, and some use it as a fishing net.

Definition of concepts
In order to clearly outline the results of this study, the following definitions were used for each concept used:  Factors influencing LLITN use: these are the factors that influence households to make the decision to use LLITNs.  Long-acting insecticide-treated mosquito net (LLITN): this is a mosquito net with a "permanent" pyrethroid imprint that does not require any further treatment or a mosquito net that has been pre-treated at the factory with an insecticide that has a duration of action of more than three years and does not require treatment. It is a mosquito net that is soaked in a bath of insecticide from the factory and protects against mosquito bites and other insects.
 Knowledge of LLITN: is the fact that a household has been informed at least once about the use of LLINTs and their benefits.
 Attitude towards LLITNs: this is the behaviour displayed towards LLITNs, in terms of its use, despite being informed about its usefulness and benefits: acceptability.
 Practice with regard to LLITNs: the behaviour displayed with regard to LLITNs, in terms of use, although accepting it: effective use.

Type of study and sampling
We conducted a cross-sectional descriptive study in households in the Health Zone of Bonzola using a KAP (Knowledge, Attitudes, and Practices) survey related to LLITNs in Mbuji-Mayi. The statistical unit for the study was the household.
The sample size (n) was estimated by the formula: = ² ² , where:  p is the proportion of households owning LLITNs in Kasai Oriental, In this study, the final sample size used is 360 households. The sample was drawn using the random sampling technique. On the basis of the enumeration that had been carried out in December 2015 in the HZ, we carried out a simple random selection to identify the households that joined our sample.
The survey took place across all 15 HAs making up the Bonzola HA. The survey questions were addressed to the heads of households and/or their representatives found in the households and able to answer our questions.

List of variables and scale of measurement
In this study, we worked with the following variables: The dependent variable is "the use of LLITNs by households". It is a dichotomous event; either the household is using it or not. Household LLITN use was therefore measured by the probability of using LLITNs.
The independent or explanatory variables selected are:  integrates elements related to socio-demographic data, knowledge, attitudes and practices in households.
The questionnaire consisted of four parts: 1. the first part focused on socio-demographic, cultural and economic characteristics 2. the second on knowledge, attitudes and practices related to LLITNs 3. The third addressed information on household LLITN use (practices).
4. The fourth dealt with the availability of LLITNs.

Data collection: authorization and period
 Obtaining authorizations: before starting the collection of data, an approval was obtained from the University of Mbuji-Mayi, followed by that of the Burgomaster of Kanshi local government area where the Bonzola Health Zone where the study was conducted is located.
At the level of each household, the informed consent of the head of the household was obtained before proceeding with the interview.
 Period of data collection: field trip with the tool. Data collection in the households was spread over a period from 10 to 30 January 2016, i.e. a total of 21 survey days.  Coding and data entry: To facilitate the analysis, the collected data were converted into figures, taking into account the categories that were created. Data were entered using Excel software for processing.

Statistical processing and analysis of data
 Before proceeding with the actual analysis, the data were organised in tables and graphs and described.
Data collected were encoded, processed and analyzed using Excel 2007 software. In our statistical analysis, we used the calculation of frequencies, mean, standard deviation and proportions. The Chisquare test (level of significance 0.05) was used to search for associations. knowledge in the population is weighted as "low" for a proportion less than 50%, "medium" for a proportion varying between 50 and 79%, and "good" for a proportion greater than or equal to 80%.

Ethical considerations
Informed consent was obtained from the respondent prior to the administration of the questionnaire.
Consent was free and verbal. In this study, data were collected anonymously and confidentially. We reserved the right to safeguard the privacy and personality of the respondent.

Limits
In this study, we did not assess respondents' knowledge of the roles of LLITNs against other vectorborne diseases, nor did we assess LLITN use in relation to housing type and suitability for different sleeping arrangements, let alone use by categorization: children under 5 years of age -pregnant women -other family members.
III.    In terms of LLITN use, respondents with medium and high levels of education, under 65 years of age and in an occupation had good practices in more than 60%. Statistical analyses reveal that education, age, gender and occupation are also significantly associated with household practices. Attitudes towards LLITNs are good in more than 95% of cases. For the majority, protection against malaria is the major reason for their acceptance.

Attitudes towards LLITNs in households in BONZOLA Health Zone.
Among the household heads surveyed with good attitudes, only 63.32% have good practices.
Statistical analyses reveal a significant association between attitudes towards LLITNs and household practices.   Thus, the use of LLITNs the day before our survey was important (90.28%). However, it is difficult to assess the sleeping habits of households taking into account the type of dwelling.

Practices related to LLITNs in households in
These results reflect what the last free distribution of LLITNs carried out in August 2015 by the Government (through the National Malaria Control Programme, in partnership with ASF/PSI) has largely produced as impact to the beneficiary population.
A two-year retrospective study (2017-2018) on the prevalence of Malaria in the study area can also give a perfect idea of the impact of utilization of LLITNs by the population. Furthermore, it will help to adapt awareness and sensitization messages to the population, strengthen health system at HZ level, provide appropriate measures and advocate for continual use of LLITNs.
We therefore recommend:  To strengthen the capacities of providers in hospitals and Health Centres in terms of malaria control strategies adopted by the NMCP.

To the population of DRC :
 To use this weapon, which is most relevant in public health, in order to contribute to the reduction of suffering in the community by changing negative behaviours into healthpromoting behaviours. And by the same token, to significantly reduce the burden of disease/health costs in the community through the simple use of the LLITN.
 Obtain and continue to use the LLITN for the well-being of the family.
The long-lasting insecticide-treated net currently remains one of the most effective means of preventing malaria and several vector-borne diseases. Ethical approval was obtained from the University of Mbuji-Mayi, followed by that of the Burgomaster of Kanshi local government area where the Bonzola Health Zone where the study was conducted is located. At the level of each household, the informed consent was obtained from the respondent prior to the administration of the questionnaire. Consent was free and verbal.

LIST OF ABBREVIATIONS
 Consent for publication: This study does not contain any individual person's data that can identify participants.
 Availability of data and materials: The datasets generated, used and analysed during the current study are available from the corresponding author on reasonable request. In this study, data were collected anonymously and confidentially. We reserved the right to safeguard the privacy and personality of the respondent.