Introduction

Malaria has long been a significant public health issue in many tropical and subtropical developing countries, particularly in African nations like Ethiopia, where socioeconomic conditions are difficult.¹ The case incidence in the WHO African Region decreased from 373 to 225 per 1000 individuals at risk between 2000 and 2019, but it climbed to 234 in 2020, primarily due to service disruptions during the COVID-19 pandemic. The incidence decreased to 229 cases per 1000 individuals in 2021.² Due to its mountainous topography, varying winds, seasonal rainfall, and ambient temperatures, Ethiopia, one of the Sub-Saharan Africa (SSA) countries most severely affected by the pandemic, provides a variety of microclimates for malaria transmission.³ Malaria affects over 60% of Ethiopians, and 68% of the country’s land area is conducive to the disease’s spread.⁴

A study showed that using an ITN lowers the prevalence of malaria parasitemia, which is used as a proxy for the disease’s burden.⁵ All populations in malaria hotspot areas are at risk unless they have access to locally adequate insecticide-treated nets and a more robust healthcare system. An estimated 552 million ITNs were provided by the National Malaria Programs (NMP) between 2015 and 2017; the bulk (83%) were given out in sub-Saharan Africa (SSA).⁶ About 80% of ownership and use are widely regarded as the minimal condition for considering universal coverage. This is based on the assumption that 2 people typically share a net, so if 1 net is made available for every 2 members of a household, then everyone can utilize an ITN^7,8

ITNs, a popular malaria preventive method,⁹ have aided in lowering the burden of the illness for more than 20 years. Despite this, the usage is still below average. About 54% of all children under the age of 5 in SSA had slept under an ITN at night.^10,11 It can provide a physical barrier to mosquitoes and offer malaria protection when used and maintained properly. ITNs are treated with an insecticide, which has a 3- to 5-year shelf life, or around 20 washes. ITNs are substantially more effective than non-treated nets because they have both an insecticide and a physical barrier. The insecticide prevents mosquitoes and, in most cases, kills or knocks them down, preventing the transmission of the malaria parasite even to people not protected by mosquito nets.¹²

According to a survey on ownership and use of long-lasting insecticidal nets in Ethiopia (2020), 66.8% of the households owned at least 1 ITN, and on average, households owned 1.8 ITNs. However, the night before the survey, 44.16% of the general population and 52.34% of children slept under ITN.¹³ On the other hand, the operational malaria plan for Ethiopia for the 2019 fiscal year states that during the 2015-16 period, nearly 30 million ITNs were supplied to homes in Ethiopia at risk of malaria.⁷ Although ITN distribution did not rely on registration to gather data on the number of children under the age of 5, pregnant women, and sleeping spaces for each household in malaria-endemic kebeles, an average of 2 ITNs per home was utilized for logistical and mathematical concerns.¹⁴

Even though a greater number of households in Ethiopia are using ITNs, usage is constrained by factors including home design and user habits. Due to a lack of awareness of the necessity for priority groups to sleep under ITNs at home, unsuccessful ITN use has been noted in numerous parts of Ethiopia.⁴ In Ethiopia’s East Mesekan District, Enseno, the research area may experience comparable conditions. Along with the aforementioned difficulties, fieldwork has revealed that people in the research area have been seen using ITNs for things besides preventing mosquito bites, like window coverings and hair accessories.

ITN utilization in households for children under the age of 5 during the survey’s prior night and associated factors have been briefly studied in Ethiopia.^11,15,16 However, to the author’s knowledge, there are no attempted studies on the ITN utilization of households with under 5 children and associated factors in this study area. Thus, this study aimed to identify ITN utilization and associated factors among households with children under the age of 5 in the East Mesekan District, Gurage Zone, Southern Ethiopia. The findings of this study will be used as a baseline for future related research by non-governmental organizations, regional health departments, and other health planners in implementing targeted malaria control strategies.

Methods and Materials

Study area, design, and period

A community-based cross-sectional study design was carried out from March 5 to April 22, 2020, in the East Mesekan District, Gurage Zone, Southern Nation Nationalities, and People Region. It is located 153 kilometers south of Addis Ababa, the capital city of Ethiopia. The area of East Mesekan District is an estimated 1767 square kilometers with a total population of 82 139, with 49% men and 51% females dispersed over 3 urban and 14 rural kebeles.¹⁷ The rural population accounts for 77% of the total population, while the urban population accounts for 23%. The total number of households is estimated to be 16 762. There are 3 functional health centers and 14 functional health posts in the district. There were ten private clinics in the district and 4 pharmacies. As our preliminary survey indicated, ITN coverage in this district is almost entirely provided by non-governmental organizations funded by the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The East Mesekan District is found in a rift valley area with a varied landscape, predominantly covered with plateau formations, and variable temperatures.¹⁷

Sample size determination and sampling techniques

The required sample size was calculated using a single population proportion formula. In the calculation, we assumed a 63% population proportion based on a study conducted in Adami Tullu District, Oromia Regional State, Ethiopia, which stated that children had slept under ITNs among net-owning households during the previous night,¹⁸ a 5% margin of error at a 95% confidence level, a 10% non-response rate, and a design effect of 1.5. The final sample size was estimated to be 591.

Six kebeles (the smallest administrative structure) were selected from all the East Mesekan District kebeles using simple random sampling. Then, lists of all the households found in each selected kebele were identified, and households with at least 1 under-5 child from each kebele were prepared in collaboration with the health extension worker from data prepared for immunization purposes. The sample was proportionally allocated to each kebele based on the number of households with under-5 children in each kebele. Households with under-5 children were selected through a systematic random sampling method for recruitment for interviews. From the list of households with under 5-year-old children, every seventh household in each group was chosen as a participant (Figure 1).

Figure 1.

Schematic presentation of sampling procedures, East Mesekan District March 2020.

Results

Socio-demographic

In this study, 591 households were included, with a response rate of 100%. More than half of the respondents were females (57.7%). Nearly half (45.9%) of the respondents were within the age group of 25 to 34. Almost all, 556 (94.1%), of the respondents, were married. Regarding educational status, 28.3% of the respondents had no formal education/were unable to read and write. Most of them, or 550 (93.1%) of the respondents’ houses, were made of corrugated material. The mean (±SD) monthly income was found to be ETB 2088.92 (±1588.79). Regarding the number of rooms for sleeping purposes, 290 (49.1%) of the respondents had 2 rooms for sleeping. More than two-thirds of households had radio/television during the survey. In terms of occupation, 265 (44.8%) of the respondents were farmers, while 147 (24.9%) were merchants (Table 1).

Table 1.

Socio-demographic characteristics of the study participants, East Mesekan District, March, 2020.

Knowledge of study participants

Knowledge on malaria

Almost all participants (570, or 96.4%) had heard of malaria. Five hundred two (88.1%) of those surveyed were aware that malaria was spread by mosquito bites. Fever was identified as the primary symptom of malaria by the majority of respondents (372, or 62.9%), followed by feeling cold. Four hundred seventy-three (80%) of the participants stated that children under the age of 5 were the most affected by malaria. In terms of malaria education messages, 562 (95.1%) respondents were reached through various mechanisms, and 453 (80.6%) of these messages were reached through health workers. Four hundred seventy-seven (80.7%) respondents said they prevented malaria by using ITN, and nearly half said they prevented malaria by spraying chemicals around the house (Table 2).

Table 2.

Knowledge about malaria among study participants, East Mesekan District, March, 2020.

Knowledge on mosquito

In this study, 360 (60.9%) of the participants reported that mosquitoes troubled them. More than half (383, or 64.8%) of participants reported mosquito bites at bedtime, and nearly all (580, or 98.1%) reported mosquito bites during the rainy season. Five hundred forty-nine (92.9%) of the respondents understood the importance of protecting themselves from mosquito bites using various mechanisms (Table 3).

Table 3.

Knowledge of the study participants regarding mosquitoes, East Mesekan District, Marh, 2020.

Insecticide treated net utilization practice

The majority of study participants (83.9%) reported that having an ITN is an advantage in that they do not get malaria. On the other hand, 89.3% of study participants stated that using ITNs had no benefit in terms of sleeping better. Regarding the disadvantages of ITN utilization, 73.4% of the study participants reported that ITN use during sleep was not too hot. Furthermore, 31.1% of study participants reported skin irritation from ITN use, and another 23.9% reported that hanging the net each night takes time. In this study, 30.3% of participants owned 1 ITNs, whereas 28.6% of the study participants had 3 or more ITNs. On the other hand, this study shows that more than half of the respondents who were surveyed (62.3%) claimed they always use ITNs for under-5 children when sleeping, while 17.7% said they never do. More than half of the households in this study (58.2%, 95% CI: [54.1%-62.2%]) used ITN for children under the age of 5 the night before the survey. In terms of household ITN ownership, 91.1% were acquired in less than 12 months, and 8.9% were acquired between 12 and 24 months (Table 4).

Table 4.

Perception and attitude toward ITNs of the study participants with under-5 children East Mesekan District, March 2020.

Knowledge and practice of ITN utilization among households with under-5 children are shown in Figure 2. According to Figure 2, only 34.3% and 29.4% of study participants had good knowledge and practice of ITN use, respectively.

Figure 2.

Knowledge and practice of ITN utilization among households with under-5 children in East Mesekan District, March, 2020.

Factors associated with ITN utilization

After bivariate analysis, factors such as the households’ residence, family size, the main material of the roof made, how long have you had your ITNs, number of ITN, presence of side effects of ITNs on skin irritation and knowledge about ITN were taken into account in the multivariable analysis. A significant association between ITN utilization for under-5 children in the study community and family size, the number of ITNs, presence of side effects of ITNs on skin irritation, having knowledge about ITN was found in a multivariable analysis (P < .05). The study participants’ residence, the main material of the roof made and length of ITN they used, however, did not significantly affect their utilization of ITNs (P > .05).

The odds of ITN utilization for respondents who had 2 ITNs were 2.58 times higher (AOR = 2.58, 95% CI: [1.54-4.39]) compared to those who had 3 ITNs. Respondents who didn’t report skin irritation related to ITN utilization were 58% less likely to have ITN utilization (AOR = 0.43, 95% CI: [0.29-0.63]) compared to those who reported skin irritation as a side effect of ITN utilization. Additionally, respondents who had low knowledge about ITN were 2.07 time more likely utilized ITN (AOR = 2.07, 95% CI: [1.33-3.20]) compared to those who had good knowledge about ITN. On the other hand, the odds of utilizing ITN among rural residents were 14% lower (AOR = 0.86, 95% CI: [0.56-1.30]) compared to urban residents, even though the difference was not statistically significant (Table 5).

Table 5.

Bivariate and multivariable logistic regression model predicting the ITN utilization for under-5 children, East Mesekan District, March, 2020.

Discussion

This study aimed to examine the household ITN utilization for under-5 children the previous night in East Mesekan District, Gurage Zone, Southern Ethiopia. According to the study’s findings, more than half (58.2%) of the participants’ children under 5 years old had slept under an ITN in the previous night. The current study finding was nearly similar to a study conducted in Senegal, which showed that 58.7% of households used ITN for children under-5 to sleep under it.²⁰ In contrast, a study conducted in Ghana found that households’ ITN use for children under 5 years old was lower (41.7%) than the counterpart.²¹ This increased household ITN utilization for under-5 children in our study might be related to improved knowledge and awareness of education and the demand creation of the community through mass media, local and community radio, or television. But the proportion of households that used ITNs for under-5 children who slept under them during the night preceding a survey was lower than the proportion of households that possessed ITNs in the study area.

In the current study, around one-third of the participants of the study population perceived that there was skin irritation among their under-5 children, which was higher than a similar study in India, where one-fourth of the respondents of ITN users complained of skin irritation.²² Other problems infrequently mentioned by studies were daily time-taking, mounting, or hanging of ITN during a sleeping time.²³ A similar study done in Bahir Dar, Amhara region, reported that it took time every night to mount or hang ITN during sleeping time. These were some of the potential underlying reasons that the people did not use ITNs in sleeping.²⁴

Regarding the malaria information, almost all of the respondents (96.4%) in the community heard the term malaria in our study. In a similar study conducted in Woreta town, North West Ethiopia, 95.8% of the participants heard about malaria.²⁵ Our study findings outperformed those of a study conducted in Kenya, which revealed that 91% of study participants had heard of the term malaria.²⁶ Therefore, this study’s findings were better than those of the previous similar study. This improvement would be because they get this information on malaria education messages from health workers.

In order to ensure efficient use of prevention tools, knowing that malaria is transmitted by infected mosquito bites is essential. In this study, 88.1% of the respondents knew that malaria was transmitted by an infected mosquito bite. In a similar study in Woreta town, north-west Ethiopia, about 59.6% of respondents rated the bite of an infected mosquito as a way of malaria transmission.²⁵ The Ethiopia national malaria indicator survey of 2015 found that 75% of the respondents had malaria, which is transmitted by the bite of an infected mosquito.⁴ The current research showed more favorable outcomes than those of the previous; the possible reason for this difference could be increased community awareness from time to time through media or health information dissemination.

In our study, more than three-fourths of respondents identified children under the age of 5 as the most affected group in the community, and 62.9% of residents identified fever as a major symptom of malaria. The current result was lower than the following similar study, 87.1% of the participant’s perceived fever, the main symptoms of malaria in Adami Tulu district, Oromia Regional state.²⁷ A similar study in Kenya explained that a symptom matching clinical descriptions of malaria, fever, or “hot body,” was mentioned by 80.2% of the respondents.²⁸ More than half of the people in the study area were unaware of the signs and symptoms of malaria, such as headache, loss of appetite, and body pain or joint pain. This finding may have the drawback of implying that the main signs and symptoms of malarial illness were not distinguished from other diseases during education time by district health office professionals and kebele health extension workers.

In the current study, only 80.7% of the respondents claimed that ITN prevents malaria. Our study’s finding was lower than the finding of a comparable Ugandan survey, which showed that 98.1% respondent claimed that ITN prevents malaria.²⁹ The possible reason for the difference might be related to the fact that, during and after distribution, the health information dissemination by health workers and others on the ITN for malaria prevention is low.

In the present study, households with less than 5 family sizes were less likely to use ITN than households with 5 or more family sizes. The findings of our study were not supported by a previous study, which found that having a family size of less than 5 increased the likelihood of using ITN compared to those respondents who had more than 5 or more children in other regions of Ethiopia.^11,30 But, an investigation carried out in Burkina Faso revealed that the size of families did not significantly affect the use of ITNs for children under the age of 5.³¹ The possible explanation is that families frequently sleep in a single room, which could be a challenge due to a lack of convenient spaces that do not permit mosquito net hanging or because the sleeping room might be used for other purposes, as evidenced by studies conducted in Ethiopia and Uganda.^32,33

Skin irritation is a rare adverse effect mentioned by ITN users, along with headaches, nausea, and eye burning. If any of these effects do occur, they are minimal and transient.³⁴ In our study, households that experience skin irritation linked to an ITN side effect were less likely to use ITNs for their children under the age of 5. This might be related to the community’s belief that children’s bed nets are poison because of their delicate skin. As a result, most people advise against covering newborns’ beds with bed nets.³⁵

In the present study, respondents who were less knowledgeable about the importance of ITNs were more likely to use ITNs for their children under the age of 5 than those who were more knowledgeable. Our study’s findings were contradictory to those of a study conducted in Eastern Ethiopia.³⁰ This may be as a result of the ITNs they possessed being damaged, dirty, or difficult to hang in their home, as well as potential limitations in the questions we used to compute knowledge. There is a limitation to this study. Self-reported responses, which made up the majority of the data, were biased toward social desirability. Cross-sectional designs have the potential to make it difficult to prove a causal connection between causes and effects. It’s possible that the 1 night prior to the survey, when the use of ITNs by children under the age of 5 was evaluated, did not accurately represent the long-term trend of ITN usage.

Conclusion

The utilization of ITNs by households for under-5 children was unsatisfactory, but it was better than the other study finding done at the country level in Ethiopia, and not all ITNs owned by households in the area were being used for under-5 children at the time of data collection. Fear of skin irritation, household size, and the number of ITNs they owned were identified as the main barriers to ITN use. It is recommended that continuous and progressive health awareness about the consistent use of ITN for malaria prevention in the study area be promoted.