Long-lasting insecticide-treated mosquito nets (ILNs) are commonly used as a physical barrier to prevent malaria infection. In sub-Saharan Africa, one of the most important interventions to reduce malaria incidence is the use of ILNs. However, information on the use of ILNs in Ethiopia is limited. Therefore, this study aims to assess the use of ILNs and associated factors among households in West Arsi County, Oromia State, Southern Ethiopia in 2023. A population-based cross-sectional survey was conducted in West Arsi County from 1 to 30 May 2023 with a sample of 2808 households. Data were collected from households using a structured interviewer-administered questionnaire. The data were checked, coded and entered into Epiinfo version 7 and then cleaned and analysed using SPSS version 25. Descriptive analysis was used to present frequencies, proportions and graphs. Binary logistic regression analysis was calculated and variables with p values less than 0.25 were selected for inclusion in the multivariate model. The final model was interpreted using adjusted odds ratios (95% confidence interval, p value less than 0.05) to indicate a statistical association between the outcome and the independent variables. About 2389 (86.2%) households have long-lasting insecticidal nets that can be used during sleep. However, the overall use of long-lasting insecticidal nets was 69.9% (95% CI 68.1–71.8). Use of long-lasting insecticidal nets was significantly associated with being a female head of household (AOR 1.69; 95% CI 1.33–4.15), number of separate rooms in the house (AOR 1.80; 95% CI 1.23–2.29), timing of long-lasting insecticidal net replacement (AOR 2.81; 95% CI 2.18–5.35), and respondent knowledge (AOR 3.68; 95% CI 2.48–6.97). Overall use of long-lasting insecticidal nets among households in Ethiopia was low compared with the national standard (≥ 85). The study found that factors such as female head of household, number of separate rooms in the house, time of replacement of long-lasting insecticidal nets and level of knowledge of respondents were predictors of LLIN use by household members. Therefore, in order to increase LLIN use, West Alsi District Health Office and stakeholders should provide relevant information to the public and strengthen the use of LLIN at the household level.
Malaria is a major global public health problem and an infectious disease causing significant morbidity and mortality. The disease is caused by a protozoan parasite of the genus Plasmodium, which is transmitted through the bite of female Anopheles mosquitoes1,2. Almost 3.3 billion people are at risk of malaria, with the highest risk in sub-Saharan Africa (SSA)3. The World Health Organization (WHO) 2023 report shows that half of the world’s population is at risk of malaria, with an estimated 233 million cases of malaria reported in 29 countries, of which about 580,000 people die, with children under five and pregnant women being the worst affected3,4.
Previous studies in Ethiopia have shown that factors influencing long-term mosquito net use include knowledge of malaria transmission patterns, information provided by health extension workers (HEWs), media campaigns, education in health facilities, attitudes and physical discomfort when sleeping under long-term mosquito nets, inability to hang existing long-term mosquito nets, inadequate facilities to hang mosquito nets, inadequate educational interventions, lack of mosquito net supplies, malaria risks, and lack of awareness of the benefits of mosquito nets. 17,20,21 Studies have also shown that other characteristics, including household size, age, injury history, size, shape, colour, and number of sleeping places, are associated with long-term mosquito net use. 5,17,18,22 However, some studies have found no significant association between household wealth and the duration of mosquito net use3,23.
Long-lasting mosquito nets, large enough to be placed in sleeping areas, have been found to be used more frequently, and numerous studies in malaria-endemic countries have confirmed their value in reducing human contact with malaria vectors and other vector-borne diseases7,19,23. In malaria-endemic areas, distribution of long-lasting mosquito nets has been shown to reduce malaria incidence, severe disease, and malaria-related deaths. Insecticide-treated mosquito nets have been shown to reduce malaria incidence by 48–50%. If widely used, these nets could prevent 7% of under-five mortality worldwide24 and are associated with a significant reduction in the risk of low birth weight and fetal loss25.
It is unclear to what extent people are aware of the use of long-lasting insecticidal nets and to what extent they purchase them. Comments and rumours about not hanging nets at all, hanging them incorrectly and in the wrong position, and not prioritising children and pregnant women deserve careful investigation. Another challenge is public perception of the role of long-lasting insecticidal nets in malaria prevention. 23 Malaria incidence is high in lowland areas of West Arsi County, and data on household and community use of long-lasting insecticidal nets are scarce. Therefore, the aim of this study was to assess the prevalence of long-lasting insecticidal net use and associated factors among households in West Arsi County, Oromia Region, southwestern Ethiopia.
A community-based cross-sectional survey was conducted from 1 to 30 May 2023 in West Arsi County. West Arsi County is located in the Oromia Region of southern Ethiopia, 250 km from Addis Ababa. The population of the region is 2,926,749, consisting of 1,434,107 men and 1,492,642 women. In West Arsi County, an estimated 963,102 people in six districts and one town live at high risk of malaria; however, nine districts are malaria-free. West Arsi County has 352 villages, of which 136 are malaria-affected. Of the 356 health posts, 143 are malaria control posts and there are 85 health centres, 32 of which are located in malaria-affected areas. Three out of five hospitals treat malaria patients. The area has rivers and irrigation areas suitable for mosquito breeding. In 2021, 312,224 long-lasting insecticides were distributed in the region for emergency response, and a second batch of 150,949 long-lasting insecticides was distributed in 2022-26.
The source population was considered to be all households in the West Alsi region and those living in the region during the study period.
The study population was randomly selected from all eligible households in the West Alsi region, as well as those living in areas with high malaria risk during the study period.
All households located in the selected villages of West Alsi County and residing in the study area for more than six months were included in the study.
Households that did not receive LLINs during the distribution period and those unable to respond due to hearing and speech impairments were excluded from the study.
The sample size for the second objective of factors associated with LLIN use was calculated based on the population proportion formula using Epi info version 7 statistical computing software. Assuming 95% CI, 80% power and an outcome rate of 61.1% in the unexposed group, the assumption was taken from a study conducted in central India13 using uneducated household heads as a factor variable, with an OR of 1.25. Using the above assumptions and comparing variables with large numbers, the variable “household head without education” was considered for the final sample size determination, as it provided a large sample size of 2808 individuals.
The sample size was allocated proportionally to the number of households in each village and 2808 households were selected from the respective villages using simple random sampling method. The total number of households in each village was obtained from the Village Health Information System (CHIS). The first family was selected by lottery. If the home of a study participant was closed at the time of data collection, a maximum of two follow-up interviews were conducted and this was considered as non-response.
Independent variables were sociodemographic characteristics (age, marital status, religion, education, occupation, family size, place of residence, ethnicity and monthly income), knowledge level and variables associated with long-term use of insecticidal nets.
Households were asked thirteen questions on knowledge about the use of long-lasting insecticides. A correct answer was given 1 point, and an incorrect answer was given 0 points. After summing up each participant’s score, an average score was calculated, and participants with scores above the average were considered to have “good knowledge” and participants with scores below the average were considered to have “poor” knowledge about the use of long-lasting insecticides.
Data were collected using structured questionnaires administered face-to-face by an interviewer and adapted from various literature2,3,7,19. The study included socio-demographic characteristics, environmental characteristics and participants’ knowledge of the use of ISIS. Data were collected from 28 people in the malaria hotspot, outside their data collection areas and supervised daily by 7 malaria specialists from health facilities.
The questionnaire was prepared in English and translated into the local language (Afan Oromo) and then re-translated into English to check for consistency. The questionnaire was pre-tested on 5% of the sample (135) outside the study health facility. After pre-testing, the questionnaire was modified for possible clarification and simplification of wording. Data cleaning, completeness, scope and logic checks were conducted regularly to ensure data quality before data entry. After checking with the supervisor, all incomplete and inconsistent data were excluded from the data. Data collectors and supervisors received a one-day training on how and what information to collect. The researcher monitored the data collectors and supervisors to ensure data quality during data collection.
The data were checked for accuracy and consistency, then coded and entered into Epi-info version 7, and then cleaned and analyzed using SPSS version 25. Descriptive statistics such as frequencies, proportions, and graphs were used to present the results. Bivariate binary logistic regression analyses were calculated, and covariates with p values less than 0.25 in the bivariate model were selected for inclusion in the multivariate model. The final model was interpreted using adjusted odds ratios, 95% confidence intervals, and p values < 0.05 to determine the association between the outcome and the independent variables. Multicollinearity was tested using the standard error (SE), which was less than 2 in this study. The Hosmer and Lemeshow goodness-of-fit test was used to test the model fit, and the p value of the Hosmer and Lemeshow test in this study was 0.746.
Before conducting the study, ethical approval was obtained from the West Elsea County Board of Health Ethics Committee in accordance with the Declaration of Helsinki. After explaining the purpose of the study, formal permission letters were obtained from the selected county and city health bureaus. The study participants were informed about the purpose of the study, confidentiality, and privacy. Verbal informed consent was obtained from the study participants before the actual data collection process. The names of the respondents were not recorded, but each respondent was assigned a code to maintain confidentiality.
Among the respondents, majority (2738, 98.8%) had heard about the use of long-lasting insecticides. Regarding the source of information about the use of long-lasting insecticides, majority of the respondents 2202 (71.1%) received it from their health care providers. Almost all the respondents 2735 (99.9%) knew that torn long-lasting insecticides can be repaired. Almost all the participants 2614 (95.5%) knew about long-lasting insecticides as they can prevent malaria. Majority of the households 2529 (91.5%) had good knowledge about long-lasting insecticides. The mean score of household knowledge about the use of long-lasting insecticides was 7.77 with a standard deviation of ± 0.91 (Table 2).
In the bivariate analysis of factors associated with long-term mosquito net use, variables such as respondent gender, place of residence, family size, educational status, marital status, respondent occupation, number of separate rooms in the house, knowledge of long-lasting mosquito nets, place of purchase of long-lasting mosquito nets, duration of long-term mosquito net use, and number of mosquito nets in the household were associated with long-term mosquito net use. After adjusting for confounding factors, all variables with p-value < 0.25 in the bivariate analysis were included in the multivariate logistic regression analysis.
The objective of this study was to assess the use of long-lasting insecticidal nets and associated factors in households in West Arsi County, Ethiopia. The study found that factors associated with the use of long-lasting insecticidal nets included female gender of respondents, number of separate rooms in the house, length of time required to replace long-lasting insecticidal nets, and level of knowledge of respondents, which were significantly correlated with the use of long-lasting insecticidal nets.
This discrepancy may be due to differences in sample size, study population, regional study setting, and socioeconomic status. Currently, in Ethiopia, the Ministry of Health is implementing multiple interventions to reduce the burden of malaria by integrating malaria prevention interventions into primary health care programs, which can help reduce malaria-related morbidity and mortality.
The results of this study showed that female heads of households were more likely to use long-lasting insecticides compared to males. This finding is consistent with studies conducted in Ilugalan County5, Raya Alamata Region33 and Arbaminchi Town34, Ethiopia, which showed that women were more likely than men to use long-lasting insecticides. This may also be a result of the cultural tradition in Ethiopian society that values women above men, and when women become heads of households, men are under minimal pressure to decide to use long-lasting insecticides themselves. Furthermore, the study was conducted in a rural area, where cultural habits and community practices may be more respectful of pregnant women and give them priority in using long-lasting insecticides to prevent malaria infection.
Another finding of the study showed that the number of separate rooms in the participants’ homes was significantly correlated with the use of durable mosquito nets. This finding was confirmed by studies in East Belessa7, Garan5, Adama21 and Bahir Dar20 counties. This may be due to the fact that households with fewer separate rooms in the house are more likely to use durable mosquito nets, while households with more separate rooms in the house and more family members are more likely to use durable mosquito nets, which may result in a shortage of mosquito nets in all separate rooms.
The timing of replacement of long-lasting insecticidal nets was significantly correlated with household use of long-lasting insecticidal nets. People who replaced long-lasting insecticidal nets up to three years ago were more likely to use long-lasting insecticidal nets than those who were replaced less than three years ago. This finding is consistent with studies conducted in Arbaminchi town, Ethiopia34 and northwest Ethiopia20. This may be because households with the opportunity to purchase new mosquito nets to replace old ones are more likely to use long-lasting insecticidal nets among household members, who may feel satisfied and more motivated to use new mosquito nets for malaria prevention.
Another finding of this study showed that households with adequate knowledge about long-lasting insecticides were four times more likely to use long-lasting insecticides compared to households with low knowledge. This finding is also consistent with studies conducted in Hawassa and southwest Ethiopia18,22. This could be explained by the fact that as the household knowledge and awareness about transmission prevention mechanisms, risk factors, severity and individual disease prevention measures increases, the likelihood of adopting preventive measures increases. Furthermore, good knowledge and positive perception of malaria prevention methods encourage the practice of using long-lasting insecticides. Therefore, behaviour change interventions aim to encourage adherence to malaria prevention programmes among household members by prioritising socio-cultural factors and universal education.
This study used a cross-sectional design and causal relationships are not shown. Recall bias may have occurred. Observation of bed nets confirms that reporting of other study outcomes (e.g., previous night’s bed net use, frequency of bed net washing, and average income) is based on self-reports, which are subject to response bias.
The overall use of long-lasting insecticide-treated nets in households was low compared to the national standard of Ethiopia (≥ 85). The study found that the frequency of use of long-lasting insecticide-treated nets was significantly affected by whether the head of household was a woman, how many independent rooms there were in the house, how long it took to replace a long-lasting insecticide-treated net, and how knowledgeable the respondents were. Therefore, the West Arsi County Health Authority and relevant stakeholders should work to increase the use of long-lasting insecticide-treated nets at the household level through information dissemination and appropriate training, as well as through sustained behavior change communication to increase the use of long-lasting insecticide-treated nets. Strengthen training of volunteers, community structures, and religious leaders on the correct use of long-lasting insecticide-treated nets at the household level.
All data obtained and/or analyzed during the study are available from the corresponding author upon reasonable request.
Post time: Mar-07-2025