Malaria,caused by protozoa of the genus Plasmodium, is a disease that claimed lives ofapproximately 445 000 people globally in 2016 1.
The public health concern of malaria goes beyond thegeneral population to special vulnerable groups such as under-fives andpregnant women. The impact of malaria inpregnancy (MIP) is well documented with effects observed on the women, fetusand the newborn 2, 3. Sub-Saharan Africa remains thehardest hit with 85% of the 25 million pregnancies at risk of malaria globally,occurring in the region 4. This results inMIP accounting for 20% and 11% of stillborn and neonatal deaths in the region,respectively 2, 3.Toreduce the burden of MIP, World Health Organization (WHO) developed threestrategies namely; Insecticide Treated Nets (ITN), Intermittent PreventiveTreatment use (IPTP) and active case management 5. Despite reports of high ITN coverages in the Sub-SaharanAfrica region, use of the same remains problematic 6-8.
InMalawi, ITN has been at the center of malaria control with a nationwide massITN distribution campaign taking place in 2012 9. In addition tothe campaign, the ITN policy also recommends that pregnant women should begiven free ITNs at antenatal care (ANC) visits. The policy, coupled with the massITN distribution campaign in 2012 and periodical mass distribution campaignsconducted in collaboration with other non-organizations has seen ITN use amongpregnant women rise from 35% in 2010 to 62% in 2014 10, 11. However, a recent Malawian study revealed adrop in ITN use among women of child bearing visiting ANC age to 53% 12. This is ofconcern considering that ITN is one of the most reliable vector control methodsin malaria prevention hence crucial in achieving malaria elimination by 2030 13.
A large body of research has demonstrated that factors such aswomen’s age 14, parity 15, education status 15, employment status 14, 16,household wealth 14, 17, andreligion 14 have significant effects on ITN utilization. For instance, womenwho had a higher education were two times more likely to use ITN than womenwith no formal education in Kenya 17. In Cameroon, 45% multigravida women as compared to 21% Primigravidawomen slept under ITN the previous night before the survey18. However, inconsistent results have been reported elsewhere withstudies revealing education 19, parity 16, and age 15 to have no significant association with ITN use among pregnantwomen. In Rwanda, community factors influenced ITN use amongunder-children 20.
Under-5 children living in communities with high education andhigh wealth were more likely to use ITN in comparison to those living in lowcommunities 20. Community characteristics have also been previously shown to havesignificant influences on health outcomes and health care utilization across Africa21, 22. However,little is known about the effects of community on ITN utilization among women.Few studies have investigated the influence of both individual and contextual factorson ITN use and whether the community effects still exist after controlling forindividual-level characteristics.
Analyzing the contextualfactors is important to ensure that future interventions such as masscampaigns, and health education messages are tailor-made for both vulnerablecommunities and women.Therefore,drawing a nationally representative sample, this study aimed to investigate theindividual- and community-level factors on ITN utilization among Malawianwomen. Specifically, the study sought to 1) to identify individual- andcommunity-level factors associated with ITN use among women in Malawi, 2) tocompare factors influencing ITN use among different groups of women (i.e.pregnant women, non-pregnant women with under-5 children and non-pregnant womenwithout under-5 children).