Research Article: Socio-economic and demographic disparities in ownership and use of insecticide-treated bed nets for preventing malaria among rural reproductive-aged women in northern Ghana

Date Published: January 29, 2019

Publisher: Public Library of Science

Author(s): Edmund Wedam Kanmiki, John Koku Awoonor-Williams, James F. Phillips, Stephen Patrick Kachur, Sabastian F. Achana, James Akazili, Ayaga A. Bawah, Ana Paula Arez.


Malaria continues to be a leading cause of morbidity and mortality in most countries in Sub-Saharan Africa. Insecticide-treated bed nets (ITNs) is one of the cost-effective interventions for preventing malaria in endemic settings. Ghana has made tremendous efforts to ensure widespread ownership and use of ITNs. However, national coverage statistics can mask important inequities that demand targeted attention. This study assesses the disparities in ownership and utilization of ITNs among reproductive-aged women in a rural impoverished setting of Ghana.

Population-based cross-sectional data of 3,993 women between the age of 15 and 49 years were collected in seven districts of the Upper East region of Ghana using a two-stage cluster sampling approach. Bivariate and multivariate regression models were used to assess the social, economic and demographic disparities in ownership and utilization of ITN and to compare utilization rates among women in households owning at least one ITN.

As high as 79% of respondents were found to own ITN while 62% of ITN owners used them the night preceding the survey. We identified disparities in both ownership and utilization of ITNs in wealth index, occupational status, religion, and district of residence. Respondents in the relative richest wealth quintile were 74% more likely to own ITNs compared to those in the poorest quintile (p-value< 0.001, CI = 1.29–2.34) however, they were 33% less likely to use ITNs compared to the poorest (p-value = 0.01, CI = 0.50–0.91). Interventions aimed at preventing and controlling malaria through the use of bed nets in rural Ghana and other similar settings should give more attention to disadvantage populations such as the poor and unemployed. Tailored massages and educational campaigns are required to ensure consistent use of treated bed nets.

Partial Text

In spite of global efforts aimed at controlling and preventing malaria, it is still the leading cause of ill health, death, poverty and low productivity in most developing countries [1, 2]. The World Health Organization (WHO) estimates that in the year 2016 alone, 216 million clinical cases of malaria were recorded while 445,000 deaths occurred globally due to malaria infection [1]. Sub-Saharan Africa alone accounted for 90% of all malaria cases and 91% of deaths due to malaria infection according to the 2017 World Malaria Report [1].

Data from a total of 3,993 women were used in this analysis; about 79% of them reported having at least one ITN in their household. Table 1 shows the background characteristics of respondents and the results of chi-square test of association with ITN ownership within the household. Variables that were significantly associated with ownership of bed nets at bivariate level are age, level of education, functional literacy, occupation, religious affiliation, place of residence, district of residence and wealth index.

Results reported in this paper show that efforts of the malaria control program in improving ownership and use of ITNs in the Upper East region is almost near the attainment of the universal coverage mark which is pegged at 80% and above. However, there are significant disparities in the ownership and use of ITNs by socio-economic and demographic factors in this rural setting. Occupation, religion, district of residence and wealth index were found to influence both ownership and utilization of ITN among reproductive-aged women in the region. Location of residence was associated with ownership of ITN but had no influence on utilization, while educational level, functional literacy and marital status was neither associated with ownership nor utilization of ITNs. Previous studies in other settings have recorded varying outcomes with regards to the association of these variables with ITN ownership. We did not find significant disparities in ownership and utilization by educational status; this is consistent with a previous study conducted in Nigeria [24]. However, some other studies found disparities in ownership and use of ITN by educational status [6, 16, 25]. According to the 2015 Ghana national demographic and health survey, 49.6% of uneducated pregnant women used ITN the night before their survey compared to 43.5% of those educated up to middle school level [5]. We are however unable to determine the statistical significance of the national survey.

The high ownership and use of treated bed-nets in the Upper East Region might be due to various interventions that have been implemented in the region in recent years. In addition to UNICEF supported interventions embarked upon by the Ghana Health Service and the National Malaria Control Program, the Upper East Regional Health Administration led the implementation of intensive health systems interventions between 2010 and 2015 and it is possible these interventions contributed significantly to the results we obtained in this analysis. However, despite the relatively high percentage of ownership and use of bed nets, the study has revealed disparities by socio-economic status such as, wealth index, occupation, district of residence, location of residence and religious affiliation. It can be inferred from the review of literature that the determinants of ITNs ownership and utilization are not static. Indeed, they are context and time-specific, a system of continuous monitoring and evaluation is therefore required so that disadvantaged sections of the society can often be targeted. Interventions aimed at mitigating inequalities in distribution and ensuring consistent use of ITNs in rural Ghana and other similar settings should give more attention to disadvantage populations such as the poor and unemployed. Tailored massages and educational campaigns are required to ensure consistent use of treated bed nets.




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