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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
Article  in  PLoS ONE · January 2019
DOI: 10.1371/journal.pone.0211365
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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
Edmund Wedam Kanmiki 1 2 3ID *, John Koku Awoonor-Williams , James F. Phillips ,
Stephen Patrick Kachur3, Sabastian F. Achana4, James Akazili4, Ayaga A. Bawah1
1 Regional Institute for Population Studies, University of Ghana, Accra, Ghana, 2 Policy, Planning,
Monitoring and Evaluation Division, Ghana Health Service, Accra, Ghana, 3 Department of Population and
a1111111111
Family Health, Mailman School of Public Health, Columbia University, New York, United States of America,
a1111111111 4 Navrongo Health Research Center, Ghana Health Service, Upper East Region, Navrongo, Ghana
a1111111111
a1111111111 * eddykan100@gmail.com
a1111111111
Abstract
OPEN ACCESS
Citation: Kanmiki EW, Awoonor-Williams JK, Background
Phillips JF, Kachur SP, Achana SF, Akazili J, et al. Malaria continues to be a leading cause of morbidity and mortality in most countries in Sub-
(2019) Socio-economic and demographic
Saharan Africa. Insecticide-treated bed nets (ITNs) is one of the cost-effective interventions
disparities in ownership and use of insecticide-
treated bed nets for preventing malaria among for preventing malaria in endemic settings. Ghana has made tremendous efforts to ensure
rural reproductive-aged women in northern Ghana. widespread ownership and use of ITNs. However, national coverage statistics can mask
PLoS ONE 14(1): e0211365. https://doi.org/
important inequities that demand targeted attention. This study assesses the disparities in
10.1371/journal.pone.0211365
ownership and utilization of ITNs among reproductive-aged women in a rural impoverished
Editor: Ana Paula Arez, Universidade Nova de
setting of Ghana.
Lisboa Instituto de Higiene e Medicina Tropical,
PORTUGAL
Received: August 27, 2018 Methods
Accepted: January 11, 2019 Population-based cross-sectional data of 3,993 women between the age of 15 and 49 years
Published: January 29, 2019 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
Copyright: © 2019 Kanmiki et al. This is an open
access article distributed under the terms of the social, economic and demographic disparities in ownership and utilization of ITN and to
Creative Commons Attribution License, which compare utilization rates among women in households owning at least one ITN.
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited. Results
Data Availability Statement: Data has now been As high as 79% of respondents were found to own ITN while 62% of ITN owners used them
provided as part of supporting information.
the night preceding the survey. We identified disparities in both ownership and utilization of
Funding: The Ghana Essential Health Intervention ITNs in wealth index, occupational status, religion, and district of residence. Respondents in
Program (GEHIP) was supported by grants from
the relative richest wealth quintile were 74% more likely to own ITNs compared to those in
the Doris Duke Charitable Foundation’s (DDCF)
African Health Initiative. Grant number 2009058B. the poorest quintile (p-value< 0.001, CI = 1.29–2.34) however, they were 33% less likely to
The funder had no role in study design, data use ITNs compared to the poorest (p-value = 0.01, CI = 0.50–0.91).
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 1 / 13
Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
collection and analysis, decision to publish, or Conclusion
preparation of the manuscript.
Interventions aimed at preventing and controlling malaria through the use of bed nets in
Competing interests: The authors have declared
rural Ghana and other similar settings should give more attention to disadvantage popula-
that no competing interests exist.
tions such as the poor and unemployed. Tailored massages and educational campaigns are
required to ensure consistent use of treated bed nets.
Introduction
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].
In Ghana, malaria remains highly endemic, even after considerable progress has been
achieved in delivering effective prevention and treatment interventions. Malaria accounts for
about 38.1% of all Out-Patient Department (OPD) cases and 50% of under-five child admis-
sions to hospitals in Ghana. Also as high as 48.4% of all under-five deaths in Ghana are attrib-
utable to malaria infection [3]. Malaria is thus ranked among the top ten causes of morbidity
and mortality in Ghana [4]. The disease affects people of all ages but children under-five years
of age and pregnant women are the most vulnerable groups [5].
The use of Insecticide Treated bed-Nets (ITNs) is one of the effective strategies recom-
mended by World Health Organization (WHO) for preventing malaria infection and its con-
sequences during pregnancy, such as maternal anemia, stillbirths and intrauterine growth
restriction in malaria-endemic settings [6, 7]. ITNs have proven to be a cost-effective method
of protection against malaria. It is effective in reducing approximately 50% of malaria episodes
among children under-five years of age and a 17% reduction in all-cause mortality [8, 9]. In
view of this, the WHO recommends the supply of treated bed-nets free of charge or at a highly
subsidized fee in malaria-endemic places using a variety of approaches including mass cam-
paigns and routine distribution channels in order to achieve greater equity of coverage [6, 10].
To promote the use of treated bed nets in Ghana, the Ministry of Health (MoH) freely dis-
tributes nets in schools, antenatal clinics and child welfare clinics [11]. Also from 2002, the
government of Ghana waived taxes on the importation of treated bed-nets in an effort to make
them accessible and affordable [12]. However, despite these efforts, key targets of Ghana’s
National Malaria Strategic Plan (2008–2015) on treated bed-nets were not fully achieved [13].
Recent surveys in Ghana have shown that significant proportion of households who have
treated nets do not actually use them [12, 14]. The most recent malaria indicator survey reveals
that just about 51% of the households have a treated bed-net for every two people in the house-
hold [14]. Also, there exist rural and urban disparities in the utilization of treated bed-nets in
Ghana [5, 14]. In addition, the proportion of household population who sleep under bed-nets
is found to decrease with increasing wealth [12, 14].
Thus, Ghana is yet to reach universal coverage of ITNs (defined as use by 80% or more of a
population in an endemic area in order to have the optimum protection [15]). There is, there-
fore, the need for continuous monitoring and assessment of ownership and utilization of bed-
nets, especially among critical sections of the population so as to inform policy and practice in
the area of malaria prevention.
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Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
Although some studies have examined treated bed-nets ownership and use in Ghana, none
has focused on a predominantly rural and deprive setting [5, 14, 16, 17]. This paper, aims to
identify and highlight the social, economic and demographic disparities in ownership and uti-
lization of insecticide-treated bed-nets among reproductive-aged women in a predominantly
rural setting of Ghana.
Materials and methods
Study setting
The data for this analysis were collected in seven districts of the Upper East region located in
the extreme north-eastern part of Ghana. The Upper East region is one of the three poorest
regions in the country and has a population of about 1,188,800 people [18]. It has a total land
area of 8,842km with a savanna grassland vegetation [19]. It is inhabited by seven major ethnic
groups and currently has 15 administrative districts. Subsistence farming is the main economic
activity of people in the region [20]. Christianity, Islam and African traditional religion are the
major religions of the people in the region [19]. This area is typical of most rural Sahelian Afri-
can settings. Findings from this region would therefore have relevance for most rural settings
in Sub-Saharan Africa. Fig 1 shows the map of Ghana indicating Upper East region.
Source of data
Data came from an independent cross-sectional survey that collected information from
women between 15 and 49 years of age in seven districts: Bolgatanga, Bongo, Builsa, Garu/
Tempane, Bawku West, Talensi/Nabdam and Bawku East. The purpose was to provide end-of-
project data for the evaluation of a health systems plausibility trial that was implemented by
the Ghana Essential Health Intervention Project (GEHIP) to improve maternal and child sur-
vival. GEHIP was a five-year health system strengthening and research program implemented
in the Upper East region from 2010 to 2015. The GEHIP approach involved strengthening the
capacity of the health system around six WHO health system building blocks and improving
the effectiveness of Ghana’s comprehensive Community-based Health Planning and Service
(CHPS) program. Details of the GEHIP program are described elsewhere [20, 21].
Data collection
A two-stage sampling approach was used in the data collection process. First, the Ghana Statis-
tical Service (GSS) sampled and provided the research team a total of 66 predominantly rural
Enumeration Areas (EAs) based on the 2010 Population and Housing Census. Guided by this
sampling frame, physical identification of EAs was done and a household listing of all mem-
bers of households in the sampled EAs was carried out. The second stage involved the sam-
pling of households proportional to the population size of each EA. Within sampled
households, all females between the ages of 15 and 49 years of age were eligible to be inter-
viewed. The paperless “Open Data Kit” (ODK) software was used to collect the data. This
technique, first developed at the University of Washington, permits instantaneous data entry,
editing and correction at the time of interviews [22]. Data collection started on the 2nd of Octo-
ber 2014 and ended on the 31st of January 2015.
The survey collected data on maternal and child health indicators, fertility, family planning,
universal health coverage among others. During the survey, two questions that relate to Insec-
ticide Treated bed-net (ITNs) were; “Does your household have an insecticide-treated bed net?”
and “Did you sleep under an insecticide-treated bed-net last night”. This analysis relies on these
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 3 / 13
Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
Fig 1. Map of Ghana showing Upper East region in red.
https://doi.org/10.1371/journal.pone.0211365.g001
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Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
two questions to explore the disparities in ownership and utilization of ITNs among this
cohort of the reproductive-aged women.
Data analysis
STATA 14 software was used in analyzing the data. Basic descriptive statistics was used to
describe the composition of variables while bivariate analysis was done using chi-square test of
association to identify variables associated with household ownership of ITNs. Furthermore,
multivariate analysis using binary logistic regression models are used to explore the disparities
in ownership and utilization of ITNs. Utilisation of ITNs was examined only among respon-
dents who reported having ITNs within their household. The variable for wealth index was
generated using Principal Component Analysis (PCA) where household assets were used as
a proxy for wealth. Assets used to generate wealth index were common household assets used
in the study area, they include: radio, television, computer, clock, mobile phone, refrigerator,
video deck, decoder, freezer, DVD/VCD, bicycle, motorcycle, motor king, animal drawn
cart, car/truck, fun and decoder. Our application of PCA to generate wealth index using these
household possessions as a proxy measure of wealth is consistent with previous studies con-
ducted in this setting [19, 20, 23].
Ten independent variables were included in the analysis. Independent variables were
first tested for multi co-linearity using the Variance Inflation Factor (VIF) before they were
included in the logistic regression models. However, this was found not to be a problem
since a mean VIF of 1.32 was found (VIF more than 20 indicates multi co-linearity). We
applied sample weighting in our regressing analysis to ensure that findings are representa-
tive of the study area. In this analysis, p-values of 0.05 or below were regarded as showing
significant relationship while p-values above 0.05 were regarded as not showing a significant
association. Both p-values and confidence intervals have been reported in the regression
models.
Ethical considerations
The data used in this paper emanates from the Ghana Essential Health Intervention Project
(GEHIP). Ethical approval was obtained from the Ethical Review Committee of the Ghana
Health Service and Institutional Review Board (IRB) of the Navrongo Health Research
Centre prior to the conduct of this study. Inform consent was administered to participants.
Data collectors read a written informed consent form/note to participants in their preferred
language and explained its content before participants who agreed to participate endorsed
two copies of the form and one copy was given to the participant. This procedure was sanc-
tioned by both ethics committees that approved of the study to be conducted. All protocols
were followed to ensure confidentiality during data collection, analysis and reporting of
findings.
Results
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.
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Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
Table 1. Background characteristics of respondents.
Variable Categories Don’t have Bed Net Have Bed Net P-value Total
Freq. % Freq. %
Age Group 15–19 38 24.05 120 75.95 <0.001 158
20–34 378 18.54 1661 81.46 2,039
35–49 427 23.78 1369 76.22 1,796
Level of Education None 661 22.94 2220 77.06 <0.001 2,881
Primary/Junior High School 157 17.80 725 82.20 882
Secondary/ Tertiary 23 10.50 196 89.50 219
Other 2 18.18 9 81.82 11
Functional Literacy(Ability to read and understand) Yes 106.00 15.77 566 84.23 <0.001 672
No 737.00 22.19 2584 77.81 3321
Marital Status Not Married yet (single) 31 24.03 98 75.97 0.396 129
Married 743 20.85 2820 79.15 3,563
Widowed 55 21.65 199 78.35 254
Devoiced/Separated 14 29.79 33 70.21 47
Marriage Type Polygamy 263 21.24 975 78.76 0.874 1,238
Monogamy 474 20.62 1825 79.38 2,299
Not specified 6 23.08 20 76.92 26
Occupation Farming 395 23.54 1,283 76.46 <0.001 1,678
Trading 156 18.01 710 81.99 866
Artisan 99 19.04 421 80.96 520
No occupation/housewife 161 24.54 495 75.46 656
Civil Servant 6 9.38 58 90.63 64
Student 10 16.13 52 83.87 62
Other 16 10.88 131 89.12 147
Religion Christianity 407 18.11 1,840 81.89 <0.001 2,247
Traditional 112 22.18 393 77.82 505
Islam 303 26.51 840 73.49 1,143
No Religion 21 21.43 77 78.57 98
Location of Residence Urban 74 21.76 266 78.24 0.031 340
Semi-Urban 148 25.08 442 74.92 590
Rural 621 20.27 2,442 79.73 3,063
District of Residence Bolga M. 60 16.57 302 83.4 <0.001 362
Bongo 76 16.03 398 84.0 474
Builsa 94 13.39 608 86.6 702
Garu/Tempani 265 29.94 620 70.1 885
Bawku West 74 18.09 335 81.9 409
Talensi/Nabdam 117 18.72 508 81.3 625
Bawku East 149 29.27 360 70.7 509
Wealth Index Quintile1 (Poorest) 232 25.89 664 74.11 <0.001 896
Quintile2 299 22.48 1,031 77.52 1,330
Quintile3 54 19.42 224 80.58 278
Quintile4 155 19.23 651 80.77 806
Quintile5 (Richest) 103 15.08 580 84.92 683
https://doi.org/10.1371/journal.pone.0211365.t001
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Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
Table 2. Multivariate analysis of ITNs ownership; logistic regression model.
Determinants Odds Ratio 95% Conf. Interval P>z
Age group (Compared to 15–19)
20–34 1.46 0.97 2.21 0.070
35–49 1.08 0.70 1.66 0.731
Level of Education (Compared with No education)
Primary/Junior High School 1.12 0.86 1.46 0.404
Secondary/Tertiary 1.80 1.00 3.24 0.051
Other 1.08 0.21 5.43 0.928
Functional Literacy(Compared with Yes)
No 1.14 0.81 1.60 0.458
Occupation (Compared with Farming)
Trading 1.12 0.89 1.40 0.356
Artisan 0.92 0.69 1.22 0.550
No occupation/housewife 0.71 0.55 0.90 0.005
Civil Servant 1.00 0.38 2.63 0.998
Student 0.81 0.37 1.75 0.586
Other 1.70 0.95 3.04 0.071
Religion (Compared with Christianity)
Traditional religion 0.73 0.56 0.95 0.021
Islam 0.96 0.77 1.19 0.699
No religion 0.87 0.51 1.49 0.618
Location of Residence(Compared with Urban)
Semi-Urban 1.39 0.96 2.00 0.078
Rural 1.87 1.35 2.60 <0.001
District of Residence(Compared with Bolgatanga)
Bongo 1.56 1.05 2.33 0.028
Builsa 2.00 1.35 2.96 0.001
Garu/Tempani 0.57 0.40 0.82 0.003
Bawku West 1.11 0.74 1.66 0.613
Talensi/Nabdam 1.20 0.83 1.75 0.336
Bawku East 0.60 0.40 0.89 0.012
Wealth Index (Compared with Quintile1;Poorest)
Quintile2 1.18 0.95 1.46 0.139
Quintile3 1.43 1.01 2.04 0.046
Quintile4 1.48 1.15 1.89 0.002
Quintile5 (Richest) 1.74 1.29 2.34 <0.001
Constant 1.35 0.67 2.73 0.399
https://doi.org/10.1371/journal.pone.0211365.t002
Ownership of ITNs
Table 2 shows the multivariate analysis of ITNs ownership. Age, level of education and func-
tional literacy were not significantly associated with ownership of ITN in the multivariate
analysis.
On occupational status, women who were housewives or had no occupation were 29% less
likely to own ITNs compared to those engaged in farming (p-value = 0.005, OR = 0. 71). For
religious affiliation, respondents who were affiliated with African traditional religion were
27% less likely to own ITNs compared to respondents affiliated to Christianity (p-value =
0.021, OR = 0.73).
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Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
Place of residence was found to have a statistically significant association with ownership of
ITNs. Respondents resident in rural settings were 87% more likely to own an ITN compared
to residents in urban settings (p-value<0.001, OR = 1.87). District of residence was also statis-
tically associated with ownership of ITNs; women resident in Bongo and Builsa districts were
1.56 and 2.00 times respectively more likely to have ITN compared to residents of Bolgatanga
the regional capital (p-value = 0.028 and <0.001, OR = 1.56 and 2.00). However, respondents
of Garu-Tempane and Bawku East districts were 43% and 40% less likely to own an ITNs com-
pared to those of Bolgatanga (p-value = 0.003 and 0.012, OR = 0.57 and 0.60).
With regards to wealth index, it is apparent from Table 2 that the likelihood of ownership
of ITN increases with higher wealth index. While those of quintile3 were 43% more likely to
have ITN (p-value = 0.046, OR = 1.43), those belonging to quintiles 4 and 5 (next richest and
richest categories) were 48% and 74% more likely to own ITNs compared to those in quintile1;
the poorest category (p-values = 0.002 and<0.001, OR = 1.48 and 1.74 respectively).
Utilization of ITNs
Table 3 presents multivariate analysis of utilization of ITNs the night before the survey. As
shown in the table, age, level of education, functional literacy and location of residence were
not significantly associated with utilization of ITN. However, occupation, religion, district of
residence and wealth index were significantly associated with utilization of ITNs.
Respondents who reported that they were students were 52% less likely to used ITN com-
pared to those engaged in farming. Also, those affiliated with Islamic religion were 40% more
likely to use ITN compared with their Christian counterparts. Residents of the Bawku West
district were more than four times more likely to used ITN compared to residents of Bolga-
tanga, the regional capital (p-value<0.001, OR = 4.10). Women in quintile 5 (richest category)
were 33% less likely to use ITNs compared with those in quintile 1 (the poorest category) (p-
value = 0.010, OR = 0.67).
Discussion
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 uni-
versal coverage mark which is pegged at 80% and above. However, there are significant dispari-
ties 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. Loca-
tion 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 own-
ership nor utilization of ITNs. Previous studies in other settings have recorded varying out-
comes 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.
Marital status was not significantly associated with ownership and use of ITNs in this analy-
sis. A study conducted in southwestern part of Ethiopia found marital status of household head
to be associated with utilization [26]. Many other studies reviewed, however, did not examine
the association of marital status with ownership and utilization of ITN [16, 25, 27, 28]. This
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 8 / 13
Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
Table 3. Multivariate analysis of ITNs utilization; logistic regression model.
Determinants Odds Ratio 95% Conf. Interval P>z
Age group (Compared to 15–19)
20–34 0.97 0.57 1.65 0.919
35–49 0.66 0.38 1.14 0.137
Level of Education (Compared with No education)
Primary/Junior High School 0.94 0.70 1.26 0.692
Secondary/Tertiary 0.85 0.50 1.44 0.547
Other 1.12 0.22 5.75 0.890
Functional Literacy(Compared with Yes)
No 1.05 0.74 1.50 0.772
Occupation (Compared with Farming)
Trading 0.88 0.68 1.12 0.295
Artisan 1.05 0.75 1.45 0.791
No Occupation/housewife 0.90 0.67 1.21 0.480
Civil Servant 0.62 0.32 1.19 0.149
Student 0.48 0.24 0.94 0.033
Other 1.14 0.70 1.85 0.604
Religion (Compared with Christianity)
Traditional Religion 1.00 0.74 1.35 0.980
Islam 1.40 1.05 1.87 0.023
No Religion 0.83 0.47 1.44 0.499
Location of Residence(Compared with Urban)
Semi-Urban 1.04 0.69 1.55 0.87
Rural 0.99 0.69 1.40 0.93
District of Residence(Compared with Bolgatanga)
Bongo 1.15 0.79 1.67 0.467
Builsa 1.40 0.97 2.01 0.074
Garu/Tempani 1.33 0.90 1.97 0.147
Bawku West 4.10 2.49 6.76 <0.001
Talensi/Nabdam 1.15 0.81 1.64 0.439
Bawku East 1.14 0.72 1.80 0.577
Wealth Index (Compared with Quintile1;Poorest)
Quintile2 1.18 0.91 1.53 0.223
Quintile3 1.48 0.94 2.33 0.088
Quintile4 1.19 0.88 1.61 0.253
Quintile5 (Richest) 0.67 0.50 0.91 0.010
Constant 3.27 1.51 7.11 0.003
https://doi.org/10.1371/journal.pone.0211365.t003
study has revealed that women without occupation were 30% less likely to own ITNs. However,
it was not so when it came to utilization. Most studies reviewed did not consider the occupa-
tional status of the respondent in relation to ownership and utilization of ITN [6, 16, 25, 27].
One study from Ethiopia that examined occupation status of household head did not find any
significant disparities in ITN ownership nor utilization [26].
This study has revealed that practitioners of African traditional religion were less likely to
own an ITN compared to those of Christian religion. This calls for a further investigation as to
why religious affiliation is associated with ownership of ITNs in the study setting. Previous
studies have not examined this either. Residents of rural areas were two times more likely to
possess ITN compared to residents of urban settings but there was no significant association
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 9 / 13
Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
with utilization of ITNs. Other studies have highlighted an association of rural/urban residents
with ownership and use of ITNs at the household level; however, there seems to be a mix in
the direction of association perhaps due to the targeting strategies employed in different set-
tings. For instance, in a study involving two states of Nigeria, urban households were more
likely to own ITN compared to their rural counterparts [29]. However, another study in the
same country that assessed ownership and use among pregnant women found those who
reside in urban settings to be less likely to own ITN compared to those in rural areas [24]. It
however, found women living in urban areas to be almost twice more likely to use ITN com-
pared to rural women [24]. A study in Equatorial Guinea also revealed higher utilization rates
for urban dwellers than rural dwellers [25]. However, we believe that high ownership of ITN
in rural northern Ghana is perhaps due to the fact that the malaria control efforts and free dis-
tribution of ITNs largely targets rural settings.
Findings of this study also reveal disparities in ITNs ownership and use among the districts
in the Upper East region of northern Ghana. While two districts (Bongo and Builsa districts)
were significantly more likely to ownITNs compared to Bolgatanga (the regional capital),
another two (Garu-Tempane and Bawku East districts) were significantly less likely to own
ITN compared to Bolgatanga. Although the reason for low ITN ownership in these two dis-
tricts may not be readily known, it is on record that around 2013/2014 there was a ban on the
use of motorbikes in Bawku Municipality due to an inter-tribal conflict in the area and this
affected health care delivery services in Bawku Municipality. Garu-Tempane district is geo-
graphically located next to Bawku Municipal and therefore might have also suffered from
accessibility challenges emanating from the Bawku conflict. The findings of this study, there-
fore, could be a pointer to the negative effect of conflicts on the delivery of health services.
Socio-economic status (wealth index) is a very important variable to consider when assessing
the effect of health interventions or programs. It is important to know if interventions are reach-
ing the poor as much as the relatively well off in society. In this study, we found an increase in
ownership of ITN with increasing wealth. In contrast to ownership, we found that the richest
category was 33% less likely to use ITN compared to the poorest category. Although only the
fifth quintile was statistically significant, Our findings support those of an early study in Ghana
by the Ghana Statistical Service [5]. Previous studies have also documented significant associa-
tion of ITNs ownership and utilization with wealth index [6, 16, 26, 29]. However, some studies
did not find any association of wealth index with ITNs ownership or use [25, 28, 30]. Among
the studies that wealth index was significantly associated with ITN utilization, while most stud-
ies found high wealth index to be associated with high utilization of ITN and low wealth index
to be associated with low ownership and use [6, 26, 29], one study found lower wealth index to
rather be associated with high utilization [16]. This implies that based on the peculiarities of
each setting and strategies used in deploying ITNs, the poor and the relatively well-off could
benefit disproportionately. It should also be noted that people of high socio-economic status
often have access to other methods for preventing man-vector contact and may therefore not
use ITN even if they have them in their households. A study in Gabon observed that relatively
wealthier people who live in houses with door and window screens often believe they are suffi-
ciently protected from mosquito bites and therefore do not make use of ITNs even if they have
them in their households [31]. This phenomenon may merit further investigation to ascertain if
the use of door and window screens offers adequate protection as that of treated bed nets.
Study limitations
As a cross-sectional quantitative study, this study is limited in understanding some of the con-
textual factors influencing ownership and use of ITN. Also findings of this study should be
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 10 / 13
Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
interpreted carefully to avoid over generalization. This notwithstanding, the study provides use-
ful information to guide malaria control intervention activities in Ghana and similar settings.
Conclusion
The high ownership and use of treated bed-nets in the Upper East Region might be due to vari-
ous 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 pos-
sible 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.
Supporting information
S1 File. De-Identified minimal dataset.
(DTA)
S1 Text. Study questionnaire.
(PDF)
Acknowledgments
The Authors wish to express their gratitude to the chiefs and people of the Upper East Region
especially the research participants for voluntarily providing information for this study.
Author Contributions
Conceptualization: Edmund Wedam Kanmiki, James F. Phillips, James Akazili, Ayaga A.
Bawah.
Data curation: Edmund Wedam Kanmiki, Sabastian F. Achana.
Formal analysis: Edmund Wedam Kanmiki.
Funding acquisition: John Koku Awoonor-Williams, James F. Phillips, Ayaga A. Bawah.
Investigation: John Koku Awoonor-Williams, Sabastian F. Achana, James Akazili.
Methodology: John Koku Awoonor-Williams, Sabastian F. Achana, James Akazili, Ayaga A.
Bawah.
Project administration: John Koku Awoonor-Williams, James F. Phillips, James Akazili,
Ayaga A. Bawah.
Resources: James F. Phillips, Ayaga A. Bawah.
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 11 / 13
Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
Supervision: Sabastian F. Achana, James Akazili, Ayaga A. Bawah.
Writing – original draft: Edmund Wedam Kanmiki, Ayaga A. Bawah.
Writing – review & editing: John Koku Awoonor-Williams, James F. Phillips, Stephen Patrick
Kachur, Sabastian F. Achana, James Akazili, Ayaga A. Bawah.
References
1. World Health Organization. World Malaria Report 2017. 2017.
2. Centers for Disease Control and Prevention. Malaria Worldwide—Impact of Malaria.
3. National Malaria Control Programme, Ghana. 2015 Annual Report: National Malaria Control Pro-
gramme, Ghana. 2016.
4. Ahorlu CK, Koram KA, Ahorlu C, De Savigny D, Weiss MG. Socio-cultural determinants of treatment
delay for childhood malaria in southern Ghana. Trop Med Int Heal. 2006; 11:1022–31.
5. Ghana Statistical Service. Ghana Demographic and Health Surveillance Report. 2014. 2015.
6. Singh M, Brown G, Rogerson SJ. Ownership and use of insecticide-treated nets during pregnancy in
sub-Saharan Africa: A review. Malar J. 2013; 12:1–10.
7. Willey BA, Paintain LS, Mangham L, Car J, Schellenberg JA. Strategies for delivering insecticide-
treated nets at scale for malaria control: a systematic review. Bull World Health Organ. 2012; 90:672–
84. https://doi.org/10.2471/BLT.11.094771 PMID: 22984312
8. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst
Rev. 2004; 2.
9. Mueller DH, Wiseman V, Bakusa D, Morgah K, Daré A, Tchamdja P. Cost-effectiveness analysis of
insecticide-treated net distribution as part of the Togo Integrated Child Health Campaign. Malar J. 7:1.
10. Roll Back Malaria. Global estrategic plan Roll Back Malaria 2005–2015. In: Global estrategic plan Roll
Back Malaria 2005–2015. RBM; 2005.
11. Ghana Health Service. Ghana Health Service 2014 Annual Report. 2015.
12. Ghana Statistical Service. Ghana Demographic and Health surveillance report. 2014.
13. Manu G, Boamah-Kaali EA, Febir LG, Ayipah E, Owusu-Agyei S, Asante KP. Low Utilization of Insecti-
cide-Treated Bed Net among Pregnant Women in the Middle Belt of Ghana. Malar Res Treat. 2017;
2017:1–7. https://doi.org/10.1155/2017/7481210 PMID: 28828192
14. GSS, GHS. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF. 2017. Ghana
Malaria Indicator Survey 2016. Accra, Ghana, and Rockville, Maryland, USA: GSS, GHS, and ICF.
2017.
15. Roll Back Malaria. Global estrategic plan Roll Back Malaria 2005–2015. In: Global estrategic plan Roll
Back Malaria 2005–2015. RBM.
16. Baume CA, Franca-Koh AC. Predictors of mosquito net use in Ghana. Malar J. 2011; 10:2–7.
17. Ernst KC, Erly S, Adusei C, Bell ML, Kessie DK, Biritwum-Nyarko A, et al. Reported bed net ownership
and use in social contacts is associated with uptake of bed nets for malaria prevention in pregnant
women in Ghana. Malar J. 2017; 16:1–10.
18. GSS. Population Statistics. Ghana Statistical Service. 2016.
19. Akazili J, Welaga P, Bawah A, Achana FS, Oduro A, Awoonor-Williams JK, et al. Is Ghana’s pro-poor
health insurance scheme really for the poor? Evidence from Northern Ghana. BMC Health Serv Res.
2014; 14:1–9.
20. Kanmiki EW, Bawah AA, Agorinya I, Achana FS, Awoonor-Williams JK, Oduro AR, et al. Socio-eco-
nomic and demographic determinants of under-five mortality in rural northern Ghana. BMC Int Health
Hum Rights. 2014; 14:1.
21. Awoonor-Williams JK, Bawah AA, Nyonator FK, Asuru R, Oduro A, Ofosu A, et al. The Ghana essential
health interventions program: a plausibility trial of the impact of health systems strengthening on mater-
nal & child survival. BMC Health Serv Res. 2013; 13:1.
22. Anokwa Y, Hartung C, Brunette W, Borriello G, Lerer A. Open source data collection in the developing
world. Computer (Long Beach Calif). 2009; 42:97–9.
23. Awintuen I, Id A, Kanmiki EW, Nonterah A, Tediosi F, Id JA, et al. Socio-demographic determinants of
low birth weight : Evidence from the Kassena-Nankana districts of the Upper East Region of Ghana.
2018;:1–10.
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 12 / 13
Disparities in ownership and use of insecticide-treated bed nets for malaria prevention
24. Ankomah A, Adebayo SB, Arogundade ED, Anyanti J, Nwokolo E, Ladipo O, et al. Determinants of
insecticide-treated net ownership and utilization among pregnant women in Nigeria. BMC Public Health.
2012; 12:105. https://doi.org/10.1186/1471-2458-12-105 PMID: 22309768
25. Garcı́a-Basteiro AL, Schwabe C, Aragon C, Baltazar G, Rehman AM, Matias A, et al. Determinants of
bed net use in children under five and household bed net ownership on Bioko Island, Equatorial Guinea.
Malar J. 2011; 10:179. https://doi.org/10.1186/1475-2875-10-179 PMID: 21714859
26. Sena LD, Deressa WA, Ali AA. Predictors of long-lasting insecticide-treated bed net ownership and utili-
zation: evidence from community-based cross-sectional comparative study, Southwest Ethiopia. Malar
J. 2013; 12:406. https://doi.org/10.1186/1475-2875-12-406 PMID: 24206749
27. Batisso E, Habte T, Tesfaye G, Getachew D, Tekalegne A, Kilian A, et al. A stitch in time: A cross-sec-
tional survey looking at long lasting insecticide-treated bed net ownership, utilization and attrition in
SNNPR, Ethiopia. Malar J. 2012; 11:1–7.
28. Graves PM, Ngondi JM, Hwang J, Getachew A, Gebre T, Mosher AW, et al. Factors associated with
mosquito net use by individuals in households owning nets in Ethiopia. Malar J. 2011; 10:1–12.
29. Eteng M, Mitchell S, Garba L, Ana O, Liman M, Cockcroft A, et al. Socio-economic determinants of own-
ership and use of treated bed nets in Nigeria: Results from a cross-sectional study in Cross River and
Bauchi States in 2011. Malar J. 2014; 13:1–8.
30. Alaii JA, Hawley WA, Kolczak MS, Ter Kuile FO, Gimnig JE, Vulule JM, et al. Factors affecting use of
permethrin-treated bed nets during a randomized controlled trial in western Kenya. Am J Trop Med
Hyg. 2003; 68 4 suppl:137–141. PMID: 12749497
31. Goesch JN, Schwarz NG, Decker M-L, Oyakhirome S, Borchert LB, Kombila UD, et al. Socio-economic
status is inversely related to bed net use in Gabon. Malar J. 2008; 7:60. https://doi.org/10.1186/1475-
2875-7-60 PMID: 18423025
PLOS ONE | https://doi.org/10.1371/journal.pone.0211365 January 29, 2019 13 / 13
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