SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
 
 
 
FACTORS INFLUENCING UTILISATION OF INSECTICIDE TREATED 
MOSQUITO NET IN AGONA EAST-CENTRAL REGION 
  
 
BY 
 
KOBLA GERSHON ANTHONY 
(10444950) 
  
 
 
 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON 
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE 
AWARD OF THE MASTER OF PHILOSOPHY DEGREE IN APPLIED 
EPIDEMIOLOGY AND DISEASE CONTROL 
 
 
                                                        JULY, 2015 
 
University of Ghana                              http://ugspace.ug.edu.gh
i 
 
DECLARATION  
I, KOBLA GERSHON ANTHONY of the University Of Ghana School Of Public 
Health, do hereby declare that except for duly acknowledged citations and ideas, this 
dissertation is an original work produced by me from a study personally undertaken under 
supervision. This work has never on any previous occasion been submitted in part or 
whole to any Institution or Board for the award of any degree. 
 
 
SIGNATURE……………………………………… 
KOBLA GERSHON ANTHONY 
(CANDIDATE) 
 
DATE......................... 
 
 
SIGNATURE…………………………………… 
DR. KEZIAH LAURENCIA MALM 
(ACADEMIC SUPERVISOR) 
 
DATE......................... 
 
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
ii 
 
DEDICATION 
This work is dedicated to my lovely family and my most cherished mother. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
iii 
 
ACKNOWLEDGEMENT 
I wish to express my profound and sincere gratitude to my academic supervisors; Dr. 
Keziah L Malm, Acting Programme Manager for the National Malaria Control Program 
and a part time Lecturer at the Epidemiology Department of the School of Public Health, 
University of Ghana. . I appreciate your invaluable guidance, contribution, advice and 
patience. May God richly bless you. 
 
I am greatly indebted to Dr. Patricia Akweongo the Head of Department of Epidemiology, 
School of Public Health, University of Ghana, Dr. Kofi Nyarko, Coordinator of the Ghana 
Field Epidemiology and Laboratory Training Programme (GFELTP),Prof. Edwin afari and  
Dr. Fred Wurapa, Dr. Samuel Sackey, Senior Lecturer at the Department of Epidemiology, 
Miss Gladys Antwi and all my lecturers at the School of Public Health for their inputs and 
encouragement in this work.  
 
My special thanks also to the District director of health Service, Agona East in the Central 
Region, Mrs. Nancy Ekyem for granting me the permission to use their district for this 
research. I am particularly grateful to the staff of the various health centers especially 
Osbert Kobla who showed much interest in this work. 
 
My special gratitude to my cohort 7 colleagues of the GFELTP for the friendship and 
encouragement to get over the programme.  
 
Finally, my sincere thanks to my wife Abigail Okrah and my children Gershon Kobla Jnr, 
Moira Fatu and Eyram Lewis for their patience and tremendous support. 
 
University of Ghana                              http://ugspace.ug.edu.gh
iv 
 
ABSTRACT 
Background 
Many countries across Sub Saharan Africa are rapidly stepping up insecticide –treated nets 
(ITN) coverage to combat malaria and Ghana is not left out in this trail. Studies have been 
done in Ghana on ITN utilization but a few of such studies have been done in the Agona 
East District of the Central of Ghana. This study was conducted to assess factors 
influencing the utilisation of ITNs in the Agona East district in the Central Region of 
Ghana, an area with an in-between in terms of household bed net utilisation in Ghana.    
Method 
A cross-sectional study with a household as the unit of the study, was done between the 
period February 2015 and July 2015 in Agona East District of the Central Region of 
Ghana. The study used both quantitative and qualitative methods. The quantitative arm 
included questions that were used to establish the demographic characteristics of 
household heads, household factors affecting ITN use and level of awareness in terms of 
use. Descriptive statistics were used to describe house hold net use and univariate and 
multivariate logistic regression analysis used to identify factors associated with use and 
non- use of nets. A qualitative component consisting of questions used to assess the level 
of awareness, observation of nets at home, some open ended questions related to use, and 
key informant interview provided further understanding of the reasons for ITNs use and 
non-use.  
  
Results 
The study covered 390 households inhabiting 1068 persons including 198 under- fives, 
519 non-pregnant women and 12 pregnant women in the Agona East District in the 
Central Region of Ghana. The ITN possession in households was 76.2% and utilisation in 
households was 38.2%; 50% utilisation among pregnant women and 52.4 % utilisation 
among children under five. Significantly households with heads who have discussed net 
use with their household or friends are more likely to have slept under a net (aOR= 3.50 
CI 1.84-6.65). The most common reason for non-use of ITN identified were the hot 
weather conditions, not having a net and the cost. Those who use the net also did so 
because they believed it protected them from mosquito bites.       
University of Ghana                              http://ugspace.ug.edu.gh
v 
 
Conclusion 
The low ITN utilisation compared to possession in the study area shows a clear gap 
between possession and usage. This suggests that campaigns and messages that persuade 
recipients to use ITNs will contribute towards closing the gap between ownership and 
usage alongside factors such as household net density and household size.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
vi 
 
TABLE OF CONTENTS 
DECLARATION ................................................................................................................... i 
DEDICATION ...................................................................................................................... ii 
ACKNOWLEDGEMENT .................................................................................................. iii 
ABSTRACT ......................................................................................................................... iv 
TABLE OF CONTENTS ..................................................................................................... vi 
LIST OF TABLES ............................................................................................................ viii 
LIST OF FIGURES .............................................................................................................. x 
LIST OF ABREVIATIONS ................................................................................................. xi 
 
CHAPTER ONE ................................................................................................................... 1 
INTRODUCTION ................................................................................................................ 1 
1.0 Background ................................................................................................................. 1 
1.1 Malaria Burden ............................................................................................................ 1 
1.1.1 Insecticide Treated Nets (ITNs) ............................................................................... 3 
1.1.2 Net Materials and Insecticides ................................................................................. 4 
1.1.3 How Do Long Lasting Insecticide Nets Work? ....................................................... 4 
1.1.4 ITNs in Ghana .......................................................................................................... 5 
1.2 Problem Statement ...................................................................................................... 7 
1.3 Conceptual Framework ............................................................................................... 8 
1.4 Justification ................................................................................................................. 9 
1.5 Objectives .................................................................................................................. 10 
1.5.1 General Objective ................................................................................................... 10 
1.5 2 Specific Objectives ................................................................................................. 10 
 
CHAPTER TWO ................................................................................................................ 11 
LITERATURE REVIEW.................................................................................................... 11 
2.1 Introduction ............................................................................................................... 11 
2.2 Demographic Factors ................................................................................................ 13 
2.3 Household Factors ..................................................................................................... 15 
2.4 Level of Awareness ................................................................................................... 19 
 
University of Ghana                              http://ugspace.ug.edu.gh
vii 
 
CHAPTER THREE ............................................................................................................. 23 
METHODS ......................................................................................................................... 23 
3.1 Study Design ............................................................................................................. 23 
3.2 Sample Size Determination ....................................................................................... 24 
3.3 Sampling Technique .................................................................................................. 25 
3.4 Variables .................................................................................................................... 26 
3.4.1 Dependent variables ............................................................................................... 26 
3.4.2 Independent variables ............................................................................................. 26 
3.5 Data Collection .......................................................................................................... 27 
3.6 Data processing and Analysis .................................................................................... 28 
3.7 Ethical Issues ............................................................................................................. 29 
3.8 Limitations ................................................................................................................. 29 
 
CHAPTER FOUR ............................................................................................................... 30 
RESULTS ........................................................................................................................... 30 
4.1 Characteristics of the Sample .................................................................................... 30 
4.2 ITN Ownership and sources in the households ......................................................... 33 
4.3 Prevalence of net use Among Household Members.................................................. 34 
4.4 Influence of Level of Awareness on net use ............................................................. 37 
4.5 Household Factors Influencing ITN use ................................................................... 41 
 
CHAPTER FIVE ................................................................................................................. 50 
DISCUSSION ..................................................................................................................... 50 
 
CHAPTER SIX ................................................................................................................... 56 
CONCLUSION AND RECOMMENDATIONS ................................................................ 56 
6.1 Conclusion ................................................................................................................. 56 
6.2 Recommendations ..................................................................................................... 56 
 
REFERENCES .................................................................................................................... 58 
Appendix A: Questionnaire for Household Heads.............................................................. 64 
Appendix B: Key Informant Guide ..................................................................................... 75 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
viii 
 
LIST OF TABLES  
Table 1: Sociodemographic characteristics of household heads in Agona East in the 
Central Region of Ghana, 2015 ............................................................................. 31 
Table 2: Household characteristics in Agona East in the Central Region of Ghana, 2015. 32 
Table 3 Influence of level of education of head of household on net possession in Agona 
East in the Central Region of Ghana, 2015. .......................................................... 33 
Table 4 Influence of type of occupation of head of household on net possession in Agona 
East in the Central Region of Ghana, 2015. .......................................................... 34 
Table 5: Reported net use in households in Agona East in the Central Region of Ghana, 
2015 ....................................................................................................................... 35 
Table 6 Distribution of net use in households in Agona East in the Central Rgion of 
Ghana, 2015. .......................................................................................................... 36 
Table 7 Estimates of the effect of number of household nets on the probability that a net 
was used the prior night in Agona East in the Central Region of Ghana, 2015. ... 36 
Table 8: Net use among household in Agona East in the Central Region of Ghana, 2015. 37 
Table 9 level of awareness in household heads in Agona East in the Central Region of 
Ghana, 2015 ........................................................................................................... 39 
Table 10: Awareness of head of household on net use in households in Agona East in the 
Central Region of Ghana, 2015 ............................................................................. 39 
Table 11 Effect of level of awareness of head of household on net use in households in 
Agona East in the Central Region of Ghana, 2015 ................................................ 40 
Table 12: Subjects discussed by house hold heads to their family or friends in Agona East 
in the Central Region of Ghana, 2015 ................................................................... 40 
Table 13: Distribution of households who slept under ITN the prior night in households 
with at least one ITN in Agona East in the Central Region of Ghana, 2015. ........ 43 
Table 14 Estimates of effect of household occupants on the probability that a net was used 
the night before in Agona East in the Central Region of Ghana, 2015. ................ 44 
Table 15: Logistic regression of predictors of households sleeping under an ITN a night 
before in households with at least one ITN in  Agona East in the Central Region 
of Ghana, 2015. ..................................................................................................... 45 
Table 16: Household head reasons for not using nets in Agona East in the Central Region 
of Ghana, 2015 ...................................................................................................... 48 
University of Ghana                              http://ugspace.ug.edu.gh
ix 
 
Table 17: Household head reasons for using net the prior night in Agona East in the 
Central region of Ghana, 2015. ............................................................................. 49 
University of Ghana                              http://ugspace.ug.edu.gh
x 
 
LIST OF FIGURES 
Figure 1: Conceptual frame work relating dependent factors to the exploratory 
variables. .................................................................................................................. 8 
Figure 2: Map showing the study site, Agona East district in the central Region 
of Ghana ................................................................................................................ 23 
Figure 3: Sources of information on net use in Agona East in the Central Region 
of Ghana, 2015 ...................................................................................................... 37 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
xi 
 
LIST OF ABREVIATIONS 
ANC          Antenatal Clinic 
DFID         Department for International Development 
DE             Design Effect 
FGD          Focus group discussion 
DHD               District Health Directorate 
DHS           Demographic and Health Survey 
GDHS       Ghana Demographic and Health Survey 
GMP          Global Malaria Protection 
GHS           Ghana Health Service 
ITN             Insecticide Treated Bed Net 
LLIN           Long Lasting Insecticide Treated Bed Net 
MDG         Millennium Development Goals 
MICS          Malaria Indicator Cluster Survey 
MOH         Ministry of Health  
NMCP       National Malaria Control Programme 
PMI           Presidents Malaria Initiative 
PSU           Primary sample unit 
PE             Protected Efficacy 
RBM          Roll Back Malaria 
SSU           Secondary sample unit 
UNICEF      United Nations Children‟s Fund 
USAID       United States Agency International Development 
WHO         World Health Organization 
University of Ghana                              http://ugspace.ug.edu.gh
1 
 
CHAPTER ONE 
INTRODUCTION 
1.0 Background 
1.1 Malaria Burden  
Globally, an estimated 3.4 billion people were at risk of malaria in 2013, according to the 
WHO 2013 malaria report and approximately 207million cases of the disease were 
reported in 2012. An estimated 627,000 lives were lost as result of the disease, mostly 
children under five years of age (77%)  in Africa: meaning 1300 young lives lost every 
day to malaria. Increased prevention and control measures have led to a reduction in 
malaria mortality rates by 47% globally since 2000 and by 54% in the WHO African 
Region according to World malaria report 2014. Malaria control is crucial in achieving the 
Millennium Development Goal 6 (MDG6), which seeks to combat the spread of 
HIV/AIDS, malaria and other diseases by 2015 and begin to reverse the incidence of these 
diseases with malaria inclusive. But malaria control also contributes to other MDGs, in 
that it accounts for an estimated 13% of post natal child death globally in 2010 and 21% in 
Sub Saharan Africa (World Malaria Report., 2014). This is crucial to MDG 4 – to achieve 
a two third reduction in the mortality rate amongst children under five between 1999 and 
2015. The focus of the World Health Organisation (WHO) and Roll Back Malaria (RBM) 
is to reduce malaria cases and deaths by 75% by 2015. But the call for elimination and 
eradication has inspired the ambitious objective of reducing deaths due to malaria to zero.    
Malaria is endemic in all parts of Ghana and a serious barrier to health and development. It 
is the leading cause of morbidity, accounting for about 38 percent of all out-patient 
attendance, 35 percent of all admissions and about 34 percent of all deaths in children 
under five years of age and 9 percent  of maternal deaths(According to a report from The 
President‟s Malaria Initiative, 2011). Ghana is among the 35 countries (30 countries in 
University of Ghana                              http://ugspace.ug.edu.gh
2 
 
Africa) responsible for the majority of the total deaths globally (“Global Malaria Action 
Plan: Introduction to Regional Strategies,” 2005.). All of Ghana‟s population is at risk of 
the disease and risk is higher in children under five years of age and pregnant women. 
Malaria transmission occurs all year round with slight seasonal variation (Roll Back 
Malaria in Ghana, 2010). In 2010 there were almost 4,000 deaths due to malaria and most 
of these deaths were in children under five years a report from Roll Back Malaria Ghana, 
2012. Malaria is therefore a significant cause of morbidity and mortality at all ages, and a 
cause of work days lost due to illness. The annual economic burden of malaria is estimated 
at 1-2 per cent of the Gross Domestic Product in Ghana (UNICEF., 2007) thus the need 
for better prevention and control.   
Malaria is caused by five species of parasite that affect humans belonging to the genus 
Plasmodium: P. falciparum, P. ovale, P. vivax, P. malariae and P. knowlesi. In Africa the 
predominant is the deadly P. falciparum(CDC, 2012a). Malaria is preventable and 
treatable provided the currently recommended intervention are implemented. (i) Vector 
control through the use of insecticide treated bed nets (ITNs), indoor residual spraying 
(IRS) and, larval control; (ii) chemoprevention for pregnant women; (iii) confirmation of 
malaria diagnosis via microscopy or rapid diagnostic tests (RDTs); and (iv) timely 
treatment with appropriate antimalarial. Prevention and control strategies have led to a 
reduction in malaria mortality rates by 42 percent globally since 2000 and by 49 percent in 
Sub-Saharan Africa(WHO, 2013).  WHO recommends the universal coverage of all 
people at risk of malaria in areas targeted for malaria prevention with ITNs to realize its 
full potential as a vector control intervention (WHO ITN position statement, 2007).  ITNs 
reduced the incidence of uncomplicated malarial episodes in areas of stable malaria by 
50% compared to no nets, and 39% compared to untreated nets; and in areas of unstable 
malaria: by 62% compared to no nets and 43% compared to untreated nets 
University of Ghana                              http://ugspace.ug.edu.gh
3 
 
for Plasmodium falciparum episodes. When compared to no nets and in areas of stable 
malaria, ITNs also had an impact on severe malaria ( 95% CI 20 - 63), parasite prevalence, 
high parasitaemia , splenomegaly , and their use improved the average haemoglobin level 
in children by 1.7% packed cell volume(Smith, Leuenberger, & Lengeler, 2001). 
WHO/GMP now recommends that Long Lasting Insecticide treated Nets (LLINs) be 
distributed to and used by all people ("universal coverage") in malarious areas, not just by 
the most vulnerable groups: pregnant women and children under 5 years. It is also calling 
on all national malaria control programmes and their partners involved in nets 
interventions to purchase only LLINs and to distribute them free of charge or at a highly 
subsidized price (WHO/GMP, 2014). LLINs are most commonly distributed through mass 
campaigns approximately every 3 years. Between 2008 and 2010, a total of 294 million 
nets were distributed in sub-Saharan Africa (CDC, 2014).The percentage of households 
owning at least one ITN in sub-Saharan Africa is estimated to have risen from 3% in 2000 
to 56% in 2012. With improved accessibility, utilization has increased to 42% in 2013 
(“WHO | World Malaria Report 2013,”) representing a gap between ownership and usage. 
Several companies have developed long-lasting insecticide-treated nets (LLINs) that 
maintain effective levels of insecticide for at least 3-5 years, even after repeated washing. 
LLINs have been associated with sharp decreases in malaria in countries where malaria 
programs have achieved high LLIN coverage. 
 
1.1.1 Insecticide Treated Nets (ITNs) 
An insecticide-treated net is a mosquito net that repels, disables and/or kills mosquitoes 
coming into contact with insecticide on the netting material. There are two categories of 
ITNs: conventionally treated nets and long-lasting insecticidal nets. A conventionally 
treated net is a mosquito net that has been treated by dipping in a WHO-recommended 
University of Ghana                              http://ugspace.ug.edu.gh
4 
 
insecticide. To ensure its continued insecticidal effect, the net should be re-treated after 
three washes, or at least once a year. A long-lasting insecticidal net is a factory-treated 
mosquito net made with netting material that has insecticide incorporated within or bound 
around the fibres. The net must retain its effective biological activity without re-treatment 
for at least 20 WHO standard washes under laboratory conditions and three years of 
recommended use under field conditions. 
 
1.1.2 Net Materials and Insecticides 
Nets may vary by size, shape, colour, material, and/or insecticide treatment status. Most 
nets are made of polyester, polyethylene, or polypropylene. 
Only pyrethroid insecticides are approved for use on ITNs. These insecticides have been 
shown to pose very low health risks to humans and other mammals, but are toxic to insects 
and kill them, even at very low doses. Pyrethroids do not rapidly break down unless 
washed or exposed to sunlight(Fishel, 2014). Previously, nets had to be retreated every 6 
to 12 months, or even more frequently if the nets were washed. Nets were retreated by 
simply dipping them in a mixture of water and insecticide and allowing them to dry in a 
shady place. The need for frequent retreatment is a major barrier to widespread use of 
ITNs in endemic countries. In addition, the additional cost of the insecticide and the lack 
of understanding its importance resulted in very low retreatment rates in most African 
countries(Kaliyaperumal, et al., 2010). 
 
1.1.3 How Do Long Lasting Insecticide Nets Work? 
Bed nets form a protective barrier around people sleeping under them. However, bed nets 
treated with an insecticide are much more protective than untreated nets. The insecticides 
University of Ghana                              http://ugspace.ug.edu.gh
5 
 
that are used for treating bed nets kill mosquitoes, as well as other insects. The insecticides 
also repel mosquitoes, reducing the number that enter the house and attempt to feed on 
people inside. In addition, if high community coverage is achieved, the numbers of 
mosquitoes, as well as their length of life will be reduced. When this happens, all members 
of the community are protected, regardless of whether or not they are using an insecticide 
treated bed net. To achieve such effects, more than half of the people in a community must 
use an ITN(CDC, 2014)  
 
1.1.4 ITNs in Ghana 
According to the Multiple Indicator Cluster Survey-Ghana, final report of 2011, more than 
half of all households (51%) own at least one mosquito net, treated or untreated and 49 
percent of all households have an insecticide treated net (ITN), the large majority(48%) 
are  long-lasting insecticidal net (LLIN). The average number of LLIN in households in 
Ghana is 1.3. About one in every four households in Ghana has at least one LLIN net for 
every two persons who stayed in the household the night prior to the survey.  
Several projects in Ghana have been rolled out to enhance ITN ownership by households 
since 2001, (Kudom & Mensah, 2010). In the late 2006, 2.1 million ITNs were distributed 
free of charge as part of the measles immunization campaign.  Between December 2010 
and August 2012, GHS/ MOH/NMCP with support from World Bank, WHO, UNICEF, 
DFID, USAID/PMI and other partners has   distributed   close to 12.8 million ITNs 
through a universal mass distribution campaign in all ten Regions of Ghana.The 2008 
Ghana Demographic and Health Survey (DHS) indicated that only 32.6% of households 
owned at least one insecticide-treated net (ITN).The 2008 NetMark Household Survey on 
ITNs also found that almost 45% of ITNs owned were not hung and ready to use.  
Although ITNs are increasingly accessible to many in the country getting people to 
University of Ghana                              http://ugspace.ug.edu.gh
6 
 
correctly and consistently use them still remains low .At this rate it would not be possible 
for the country to achieve the national and international targets of ITN use unless factors 
hindering utilization are recognized and appropriate solutions found to it.  
Ghana since 2002 has waived taxes on ITN importation and benevolent partners have 
aided in its supply and distribution. The Ghana Demographic and Health survey 2008 data 
showed that 45 percent of households in Ghana owned a mosquito net whether treated or 
not treated and 19 percent own more than one net. ITNs have been shown to significantly 
reduce malaria –related morbidity and all-cause child mortality by 14-33 percent in sub-
Saharan Africa (Binka & Adongo, 1998). In Ghana ITNs are associated with 17 percent 
reduction in all-cause mortality in children (Adongo et al, 1998.) resulting in advocacy for 
the inclusion of ITNs in malaria prevention and control strategy. This strategic tool forms 
the cornerstone for Ghana Health Services (GHS) bid to reduce malaria – related deaths 
and morbidity by 75 percent by the year 2015 as reported by the National Malaria Control 
Program. 
Insecticide-treated bed nets (ITNs) are a major intervention for malaria control. They offer 
a form of personal protection that has been shown to reduce malaria illness, severe 
disease, and death due to malaria in endemic regions. In community-wide trials in several 
African settings, ITNs have been shown to reduce the death of children under 5 years from 
all causes by about 20%(CDC, 2012). ITNs have been effective in reducing maternal 
anaemia, placental infection and low birth weight in pregnant women and reduction of 
anaemia, lower infant and child mortality, and fewer episodes of uncomplicated malaria in 
young children(Haghdoost, Alexander, & Smith, 2007).   
University of Ghana                              http://ugspace.ug.edu.gh
7 
 
1.2 Problem Statement  
According to the Ghana DHS 2008 survey, households owning at least one mosquito net 
(ITN) is 33% of the population. Mosquito net use however is low, 28% in children under 
five and 20% in pregnant women. The post hang up campaign evaluation report released 
on May 2013, revealed that the proportion of households owning at least one ITN after the 
campaign was 79.7% in Central Region, the proportion of all individuals sleeping under 
ITN however  was 45.0%(Smith Paintain et al., 2014). 
 ITN utilisation is influenced by certain socio demographic characteristics, (Ng‟ang'a et 
al., 2009) household factors and level of awareness, knowledge and perceptions  of the 
households (Hightower et al., 2010). Studies have shown that children under five and 
women in reproductive age are more likely to sleep under nets (Baume & Marin, 
2007);Tsuang, Lines, & Hanson, 2010). Low level of education of household head 
(Pettifor et al., 2008), low homestead wealth (Githinji et al., 2010) are less likely to sleep 
under nets. Household factors such as decision making, sleeping space(Lam et al., 2014), 
fewer nets in the households (Baume & Franca-Koh, 2011) large household size or family 
size (Oresanya, Hoshen, & Sofola, 2008) affect the use of ITN as well as poor sleeping 
arrangements (Iwashita et al., 2010). Level of awareness, perception and beliefs (Bennett 
et al., 2012) on effectiveness of ITN (Nuwaha, 2001) as a preventive measure  affects its 
utilisation within the household. Good household practices, perception and improved level 
of awareness towards ITN utilisation, proper deployment of ITNs and consistence in usage 
of net will lead to increased utilisation. 
In Ghana studies have been done to prove that ITNs are highly effective in reducing 
malaria morbidity and mortality if correctly and consistently used (Lengeler, 1996), yet 
utilization is below the target level of 75% (World Health Organization, 2013). 
University of Ghana                              http://ugspace.ug.edu.gh
8 
 
1.3 Conceptual Framework 
Figure 1; presents the summary of data frame work for analysis of association between 
sleeping under ITN and explanatory factors. 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1: Conceptual Framework relating dependent factors to the exploratory 
variables. 
Insecticide treated 
mosquito net use  
 
Social demographic 
characteristics; 
-Age  
-Sex 
-Education 
-Marital status 
-Occupation 
Household factors; 
-Household size 
-Number of nets in the household 
-Decision making 
-Household wealth  
 
Programme 
factors; 
-Policy 
-Proper 
deployment of 
nets  
 
Individual Factors; 
Perceptions 
Attitude  
Beliefs  
-Effectiveness of ITN 
-Causes heat and suffocation 
-Causes disease 
Level of awareness; 
-Information on net use  
-Information on source of net 
-Discussion of net use with family and 
friends 
 
University of Ghana                              http://ugspace.ug.edu.gh
9 
 
 The utilization of ITNs is influenced by the socio demographic factors like age, sex, 
educational level, occupation, income of the household and marital status that work 
through the intra-household factors like structure of the household, number of household 
occupants, number of nets that a household can possibly afford to buy if need be ,sleeping 
arrangements and decision making which may involve the household head. Utilization is 
also influenced by perceptions towards ITNs, beliefs, attitudes, knowledge on proper use 
in terms of consistence in usage. Therefore, with the good intra-household practices, 
perceptions and attitudes towards ITNs, utilization is possibly manifested through proper 
deployment of ITNs, consistence on usage. This leads to increased utilization of ITNs 
within households and especially with children under five years. 
 
1.4 Justification 
Studies have been done in Ghana, but a few done in Agona East in the Central Region of 
Ghana especially after several efforts made at improving on ownership (possession of a 
net or ITN). It is of essence to distinguish between net ownership and net use (actual use 
of net owned). The focus going forward for the National Malaria Control programme in 
the country is to get people to use the ITNs. Information from such a study will inform any 
efforts at increasing utilization of ITNs. It is also expected to be of immense help to policy 
planners, the ministry of health specifically in the department of malaria control and 
contribute to the body of literature, provide appropriate guide to policies for the promotion 
of ITNs and basis for further research on ITNs in malaria prevention. This study seeks to 
unravel these factors that may be contributing to the   gap between possession and use, and 
to address problems associated with actual use of nets within the households, rather than 
net ownership.  
University of Ghana                              http://ugspace.ug.edu.gh
10 
 
1.5 Objectives   
1.5.1 General Objective   
To assess factors that influence use of ITNs in the Agona East, Central Region 
1.5 2 Specific Objectives 
1. To determine the prevalence of ITNs utilisation among households in Agona East 
in the Central Region. 
2. To assess level of awareness in terms of ITN use among households in Agona East 
in the Central Region. 
3. To assess household factors affecting ITN use in Agona East in the Central 
Region.  
 
 
 
 
 
 
 
 
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
11 
 
CHAPTER TWO 
LITERATURE REVIEW 
2.1 Introduction  
In 2013, almost half of the population of Sub Saharan Africa were at risk of malaria, 49% 
had access to an ITN in their households compared to 3% in 2004. An estimated 44% of 
the population at risk were sleeping under an ITN in 2013, compared to 2% in 2004. A 
total of 214 million nets are projected to be delivered to countries in Sub Saharan Africa 
by the end of 2014. A key indicator for assessing progress towards Global Malaria Action 
Plan (GMAP) target is the „proportion of population that slept under an ITN the previous 
night. Although an increasing number of studies have documented ITN ownership and 
use, including Ghana (Baume & Franca-Koh, 2011)(Agyepong & Manderson, 1999), a 
few have systematically investigated ITN use.  
 The use of insecticide treated bed nets is an intervention in earnest to curb malaria 
transmission in Ghana according to the Ghana DHS (Ghana DHS,. 2014).The current 
LLINs are designed to last for 3 to 5 years after which it could be replaced. The average 
number of ITN per a household in Ghana is 1.3 and is same in the Central Region where 
the study was under taken. The universal net coverage is measured by assuming that there 
is one net for every two people in household.  Households with at least one net is 69.7% of 
study population. Net use by the vulnerable ones mentioned in the DHS especially 
children was 43% and pregnant women is 47% .Net use is still on the low side in Ghana 
and  this is what we seek to find in this study. Compared to a malaria indicator survey 
done in the southern part of Sudan, which showed that the utilization of insecticide-treated 
nets was low; 25.3% (95% CI: 23.9-26.7) for children under five (U5) and 35.9% (95% 
CI: 31.9-40.2) for pregnant women (OR: 1.66 (1.36-2.01); P =0.175) (Eyobo et al., 2014). 
Rural  setting is found to significantly associated with net use in Ghana according to this 
University of Ghana                              http://ugspace.ug.edu.gh
12 
 
study (Baume & Franca-Koh, 2011). Agyepong and Manderson in their study found far 
higher bed net ownership and use in rural than urban areas, which was related partly to 
perceived affordability and partly to the different contexts of and reasons for avoiding 
mosquitoes (Agyepong & Manderson, 1999)(Gunasekaran, Sahu, Vijayakumar, & 
Jambulingam, 2009). Most nets are gotten as a result of free distribution in mass 
campaigns and the rural folks realizing the importance of net use in this respect take 
advantage of such situations. In another cross sectional study done in the rural area of 
Western Kenya found only 59% of household residents sleeping under a net during the 
night prior to the survey(Githinji et al, 2010). 77% of those who slept under a net used an 
insecticide-treated net (ITN) or long-lasting insecticide-treated nets (LLIN).  Nuwahu 
(2011), in their study in the Mbara municipality of Uganda 50% percent (356 of 643) of 
the households used bed net. In another  study in 6 different countries in Sub Saharan 
Africa with Ghana inclusive  women of reproductive age and children under 5 (without 
gender bias) were most likely to use the net; least likely were children of age 5-14 and 
adult males(Baume & Marin, 2007).In a Ugandan hospital based survey it was observed 
that thou the prevalence of ITN utilization among children  was 34.2%,  ITN utilization 
was higher among children of age <5 years [37.0, 95% CI 31.81-42.21] as compared to 
children aged ≥5 years [22.9, 95% CI 13.77-32.01](Nankinga et al., 2012). In a cross 
sectional study using existing data in Tanzania involving mainly pregnant women and 
their children it was observed that ITNs were most likely to be used by infants, young 
children (1-4 y), and women of childbearing age; they were least likely to be used by older 
women (>or=50 y), older children (5-14 y), and adult men(Tsuang et al., 2010).   
University of Ghana                              http://ugspace.ug.edu.gh
13 
 
2.2 Demographic Factors 
Demographic factors such as age, gender, occupation, level of education and marital status 
of head of household have been shown to be associated with net use or non-use(Nankinga 
et al., 2012)(Baume & Franca-Koh, 2011)(Negash, Haileselassie, Tasew, Ahmed, & 
Getachew, 2012). According to a study in India, West Bengel population, factors 
independently associated with net use in multivariate analysis included age < 35 years 
(P<0.001)(Biswas et al, 2010). In a study conducted  in Ethiopia  by Graves et al.,(2006),it 
was  found that an increase net use was associated with age 25-49 years ( OR=1.4 CI 1.2-
1.7) as compared to children under 5 years., but reduced net use was associated with age 
5-24years (OR=0.2, CI 0.2-0.3) compared to the under-fives. Another study done in 
Ethiopia in Afar region of the country, examining ownership and utilisation of nets, found 
that among the potential determinants explored regarding utilization of LLINs, age to be 
significantly associated with LLIN utilization and the under-fives were more likely to 
sleep under bed nets , similarly a cross sectional survey conducted in central Kenya 
revealed a similar finding with bed net use with age (χ2 = 74.483 P = 0.000), (Ng‟ang‟a et 
al.,2009)(Negash et al., 2012). A cross sectional study done by Graves et al (2011) in 
assessing factors associated with mosquito net use by individuals in households owning 
nets in Ethiopia  also showed increased net use associated with age( OR=1.4, 95% CI 1.2-
1.7) compared to children under five.   
Gender has been found to be very much associated with net use(Ng‟ang'a et al., 2009) in 
some households Gender norms and values that influence the division of labour, leisure 
patterns, and sleeping arrangements may influence net use for men and women., a female 
gender (OR=1.4 CI 1.2-1.5) was associated with net use, according to Graves et al 
(2006).A cross sectional study done in Central Kenya also revealed significant variation in 
bed net use with gender (Chi2= 4.25 P- 0.039). Gqrley et al, (2013) found that females 
University of Ghana                              http://ugspace.ug.edu.gh
14 
 
used ITNs compared to males (57.2% vs 48.8%). After controlling for several covariates, 
females remained more likely to use ITNs compared to males (OR: 1.5, 95% CI: 1.3-1.7) 
in a post campaign survey in Kano State in Nigeria.   
According to a study done in Afar in northeast Ethiopia regarding utilization of nets, 
occupation of household head  was significantly associated with net use( Negash et al, 
2012) (Ng‟ang'a et al., 2009). so also is a study done in Central Kenya in a rice farming 
community, a cross sectional study where the predominant job was farming found 
occupation( Chi2-7.955 P-0.047) to be associated with net use. Households whose heads 
were engaged as a farmer (adjusted OR 0.137; 95% CI: 0.04-0.50) and housewife (OR 
0.26; 95% CI: 0.08-0.82) were less likely to use ITN than those of other occupations 
(Biadgilign, Reda, & Kedir, 2012) According to this study done in Uganda involving care 
givers, a hospital based crosss sectional study, ITN utilisation was significantly associated 
with  formal employment by head of household (OR = 6.00, 95% CI = 1.95-
18.48)(Nankinga et al., 2012) 
Level of education  of heads of households is crucially associated with net use(Ng‟ang'a et 
al., 2009)(Noor et al). Positive predictors for LLINs utilization are increasing educational 
levels (Jombo,et a 2011)(Rhee et al., 2005), being able to read instructions on leaflets 
attached to nets is good enough to enhance the correct use of it, Women who had 
secondary school or higher education were 3.4 times more likely to own a net and 2.8 
times more likely to have used a net compared to women with less than secondary school 
education (Pettifor et al., 2008) a cohort study done in Kinshasa in the Democratic 
Republic of Congo among pregnant women  on attending the clinic and given nets free of 
charge and followed up for use. In multivariable analyses examining factors associated 
with net ownership and use, level of education remained strongly associated with both. To 
re enforce this observation a hospital-based descriptive study done in Imo State, South-
University of Ghana                              http://ugspace.ug.edu.gh
15 
 
Eastern Nigeria. Bivariate analysis showed that Parents who had secondary education and 
above used ITNs more than those who had primary education and below 
(57.3% vs 42.7%, P value = 0.009) (Iloh et al, 2013). Adogu and Ijemba, in 2013 found 
that the use of ITN the night before was only 12.7% for those with tertiary education but 
significantly increased to 29.8% and 24% for those with secondary and primary education 
respectively (p=0.05). Fugie et al, (2015) found in his study in Shashogo southern 
Ethiopia, that level of education was a high determinant of net use (p < 0.05). In another  
cross sectional study done in Azendabo village in Ethiopia the association between 
educational status and frequency of ITNs utilization was statistically significant (chi2 = 
13.99; p = 0.029; df = 6)(Kaliyaperumal et al., 2010). A contrary view was observed in a 
community based cross sectional study in Lagos state in Nigeria among care givers, 
educational level of care givers was not significant determinants ITN utilisation(Okafor & 
Odeyemi, 2012). 
Marital status of heads of households is observed to be an insignificant factor in terms of 
utilisation of nets (Mudenyo & Nobuyuki, 2010). In another study done in Makueni 
district, Kenya among caregivers it was observed that ITN utilisation of nets by the under-
fives  was positively associated with the marital status of the care givers (Malusha,. 2009).  
 
2.3 Household Factors 
House hold factors are known to play a vital role in net ownership and use, nets in most 
instances are given for free, households with good socioeconomic status and  know the 
importance of this preventive measure may not hesitate to purchase a net (Gebresilassie & 
Mariam, 2011), but in a situation where one has to purchase the net then the socio 
economic level of the house becomes important. According to a cross sectional survey in 
rural area of Southern Mozambique it was observed that the lower the socioeconomic 
University of Ghana                              http://ugspace.ug.edu.gh
16 
 
status of a household the likelihood that it was going to receive a free bed net(Chase et al., 
2009).  In a knowledge attitude and practices study done Kimbibi sub district hospital in 
Kenya it was observed that almost 90% of households reported owning and using an 
insecticide treated bed net and 81% reported buying the nets emphasizing the need to 
protect oneself from getting malaria(Okech et al., 2008) if it meant purchasing it yourself. 
According to a cross sectional study in suburban Accra where groups of  families were 
assessed for  treatment delays in accessing health care, only half of families in the lowest 
income group utilized insecticide-treated mosquito nets, while all six families in the 
highest income group use the precaution(Wong, 2011). In a cross sectional study 
conducted in rural Kenya to assess determinants of retail sector acquisition of nets, 
homestead wealth (adjusted OR = 10.17, 95% CI = 5.45-18.98), was significantly 
associated with use of retail sector nets by children aged less than 5 years(Noor et al, 
2006). But in a cross sectional study done at the Medical Research unit of the Albert 
Schwetzer hospital in Lambrene, Gabon, where women were classified into levels of 
socioeconomic status, it was found to be inversely related to bed net use (Goesch et al., 
2008). Bennet et al,(2012), found no difference by socioeconomic status of house hold 
head  6 months after a mass distribution of nets country wide in Sierra Leone to determine 
possession and use of the nets, a cross sectional study. In another study in Northern 
Nigeria among women of varying wealth quintiles it was observed that  ITN use 
(individuals reporting having slept under an ITN the night before the survey visit) among 
individuals from households owning at least one ITN, was 53.1% with no statistically 
significant difference between the lowest, second, third and fourth wealth quintiles and the 
highest wealth quintile (lowest: odds ratio (OR) 0.87, 95% confidence interval (CI) (0.67 ; 
1.13); second: OR 0.85, 95% CI (0.66 ; 1.24); third: OR 1.10 95% CI (0.86 ; 1.4) and 
fourth OR 0.91 95% CI (0.72 ; 1.15)(Ye, Patton, Kilian, Dovey, & Eckert, 2012)  But in 
University of Ghana                              http://ugspace.ug.edu.gh
17 
 
this study low socioeconomic status is strongly associated with net use(Baume & Franca-
Koh, 2011). Positive predictors for LLINs utilization were increasing educational levels, 
increasing wealth index and presence of an under five child, while lower wealth index and 
cultural beliefs negatively contributed to LLINs utilization(Jombo, et al 2011). According 
to a  study done by Macintyre et al., (2002) it was  found that wealth and formal education 
were significantly associated with net use. 
Ownership and use of insecticide treated bed nets by pregnant women attending antenatal 
clinics in Anambra state, south eastern Nigeria, it was found that 60% of the women 
owned nets at home, 46% used the net partially or fully and 56% never used the nets. 
(Ukibe et al., 2013).Increased ownership as witnessed in a post campaign house hold 
survey comparing 4 countries; Nigeria, Senegal, Ghana and Zambia  comparing data from 
2000, 2004 and 2006. All countries made commensurate gains in the proportion of under-
fives sleeping under a net and again in all countries the proportion of pregnant women 
sleeping under a net increased greatly. In a cross sectional study assessing several 
countries for net utilisation concluded that intra-household access to ITNs is the strongest 
and most consistent determinant of use among children (Eisele, Ke,et al 2009). 
It is expected that most nets hanged are to be used or slept under, in a household survey 
conducted in some Regions in Ghana which included the Region of the study, LLIN use 
was greater in households in which one or more campaign LLINs were hung by a 
volunteer (OR  =  1.57; 95% CI  =  1.09, 2.27; p  =  0.02)(Smith Paintain et al., 2014). 
This goes to emphasize the essence of hung up campaigns, an adoptable strategy. Not all 
nets deployed or hanging are used the night prior in a study conducted in semi urban 
community in River state in Nigeria on use and misuse of nets it was observed that, of the 
102 ITNs that were properly deployed, only 27.5% were occupied the night before the 
survey (Ordinioha, 2012). But in several countries, a sizable minority of nets owned were 
University of Ghana                              http://ugspace.ug.edu.gh
18 
 
not used(Baume & Marin, 2007). Bed net use is affected by the weather conditions as 
witnessed in a study in communities in Malaita, Solomon Island, bed net use was affected 
by seasonality; 99% of the population used bed nets during the rainy season, 52% used 
them all year (Yohannes et al., 2000). The hot weather conditions makes the use of bed 
nets uncomfortable worse off in Ghana where electricity is a problem.    
Bed net density is associated with net use(Hightower et al., 2010)(Belay & Deressa, 2008), 
the number of nets in the household will determine how many of the house hold would 
sleep under net, priority given to the head of households. In a  descriptive study in 4 
districts in Uganda examining household net allocation preferences,  sleeping space 
surveys revealed that heads of household sometimes receive priority over children less 
than five years of age when households have too few nets to cover all members (Lam et 
al., 2014)  but in other situations such as in households in Tanzania under-fives were more 
likely to sleep under net compared to  older women(˃ 50 years) and older children (5-15 
years) (Tsuang et al., 2010).   Bed net density is found to be significantly  associated with 
a reduction in under five mortality in a rural  Southern Tanzania where the spatial 
distribution  of net was assessed for its effect on childhood mortality (Gosoniu et al., 
2008). Fewer nets is  significantly associated with net use as envisaged in some studies 
(Baume & Franca-Koh, 2011). In several countries, a sizable minority of nets owned were 
not used. In a cross sectional study involving Ghana and several other countries in sub 
Saharan 91% of household owned at least one ITN, but only 65% of ITNs owned had been 
used the prior night. The multivariate analysis found that the factors significantly 
associated with an ITN being used was family size (Baume, Reithinger, & Woldehanna, 
2009) in another study in Mopti Region of Mali it was observed that one of the significant 
predictors of ITNs use was  household with larger family size(Rhee et al., 2005), this is 
University of Ghana                              http://ugspace.ug.edu.gh
19 
 
tied down to the high level of education of the household head and level of awareness in 
terms of net use (SMITH GREENAWAY, LEON, & BAKER, 2012). 
In a descriptive study conducted in Uganda on prioritizing  net use among households, it 
was unanimously agreed  that priority be  given to pregnant women, infants and children 
under five when it came to the use of net, in the same  study sleeping space survey 
revealed that sometimes priority was given to the head of the household when households 
had few nets to allocate (Lam et al., 2014). Sleeping arrangement coupled with decision 
making in the household affect net use among household members(Iwashita et al., 
2010)(Chicuecue et al., 2012)     
 
2.4 Level of Awareness on Net Use 
Level of awareness has a lot of influence on net use (Vanden Eng et al., 2010), a constant 
awareness is important in net usage. A constant hammering of the need to use nets and the 
benefits with it is the key to achieving a universal coverage (Hetzel et al., 2014), of course 
low level of awareness is associated with low level of use of nets(Singh, Brown, & 
Rogerson, 2013) . Households who received or were told about ITN in the last 6 months 
were three times more likely to have used ITN than those who were not (OR 3.25; 95% CI 
1.5-7.10) a clear indication of the essence of the longevity of information and its effect on 
net use (Biadgilign et al., 2012). In another study in rural Uganda only half the nets owned 
were being used correctly by those most vulnerable to the illness(Williams et al., 2009). 
The findings suggest that mosquito nets must be provided with an effective education 
program and may be more successful if conducted in whole districts simultaneously rather 
than on a per-community. In a study in Ghana assessing the impact of mass media 
education on net use by children, individual Messages delivered by a health worker or a 
dedicated radio programme, had the highest effect for one or more children sleeping under 
University of Ghana                              http://ugspace.ug.edu.gh
20 
 
a net the night before (OR adjusted=1.65; 95% CI=1.44) while hearing of more  messages  
resulted in the highest odds for one or more children (OR adjusted=3.06; 95% CI=2.27 to 
4.12) sleeping under a bed net(Owusu Adjah & Panayiotou, 2014).  A descriptive study 
carried out in the Northern state of Nigeria found a third of the women were aware of ITN 
prevention but less than a third ever used it. A little over 70% of the respondents had never 
used ITN before because of lack of awareness, (Musa et al, 2009). Another study done by 
BO et al in 2010 in Enugu, Nigeria found awareness of ITN to be high (80%) of 
respondents interviewed but only 26% used nets for their children. In a cross sectional 
study involving caregivers, the utilisation of net by their wards was found to positively 
associated with knowledge about ITN use (Malusha et al., 2009). 
In a cross sectional study designed to assess the level of awareness, in Anambra state, 
south eastern Nigeria, it was found that 93% of the women in the study were fully aware 
of the use of nets, 60% owned nets at home, 46% used the net partially or fully and 56% 
never used the nets. (Ukibe et al., 2013). 
Baume  et al in 2009, reported in the qualitative  aspect of a household survey determining 
factors associated use and non-use of nets owned in Oromia and Amhara Regional states 
in Ethiopia, that the most common reason for net non-use was there are few mosquitos 
around or malaria was not a serious problem. Pulford et al in review of studies that 
examined barriers to mosquitoe net use looking at self-reported reasons for not using a 
mosquito net amongst „net owning‟ individuals found that, discomfort primarily due to 
heat, and perceived (low) mosquito density were the most widely identified reason for 
non-use. Social factors, such as sleeping elsewhere, or not sleeping at all, were also 
reported across studies as were technical factors related to mosquito net use (i.e. not being 
able to hang a mosquito net or finding it inconvenient to hang) and the temporary 
unavailability (Pulford et al., 2011).   Baume et al in 2009, observed an increase in the 
University of Ghana                              http://ugspace.ug.edu.gh
21 
 
proportion of pregnant women sleeping under a net, after an improved level of awareness 
with distribution of nets. In a household survey done by Bennet et al in 2012, among the 
individuals in households possessing ≥1 ITN, 76.5% slept under an ITN the night before. 
Individuals in households where the household head heard malaria messages were more 
likely to have slept under ITN. The use of the media in creating awareness cannot be over 
emphasized in outlining the impact of awareness through mass media campaign on net 
use, a cross sectional survey done by Bowen in 2013 in Cameroun where a mass 
distribution was followed by a Night Watch Programme to ensure use of net at night, 
revealed that Camerounians with at least one net in their households exposure to the Night 
Watch programme was associated with a  6.6% point increase in last night net use among 
the respondents‟ children (79.6% vrs. 67.6% p < 0.025)(Bowen, 2013).Level of awareness 
is not enhanced by only what one sees or hears but also the ability to discern, hence the 
level of education with awareness in a study done by BO et al in 2014. There was 
statistically significant difference in terms of awareness of ITN between the mothers with 
tertiary education and those with secondary education and below (.p = 0.000). In terms of 
use of ITN among those that have the awareness, however, there was no significant 
difference between the two groups of mothers (p = 0.404). Use of insecticide treated bed 
nets by pregnant women attending antenatal clinics in Anambra state, south eastern 
Nigeria, it was found that 93% of the women in the study were fully aware of the use of 
nets, 46% used the net partially or fully and 56% never used the nets. (Ukibe et al., 2013) 
A review of published literature on net use when one owned one by Pulford et al in 
2011 revealed discomfort, primarily due to heat, and perceived (low) mosquito density 
were the most widely identified reason for non-use. Social factors, such as sleeping 
elsewhere, or not sleeping at all, were also reported across studies as were technical 
factors related to mosquito net use (i.e. not being able to hang a mosquito net or finding it 
University of Ghana                              http://ugspace.ug.edu.gh
22 
 
inconvenient to hang) and the temporary unavailability of a normally available mosquito 
net (primarily due to someone else using it).  
A cross-sectional surveys done in Western Kenya conducted on ITN ownership 
(possession), compliance (actual usage among those who own ITNs), and malaria 
infections in occupants of randomly sampled houses in the dry and the rainy seasons of 
2009, observed that despite ITN ownership reaching more than 71%, that part of Kenya 
compliance was low at 56.3%. The compliance rate was significantly higher during the 
rainy season compared with the dry season (62% vs. 49.6%) (Atieil et al, 2011), this is 
because of the heat that comes with this weather conditions(Cohee et al., 2009)  . 
Awareness of ITN was found in 184 (80%) of the mothers. Only 46 (20%) did not know 
about ITN. Of the mothers that know about ITN, 48(26.1%) had their children sleep under 
the net (Bo et al, 2014). 
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
23 
 
CHAPTER THREE 
METHODS 
3.1 Study Design  
A Cross-sectional study with a household as the unit of study and the head the respondent, 
was done between the period February 2015 and July 2015. The study used both 
quantitative and qualitative methods. The quantitative arm included questions that were 
used to establish the household factors and demographic characteristics of household 
heads, ITN ownership and questions regarding the characteristics and use of household 
ITN. The qualitative component was integrated into the questionnaire and it included 
questions used to assess the level of awareness, observation of nets at home, some open 
ended questions related to use, and in-depth interview with key informants.  
Study Area  
 
Figure 2: Map of Agona East District, Central Region of Ghana 
Source: Courtesy Agona East District Assembly 
The study was conducted in Agona  East District. Agona East District is situated in the 
eastern corner of the Central Region within latitudes 5030‟ and 5050‟N and between 
longitudes 0035‟ and 0055‟ W. It has a total land area of 667square kilometers; the district 
University of Ghana                              http://ugspace.ug.edu.gh
24 
 
is divided into Five (5) sub-districts or Town/Area Councils namely Nsaba, Duakwa, 
Asafo, Kwanyako and Mankrong area councils. The district is among the 20 districts and 
municipalities of Central Region of Ghana, Nsaba is the administrative capital. Generally, 
the District lies in the wet semi-equatorial climatic zone. It has a bio-modal pattern of 
rainfall with the maximum occurring in May/June and September/October. The annual 
rainfall figure lies within the range of 1000mm – 1400mm. The dry season starts in 
December and ends in March with the highest mean monthly temperature of 33.80 
occurring between March/April and the lowest of about 29.40 C in August (“District 
Assembly, Agona East,. 2012). The Agona East District‟s Estimated Population now 
stands at 85,920 with about 21,021 households and a household size of 4. Female slightly 
dominating at an estimated population of 44,885 while the male population was estimated 
at 41,035 (source: 2010 population census). The number of pregnant women is 4004 and 
children under five is 20,010 (Agona East DHD., 2015).  There are 134 communities 
district wide; 70 in Nsaba-Duakwa, 9 in Asafo, 42 in Kwanyako and 13 in Mankrong. The 
district has 5 health centers situated in all 5 Subdistricts. Malaria remains a major cause of 
ill-health in the Agona East District and it is one of the districts in the Central Region that 
benefitted from the house to house hang up campaign in 2010. The Central Region on the 
average has 1.3 ITNs per a household, 69.7% households own at least one net and 58% of 
households with access to ITN. It has approximately 526,764 households and a population 
size of 2,201,863 (GDHS, 2014 and Population Census, 2010).  
 
3.2 Sample Size Determination 
For the quantitative aspect of this study, a modified form of the Expanded Program for 
Immunization (EPI) 30 cluster survey method for random cluster sampling was used. 
Assuming a desired precision (d) of ±5% with 95% confidence level (t) and a frequency of 
University of Ghana                              http://ugspace.ug.edu.gh
25 
 
net use of 45% (P) {which is the prevalence of population sleeping under nets in the 
Central Region which is used as a proxy} (GDHS, 2015), imputed into the formula below  
gives a sample  size(n) as 380. 
Formula:  
n= t² x p(1-p) 
  d² 
Description: 
n = required sample size 
t = confidence level at 95% (standard value of 1.96) 
p = estimated prevalence of ITN use in Agona East District in the Central Region 
d = desired precision at 5% (standard value of 0.05) 
Taking into account contingencies such as non-response, recording errors and using the 
standard number of clusters (i.e. 30) established by the EPI on cluster survey, the number 
is adjusted to 390, as the final sample size.   
Number to sample per cluster:  
                                              = n/m 
Where m = number of clusters, this gave 30 clusters with a cluster size of 13. 
For the qualitative aspect of the study, 13 key informants were interviewed. 
3.3 Sampling Technique  
Quantitative Arm 
A two stage cluster sampling was used for the study. Thirty communities (cluster) out of 
134 communities were selected. The number of communities selected per a sub district 
were proportionate to the population size of the sub district. This was followed by 
selection of 13 households per a community. The following procedure was used to select 
each household. In each selected cluster the interview team stood at the centre of the Main 
Street in the community and a direction was randomly chosen by spinning a pencil and the 
University of Ghana                              http://ugspace.ug.edu.gh
26 
 
direction of the tip of the pencil was chosen. Each household in that direction was visited 
till target number of households per community were reached. If target was not reached 
we came back to the starting point and took the opposite direction until a target of 13 
households per community was achieved.  
Qualitative Arm 
The key informants for the in-depth interview were purposively selected. The following 
categories of key informants were selected purposively; all 5 in charges of health centres, 
2 midwifes, 2 opinion leaders,1 district malaria focal person, 2 women traditional leaders 
and the district director of health. These key informants were considered because they are 
believed to be more knowledgeable about ITN as a preventive tool for malaria. 
    
3.4 Variables 
3.4.1 Dependent variables 
The dependent variable was sleeping under an ITN the night before. 
3.4.2 Independent variables  
The independent variables were age and sex of the household heads, household factors and 
the level of awareness on ITN utilisation. 
Categorized as; 
I. Sociodemographic characteristics of household head; the age, sex, marital 
status, level of education; whether respondent was educated or not, employed or 
unemployed and the occupation of the household head. The socioeconomic status 
of households were measured using the International Wealth Index (IWI) scale. 
The household wealth index was derived from possession of consumer durables 
University of Ghana                              http://ugspace.ug.edu.gh
27 
 
e.g.: television, refrigerator, telephone, car, motor bike, or a bicycle, access to 
basic services e.g.: source of drinking water and electricity., and housing 
characteristics as in number of rooms used for sleeping and material used for 
construction of house. These items have weight derived from the IWI formula, 
which is the central component of the IWI. Using this formula, each household for 
which the asset values are known can be ranked on the IWI scale. The scale is 
additive the scores are from 0 to 100 and are grouped into 5 quintiles (q), from the 
lowest q1, (score of between 0 to 19) to the highest q5, (between 80 to 100). 
(Smits, Jeroen & Roel Steendijk, 2014). 
II. Household characteristics; household size.  
III. Household nets use and source; the presence of nets and the number of nets and 
source of the net. 
IV. Household level of awareness on net use; This included information on net use 
such as, regular use of net, airing of nets before use, to hang nets before night fall, 
the fact that torn nets can be sewn, not lighting candles under nets and washing 
dirty nets. The sources of the information on net use e.g. the media, the health 
worker, posters and vouchers and others. And lastly having discussed with family 
or friends, why they should sleep under net, what these nets are, and how to care 
for these nets and so on.   
 
3.5 Data Collection 
The tool for data collection was a questionnaire for the quantitative data collection and an 
interview guide for the qualitative data collection. The head of the household answered 
University of Ghana                              http://ugspace.ug.edu.gh
28 
 
questions on behalf of all household members including those relating ITN ownership and 
usage  among all household members. 
  
Data collection was done during the start of the dry season (February to March) using a 
modified Malaria Indicator Cluster Survey ((MICS) structured questionnaire about 
household ownership and utilization of mosquito nets (treated or untreated). The modified 
questionnaire was shared for inputs from stake holders. It was then finalized and pre tested 
to check its validity and reliability.  
 
3.6 Data processing and Analysis 
Data collected was entered into Epi-data, version 3.1 and backed up in Excel 2013. It was 
cleaned and checked for accuracy and completeness in Excel 2013. The data is transferred 
to Stata SE 13 software for analysis.  
The association of each possible independent variable with the dependant variable (ITN 
used or not used the night before) was tested by estimating bivariate odds ratio (OR). 
Multivariate logistic regression was used to assess independent predictors of ITN use. All 
variables that were significant via the bivariate analysis (p< 0.05) were used in the 
multivariate analysis. 
The qualitative analysis was done manually. The data was analysed by summarizing 
findings at the end of the day per each interview using these tentative themes bringing 
together similar views from different respondents together. Trends by various key 
informants were looked at, described and interpreted. 
University of Ghana                              http://ugspace.ug.edu.gh
29 
 
3.7 Ethical Issues 
Proposal was submitted to the Research and Ethical Review Committee for approval. 
Permission was also obtained from the Regional and district director of health services as 
well as the District Chief executive and the chiefs and elders of the community. Informed 
consent was sought from respondents. This was done both verbally and in a written form 
and the calibre of people to be interviewed.  
A written Consent was sought from heads of house-holds before interview was conducted, 
and they had the right to opt out if so wished.   
All information gathered was handled anonymously and confidentiality and privacy was 
assured. The information was re-coded and numbers alone assigned, only supervisor and 
principal investigator had access to this information.   
. 
 
3.8 Limitations 
Failure of key informants to fulfil appointments made with them. 
The poor road network and dusty nature of the roads rendered some places inaccessible. 
 
University of Ghana                              http://ugspace.ug.edu.gh
30 
 
CHAPTER FOUR 
RESULTS 
4.1 Characteristics of the Sample 
 Overall 390 households were involved in the study. Of the 390 household heads, 52.6% 
(205) were males and 47.4% (185) were females. The average age of the household head 
was 45.1 (CI 43.42-46.78) years; with a minimum age of 17 years and the maximum of 
108 years.  With regards to marital status 73.6 %( 287) were either married or co habiting, 
10 %( 39) were widowed, 7.4% (29) were divorced and 9.0% (35) were never married or 
currently single.  
The majority, 49.5% (193) of the respondents (household heads) had attained primary 
education, while 20.0% (78) had no education, 26.5% (104) had attained secondary 
education and a few, 4.0% (15) had attained tertiary education. Majority of the 
respondents, 52.8% (196) were peasant farmers followed by traders 19.7% (73), 
professional workers government or privately employed were 12.4% (46) and artisans and 
labourers were 15.1% (56). Most of the surveyed households in Agona East were in the 
second wealth quintile (32.9%), this is followed by those in the third quintile (29.3%) and 
then the fourth quintile (Table1). 
University of Ghana                              http://ugspace.ug.edu.gh
31 
 
Table 1: Sociodemographic characteristics of household heads in Agona East in the 
Central Region of Ghana, 2015 
Sociodemographic characteristic Proportion (%) 
Age group (years)  
≤19 4(1.0) 
20-29 81(21.0) 
30-39 86(22.0) 
40=49 92(23.5) 
≥50 127(32.5) 
Gender  
Male 205(52.6) 
Female  185(47.4) 
Level of education  
No education 78(20.0) 
Primary 193(49.5) 
Secondary 104(26.5) 
Tertiary 15(4.0) 
Employment status  
Employed  369(94.6) 
Unemployed 21(5.4) 
Occupation  
Professional 46(11.8) 
Trader 73(18.7) 
Artisan 54(13.8) 
Labourer 2(0.6) 
Farmer 215(55.1) 
Marital status   
Married 287(73.6) 
Never Married 35(9.0) 
Divorced 29(7.4) 
Widowed 39(10.0) 
Wealth quintile  
University of Ghana                              http://ugspace.ug.edu.gh
32 
 
 Poorest 37(9.5) 
Second 108(27.7) 
Middle 94(24.0) 
Fourth 66(17.0) 
Richest 85(21.8) 
 
 A total population of 1196 were in the 390 households, 45.9 % (549) were males 54.1% 
(647) were females and 2.3% of these females were pregnant. Of the total population 
17.6% (210) were children under age five. 
House hold size ranges from 1to 12 with a mean size of 4.2 (95% CI 4.05-4.43) (Table 2).  
 
Table 2: Household characteristics in Agona East in the Central Region of Ghana, 
2015. 
Characteristics Proportion (%) 
Age of household members(years)  
<5 210(17.6) 
5-14 384(32.1) 
15-49 518(43.3) 
5˃0 84(7.0) 
Gender of household members  
Male 549(45.9) 
Female 647(54.1) 
Women pregnant 12(2.3) 
Household size  
1-4 209(53.6) 
5-7 163(41.8) 
7˃ 18(4.6) 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
33 
 
4.2 ITN Ownership and sources in the households 
Of the 390 households interviewed, 76.2% (297) were in possession of any net either 
retreat able or long lasting insecticide treated bed nets, while 2.8% did not have any 
mosquito net. The mean of net ownership of 2 nets per a household (95% CI 1.72-1.80) . It 
was found out that there was a relationship between net ownership and level of education 
of head of household (Table 3). Majority of the household heads (36.4%) who had any 
kind of nets in their households had attained primary education. Table 3, revealed that 
those with no education were least likely to possess nets. Out of the household heads with 
no education 4.4 % (17) had no nets..         
Table 3 Distribution of level of education of head of household with household net 
possession in Agona East in the Central Region of Ghana, 2015. 
 Net possession 
Level of education of head of 
head of household  
Yes (%) No (%) 
No education 61(15.7) 17(4.4) 
Primary 142(36.4) 51(13.0) 
Secondary 80(20.5) 24(6.1) 
Tertiary 14(3.6) 1(0.3) 
Total  297(76.2) 93(23.8) 
p-value=0.339 
 
University of Ghana                              http://ugspace.ug.edu.gh
34 
 
Household heads engaged in farming formed the majority (55.0%) of those who owned 
nets (42.8%), they also formed majority those that do not possess any net (12.2%) (Table 
4).  
Table 4 Distribution of occupation of head of household with household net 
possession in Agona East in the Central Region of Ghana, 2015. 
 Net possession 
Occupation of head of household Yes  No  
 Proportion (%) Proportion (%) 
Professional 36(9.2) 10(2.6) 
Trader 50(12.8) 23(5.9) 
Artisan 42(10.8) 12(3.1) 
Labourer 2(0.5) 0 
Farmer 167(42.8) 48(12.2) 
Total  297(76.2)  93(23.8) 
p- value= 0.431 
 
4.3 Prevalence of net use Among Household Members 
Of the total households 64.4% (251/390) reported use of any kind of net. Of this total 
number of households that reported use, 23.1% had more than 3 nets in their households, 
35.5% of these households had 2 nets and the majority (41.4%) of households with only 1 
net. (Table 5). And out of this 59.4% (149/251) of them used nets, giving a total household 
net use of 38.2% (149/390) Household number of nets was found to be significantly 
associated with household net use in the bivariate analysis and the odds of net use is 
University of Ghana                              http://ugspace.ug.edu.gh
35 
 
increased with higher household net density compared to households with lower net 
density (Tables 6 & 7) Majority of these nets (38.7%) were sourced from mass campaigns 
and from the clinic (24.4%), the least sourced was the vending sites. Of the total nets used, 
96.4% of them were reported to be the long lasting insecticide treated net (LLIN) type of 
net and the  rest 3.6%  were  the retreatable ones. 
Table 5: Reported net use in households in Agona East in the Central Region of 
Ghana, 2015 
Number of household nets Proportion 
(%)  
   
1  104(41.4) 
2 89(35.5) 
3˃ 58(23.1) 
 
University of Ghana                              http://ugspace.ug.edu.gh
36 
 
Table 6 Distribution of net use in households in Agona East in the Central Region of 
Ghana, 2015.  
Number of household nets Use of net 
No (%) 
Non- use of net 
No (%) 
Significance (P - 
value)  
1 64(61.5) 40(38.5)  
2 50(56.2) 39(43.8) 0.001 
3˃ 35(60.3) 23(39.7)  
 
Table 7 Estimates of the effect of number of household nets on the probability that a net 
was used the prior night in Agona East in the Central Region of Ghana, 2015.  
Number of household nets Use of net 
No (%) 
Non -use of net 
No (%) 
OR(95% CI) 
1 64(61.5) 40(38.5) 1.0 
2 50(56.2) 39(43.8) 1.2(0.7-2.2) 
3˃ 35(60.3) 23(39.7) 1.2(0.5-2.0) 
 
The odds of net use in the household is increased with a higher number of household nets 
compared to a low number of household net ownership (Table 7). 
 To ascertain source of information on net use the heads were asked their source of 
information on net use. More than one option was possible. The predominant source of 
information on net use were the mass media and through health workers (figure 3). 
University of Ghana                              http://ugspace.ug.edu.gh
37 
 
0
50
100
150
200
250
health 
worker
radio community 
based 
volunteers
television poster leaflets and 
brochure
no media 
exposure
others
F
r
q
u
e
n
c
y
 
o
f
 
s
o
u
r
c
e
 
source of information on  mosquito nets 
 
Figure 3: Sources of information on net use in Agona East in the Central Region of 
Ghana, 2015 
 
Table 8: Net use among household in Agona East in the Central Region of Ghana, 
2015. 
 Sleeping under ITN 
 
Significance (P - value)  
Category Yes (%) No (%) 
Age of household 
members (years) 
   
<5 110(9.2) 100(8.4) 0.244 
5-14  212(17.7) 172(14.4)  
15-49 306(25.6) 212(17.7)  
5˃0 49(4.1) 35(2.9)  
    
Women  pregnant  6(0.5) 6(0.5) 0.117 
 
4.4 Level of Awareness on net use 
 The level of awareness  on net use amongst the 390 households in Agona East indicated 
that , majority of the household heads  87.2 %( 340) responded „yes‟ to having had an 
information on the use of net and 12.6% denied having had any information on net use. 
University of Ghana                              http://ugspace.ug.edu.gh
38 
 
Thirty three percent (130) of the house heads responded „yes‟ to having discussed the use 
of net with the family or friends but a majority of them (66.7%) did not discuss net use 
with their family members or friends  (table 9). Examining net use with level of awareness 
indicates that a majority of heads (34.2%) who used nets had ever had information on net 
use. On the other hand, having discussed net use with the family or friends was least likely 
to have used net (7.4%). Majority of those who did not discuss net use (66.7%) used it 
(35.8%). Those who discussed net use (33.3%) a majority of them (25.9%) failed to use 
nets the prior night (Table 10). Level of awareness of head of household on net use was 
significant in the univariate analysis. The odds of net use is increased by almost 4 times 
comparing not having had any information on net use to having had any information on 
net use. Similarly having discussed net use with family or friends is 4 times likely to have 
used a net compared to having ever discussed net use in the past month with friends or 
family members (Table 11).  The predominant subject dis cussed was why the family 
should sleep under a bed net, all other reasons were equally predominantly discussed 
(Table 6) (Table 9). The predominate source of information on net use were the health 
worker (224/390) followed by the radio (211/390), the community based volunteers 
(172/390) and through posters (85/390). A minority of the heads (21/390) had no form of 
media exposure, the other sources of information included family members and at school 
amongst others (figure 2). Predominate sources of information are obvious since in most 
district set ups these are the foot soldiers and with radio it is one of the commonest source. 
. 
University of Ghana                              http://ugspace.ug.edu.gh
39 
 
Table 9 level of awareness in household heads in Agona East in the Central Region of 
Ghana, 2015 
Subject Proportion (%) 
House hold head has ever had information on net use   
No 50(12.8) 
Yes 340(87.2) 
House hold head has discussed with family or friends 
about net  use the last one month 
 
No 260(66.7) 
Yes 130(33.3) 
 
  
Table 10: Awareness of head of household on net use in households in Agona East in 
the Central Region of Ghana, 2015 
Issue on awareness in terms 
net use  
Use of net 
№ (%) 
Non-use of 
net № (%) 
Total (%) P value 
House hold head has ever 
had information on net use  
    
No 35(9.0) 15(3.8) 50(12.8) 0.001 
Yes 134(34.2) 206(53.0) 340(87.2)  
House hold head has 
discussed with family or 
friends about net  use the 
last one month 
    
No 140(35.8) 120(30.9) 260(66.7) 0.001 
Yes 29(7.4) 101(25.9) 130(33.3)  
 
 
University of Ghana                              http://ugspace.ug.edu.gh
40 
 
Table 11 Effect of level of awareness of head of household on net use in households in 
Agona East in the Central Region of Ghana, 2015 
Issue on awareness in terms 
net use  
Use of net 
№ (%) 
Non-use of net 
№ (%) 
Total (%) cOR (95% CI) 
House hold head has ever 
had information on net use  
    
No 35(9.0) 15(3.8) 50(12.8) 1.0 
Yes 134(34.2) 206(53.0) 340(87.2) 3.59(1.86-6.92) 
House hold head has 
discussed with family or 
friends about net  use the 
last one month 
    
No 140(35.8) 120(30.9) 260(66.7) 1.0 
Yes 29(7.4) 101(25.9) 130(33.3) 4.06(2.45-6.72) 
 
 
Table 12: Subjects discussed by house hold heads to their family or friends in Agona 
East in the Central Region of Ghana, 2015 
Subject  Proportion (%) 
Why you and your family should sleep under nets 89(22.8) 
What treated nets(LLIN) are  61(15.6) 
How to use treated nets 60(15.4) 
How to care for the treated nets 68(17.4) 
How to hang nets  55(14.0) 
Who should use treated nets 60(15.4) 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
41 
 
4.5 Household Factors Influencing ITN use 
Household factors were cross tabbed with household sleeping under any net prior to the 
survey. A majority (17.7) of those who slept under nets were from households whose 
heads were 50years and above, interestingly the majority of those who did not also sleep 
under nets were from households with heads of similar age group. The likely hood of a 
household member sleeping under net was more with older household heads. However, 
influence of household head age on the household use of net did not show significance 
(Table 13),  
 Household use of net the prior night with level of education of head of house hold 
indicated a greater likelihood of net use among households with heads who had attained 
primary education or no education (39.5%) as compared to those households with heads 
with higher educational attainment (17.2%). A critical look at the table shows that even 
though there were a few of household heads with tertiary education, two thirds of them 
had their households sleeping under nets. Level of education of household head did not 
show significance with household net use (Table 13). 
Households with male heads (33.5%) were more likely to have slept under nets compared 
to households with female heads (23.2%). More than half of the households with female 
heads (24.3%) did not sleep under nets (Table 13). Influence of household head gender on 
household use of net is significant and the likelihood household net use with female heads 
is decreased by 55% compared to households with male household heads (Table 14). 
Majority of Households (54.4%) with heads engaged in some form of employment used 
net and similarly majority of households (40.2%) with employed household head did not 
sleep under net. Most these household heads are peasant farmers and they form the chunk 
of the employed house hold heads. Influence of employment on household use of net 
however, was not significant (13).  
University of Ghana                              http://ugspace.ug.edu.gh
42 
 
Household level of wealth was not significantly associated with household net use, 
however individuals from the richest households (13.1%) and second quintile households 
(17.2%) and middle quintile (13.3%) were more likely to have slept under net the previous 
night compared to households in the poorest quintile (Table 13).  
 House hold size was not significantly associated with household sleeping under net, how 
ever increasing household size decreased the likelihood of the household sleeping under 
net the previous night (Table 13) (Table 14).  
 
University of Ghana                              http://ugspace.ug.edu.gh
43 
 
Table 13: Distribution of households who slept under ITN the prior night in 
households with at least one ITN in Agona East in the Central Region of Ghana, 
2015. 
Socio-demographic 
Characteristics  
Non-use of 
net № (%) 
 Use of net   
№(%) 
Significance 
(P - value)  
Age of head of household 
(years) 
   
<19 2(0.5) 2(0.5) 0.680 
20-29 38(9.7) 43(11.0)  
30-39 37(9.5) 49(12.6)  
40-49 34(8.7) 58(14.8)  
>50 58(14.9) 69(17.7)  
    
Level of education of head of 
household 
   
No education 32(8.2) 46(11.8) 0.651 
Primary 85(21.8) 108(27,7)  
Secondary 47(12.0) 57(14.6)  
Tertiary 5(1.3) 10(2.6)  
Gender of head of household    
Male 74(19.0) 130(33.5)  
Female 95(24.3) 91(23.2) 0.003 
Employment status of head 
of household 
   
Employed 157(40.2) 212(54.4)  
Unemployed 12(2.1) 9(2.3) 0.190 
Occupation of head of 
household 
   
Professional 18(4.6) 28(7.2)  
Trader 36(9.2) 37(9.5) 0.329 
Artisan 26(6.7) 28(7.2)  
Labourer 0(0) 2(0.5)  
University of Ghana                              http://ugspace.ug.edu.gh
44 
 
Farming 77(19.7) 119(30.5)  
Household wealth quintile    
Poorest 20(5.1) 17(4.4) 0.167 
Second 41(10,5) 67(17.2) 0.185 
Middle 42(10.8) 52(13.3) 0.762 
Fourth 32(8.2) 34(8.7) 0.354 
Richest 34(8.7) 51(13.1) 0.483 
Household size    
1-4 99(25.5) 105(27.0)  
5-7 57(16) 98(24.2)  
7˃ 10(2.5) 21(5.5) 0.003 
    
  
Table 14 Estimates of effect of household occupants on the probability that a net was used 
the night before in Agona East in the Central Region of Ghana, 2015. 
Characteristics Use of net 
№ (%) 
Non-use of net 
№ (%) 
OR(95% CI) 
Gender of head of household    
Male 74(36.3) 130(63.7) 1.00 
Female 95(51.1) 91(48.9) 0.55(0.36-0.82) 
Household size    
1-4 68(32.5) 141(67.5) 1.0 
5-7 76(46.6) 87(53.4) 0.6(0.4-0.8) 
7˃  10(83.3) 2(16.7) 0.1(0.1-0.4) 
 
In the final model of analysis there was significant difference in net utilisation between 
individuals who come from households where the head of the household had discussion 
with family or friend s compared to those in households where heads had no discussion 
about net use.  (aOR=3.5) (Table 15). 
 
University of Ghana                              http://ugspace.ug.edu.gh
45 
 
Table 15: Logistic regression of predictors of households sleeping under an ITN a 
night before in households with at least one ITN in Agona East in the Central Region 
of Ghana, 2015. 
Characteristics  
aOR 95% CI 
 
P 
value 
Household size(compared to a 1-4 household size)   
5-7 1.34(0.58-3.09) 0.498 
7˃ 1.60(0.17-16.48) 0.655 
Sex of head of household     
Female 
Number of nets in household  
1 
2 
0.67(0.39-1.17) 
 
0.66(0.32-1.38) 
1.2290.56-2.70) 
0.159 
 
0.272 
0.615 
≥ 3 1.00  
Having discussed net use with family or friends    
Yes 3.50(1.84-6.65) 0.001 
 House hold head has ever had information on net   
Yes 1.03(0.41-2.64) 0.07 
Note; aOR- adjusted odds ratio, CI confidence interval 
 
 Household reasons for not sleeping under net the previous night were clustered around the 
respondent (head of the household). These reasons could be cited once or more by the 
respondents. The predominantly cited reasons bordered around environmental and social 
factors associated with net use.  Amongst them were the hot weather conditions (50/169), 
not having a net (72/169), disruption of sleeping arrangements (18/169), the feeling of 
lying in a tomb (23/169) and of course the cost of the nets (22/169) (Grabowsky et al., 
2005)amongst others (Table 16). Key informants gave similar reasons for the non-use of 
nets. One of the women leaders had this to say; „the weather at this time is too hot for us 
to use the nets, more so the net generates a lot of heat making sleep difficult for me „ some 
went onto say that it made them sweat and to develop heat rashes. One of the respondents 
commented. „ my children and myself sleep in one room , if we are to use nets we may not 
have enough space to sleep and the nets may affect our sleeping arrangement’.  One of the 
midwifes had this to say; „ I am alone here in this vicinity as the chief midwife and so on 
University of Ghana                              http://ugspace.ug.edu.gh
46 
 
call, I know very well that I must use nets but I get home so tired and don even think I need 
to put down my net for sleep’ . One of the respondents said „the nets are not given to us for 
free sometimes we have to pay some money to have it especially from the market place and 
with our meagre income I don’t think i can purchase a lot for my huge household and 
again I cannot go buy a net when I have so many mouths to feed’ lack of financial 
capability was frequently mentioned by key informants as an important barrier to owning a 
net(. Another respondent said 
 „I have bad dreams when I sleep under the nets it is as if I am being chased in 
my dreams so I have stopped using it’.  
This is a belief that is held tight by some of them and was admitted by the director of 
health services.  
‟instructions given to the nurses are that they should give the nets to the newly 
registered pregnant women and so some of us who did not start our antenatal 
clinics early did not get one’, and ’i prefer the conical ones to the rectangular 
ones since they occupied lesser space’  
was the reason given by one of the informants who had just delivered. 
 ’I don’t have a net because when the nets arrived at the health centres we are 
told it was meant it was meant for the children and pregnant women’ 
 was what one of the respondents said.  
Some knew that it was the responsibility of the government to provide the under to 
provide ITNs to children under five. „The nets brought are not enough to cater for 
everybody’. Some of the informants at another breath expressed doubts about securing a 
net from the open market or the vending sites,‟ I don’t know where in this town that they 
sell nets „this was what one of the respondents said. Some people expressed interest in the 
nets but did not know where to get one or was not sure if some were available to buy.         
University of Ghana                              http://ugspace.ug.edu.gh
47 
 
 Reasons for sleeping under net the previous night were predominantly social and 
environmental, they included the presence of mosquitoes in the environment (197/221), 
and followed by the obvious reason that it protected us from mosquito bites (195/221) 
amongst others (Table17).  
 
University of Ghana                              http://ugspace.ug.edu.gh
48 
 
Table 16: Household head reasons for not using nets in Agona East in the Central 
Region of Ghana, 2015 
 Reasons   Proportion (%)   
Environmental The weather is hot 50(30) 
 There are no mosquitoes here 10(6) 
Social I forgot to hang the net last night   3(2) 
 It makes me feel like I am lying in a tomb 23(14) 
 It disrupts our sleeping arrangement 18(11) 
 I don‟t have a net 72(42) 
 It is expensive to buy 22(13) 
 It is not available to buy 12(10) 
Technical  The size of the room are too small to hang nets 15(9) 
 The type of roof construction will not allow us to 
hang net 
7(4) 
 The size of net to bed is too small making it difficult 
to hang nets 
2(1) 
 I have difficulty putting down or up net 6(4) 
 The net is torn so I can‟t hang it  21(12) 
 Net is washed or retreated 3(2) 
   
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
49 
 
Table 17: Household head reasons for using net the prior night in Agona East in the 
Central region of Ghana, 2015. 
Factor Reasons Proportion 
(%) 
Environmental There are mosquitoes here 197(89) 
Social It protects us from mosquito bites 195(88) 
Technical  The size of the rooms are o k to hang nets 69(31) 
 The type of roof construction allows us to hang nets 34(15) 
 The size of net to bed is o k 57(26) 
 It is not difficult putting up or down the net 57(26) 
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
50 
 
CHAPTER FIVE  
DISCUSSION 
Key indicator for the universal coverage in terms of net use as outlined in the WHO report 
is ownership. Net ownership is important to assess the effectiveness of the distribution 
channels of the policy implementers and suggest program modifications where there are 
lapses. Studies have shown the importance of ownership on utilisation in several countries 
including Ghana (Baume & Franca-Koh, 2011) and elsewhere. ITN ownership in study 
area (Agona East) was high compared to the Region (76.2% versus 69.7%, at least one 
net) similarly in  studies done in Oromia and  Amhara Regions of Ethiopia where the 
prevalence was 49.1%(Deressa et al., 2011) and some places in Africa(Korenromp et al., 
2003) and in Mozambique in a post household mass campaign (Macedo de Oliveira et al., 
2010) where ownership was 20.6% This reflects the massive efforts in ITN distribution in 
the past years especially to the hinterlands primarily implemented by NMCP/GHS. And it 
suggests that a strategy targeting free ITNs to rural and poorer households optimizes 
ownership(Pettifor et al., 2008). Educational level of head of household in this study was 
found to influence possession of net in this study population though not significant. 
Respondents who had no education were least likely to possess nets (Baume & Franca-
Koh, 2011). Household heads engaged in farming were the majority and therefore 
majority of those who possessed net. Professional were only a few but a majority of them 
owned nets, this is due to the fact that the professionals are implicitly richer and could 
afford to buy a net.  
 Households with higher number of nets were likely to use nets as witnessed in most 
studies done elsewhere(Baume et al., 2009). Campaigns aimed at giving free nets to 
individuals can increase ownership ( Ordinioha, 2012) and by extension improve on 
utilisation(Koenker & Kilian, 2014). We should not forget that improving ownership alone 
University of Ghana                              http://ugspace.ug.edu.gh
51 
 
does not always lead to utilisation (Vanden Eng et al., 2010)(Githinji et al., 2010), it 
involves other factors which may be household factors associated with net use. 
Reported household use of any kind of net was 38.2%. Net use in pregnant women is 
higher in Agona East District compared to the Central Region (50% verses 44.7%) 
according to the GDHS and similarly high in children under five in the study area 
compared to the Central Region (52.4% verses 51.2%), and to the findings done in 
Southern Sudan  involving children under five and pregnant women (Eyobo et al., 2014). 
However, this is low compared to the National target of 70% for children under age five 
(MOH., 2012).  In the study, even though net use was good in household with children 
under five and pregnant women in the Agona East compared to other places, much needs 
to be done if we are to achieve the universal coverage and utilisation of ITNs.    
 Households where ITN utilisation is discussed with households and friends were more 
likely to use nets and least likely to use net if the head did not discuss net use with family 
or friends. This stresses the need for awareness in net use to optimize its use(Baume & 
Marin, 2007) especially through health personnel and  the mass media (Bowen, 2013).   
The study did not observe an association between net use and age of the heads of the 
households, however households with under- fives are more likely to have slept under a 
net the prior night. This was in contrast to the study conducted in Ethiopia by Graves et 
al., (2006) who found that an increased net use was associated with age 25-49 years 
(OR=1.4 CI 1.2-1.7) as compared to children under 5 years. Ng‟ang‟a et al in  2009  in 
Central Kenya in their study to assess bed net use and associated factors in rice farming 
communities observed a significant variation in bed net use with age, unlike in  Agona 
East district which is also predominantly a farming community. Most of the heads were in 
the middle age group 20-49 years and odds of net use was high within this age group as 
compared to the extreme age groups in the bivariate analysis. It is obvious that a 
University of Ghana                              http://ugspace.ug.edu.gh
52 
 
household head will be in a certain age group at least above 18 years in Ghana, since at 
this age most Ghanaians will want to be on their own. 
Levels of education of the heads was not observed in the study to be significantly 
associated with net use by the household heads. This was in contrast with the Ng‟ang‟a et 
al study in central Kenya, where educational levels of the household head or spouse was 
significantly associated with net use. Most of the household heads in Agona East either 
had no education or attained a secondary education. The odds of net use was three times in 
those who attained tertiary education compared to their compatriots who had no education. 
Higher educational standard is known to be associated with net use as witnessed in a study 
in a rural population in northern Ethiopia (Belay & Deressa, 2008)  In the bivariate 
analysis of the hospital based study conducted by Iloh et al in South Eastern Nigeria 
observed that secondary education and above used ITNs more than those who had primary 
education and below. It is believed that well educated people are the most informed in the 
and likewise their household in terms of net use. There are a few of them in such semi 
urban areas as envisaged in the study but with a relatively high use of nets in their 
households. Contrastingly Adogu and Ijemba, in 2013 found that the use of ITN the night 
before was low for those with tertiary education but significantly increased for those with 
secondary and primary education respectively. This is to say that level of education is 
quiet crucial, but with our folks in such areas attaining higher education is difficult 
because of the associated cost of education. May be with promised free education we hope 
to see a lot people in school and graduating to high levels to improve on net use and to 
help eradicate malaria. 
Gender of the household head was clearly significant with household use of nets. This 
finding were found in studies done in Ethiopia(Agyepong & Manderson, 1999). The study 
observed that for female heads the odds of household net use was reduced by 5 folds 
University of Ghana                              http://ugspace.ug.edu.gh
53 
 
comparing them to the males, this was a significant finding but was in contrast with what 
Ngondi et al saw in the individual study done in Ethiopia, the study found female gender 
to be significantly associated with increased net use(Ngondi et al., 2011), Pethifor et al , 
2008, also found same with net use in Kinshasa, Democratic Republic of Congo. This 
difference in findings may be attributed to the settings as a „nursing mother „and a‟ 
household head‟. Secondarily, being a household head is not a common place for women 
in Ghana and possibly elsewhere in Sub Saharan Africa. 
Our study did not observe a significant probability of household net use with occupation 
of head of household, .Ng‟ang‟a et al., (2009) on the other hand observed a level of 
significance with net use. And so also was Negash et al, (2012) in Ethiopia. A number of 
the heads were farmers and the least were professionals, the odds of net use in the other 
forms of occupation were low compared to the professionals. This may be seen in the 
trend of level of education, professionals are the more educated. 
A study done at the Medical Research unit of the Albert Schwetzer hospital in Lambrene, 
Gabon, found levels of socioeconomic status to be inversely related to bed net use 
(Goesch, 2008).Socioeconomic status of heads of households in the study on the other 
hand did not come out to be significant in terms of net use. The extremes of wealth 
quintile in the study showed high odds of net use compared to the second and middle 
groups. Most respondents‟ households in the study lie within the second and middle 
wealth quintile. 
Household size in the study was not observed to be significant in terms of net use, but the 
dominant house hold sizes were one and two. The bivariate analysis showed an increasing 
odds of net use in households with high density population as compared to the ones with 
low density population.  Much is not known about household sizes and net use, but 
University of Ghana                              http://ugspace.ug.edu.gh
54 
 
nevertheless they are good parameters used during household net distribution, hence 
ownership. 
Level of awareness was observed to significant in the study, the odds of net use in 
households whose heads have discussed mosquito net with family members or friends are 
3.5 times likely to use nets the previous night compared to those in households whose 
heads failed to discuss mosquito nets with their friends or families, In outlining the impact 
of awareness through mass media campaign on net use, studies have shown the impact of 
awareness in net use (Bowen et al., 2013)(Owusu Adjah & Panayiotou, 2014).  Bennet et 
al in 2012, in their study in Sierra Leone household heads who heard malaria messages 
were more likely to have slept under ITN. We cannot therefore down play the essence of 
creation of awareness within the populace to encourage net use within households. A 
descriptive study carried out in the Northern state of Nigeria found a third of the women 
were aware of ITN prevention but less than a third had ever used (Musa et al., 2009). 
Awareness though an important tool in assessing net use, increased awareness is not 
always commensurate with net use in households, that is to say that there is more to it than 
the awareness or discussing net use with people or having an information on net use. In 
this study a number of households whose heads had information on net use were more 
likely to have used net compared to having had information on net use. 
In assessing household reasons for non-use of nets the dominant answers given were 
equally observed in a review of published literature on net use when one owned one by 
Pulford et al in 2011 that, discomfort, primarily due to heat, and perceived (low) mosquito 
density were the most widely identified reason for non-use. Baume et al in 2009, also 
observed that the most reason for net non-use was there are few mosquitos around or 
malaria was not a serious problem. In the study issues about weather was obvious because 
of the study period, which was actually during the hot dry season. In a study done by 
University of Ghana                              http://ugspace.ug.edu.gh
55 
 
Atieil et al in 2011, the compliance rate in terms of net use was significantly higher during 
the rainy season compared with the dry season. In the qualitative analysis some of these 
issues came up during the key informant interview. Unavailability of air conditioners in 
these homes and even in the presence of an air conditioner there is a power crisis in the 
country will hamper net use in some homes. Most of our folks want to be given nets free 
of charge and would not be prepared to even pay a penny to acquire it, hence the cost issue 
even when nets are available at certain vending sites. The dominant use of LLINs in 
households is a manifestation of benefit from mass campaigns, more than half of the nets 
in households were as a result of free donations from mass campaigns and from health 
personnel. 
The dominant reason for use of nets was obvious, protection from mosquito bite was the 
definition given for an ITN in the key informant interview. These are tangible reasons and 
need to be encouraged.  
This obvious reason for the use of net was the predominant answer to what a mosquito net 
was in the key informant interview with some of the respondents. This definition runs 
through  most of the interviews held, the name given to the net was put literally as 
„mosquito house‟   not to mean a house for mosquitoes but are „house‟ protecting us from 
the bite of the mosquito. This is to say that most people had knowledge of ITN but putting 
this knowledge to action was the problem. 
The major source of information on net use clearly states the role of the media in 
improving the health needs of the populace (Owusu Adjah & Panayiotou, 2014)(Bowen, 
2013)   
University of Ghana                              http://ugspace.ug.edu.gh
56 
 
CHAPTER SIX 
CONCLUSION AND RECOMMENDATIONS 
6.1 Conclusion 
This study clearly shows a gap between household possession of net and usage and it also 
demonstrates that in Agona East District of Ghana ITN use in households is significantly 
associated with household head level of awareness in terms of ITN use, which should be 
incorporated into programme policy. ITN use in Agona East in the Central Region of 
Ghana is low and could be stepped up by increasing the level of awareness and stepping 
up mass campaigns offering free nets to the populace. Household factors such as 
household net density and household size have an influence on net use, they affect the 
affect consistency in utilisation of ITNs and the proper deployment. This is the knowledge 
of the study. 
 
 
6.2 Recommendations 
National Malaria Control Programme (NMCP) 
1. Should continue the free distribution of ITNs to improve on household ownership 
and utilisation. 
2. Should continue mass education through the media and health education or talks in 
the communities by health workers so as   to improve on level of awareness on net 
use. 
3. Coerce government to support the use of ITN as a preventive measure for malaria. 
Agona East District Health Directorate  
1. Communities should be sensitized on the importance of ITN as a preventive 
measure for malaria 
2. Improved information and communication could be used to erase erroneous 
perceptions and in addition improve on the awareness level in the community. 
University of Ghana                              http://ugspace.ug.edu.gh
57 
 
Agona East District Health Centers  
1. Educate clients on the use of ITN as a preventive measure for malaria. 
2. Educate clients on the consistent and correct use of ITNs. 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
58 
 
REFERENCES 
Agyepong, I. A., & Manderson, L. (1999). Mosquito avoidance and bed net use in the 
Greater Accra Region, Ghana. Journal of Biosocial Science, 31(1), 79–92. 
http://doi.org/10.1017/S0021932099000796 
Ankomah, A., Adebayo, S. B., Arogundade, E. D., Anyanti, J., Nwokolo, E., Ladipo, O., 
& Meremikwu, M. M. (2012). Determinants of insecticide-treated net ownership and 
utilization among pregnant women in Nigeria. BMC Public Health. 
http://doi.org/10.1186/1471-2458-12-105 
Baume, C. A., & Franca-Koh, A. C. (2011). Predictors of mosquito net use in Ghana. 
Malaria Journal. http://doi.org/10.1186/1475-2875-10-265 
Baume, C. A., & Marin, M. C. (2007). Intra-household mosquito net use in Ethiopia, 
Ghana, Mali, Nigeria, Senegal, and Zambia: Are nets being used? Who in the 
household uses them? American Journal of Tropical Medicine and Hygiene, 77(5), 
963–971. 
Baume, C. A., Reithinger, R., & Woldehanna, S. (2009). Factors associated with use and 
non-use of mosquito nets owned in Oromia and Amhara regional states, Ethiopia. 
Malaria Journal, 8, 264. http://doi.org/10.1186/1475-2875-8-264 
Belay, M., & Deressa, W. (2008). Use of insecticide treated nets by pregnant women and 
associated factors in a pre-dominantly rural population in northern Ethiopia. Tropical 
Medicine and International Health, 13(10), 1303–1313. 
http://doi.org/10.1111/j.1365-3156.2008.02159.x 
Bennett, A., Smith, S. J., Yambasu, S., Jambai, A., Alemu, W., Kabano, A., & Eisele, T. 
P. (2012). Household possession and use of insecticide-treated mosquito nets in sierra 
leone 6 months after a national mass-distribution campaign. PLoS ONE, 7(5). 
http://doi.org/10.1371/journal.pone.0037927 
Biadgilign, S., Reda, A., & Kedir, H. (2012). Determinants of ownership and utilization of 
insecticide-treated bed nets for malaria control in Eastern Ethiopia. Journal of 
Tropical Medicine. http://doi.org/10.1155/2012/235015 
Biswas, A. K., Hutin, Y. J., Ramakrishnan, R., Patra, B., & Gupte, M. D. (2010). 
Increased financial accessibility and targeted education messages could increase 
ownership and use of mosquito nets in Purulia District, West Bengal, India. 
Transactions of the Royal Society of Tropical Medicine and Hygiene, 104(6), 423–
428. http://doi.org/10.1016/j.trstmh.2010.01.001 
Bowen, H. L. (2013). Impact of a mass media campaign on bed net use in Cameroon. 
Malaria Journal, 12(1), 36. http://doi.org/10.1186/1475-2875-12-36 
CDC. (2012a). CDC - Malaria - About Malaria - Biology - Malaria Parasites. 
CDC. (2014). 11. Malaria Prevention: Insecticide Treated Nets: 11.1.1 How ITNs work - 
Communicable Diseases HEAT Module - HEAT_CD_ET_1.0. 
University of Ghana                              http://ugspace.ug.edu.gh
59 
 
CDC, C.-C. for D. C. and. (2012b). CDC - Malaria - Malaria Worldwide - How Can 
Malaria Cases and Deaths Be Reduced? - Insecticide-Treated Bed Nets. 
Chase, C., Sicuri, E., Sacoor, C., Nhalungo, D., Nhacolo, A., Alonso, P. L., & Menéndez, 
C. (2009). Determinants of household demand for bed nets in a rural area of southern 
Mozambique. Malaria Journal, 8, 132. http://doi.org/10.1186/1475-2875-8-132 
Chicuecue, S., Morgan, J., Mussa, A., Mabunda, S., Kachur, P., Macete, E., & Guinovart, 
C. (2012). How many bednets per household need to be distributed? evaluation of a 
universal coverage bed net distribution campaign in four districts in sofala province, 
mozambique. American Journal of Tropical Medicine and Hygiene, 1), 410. 
Retrieved from 
http://www.ajtmh.org/content/87/5_Suppl_1/378.full.pdf+html\nhttp://ovidsp.ovid.co
m/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=emed11&AN=7104
1984\nhttp://lshtmsfx.hosted.exlibrisgroup.com/lshtm?sid=OVID:embase&id=pmid:
&id=doi:&issn=0002-9637&isbn=&volu 
Cohee, L., Mills, L. A., Kagaayi, J., Jacobs, I., Galiwango, R., Ludigo, J., … Reynolds, S. 
J. (2009). High retention and appropriate use of insecticide-treated nets distributed to 
HIV-affected households in Rakai, Uganda: results from interviews and home visits. 
Malaria Journal, 8, 76. http://doi.org/10.1186/1475-2875-8-76 
Deressa, W., Fentie, G., Girma, S., & Reithinger, R. (2011). Ownership and use of 
insecticide-treated nets in Oromia and Amhara Regional States of Ethiopia twoyears 
after a nationwide campaign. Tropical Medicine and International Health, 16(12), 
1552–1561. http://doi.org/10.1111/j.1365-3156.2011.02875.x 
Eisele, T. P., Keating, J., Littrell, M., Larsen, D., & Macintyre, K. (2009). Assessment of 
insecticide-treated bednet use among children and pregnant women across 15 
countries using standardized national surveys. American Journal of Tropical 
Medicine and Hygiene, 80(2), 209–214. 
Eyobo, M. B., Awur, A. C., Wani, G., Julla, A. I., Remijo, C. D., Sebit, B., … Chanda, E. 
(2014). Malaria indicator survey 2009, South Sudan: baseline results at household 
level. Malaria Journal, 13(1), 45. http://doi.org/10.1186/1475-2875-13-45 
Fishel, F. M. (2014, March). Pesticide Toxicity Profile: Synthetic Pyrethroid Pesticides. 
Gebresilassie, F. E., & Mariam, D. H. (2011). Factors influencing people‟s willingness-to-
buy insecticide-treated bednets in Arbaminch Zuria district, southern Ethiopia. 
Journal of Health, Population and Nutrition, 29(3), 200–206. 
http://doi.org/10.3329/jhpn.v29i3.7867 
Githinji, S., Herbst, S., Kistemann, T., & Noor, A. M. (2010). Mosquito nets in a rural 
area of Western Kenya: ownership, use and quality. Malar.J., 9(1475-2875 
(Linking)), 250. Retrieved from PM:20813034 
Goesch, J. N., Schwarz, N. G., Decker, M.-L., Oyakhirome, S., Borchert, L. B., Kombila, 
U. D., … Grobusch, M. P. (2008). Socio-economic status is inversely related to bed 
net use in Gabon. Malaria Journal, 7, 60. http://doi.org/10.1186/1475-2875-7-60 
University of Ghana                              http://ugspace.ug.edu.gh
60 
 
Gosoniu, L., Vounatsou, P., Tami, A., Nathan, R., Grundmann, H., & Lengeler, C. (2008). 
Spatial effects of mosquito bednets on child mortality. BMC Public Health, 8, 356. 
http://doi.org/10.1186/1471-2458-8-356 
Grabowsky, M., Farrell, N., Hawley, W., Chimumbwa, J., Hoyer, S., Wolkon, A., & 
Selanikio, J. (2005). Integrating insecticide-treated bednets into a measles vaccination 
campaign achieves high, rapid and equitable coverage with direct and voucher-based 
methods. Tropical Medicine and International Health, 10(11), 1151–1160. 
http://doi.org/10.1111/j.1365-3156.2005.01502.x 
Gunasekaran, K., Sahu, S. S., Vijayakumar, K. N., & Jambulingam, P. (2009). 
Acceptability, willing to purchase and use long lasting insecticide treated mosquito 
nets in Orissa State, India. Acta Tropica, 112(2), 149–155. 
http://doi.org/10.1016/j.actatropica.2009.07.013 
Haghdoost, A. A., Alexander, N., & Smith, T. (2007). Maternal malaria during pregnancy 
and infant mortality rate: Critical literature review and a new analytical approach. 
Journal of Vector Borne Diseases, 44(2), 98–104. 
Hetzel, M. W., Choudhury, A. A., Pulford, J., Ura, Y., Whittaker, M., Siba, P. M., & 
Mueller, I. (2014). Progress in mosquito net coverage in Papua New Guinea. Malaria 
Journal, 13(1), 242. http://doi.org/10.1186/1475-2875-13-242 
Hightower, A., Kiptui, R., Manya, A., Wolkon, A., Vanden Eng, J. L., Hamel, M., … 
Akhwale, W. (2010). Bed net ownership in Kenya: the impact of 3.4 million free bed 
nets. Malaria Journal, 9, 183. http://doi.org/10.1186/1475-2875-9-183 
Iwashita, H., Dida, G., Futami, K., Sonye, G., Kaneko, S., Horio, M., … Minakawa, N. 
(2010). Sleeping arrangement and house structure affect bed net use in villages along 
Lake Victoria. Malaria Journal, 9, 176. http://doi.org/10.1186/1475-2875-9-176 
Jombo, G. T. A., Alao, O., Araoye, M. O., & Damen, J. G. (2011). Impact of a decade-
long anti-malaria crusade in a West African community. Asian Pacific Journal of 
Tropical Disease, 1(2), 100–105. http://doi.org/10.1016/S2222-1808(11)60045-5 
Kaliyaperumal, K., Mengistie, E., Dagnew, Z., & Deboch, B. (2010). Examining 
household possession and willingness to pay for the retreatment of ITNs with 
insecticides among local residences in a malaria endemic area. East African Journal 
of Public Health, 7(4), 305–310. 
Koenker, H., & Kilian, A. (2014). Recalculating the net use gap: A multi-country 
comparison of ITN use versus ITN access. PLoS ONE, 9(5). 
http://doi.org/10.1371/journal.pone.0097496 
Korenromp, E. L., Miller, J., Cibulskis, R. E., Cham, M. K., Alnwick, D., & Dye, C. 
(2003). Monitoring mosquito net coverage for malaria control in Africa: Possession 
vs. use by children under 5 years. Tropical Medicine and International Health, 8(8), 
693–703. http://doi.org/10.1046/j.1365-3156.2003.01084.x 
University of Ghana                              http://ugspace.ug.edu.gh
61 
 
Lam, Y., Harvey, S. a, Monroe, A., Muhangi, D., Loll, D., Kabali, A. T., & Weber, R. 
(2014). Decision-making on intra-household allocation of bed nets in Uganda: do 
households prioritize the most vulnerable members? Malaria Journal, 13(1), 183. 
http://doi.org/10.1186/1475-2875-13-183 
Lengeler, C. (1996). Insecticide-treated bed nets and curtains for preventing malaria. In 
Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. 
Macedo de Oliveira, A., Wolkon, A., Krishnamurthy, R., Erskine, M., Crenshaw, D. P., 
Roberts, J., & Saúte, F. (2010). Ownership and usage of insecticide-treated bed nets 
after free distribution via a voucher system in two provinces of Mozambique. 
Malaria Journal, 9, 222. http://doi.org/10.1186/1475-2875-9-222 
Macintyre, K., Keating, J., Sosler, S., Kibe, L., Mbogo, C. M., Githeko, A. K., & Beier, J. 
C. (2002). Examining the determinants of mosquito-avoidance practices in two 
Kenyan cities. Malaria Journal, 1, 14. http://doi.org/10.1186/1475-2875-1-14 
Malusha, J. M., Mwanzo, I., Yitambe, A., & Mbugi, J. P. (2009). Use of insecticide 
treated nets among caregivers of children under five years in Makueni district, 
Kenya. East African Medical Journal, 86(7), 308–313. 
http://doi.org/10.4314/eamj.v86i7.54144 
Matovu, F., Goodman, C., Wiseman, V., & Mwengee, W. (2009). How equitable is bed 
net ownership and utilisation in Tanzania? A practical application of the principles of 
horizontal and vertical equity. Malaria Journal, 8, 109. http://doi.org/10.1186/1475-
2875-8-109 
Mudenyo, M. O., & Nobuyuki, H. (2010). Factors influencing utilisation of insecticide 
treated nets and prevalence of malaria among children under five years. East African 
Medical Journal, 87(12), 509–512. 
Musa, O. I., Salaudeen, G. A., & Jimoh, R. O. (2009). Awareness and use of Insecticide 
Treated Nets among women attending ante-natal clinic in a Northern state of Nigeria. 
Journal of the Pakistan Medical Association, 59(6), 354–358. 
Nankinga, Z., Muliira, J. K., Kalyango, J., Nankabirwa, J., Kiwuwa, S., Njama-Meya, D., 
& Karamagi, C. (2012). Factors associated with utilization of insecticide-treated nets 
in children seeking health care at a Ugandan Hospital: Perspective of child 
caregivers. Journal of Community Health, 37(5), 1006–1014. 
http://doi.org/10.1007/s10900-012-9546-z 
Negash, K., Haileselassie, B., Tasew, A., Ahmed, Y., & Getachew, M. (2012). Ownership 
and utilization of long-lasting insecticide-treated bed nets in Afar, northeast Ethiopia: 
a cross-sectional study. The Pan African Medical Journal, 13 Suppl 1, 9. 
Ng‟ang'a, P. N., Jayasinghe, G., Kimani, V., Shililu, J., Kabutha, C., Kabuage, L., … 
Mutero, C. (2009). Bed net use and associated factors in a rice farming community in 
Central Kenya. Malaria Journal, 8, 64. http://doi.org/10.1186/1475-2875-8-64 
University of Ghana                              http://ugspace.ug.edu.gh
62 
 
Ngondi, J. M., Graves, P. M., Gebre, T., Mosher, A. W., Shargie, E. B., Emerson, P. M., 
& Richards, F. O. (2011). Which nets are being used: factors associated with 
mosquito net use in Amhara, Oromia and Southern Nations, Nationalities and 
Peoples‟ Regions of Ethiopia. Malaria Journal, 10, 92. http://doi.org/10.1186/1475-
2875-10-92 
Noor, A. M., Omumbo, J. A., Amin, A. A., Zurovac, D., & Snow, R. W. (2006). Wealth, 
mother‟s education and physical access as determinants of retail sector net use in 
rural Kenya. Malaria Journal, 5, 5. http://doi.org/10.1186/1475-2875-5-5 
Nuwaha, F. (2001). Factors influencing the use of bed nets in Mbarara municipality of 
Uganda. American Journal of Tropical Medicine and Hygiene, 65(6), 877–882. 
Okafor, I. P., & Odeyemi, K. A. (2012). Use of insecticide-treated mosquito nets for 
children under five years in an urban area of Lagos State, Nigeria. Nigerian Journal 
of Clinical Practice, 15(2), 220–223. http://doi.org/10.4103/1119-3077.97325 
Okech, B. A., Mwobobia, I. K., Kamau, A., Muiruri, S., Mutiso, N., Nyambura, J., … 
Mwandawiro, C. S. (2008). Use of integrated malaria management reduces malaria in 
Kenya. PLoS ONE, 3(12). http://doi.org/10.1371/journal.pone.0004050 
Ordinioha, B. (2012). The use and misuse of mass distributed free insecticide-treated bed 
nets in a semi-urban community in Rivers State, Nigeria. Annals of African Medicine. 
http://doi.org/10.4103/1596-3519.96879 
Oresanya, O. B., Hoshen, M., & Sofola, O. T. (2008). Utilization of insecticide-treated 
nets by under-five children in Nigeria: assessing progress towards the Abuja targets. 
Malaria Journal, 7, 145. http://doi.org/10.1186/1475-2875-7-145 
Owusu Adjah, E. S., & Panayiotou, A. G. (2014). Impact of malaria related messages on 
insecticide-treated net (ITN) use for malaria prevention in Ghana. Malaria Journal, 
13(1), 123. http://doi.org/10.1186/1475-2875-13-123 
Pettifor, A., Taylor, E., Nku, D., Duvall, S., Tabala, M., Meshnick, S., & Behets, F. 
(2008). Bed net ownership, use and perceptions among women seeking antenatal care 
in Kinshasa, Democratic Republic of the Congo (DRC): opportunities for improved 
maternal and child health. BMC Public Health, 8, 331. http://doi.org/10.1186/1471-
2458-8-331 
Pulford, J., Hetzel, M. W., Bryant, M., Siba, P. M., & Mueller, I. (2011). Reported reasons 
for not using a mosquito net when one is available: a review of the published 
literature. Malaria Journal, 10, 83. http://doi.org/10.1186/1475-2875-10-83 
Rhee, M., Sissoko, M., Perry, S., Dicko, A., McFarland, W., & Doumbo, O. (2005). 
Malaria prevention practices in Mopti region, Mali. East African Medical Journal, 
82(8), 396–402. http://doi.org/10.4314/eamj.v82i8.9323 
Singh, M., Brown, G., & Rogerson, S. J. (2013). Ownership and use of insecticide-treated 
nets during pregnancy in sub-Saharan Africa: a review. Malaria Journal, 12(1), 268. 
http://doi.org/10.1186/1475-2875-12-268 
University of Ghana                              http://ugspace.ug.edu.gh
63 
 
SMITH GREENAWAY, E., LEON, J., & BAKER, D. P. (2012). UNDERSTANDING 
THE ASSOCIATION BETWEEN MATERNAL EDUCATION AND USE OF 
HEALTH SERVICES IN GHANA: EXPLORING THE ROLE OF HEALTH 
KNOWLEDGE. Journal of Biosocial Science. 
http://doi.org/10.1017/S0021932012000041 
Smith Paintain, L., Awini, E., Addei, S., Kukula, V., Nikoi, C., Sarpong, D., … 
Mangham-Jefferies, L. (2014). Evaluation of a universal long-lasting insecticidal net 
(LLIN) distribution campaign in Ghana: cost effectiveness of distribution and hang-
up activities. Malaria Journal, 13(1), 71. http://doi.org/10.1186/1475-2875-13-71 
Smith, T. A., Leuenberger, R., & Lengeler, C. (2001). Child mortality and malaria 
transmission intensity in Africa. In Trends in Parasitology (Vol. 17, pp. 145–149). 
http://doi.org/10.1016/S1471-4922(00)01814-6 
Tsuang, A., Lines, J., & Hanson, K. (2010). Which family members use the best nets? An 
analysis of the condition of mosquito nets and their distribution within households in 
Tanzania. Malaria Journal, 9, 211. http://doi.org/10.1186/1475-2875-9-211 
Vanden Eng, J. L., Thwing, J., Wolkon, A., Kulkarni, M. A., Manya, A., Erskine, M., … 
Slutsker, L. (2010). Assessing bed net use and non-use after long-lasting insecticidal 
net distribution: a simple framework to guide programmatic strategies. Malaria 
Journal, 9, 133. http://doi.org/10.1186/1475-2875-9-133 
WHO. (2013). 10 Facts on Malaria in Africa - WHO | Regional Office for Africa. 
Williams, P. C. M., Martina, A., Cumming, R. G., & Hall, J. (2009). Malaria prevention in 
sub-saharan Africa: A field study in rural Uganda. Journal of Community Health, 
34(4), 288–294. http://doi.org/10.1007/s10900-009-9151-y 
Wong, K. R. (2011). Pediatric malaria treatment delays across socioeconomic levels in 
suburban Accra, Ghana. Journal of Investigative Medicine, 59 (1), 140–141. 
http://doi.org/http://dx.doi.org/10.231/JIM.0b013e31820501bd 
World Health Organization. (2013). World Malaria Report 2013. Nature. Retrieved from 
www.who.int 
Ye, Y., Patton, E., Kilian, A., Dovey, S., & Eckert, E. (2012). Can universal insecticide-
treated net campaigns achieve equity in coverage and use? the case of northern 
Nigeria. Malaria Journal. http://doi.org/10.1186/1475-2875-11-32 
Yohannes, K., Dulhunty, J. M., Kourleoutov, C., Manuopangai, V. T., Polyn, M. K., 
Parks, W. J., … Bryan, J. H. (2000). Malaria control in central Malaita, Solomon 
Islands 1. The use of insecticide-impregnated bed nets. Acta Tropica, 75(2), 173–183. 
http://doi.org/10.1016/S0001-706X(00)00055-3 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
64 
 
Appendix A: Questionnaire for Household Heads 
FACTORS INFLUENCING INSECTICIDE TREATED MOSQUITO BED NET USE IN 
THE AGONA EAST DISTRICT-CENTRAL REGION. 
 
INTRODUCTION AND CONSENT  
Hello, my name is ………………………………..(Interviewers name) I am working 
with…………………………………………………………………… (Name of 
organization). My telephone number is…………………………………………….. 
(Interviewers’ telephone number) and our E-mail address is gkobanthony@yahoo.com 
.We are conducting a survey about the use of Insecticide treated bed nets (ITNs) in the 
Agona East District. Malaria is gotten through the bite of a mosquitoe, we can prevent 
ourselves from getting the disease if we protect ourselves from the bite of the mosquitoe 
.A number of strategies or interventions have been put in place to prevent us from getting 
malaria, and one of such is the use of ITNs .The past decade has witnessed the distribution 
of ITNs in various ways so as to increase ownership. This survey is to determine the 
factors that influence the use of ITNs.  The information we collect will help address future 
issues on ITNs use. I am assuring you that all the information you give will be kept 
confidential. Furthermore, privacy will be up held and there will be no mention of name 
should the results of the study be published or at any medical meetings. The questions 
asked may make you or the rest the house hold feel uncomfortable. I must also make you 
aware that there is no personal benefit to you and the rest of the household for 
participating. You don‟t have to be in the survey, but we hope you will agree to answer the 
questions since your views are important. If I ask you any question you don‟t want to 
answer, just let me know and I will go unto the next question or you can stop the interview 
at any time. 
Do you have any questions? 
May I begin the interview now? 
SIGNATURE OF INTERVIEWER ………………………………………………OR 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
65 
 
THUMB PRINT 
 DATE………………………………………………. 
Did respondent agree to be interviewed?.................................................................Yes/ No 
     
 IDENTIFICATION 
Sub district Name…………………………………… 
Community Name……………………………… 
Household Number………………………..  
Total Persons in House hold………………… 
DERMOGRAPHIC CHARACTERISTICS OF HEAD OF HOUSEHOLD (tick or write 
appropriately) 
Name ……………… 
Age ………………… 
Sex ……………………M/F 
Marital status……………………………………………. 
Married 
Never Married 
Divorced                               
Widowed                                                                             
Last educational level attained……………………      
No education 
Primary 
Secondary 
Tertiary 
                                                                        
University of Ghana                              http://ugspace.ug.edu.gh
66 
 
Employment status……………………………………… 
                                                                                 Employed 
                                                                               Not employed 
Occupation………………………………………………….         
                                                                                 Professional 
                                                                                 Trader 
                                                                                 Artisan 
                                                                                Labourer 
                                                                                 Farmer 
                                                                               
SOCIOECONOMIC STATUS OF HOUSEHOLD 
Does your house hold own or have ……………         
    A television 
    A refrigerator 
   A telephone (mobile or land) 
   A bicycle 
    A motor bike 
    A car 
   An electricity 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
67 
 
What is the main source of drinking water? 
Piped borne water 
Bore hole 
Dug well 
Water from spring 
Rain water 
Tanker truck 
Surface water (river/dam/lake/pond/stream etc.) 
Bottled water 
Others (specify)  
 
How many rooms are used for sleeping? 
                                                                            One 
                                                                            Two 
                                                                             Three 
                                                                            Others (specify) 
What is the main floor material? (Observed) 
Natural floor 
Rudimentary floor (palm branches/wood/etc.) 
Finished floor (carpet/cement/ceramic tiles/ etc.) 
Others (specify) 
                                                                           
                                     
 
University of Ghana                              http://ugspace.ug.edu.gh
68 
 
 HOUSEHOLD LISTING 
We would like to have some information about the people living in your household or 
staying with you now. 
USUAL 
RESIDENTS 
AND 
VISITORS 
RELATIONSH
IP TO HEAD 
OF 
HOUSEHOLD
* 
SEX            RESIDENCE 
 
AGE CURRENTLY 
PREGNANT 
Please give me 
the name(s) of 
the person(s)  
who usually 
live in your 
household and 
guest(s) who 
stayed 
overnight 
What is the 
relationship of 
(NAME) to 
head of house 
hold? 
(quote code 
below) 
Is (NAME), 
male or 
female? 
(circle 
appropriatel
y) 
Does 
(NAME) 
usually live 
here? 
(circle 
appropriatel
y) 
 
Did (NAME) 
stay 
overnight? 
(circle 
appropriately
) 
How old 
is 
(NAME
)? 
If female and in 
reproductive 
age ASK, is 
(NAME) 
Pregnant? 
(circle 
appropriately) 
(1) * M          F 
 
YES      NO YES       NO  IN 
YEARS 
YES   NO   
D/K N/A 
(2) * M          F YES      NO YES      NO  YES   NO   
D/K  N/A 
(3) * M          F YES      NO YES      NO  YES   NO   
D/K   N/A 
(4) * M          F YES      NO YES      NO  YES   NO   
D/K   N/A 
(5) * M          F YES      NO YES      NO  YES   NO   
D/K    N/A 
(6) * M          F YES      NO YES      NO  YES   NO   
D/K   N/A 
 
*CODES FOR RELATIONSHIP TO HEAD OF HOUSEHOLD 
02-WIFE/HUSBAND       03-SON/DAUGHTER     04-SON IN-LAW/DAUGHTER IN-LAW 
05-GRAND CHILD          06-PARENT                  07-PARENT IN-LAW 
08-BROTHER/SISTER   09-OTHER RELATIVE       10-ADOPTED/FOSTER/STEPCHILD 
11-NOT RELATED                 12- DON’T KNOW 
 
University of Ghana                              http://ugspace.ug.edu.gh
69 
 
NET POSSESSION AND USAGE  
Does your household have any mosquito nets that can be used while 
sleeping?.................Yes/No?  (Circle appropriately) 
How many mosquito nets does your household have……………?  
How many people in the house hold slept under a mosquitoe net last night?  
 
Ask 
respondents 
to show you 
all net(s) in 
household 
Net 1 Net 2 Net 3 Net 4 
 Observed ...yes/no 
Hanging…yes/no 
Observed ...yes/no 
Hanging…yes/no 
Observed…..yes/no 
Hanging….yes/no 
Observed…..yes/no 
Hanging….yes/no 
LLIN 
Source……. 
LLIN 
Source……. 
LLIN 
Source……. 
LLIN 
Source……. 
 RETREATABLE 
NET 
Source……….. 
RETREATABLE 
NET 
Source……….. 
RETREATABLE 
NET 
Source……….. 
RETREATABLE 
NET 
Source……….. 
ORDINARY NET 
Source……….. 
ORDINARY NET 
Source……….. 
ORDINARY NET 
Source……….. 
ORDINARY NET 
Source……….. 
OTHERS 
Source……….. 
OTHERS 
Source……….. 
OTHERS 
Source……….. 
OTHERS 
Source……….. 
DON‟T KNOW 
Source………. 
DON‟T KNOW 
Source………. 
DON‟T KNOW 
Source………. 
DON‟T KNOW 
Source………. 
NET 1 NET 2 NET 3 NET 4 
 
Example of sources; clinics, vendors, pharmacy shops, recent mass campaign, health 
personnel (nurse or midwife or health care worker or community based volunteers) 
  
University of Ghana                              http://ugspace.ug.edu.gh
70 
 
What are the Conditions of the net(s)? (Tick or circle good or bad) 
Net 1 Net 2 Net 3 Net 4 
Good  
Bad 
Good 
Bad 
Good 
Bad 
Good 
Bad 
 
Did you sleep in the mosquito net last night? (For individual members of the house hold to 
answer followed by filling of the table below accordingly) 
 NAME(S) 
of person(s)  
Is (NAME), male or female? 
(circle appropriately) 
Age  IN YEARS  Pregnant or not 
 
Slept (Y/N)   
(write Y or N )       
(1) M          F  YES   NO   D/K N/A  
(2) M          F  YES   NO   D/K   N/A  
(3) M          F  YES   NO   D/K   N/A  
(4) M          F  YES   NO   D/K   N/A  
(5) M          F  YES   NO   D/K   N/A  
(6) M          F  YES   NO   D/K  N/A  
 
University of Ghana                              http://ugspace.ug.edu.gh
71 
 
Did you sleep under the mosquitoe net…………………….Yes/No (for head of house hold 
to answer) 
 
If yes, why? 
                  Suggested options (tick appropriately) 
 Environmental        
     The weather is too cold 
    There are mosquitoes here  
 Social                     
     It protects us from mosquitoe bites 
 
 Technical 
The size of the rooms are ok to hang nets                                               
The type of roof construction allows us to be able to hang nets                                            
The size of net to bed is o k                                                                                       
It is not difficult putting up or down the net                                                                        
 Other reasons  
 
University of Ghana                              http://ugspace.ug.edu.gh
72 
 
If no, why?  
Suggested options (tick appropriately) 
 Environmental        
                              The weather is too hot 
                              There are no mosquitoes here 
 Social                     
                  I forgot to hang the net last night                                                                                    
                  „It makes me feel like I am lying in a tomb‟                                                                                    
                    It disrupts our sleeping arrangement                                                                                                                                
                    I don‟t have a net                                                                                      
                    I returned home too late to hang the net                                                                                
                    It is expensive to buy                                                                                   
                    It is not available to buy or purchase 
 
 Technical 
        The size of the rooms are too small to hang nets                                                                   
       The type of roof construction will not allow us to hang net                                              
       The size of net to bed is too small making it difficult to hang nets                                                                                          
        I have difficulty in putting up or down net                                           
        The net is torn so I can‟t hang it                                                                                                                     
       Net is washed or retreated  
 Other reasons  
 
 
University of Ghana                              http://ugspace.ug.edu.gh
73 
 
LEVEL OF AWARENESS ON NET USE (tick appropriate response)  
Has your household ever had any information on mosquitoe nets?...........Yes/ No 
Where did you get this information? 
              Television 
              Radio  
              Poster 
              Leaflets /brochures 
              Health worker 
              Community based volunteer 
              No media exposure 
              Others (specify) 
 
If yes what was the information about? (Open ended question with options) 
Air the net in the shade 24 hours before use.                                                                                  
Regularly OR daily sleep under nets to protect us from mosquitoe bite                                                                                  
Choose nets that fit the size of the bed  
To hang nets before nightfall  
Wash dirty net with water and mild soap and dry in only shady areas 
Tuck in net under the mattress or mat 
Torn nets can be sewn 
Do not place lighted candle near the net                                                                                  
Others (specify)  
 
University of Ghana                              http://ugspace.ug.edu.gh
74 
 
Have you discussed with your family or friend in the last month about ITNs?......Yes/No 
If yes, what did you discuss? (Open ended question with options) 
    Why you and your family should sleep under a treated net? 
    What treated nets (LLIN) are?   
    Who should use a treated net? 
    How to use treated nets (LLIN)? 
    How to care for your treated net? 
    How do you hang your treated nets when you want to sleep? 
    Others (specify) 
 
 
 
 
University of Ghana                              http://ugspace.ug.edu.gh
75 
 
Appendix B: Key Informant Guide 
FACTORS INFLUENCING THE UTILIZATION OF INSECTICIDE TREATED 
NETS IN  AGONA EAST IN THE CENTRAL REGION OF GHANA. 
Hello, I am Dr. Kobla Gershon Anthony, a student of University of Ghana and with the 
Ghana Field Epidemiology and Laboratory training and the convener. We are conducting a 
survey on the use of insecticide treated mosquito nets.    
Malaria is a disease caused by the bite of a mosquito .Every year several hundreds of 
millions of become ill with malaria. Over 90% of cases and deaths occur in sub-Saharan 
Africa with children and pregnant women being affected mostly. In Ghana the disease is 
the number one cause of out –patient attendance and admissions. A number of strategic 
Interventions are available for the prevention of malaria and one of such interventions is 
the use of insecticide treated mosquito nets.  The past decade has witnessed the country 
wide distribution of insecticide treated mosquito nets in various ways so as to increase 
ownership. . This survey is to determine the factors that influence the use of ITNs.  The 
information we collect will help address future issues on ITNs use. This discussion would 
be audio taped, but I am assuring you that all the information you give will be kept 
confidential and tapes kept as long as possible but well secured with me the principal 
investigator the only one with access. Furthermore, privacy will be up held and there will 
be no mention of name should the results of the study be published or at any medical 
meetings. The discussions may make you feel uncomfortable. I must also make you aware 
that there is no personal benefit to you and the rest of the household for participating in 
this discussion but  hould the interview go too long or late you have the right to stop me. 
You don‟t have to be in this interview session, but we hope you will agree to be part since 
your views are important. If interview is going too much into you time and session  is 
becoming irrelevant, just let me know and I will act accordingly. 
If you wish to have some matters relating to the study, farther clarified, do not hesitate to 
contact me on phone number 0244751602.  
If there are no questions can we set the ball rolling? 
   
 
University of Ghana                              http://ugspace.ug.edu.gh
76 
 
Background Information 
The following must be recorded 
 Name and Designation 
 Gender 
 Location 
 Date and time  of interview 
 
• What is ITN? 
• What is it used for? 
• Who has to use ITN? 
• Why do/ don‟t we use it? 
• Which other way do you use the nets for? 
• Do you use ITNs 
• If yes. Why? 
• If no, why? 
• How can we get more people to sleep under an ITN every night? 
• Why are treated Nets the best way to prevent malaria? Bearing in mind the 
following 
• Convenience in terms of net set up and dismantling  
• Potential hazard and safety concerns 
• Issue of family composition and nature of accommodation 
• Humid weather conditions 
• Perception of effectiveness of net  
• Beliefs 
University of Ghana                              http://ugspace.ug.edu.gh
77 
 
• Views of acceptability, typical conditions when a net is used and when not used 
• Factors that put people off not using the net, aspects of the net that the people like 
or did not like and so not use the net 
• Decision making on the use of nets  
• Sources of information on net use 
 
THANK YOU VERY MUCH FOR YOUR TIME 
 
University of Ghana                              http://ugspace.ug.edu.gh