## INTRODUCTION

Malaria is a disease that threatens the lives of 3.2 billion people throughout the world and has a cascading impact on pregnant women and children under the age of five1. Malaria is one of the leading causes of illness, mortality, poverty, and low productivity, among the majority of people living in low- to middle-income countries (LMICs)2. Malaria increases the risk of serious pregnancy complications for the mother, fetus, and newborn3. Insecticide-treated bed nets (ITNs) are a type of personal protection that has been proved to minimize malaria infection, severe disease, and death4. The effective use of ITNs has reduced malaria sickness by 50% in children aged <5 years, and reduced mortality by 17%5. The WHO Roll Back Malaria (RBM) project, which began in 1998, intended to prevent and control malaria during pregnancy via the use of ITNs and other measures4. In a meta-analysis of malaria-prevention datasets from several African countries, it was discovered that ITNs are critical in avoiding malaria in pregnancy3. Miscarriages and stillbirths are reduced by roughly 33% when ITNs are used throughout pregnancy6.

In Ethiopia, 39% of pregnant women did not have a positive attitude towards ITNs7. In the Democratic Republic of Congo, about 82% reported having an ITN in their household, of these only 78.4% used ITNs the night before the study survey8. In Sudan, the ownership of ITNs was nearly 57%, however, only 11.5% used ITNs frequently9. About 92% demonstrated sufficient knowledge on the cause of malaria, and 60% exhibited appreciable knowledge on the reasons why ITNs are used. Despite the above, only 22.1% knew the correct usage of ITNs9.

Ghana is one of the world’s fifteen countries with the greatest malaria infection rate10. Malaria infection is among the ten topmost diseases in Ghana11. Malaria affects all people, but it is common with expectant mothers and babies with very dire consequences12. Ghana saw the biggest increase in absolute case counts (about 0.5 million new cases) between 2017 and 2018, indicating a 5% increase over 2017 levels (from 213 to 224 per 1000 at risk)2. In Sub-Saharan Africa, Ghana has the highest incidence of Intermittent Preventive Treatment in Pregnancy (IPTp) for pregnant women (78%). The percentage of pregnant women taking the third dosage of IPTp climbed from 39% to 60% in 2016, to 61% in 201913. IPTp involves giving all pregnant women a curative dose of an effective antimalarial medicine (now sulfadoxine-pyrimethamine) without first determining whether or not they have malaria. It is recommended that pregnant women take at least three doses of IPTp starting from second trimester till birth14.

The intentional campaign and intervention on ITNs have resulted in a rise in household ownership of ITNs from 49% in 2011 to 68% in 20146,15. In Ghana, the usage of ITNs among pregnant women grew from roughly 33% in 2011 to 43% in 2014. Lack of availability of ITNs, as well as a lack of information and perception about ITNs and malaria, have previously been identified as significant hurdles to ITN adoption in Africa16. Indication from Ghana has shown that over 40% of ITNs available in the households go unused17. A study conducted in the middle belt of Ghana showed that pregnant women knew how crucial ITNs are to preventing malaria. Some pregnant women due to financial constraints, and missed chance during the free distribution of ITNs, do not own a bed net and do not sleep under one. Aside from the above genuine excuses, some of the pregnant women were also not using ITNs because of discomfort resulting from heat, the smell of the net, and difficulty in hanging the net18.

Despite the progress achieved in carrying out active preventive and treatment measures, malaria is still very prevalent in Ghana. Malaria accounts for 38.1% of all outpatient department cases and more than half of all hospital admissions in Ghana among children aged <5 years. Malaria infection is responsible for about half of all fatalities among children aged <5 years in Ghana19. Available literature in Ghana has demonstrated that the most households who own bed nets, do not sleep under them20. In addition, research performed in seven districts of Ghana’s Upper East region found that while 79% of pregnant women had bed nets, only 62% utilized them the night before the survey15. In addition to the above, there is a vast difference with regard to the utilization of bed nets between urban and rural areas of Ghana20.

Ghana is still working to achieve universal ITN coverage (defined as use by 80% or more of the population in an endemic region) to provide the best possible protection4. As a result, continuous monitoring and assessment of access to and use of treated bed nets are required to guide malaria control policy and practice, particularly in high-risk parts of the nation. There are vast studies on ITNs utilization in Ghana but most are often in the urban settings17,20-22 with limited studies in deprived areas23. Malaria prevention especially among pregnant women and children aged <5 years is a topmost priority for the Ghana government. As such, studies across the countries are required to inform policy decisions aimed at eradicating or reducing malaria infection among the general population. The Kassena-Nankana East Municipality is mostly rural with no study conducted in this area on ITN usage. To bridge this gap, this study aims to assess the utilization of Insecticides Treated Mosquito Nets (ITNs) among pregnant women in Kassena-Nankana East Municipality in the Upper East Region of Ghana.

## METHODS

### Study setting

The study setting was conducted in the Kassena-Nankana East Municipality, which was upgraded by legislative instrument (LI) 2106 from the District level in 2012. The municipality has Navrongo as its political and administrative capital. The study setting was chosen because the municipality is predominately rural with no study conducted on ITN.

### Study design

The study employed a descriptive cross-sectional survey with a quantitative approach to explore the utilization of ITNs among pregnant women in Kassena-Nankana East from May to July 2021.

Inclusion and exclusion criteria

The study included pregnant women who resided in the Kassena-Nankana East Municipality, who were of sound mind, and agreed to participate in the study voluntarily. All other persons who were outside these criteria were excluded including pregnant women who were on admission.

Sample size determination, sampling techniques, and procedure

The sample size was computed using the Snedecor and Cochran24 formula for a point estimate sample. The utilization of ITNs among pregnant women was 62%23. From the Snedecor and Cochran formula, the sample size was calculated as 362. All communities with a hospital, health center or community-based health planning and service (CHPS) center, were all written on pieces of paper, and ten health facilities were chosen at random without replacement. The study used simple random sampling in recruiting the sample unit in each facility. Thus, for each of the communities (health facilities) visited, 30 pregnant women were recruited at random, except the District Hospital where 92 pregnant women were recruited. The District Hospital serves as a referral center for all the other facilities and most pregnant women choose to go there for their ANC irrespective of the distance.

### Data collection tools and procedures

The questionnaire was adapted from existing literature15,25,26 and modified to suit the study objectives (Supplementary file Questionnaire). The questionnaire was structured for the specific objectives of the study consisting of Section A: Sociodemographic data of the respondents; Section B: knowledge on ITNs; Section C: utilization of ITNs; and Section D: barriers to the use of ITNs as a preventive and control tool against malaria among pregnant women. The questions were both open and close-ended.

The study explored the use of self-administered questionnaire techniques. A total of six field assistants were trained on the data collection tool to gather the data within the shortest possible time. Data collectors were also trained on the simple random sampling procedure for the selection of respondents.

### Reliability and validity of the study

To ensure that the data collected were reliable and valid, the field enumerators were trained on the use of data collection tools. Thirty pregnant women in Paga (a community similar to the study area) were interviewed during pretesting (piloting). Pre-testing helped in restructuring the questionnaire to elicit the right response for the specific objective. It also offered the field enumerators the chance to familiarize themselves with the data collection process and to rectify all difficulties before the main data collection process. For the validity of this study, the questionnaires were asked in plain language to solicit the right response. The questionnaire was also shown to experienced researchers in the area for face validity. The Supplementary file Dataset contains a dataset from the pre-testing (piloting). Internal consistency (reliability) of the measurement scales of the instrument was computed using Cronbach’s alpha. The overall alpha of the instrument was α=0.81 while the alpha values for the scales of knowledge, utilization and barriers of ITNs were α=0.86, α=0.89 and α=0.68, respectively. The overall alpha was considered as good.

### Data analysis and presentation

Data were analyzed using SPSS version 25.0. Data are presented using descriptive and inferential statistics. Chi-squared analysis was used to determine the statistical association between background characteristics and ITN utilization. All statistics were performed at a 95% confidence level, and p<0.05 was considered significant.

## RESULTS

### Sociodemographic characteristics

Most (46.4%) of the respondents were aged 30–39 years. Over 90% of the respondents had some level of education, with only 9.10% not having gone to school. A majority, 64.9%, 87.6%, and 52.2% of the respondents were Christians, married, and resided in rural areas, respectively (Table 1).

##### Table 1

Sociodemographic characteristics of the participants

Characteristicsn%
Age (years)
<207219.90
20-299225.40
30-3916846.40
≥40308.30
Education level
No formal education339.10
Junior high school and below13737.80
Senior high school9125.10
Tertiary10127.90
Religion
Christianity23564.90
Islam12534.50
Marital status
Single339.10
Cohabiting20.60
Married31787.60
Divorced61.70
Separated41.10
Occupation
Farmer8222.70
Teacher6818.70
Health worker277.50
Housewife4111.30
Seamstress164.40
Students143.90
Hairdresser92.50
Other92.50
Number of children
1–225971.50
3–48523.50
5–6174.70
>610.30
Area of residence
Rural18952.20
Urban17347.80
Average monthly income (GHS)
<50018150.00
500-10009827.10
1001-15006217.10
1501-2000154.10
>200061.70
Ethnicity
Frafra5816.00
Nankam7921.80
Kassena17448.10
Builsa164.40
Mamprusi113.10

### Association between sociodemographic characteristics and utilization of ITNs

With regard to place of stay, 96.8% of respondents in rural and 92.5% in urban areas used ITNs, while 3.2% and 7.5% of respondents in rural and urban areas, respectively, did not use the treated nets. The study revealed a significant association between area of residence and utilization of ITNs (χ2=3.4; p=0.04). Also, increasing average monthly income was associated with utilization of ITNs (χ2=46.4; p<0.001) (Table 5).

##### Table 5

Association between sociodemographic characteristics and utilization of insecticides treated mosquito bed nets (ITNs)

VariablesTotalDo you use ITNs?
Statistical test
Yes n (%)No n (%)
Age (years)
<207271 (98.6)1 (1.4)χ2=5.4
20–299289 (96.7)3 (3.3)p=0.14
30–39168156 (92.9)12 (7.1)
≥403027 (90.0)3 (10.0)
Education level
No formal education3332 (97.0)1 (3.0)χ2=3.1
Junior high school and below137128 (93.4)9 (6.6)p=0.38
Senior high school9189 (97.8)2 (2.2)
Tertiary10194 (93.1)7 (6.9)
Religion
Christianity235220 (93.6)15 (6.4)χ2=1.8
Islam125121 (96.8)4 (3.2)p=0.41
Marital status
Single230 (90.9)3 (9.1)χ2=3.1
Cohabiting22 (100.0)0 (0.0)p=0.54
Married317302 (95.3)15 (4.7)
Divorced65 (83.3)1 (16.7)
Separated44 (100.0)0 (0.0)
Area of residence
Rural189183 (96.8)6 (3.2)χ2=3.4
urban173160 (92.5)13 (7.5)p=0.04
Average monthly income (GHS)
<500181170 (93.9)11 (6.1)χ2=46.4
500–10009892 (93.9)6 (6.1)p<0.001
1001–15006260 (96.8)2 (3.2)
1501–20001515 (100.0)0 (0.0)
>200066 (100.0)0 (0.0)

[i] GHS: 1000 Ghanaian Cedis about US\$160.

## DISCUSSION

This study aimed to assess the use of ITNs among pregnant women in the Kassena-Nankana East Municipality. The study revealed that almost all respondents had heard about ITNs. This is consistent with other studies conducted elsewhere. For instance, in the Ho municipality, Ghana, a study showed that 98.7% of pregnant women had heard about bed nets26. Amara27 revealed that, in the Greater Accra Region of Ghana, over 60% of the mothers with children aged <5 years had heard about ITNs. Also, in the Nanumba South District in the Northern Region of Ghana, over 80% of pregnant mothers had heard about bed nets10. In Nigeria, 93.2% of pregnant women were aware of bed nets28. These similarities are justified by the fact that, in Ghana and in most African countries, there have been focused attempts by the Ministry of Health, through the support of WHO and UNICEF, to provide education on malaria prevention. This is because malaria is among the key causes of maternal anemia. Maternal anemia is one of the leading causes of infant and maternal morbidity and mortality in Sub-Saharan Africa (SSA). Insecticides treated mosquito nets are the simplest most effective way of preventing malaria22. This, therefore, explains why most respondents in Africa are aware of ITNs.

The majority of the pregnant women in this study reported having obtained their ITNs from a health facility. According to Nungbaso et al.25, the majority of the respondents in the Tamale metropolis benefitted from the free distribution of bed nets from the health facilities. Even though the respondents are different, the policies regarding the free distribution of ITNs are often targeted at the general population with interest among pregnant women and children aged <5 years29.

About 90% of the respondents knew that ITNs were used to prevent malaria. Available literature in Ghana supports the current findings. For instance, 91.1% and 97.8% of the respondents in Ho26 and Greater Accra27, respectively, knew about the general usage of ITNs. However, in Nigeria, Musa30 showed that only 36% of the respondents knew the correct usage of ITNs. This difference could be attributed to the geographical difference, beliefs, and sociocultural characteristics of the respondents.

The ownership of ITNs was determined as 97.8% in this study. The current findings are higher than the 71% reported in Western Kenya by Atieli et al.31 and 64.9% reported in Nigeria by Ezire et al.28. Though these studies indicate that the majority of their respondents owned ITNs, they were observed to be lower than the findings of the current studies. This suggests that the Ministry of Health of Ghana has adopted a robust method to distribute the ITNs.

The majority of the respondents indicated that they believed ITNs were effective. This is consistent with a study by Abokyi et al.32 where over 95% of respondents believed ITNs were very effective in preventing malaria. This is crucial in determining the utilization of ITNs because, if the population does not believe in the efficacy of ITNs, the patronage would be lower. This is evident by the 94.8% of pregnant women in this study using ITNs. In other studies, the majority of respondents said that they were using ITNs10,31. However, Amara27 reported very low usage of ITNs. This could be attributed to the differences in government policies on free ITN distribution and behavioral and personal preferences of the respondents.

Though the use of ITNs was observed to be high in the study, only 47.8% were using ITNs every day. The actual utilization of ITNs is varied across the globe. For example, Atieli et al.31 showed that the majority used ITNs throughout the year, Bukari10 reported 34.4% actual utilization, and 19% were using ITNs in another study27. What this tells us is that ownership of ITNs does not always result in utilization due to sociocultural and logistic reasons. Some of the women having ITNS, do not use them all year round. For some of the respondents in this study, ITNs were used frequently only in the rainy season. This is because the cases of malaria often increase during rainy periods25. Some also reported dissatisfaction with the use of ITNs and as such resort to other preventive measures. This is supported by available literature, where some people prefer other methods of protection such as mosquito coils, repellents, electric fans, etc33. From the foregoing, the use of other preventive measures could be a reason for the difference between ownership and actual utilization of ITNs.

The study revealed a wide variety of challenges such as ITNs being inaccessible, side effects, ITNs being warm, among others. This is similar to a study where respondents currently using ITNs complained of scarcity of new nets, difficulty in getting chemicals for re-treatment of nets, non-availability of quality ITNs for sale, resulting in disuse of ITNs26. Also, the cost of the nets was featured among the barriers to effective utilization of ITNs. In Ghana, there are free distributions of ITNs at antenatal care (ANC) units, child welfare clinics (CWC), postnatal care (PNC) service centers as well as household distributions. The authors do not understand why issues of cost and accessibility are being raised by the respondents. These revelations by the respondents are sensitive and as such require further studies on the reasons for not using ITNs, using a mixed-method approach to bring in-depth understanding to these issues especially among those who cite cost as a barrier to ITN utilization.

The study also showed a significant association between area of residence and use of ITNs. This is similar to in the Upper West Region, Ghana where pregnant women in urban areas tend to use ITNs more than their counterparts in the rural setting34. In relation to the above, increasing average monthly income is associated with utilization of ITNs. This is consistent to a study in Northern23 and a systematic review in Sub-Sahara Africa35 where higher wealth index is associated with higher ITN ownership and usage, and vice versa. However, Garcia-Basteiro et al.36 did not establish any association between wealth index and ITN ownership and use. This means that, depending on the unique characteristics of each area and the tactics employed to deploy ITNs, the impoverished and relatively well-off may gain differentially. Often, the person with higher wealth index stays in the urban areas which are accessible and could be reached during distribution of ITNS. Also, people with a high socioeconomic class typically have access to other measures for preventing malaria. Whilst it is important to evenly distribute ITNs, extra efforts are required to reach the hard-to-reach rural folk and the poor.

### Limitations

As with self-reported surveys, our study is subject to information bias coupled with our inability to confirm the responses given. The study does, however, provide population-based data on ITN use among pregnant women in the study area. This can be relied on by agencies, including the Ministry of Health, Ghana Health Services, and other stakeholders for informed targeted public health interventions.

## CONCLUSIONS

The study revealed a high awareness and knowledge of ITNs. Though the majority of the respondents owned Insecticides Treated Mosquito Nets (ITNs), it did not translate to effective utilization of ITNs among pregnant women. Thus, distribution of ITNs to pregnant women is not enough, there is the need to establish practical measures to ensure that persons who have the bed nets sleep under them. The free distribution of ITNs for the majority means that most people obtained ITNs. However, some persons whose residence were hard to reach due to bad roads are often left out of the free distribution of ITNs. They are therefore compelled to buy ITNs, which they think are very expensive. To resolve this, we recommend to the Ghana Health Service to train volunteers at local level to aid in the distributions of bed nets.