Socio-demographic determinants associated with ownership and use of long lasting insecticide treated nets among pregnant women in the Wa Municipality of Ghana

Introduction An estimated 125 million pregnancies around the world are at risk of malaria infection every year. Insecticide Treated Bed Nets is a form of personal protection that has reportedly been shown to reduce severe disease and mortality due to malaria in endemic regions. This study investigated ownership and utilization of Long Lasting Insecticide Nets among pregnant women attending antenatal clinics in Wa Municipality of Ghana. Methods A cross-sectional study design was adopted to collect data among 394 pregnant women in six antenatal clinics. A two stage sampling technique was adopted and the data collection tool used was a semi-structured questionnaire. Descriptive and inferential statistics involving logistic regression were performed using Stata 14. Results More (33.3%) of the pregnant women were aged between 25-29 years with no formal education (29.9%) whiles most (69.6%) of the pregnant women were in Islam religion. About 95.9% have heard about Long Lasting Insecticide Nets and its benefits. Intuitively, ownership of Long Lasting Insecticide Nets was 82.2% with 69.3% utilization of Long Lasting Insecticide Nets. Pregnant women aged 30-34 and 35 years and above were significant predictors, however, less likely to own Long Lasting Insecticide Nets compared to 15-19 years [AOR(95%CI)=0.29(0.10-0.87) and 0.08(0.01-0.72) respectively] whiles pregnant women aged 35 years and above were significantly less likely to utilize Long Lasting Insecticide Nets compared to 15-19 years [OR(95%CI)=0.12(0.03-0.48)]. Conclusion The study found utilization of Long Lasting Insecticide Nets among pregnant in the Wa Municipality low as compared to the National Malaria Control Program target in Ghana although Long Lasting Insecticide Nets ownership was high. The study recommends that Public Health Nurses and Disease Control Officers should intensify sensitization on the importance and misconception of the use of Long Lasting Insecticide Nets during outreach clinics.


Introduction
Globally, malaria is a public health problem in the world that threatens the lives of 3.2 billion people and leads to over one million deaths annually [1]. At least 300 million acute cases of malaria occur each year worldwide with about 90% of malaria deaths occurring in Africa [1,2]. In sub-Saharan Africa (SSA), 80-90% of the world's malaria cases occur of which approximately 19-24 million women are at risk of malaria and its adverse consequences during pregnancy [3].
The use of Insecticide Treated Nets (ITNs) is one of the effective intervention strategy for the prevention of malaria in endemic areas [3,4]. Awareness-use nexus of bed net use and the outcomes for malaria are reported in some studies in Africa. In Malawi for instance awareness of bed net was as high as 70%, while Long Lasting Insecticide Nets (LLIN) use was as low as 3% [5].
Furthermore, in Nigeria out of the 148 women who owned ITNs, 31.6% utilized ITNs among the 335 women studied [6]. Also, in Ethiopia, from the total households surveyed, 89.94% (456) own at least one LLIN in a household whiles 85.1% (388) had utilized LLIN the night before the survey [7].
In community-wide trials in several African countries bed nets have been shown to reduce child mortality by about 20% as well as reducing malaria incidence by about 50% [8]. Long lasting insecticide nets is a cost-effective measure adopted by the World Health Organization (WHO) aimed at reducing the incidence of malaria in endemic countries. The bed nets are treated with chemicals (parathyroid) to prevent mosquitoes from biting people whilst they sleep under the net. Depending on the type of chemical used, some remain potent for six months and others for years. This method has been tried and found to be effective in reducing the incidence of malaria in endemic countries including Ghana [8]. Malaria is the number one cause of morbidity accounting for 40.2% of all outpatient illnesses in Ghana [9]. ITNs is a form of personal protection that has reportedly been shown to reduce severe disease and mortality due to malaria in endemic regions. In Ghana, various types of ITNs have been on the market. They include the LLINs that require re-treatment only after about four years or twenty standard washes and the standard insecticide-treated nets that need to be re-treated every six months or after three washes [10]. This strategy is aimed at preventing mosquito contact, can aid in reducing infective bite and malaria transmission [11]. Malaria is hyper endemic in Ghana and among pregnant women, it accounts for 17.6% of outpatient department (OPD) attendance, 13.7% of admissions and 3.4% of maternal deaths [12]. A number of studies have investigated the awareness and utilization of mosquito bed net among pregnant women in Ghana. It was identified in Brong Ahafo, region, Ghana that, 96% of pregnant women were aware of the ITN and how it is used to prevent malaria [13]. Awareness about bed nets does not automatically translate into better utilization of LLIN especially in Ghana where the Ghana Demographic Health Survey report identified that, only 43% of pregnant women sleep under LLIN [14].
The attempt to control malaria in Ghana aimed at reducing malaria disease burden till it is of no public health significance began in 1950s [14]. In an effort to make mosquito nets more affordable, the government of Ghana has since 2002 waived taxes on the importation of nets into the country [14]. Development partners have also contributed by supplying some LLIN for distribution at subsidized costs to pregnant women and children under five in disadvantage areas. It has been the desire that the introduction of LLIN will help bring malaria under control. The LLIN has other advantages of controlling and prevention of yellow fever, lymphatic filariasis since these diseases are also transmitted by mosquitoes and also nuisances from other insects like houseflies, bed bugs and cockroaches [14].
Although Ghana has made significant progress over the last few years, much effort is still required to extend individual and household ownership coverage and use of ITNs. There are still 48.9% of households without ITN coverage and 57% of pregnant women not using ITN [14]. Given that a high proportion of pregnant women do not use ITN in Ghana as reported by Ghana Statistical Service, Ghana Health Service & ICF [14] is of public health concern. This study Sampling method: a two staged-sampling technique was adopted in the study. Simple random sampling technique was adopted to sample a Health Center each from Bamahu, Busa, Charia, Charingu, Kambali and Wa Central as the study zones. Proportionate sampling was then used to determine participants needed from each zone.
Simple random sampling was finally adopted in each zone to recruit pregnant women for the study.
Data collection procedure: the data collection tool used was a semi-structured questionnaire. Fifteen (15) participants were used for pre-testing of the questionnaire at Wa urban health centre prior to final data collection to validate and ensure the quality of data. The languages that were used to administer the questionnaire were English, Waale and Dagaale. respectively and were statistically significant (AOR=0.29, 95% CI 0.10-0.87; AOR=0.08. 95% CI 0.10-0.72 respectively). Moreover, pregnant women aged 20-24 years and 25-29 years were 39% and 53% less likely to own LLIN as compared to age group 15-19 years respectively but were not statistically significant (AOR=0.61, 95% CI=0.23-1.59 and AOR=0.47, 95%CI= 0.17-1.27 respectively).
Regarding educational status, pregnant women who had attained tertiary level were 6.74 times more likely to own LLIN as compared to pregnant women with no formal education (AOR=6.74, 95% CI= 1.62-27.95). In terms of occupational with statistical significance, traders were 3.14 times more likely to own LLIN as compared to pregnant women in the civil sector (AOR=3.14, 95% CI=0.87-11.20) (  (Table 3).

Discussion
Malaria is a major public health problem in the world that threatens own nets, about 70% of women used them frequently [18]. According to Deladem (2013), the use of LLIN was high among pregnant women of northern tribes as compare to other groups [19]. Moreover, this current study identified only age as significant predictor of pregnant women utilization of LLIN. The findings of Deladem (2013) again confirms that age is predictor of pregnant women utilization of LLIN [19].

Conclusion
The study discovered that LLIN ownership was high. Although utilization was low as compared to the NMCP target, it has been improved. It is being understand that, owning LLIN facilitates its use but this study concludes that, owning LLIN does not necessarily make one to use. Pregnant women who did not use LLIN stated reasons such as embarrassments due to heat, lack of ownership of LLIN and preference of using mosquito spray as some of the barriers to LLIN utilization. Although the target of the NMCP 85% utilization of LLIN were not met, there has been an improvement on the ownership and utilization of LLIN by the findings of this study.

Recommendations: this study recommends that Public Health
Nurses and Disease Control Officers should intensify sensitization on the importance and misconception of the use of LLIN during outreach clinics as well as local radio presentations.
What is known about this topic • 82.2% of pregnant women own LLIN.

Competing interests
The authors declare no competing interests.

Authors' contributions
Ernest

Acknowledgments
We are grateful to the Wa Municipal Health Administration for their permission for this research work and assistance during the survey.
Moreover, we are grateful to the pregnant women who were involved in the study and finally, special acknowledgement goes to Miss Agustina Dede Tetteh for her inspirations and support during the research work. Table 1: demographic characteristics of respondent