Sociodemographic factors associated with the use of insecticide treated nets among under-fives in Nigeria: Evidence from a national survey

Abstract

Insecticide treated nets (ITN) are effective in malaria prevention; however, they remain underutilized among children. A secondary analysis of the 2018 Nigeria-Demographic and Health Survey including logistic regression was conducted to determine factors influencing ITN use among under-fives (U5s). Overall, 22,954 (72.4%) slept under ITN the night before the survey. Children <4 years and those in the northern regions had significantly higher odds of using ITN, as did those from households with ≤6 members and those from the lowest to middle wealth quintiles. However, among those households recorded as having “universal ITN coverage” i.e. at least one net between two persons, children <3 years, those from the rural northern regions and those from the lowest wealth category had significantly higher odds of using ITN. Interventions to improve ITN use by U5s should be intensified among households with larger size, those from the highest wealth quintiles and residents in southern Nigeria.

Keywords

Insecticide net use children households Nigeria

Introduction

Malaria remains a public health issue especially in sub-Saharan Africa where children under 5 years and pregnant women are at risk of severe disease,¹ particularly in Nigeria which accounts for 25% of all malaria deaths worldwide.^2,3 Malaria is the commonest reason for outpatient consultation in Nigeria and accounts for 60% of all outpatient consultations and 30% of all hospital admissions.⁴ Malaria predominantly affects poor rural dwellers with pregnant women and under-five children at highest risk of severe disease and death.⁵ In Nigeria, the burden of malaria among under-fives is more in the northern states, although there has been a gradual decline in malaria prevalence in the last few years.⁶

WHO advocates protection for persons susceptible to malaria by the use of effective malaria vector control, of which two methods: use of insecticide-treated mosquito nets and indoor residual spraying, are effective especially for high risk groups.²

Insecticide-treated bed nets (ITNs) remain a potent and affordable form of personal protection.⁷ A meta-analysis of relevant studies found a marked reduction in disease burden and deaths among under-fives who slept under ITN compared to those who did not.⁸ In trials conducted across African countries, ITNs reduced all-cause mortality from malaria by 20% among under-fives.⁹ Several other studies conducted in sub-Saharan Africa also affirmed the effectiveness of ITN in reducing malaria morbidity and mortality especially among the vulnerable groups^10–13 even in areas with highly resistant malaria vectors.¹⁴

Despite the reported effectiveness of ITN in malaria prevention, the possession and use of these ITNs are suboptimal and regional differences in ITN ownership are highest in the North-west rural areas, and lowest in the South-west.¹⁵ Hence, to address the issue of inequality in access to ITNs and other key malaria control interventions, the Roll Back Malaria (RBM) partnership, alongside the United Nations Secretary-General, established the initiative “Cover the Bed Net Gap” in 2008 to ensure universal bed-net coverage by the year 2010. The initiative aimed to ensure that all members of households at risk of malaria are protected by having access to insecticide-treated net (ITN) via mass net-distribution campaigns.¹⁶ This initiative and similar programmes have resulted in many African countries having significantly high coverage of ITNs.

In Nigeria, before this project was initiated, ITN ownership and use was more likely in households with higher wealth because they had better access to health care services as compared with those in the lowest wealth quintile,¹⁷ because ITN distribution was provided to caregivers of infants during routine vaccination programmes. Also, pregnant women who attended a certain number of antenatal care visits received free nets.¹⁸ Furthermore, ITNs became more readily available for purchase at health facilities and private markets. Despite all the mass distribution campaigns in Nigeria, under-five children do not utilize them optimally.^19,20 Apparent reasons include insufficient bed nets to cover all household members,²¹ heat or discomfort while sleeping under the net,^20,22 phobia for chemicals and ignorance.^20,23 Nonetheless, it is important to understand the effect of personal and household characteristics on ITN use among under-fives.

Methods

The data used for our secondary analysis were from the 2018 Nigeria demographic health survey (DHS),²⁴ which was conducted between August and December 2018 using a multi-stage random sampling technique. In all, 42,000 households participated. Women of reproductive age (15–49 years) who were permanent residents of households in the 2018 Nigeria DHS sample or visitors present in the households on the night before the survey were eligible to be interviewed.²⁵

In all, 40,427 out of 41,668 households selected were successfully interviewed. A total of 42,121 women aged 15–49 years had complete interviews. Relevant information collected included socio-demographic characteristics of each person listed, such as age, sex, educational status, relationship to the head of the household, ownership and use of ITNs among others.²⁵

Data were analyzed using Stata version 16 (Statcorp, College Station, TX, USA). For our analysis, all children born within the 5 years preceding the survey to interviewed women, and alive at the time of the survey, were included. Datasets²⁴ were combined to derive all variables of interest. Sample weight was applied to the analysis based on the population of the selected regional domains. The details of how the weighting was estimated for the different regional domains are available in the 2018 NDHS full report.²⁵ Hence, only weighted survey data are presented in the results section of this study.

Place of residence was classified into rural or urban based on the classification by the demographic and health survey (DHS) programme.²⁶ Typically, urban areas are large cities (over 1 million inhabitants), small cities (inhabitants over 50,000), and towns while rural areas refer to the countryside.²⁶ Household size was categorized by using the median value of six, thus households with <6 household members were categorized as small while households with >6 as large. Household wealth index was measured by assessing ownership of some selected assets viz. television, access to electricity etc. Principal component analysis was then used to categorize the wealth index into five quintiles namely “lowest”, “second”, “middle”, “fourth” and “highest”.²⁶

The socio-demographic characteristics of study participants were summarized using frequencies and proportions. Association between categorical variables (e.g. place of residence and use of ITN) was determined using chi square test. A multivariable binary logistic regression model was used to assess the factors associated with the use of ITN among under-fives alongside the adjusted odds ratio and 95% confidence interval. The outcome variable was “child slept under ITN the night prior to the survey”. Independent variables included in the model were: age, gender, place of residence, household size and household wealth status. Only independent variables that were associated with ITN use (at p < 0.1) were included in the regression model. For all analyzes, a p-value of <0.05 was taken as statistically significant.

Ethical approval

The permission to use the NDHS 2018 dataset was obtained from the DHS programme. The NDHS 2018 survey protocol, was approved by the Institutional Review Board of ICF International, and the National Health Research Ethics Committee (NHREC) of the Federal Ministry of Health Abuja, Nigeria. A written informed consent was obtained from all survey participants.

Results

Overall, data was analyzed for 32,657 children in Nigerian households, among whom slightly more than half (17,044; 52.2%) slept under an ITN. In households owning at least one net, almost three-quarters slept under one the night before the survey, and in those owning at least one net between 2 persons, i.e. within universal coverage range, the majority slept under a net the night before the survey.

A significantly higher proportion of infants (aged <1 year) slept under a net when compared with older children (>4 years old). Significantly more children in rural areas slept under the net compared with those in urban areas, and likewise more in the North West region than the South South. Where children slept in male-headed households significantly more slept under the net than in female-headed households (See details in Table 1). The regions of the country are shown in Figure 1.

Figure 1.

Map of Nigeria showing the geopolitical regions. ©Wikipedia.

Table 1.

Association between the use of ITN and socio-demographic characteristics of under-five children in Nigerian households 2018. N = 32,657.

Characteristics	Slept under ITN last night = NO, n = 15,613		Slept under ITN last night = YES, n = 17, 044		Total	Statistical comparison
Characteristics	%	N	%	N	Total	Statistical comparison
Age in years
<1	43.0	2773	57.0	3684	6457
1	45.8	2913	54.2	3449	6362
2	47.8	2960	52.2	3239	6199
3	49.8	3332	50.2	3365	6697
4	52.4	3635	47.6	3307	6942	p < 0.001
Child’s gender
Male	47.9	7969	52.1	8666	16,634
Female	47.7	7644	52.3	8379	16,022	p = 0.762
Residence
Urban	55.2	7121	44.8	5780	12,901
Rural	43.0	8492	57.0	11,264	19,756	p < 0.001
Region
North East	52.6	3159	47.4	2845	4461
North Central	52.6	2346	47.4	2116	6004	p < 0.001
North West	27.3	3115	72.7	8301	11,416
South East	63.5	2171	36.5	1249	3419
South South	66.5	1969	33.5	992	2962
South West	64.9	2853	35.1	1542	4395
Wealth Index
Lowest	40.1	2833	59.9	4234	7067
Second	41.0	2953	59.0	4259	7211	p < 0.001
Middle	46.3	3114	53.7	3606	6720
Fourth	55.0	3351	45.0	2741	6092
Highest	60.4	3362	39.6	2205	5567
Household size
≤6 members	46.7	8370	53.3	9564	17,934
≥7 members	49.2	7243	50.8	7480	14,723	p = 0.013
Gender of head of household
Male	47.3	14,010	52.7	15,623	29,633
Female	53.0	1601	47.0	1423	3024	p < 0.001

Among children in households that own at least one ITN, more infants slept under ITN the night before the survey when compared with four-year old children. A significantly higher proportion of children who resided in rural areas slept under the ITN the night before the survey compared with those in the urban areas. Also, a significantly higher proportion of children from households with the lowest wealth quintiles and those from large households (≥7 members) slept under the ITN the night before the survey. See details in Table 2.

Table 2.

Association between the use of ITN and socio-demographic characteristics of under-five children in Nigerian households who own at least one ITN, 2018. N = 22,954.

Characteristics	Slept under ITN last night = NO (n = 5910)		Slept under ITN last night = YES (n = 17,044)		Statistical comparison
Characteristics	%	N	%	N	Statistical comparison
Age in years
<1	20.9	976	79.1	3684
1	23.1	1036	76.9	3449
2	24.9	1075	75.1	3239
3	28.3	1325	71.7	3365
4	31.2	1498	68.8	3307	p < 0.001
Child's gender
Male	25.7	2992	74.3	8666
Female	25.8	2918	74.2	8379	p = 0.8119
Residence
Urban	28.7	2325	71.3	5780
Rural	24.1	3385	75.9	11,264	p < 0.001
Region
North East	30.6	1255	69.4	2845
North Central	24.0	669	79.0	2116	p < 0.001
North West	19.6	2023	80.4	8301
South East	33.8	638	66.2	1249
South South	37.1	585	62.9	992
South West	32.4	739	67.6	1542
Wealth Index
Lowest	22.0	1193	78.0	4234
Second,	23.1	1277	76.9	4259	p < 0.001
Middle	24.9	1192	75.2	3606
Fourth	30.1	1182	69.9	2741
Highest	32.6	1065	67.4	2205
Household size
≤6 members	20.8	2507	79.2	9564
≥7 members	31.3	3403	68.7	7480	p < 0.001
Gender of head of household
Male	25.8	5436	74.2	15,622
Female	25.0	474	75.0	1423	p = 0.266

Among children in households that own at least one ITN for every two persons (universal ITN coverage), a higher proportion of two-year-olds and children in rural areas slept under ITN the night before the survey. More children from households in the second wealth quintile and those in male headed households slept under the ITN the night before the survey. Details in Table 3.

Table 3.

Sociodemographic factors associated with ITN use among under-fives in households with universal ITN coverage (at least one ITN for every two people n = 6281).

Characteristics	Slept under ITN last night = NO (n = 958)		Slept under ITN last night = YES (n = 5323)		Statistical Comparison
Characteristics	%	N	%	N	Statistical Comparison
Age in years
<1	14.6	181	85.4	1055
1	13.5	169	86.5	1089
2	12.7	153	87.3	1049
3	17.1	222	82.9	1075
4	18.1	234	81.9	1055	p < 0.001
Child's gender
Male	15.6	492	84.4	2666
Female	14.9	466	85.1	2657	p = 0.350
Residence
Urban	18.7	389	81.3	1692
Rural	13.6	569	86.4	3631	p = 0.003
Region
North East	17.1	157	82.3	732
North Central	16.1	108	83.9	566	p < 0.001
North West	9.5	298	90.5	2855
South East	22.4	118	77.6	408
South South	30.4	123	69.6	282
South West	24.3	154	75.7	478
Wealth Index
Lowest	11.7	173	88.3	1301
Second	10.9	162	89.1	1325	p < 0.001
Middle	15.0	195	85.0	1105
Fourth	19.1	203	80.9	860
Highest	23.6	225	76.4	732
Household size
≤6 members	15.0	676	85.0	3836
≥7 members	16.0	282	84.0	1487	p = 0.561
Gender of head of household
Male	14.5	811	85.5	4765
Female	20.9	147	79.1	558	p < 0.001

Binary logistic regression analysis of sociodemographic factors associated with ITN use among under-fives in households with at least one ITN showed that children less than four years had significantly higher odds of sleeping under ITN the night before the survey when compared with four year olds. In addition, children in the North-central, North-east and North-west region had significantly higher odds of sleeping under ITN the night before the survey when compared with children in the South South region. Also, children from households in the from the lowest, second and middle wealth quintiles had significantly higher odds of sleeping under ITN the night before the survey when compared with children from households in highest wealth quintile. Similarly, children from households with 6 members or less had higher odds of sleeping under ITN the night before the survey when compared with children from households with 7 or more members. See details in Table 4.

Table 4.

Binary logistic regression analysis of the association between the use of ITN and socio-demographic characteristics of under-five children in Nigerian households who own at least one ITN, 2018. (N = 22,954) and Nigerian households with Universal ITN coverage (at least one ITN for every two people), 2018, n = 6821.

Variables	Households own at least one ITN, (n = 22,954)		Households with universal ITN coverage (at least one ITN for every two people), (n = 6821)
Variables	Adjusted odds ratio	95.0% C.I (p-value)	Adjusted odds ratio	95.0% C.I
Age in years
<1	1.7	1.5–1.8 (p < 0.001)	1.3	1.02–1.6
1	1.5	1.3–1.6 (p < 0.001)	1.5	1.2–1.8
2	1.3	1.2–1.5 (p < 0.001)	1.5	1.2–1.9
3	1.1	1.01–1.2 (0.037)	1.1	0.8–1.3
4	Ref		Ref
Residence
Urban	Ref		Ref
Rural	1.0	0.8–1.2 (0.910)	0.9	0.68–1.17
Region
South south	Ref		Ref
North central	2.0	1.5–2.5 (p < 0.001)	2.1	1.4–3.2
North East	1.5	1.2–1.9 (0.001)	1.6	1.02–2.6
North West	2.9	2.3–3.6 (p < 0.001)	3.4	2.3–5.0
South East	1.3	1.0–1.7 (0.059)	1.4	0.9–2.3
South West	1.2	0.9–1.6 (0.136)	1.4	0.9–2.0
Wealth Index
Lowest	1.6	1.2–2.0 (p < 0.001)	1.7	1.1–2.5
Second	1.4	1.2–1.8 (0.001)	1.9	1.3–2.8
Middle	1.4	1.2–1.7 (p < 0.001)	1.5	1.1–2.2
Fourth	1.1	0.7–1.1 (0.196)	1.3	0.9–1.7
Highest	Ref		Ref
Household size
≤6 members	2.2	2.0–2.5 (p < 0.001)
≥7 members	Ref
Gender of head of household
Male			Ref
Female			0.8	0.6–1.1

Binary logistic regression analysis of sociodemographic factors associated with ITN use among under-fives in households with at least one ITN for every 2 persons revealed that children less than three years old had significantly higher odds of sleeping under ITN the night before the survey when compared with four-year olds. Also, children in the North Central, North East and North West had significantly higher odds of sleeping under ITN the night before the survey when compared with children in the South South region. Children from the lowest, second and middle wealth quintiles had significantly higher odds of sleeping under ITN the night before the survey when compared with children in households from the highest wealth quintile. Details in Table 4.

Discussion

Our study assessed the sociodemographic factors associated with ITN use among under-fives in Nigeria using a nationally representative sample. Although ITN ownership is increasing nationwide, the 80% target of the RBM partnership and the Nigeria national malaria strategic plan is yet to be achieved.²⁷ However, ITN ownership was found to be much lower in other West African countries assessed.^28,29 In this study we observed that with increasing age of the child, and rising household wealth quintile, there was a significant decline in ITN use. However, with improved ITN availability in households, ITN use among under-fives improved appreciably.

This study reported that a significant proportion of infants slept under ITN the night before the survey. A similar trend was reported from a study by Auta³⁰ and another study in a rural community in South-west Nigeria, where mothers were said to have kept their bed net for their newborns because they believe the newborns were more susceptible to malaria.²² The same pattern was observed in other African countries.³¹ Also, mothers and caregivers may perceive a lesser risk for severe malaria as a child's age increases. Notably, while under-fives are vulnerable to severe malaria, older children can serve as reservoirs of infection even though they maybe asymptomatic or have uncomplicated malaria.³² This emphasizes the need to educate mothers and caregivers that the use of ITN is meant to reduce transmission of all forms of malaria among children and other household members.

That more children in the North-west region slept under the ITN the night before the survey may be related to the net ownership rate, perceived severity of malaria and risk of contracting malaria among caregivers in that region.^15,33 Similarly, children from households in the lowest wealth quintiles were significantly more likely to use ITN suggesting that affluence does not translate to utilization of ITN. It is possible that richer households may prefer and employ other malaria control measures (such as indoor residual spraying and mosquito repellents) that are more convenient to use than ITN which may be more costly for households in the lowest wealth quintiles.³⁴

The difference in net utilization in the rural vs urban regions may be due to wider net availability in the rural areas of Nigeria¹⁵ and perhaps a higher perceived risk of malaria acquisition by the rural dwellers since malaria is more prevalent among the poor and rural dwellers.⁵ A study from Ghana reported that children in households with 5 to 10 members were about two times more likely to sleep under ITN when compared with households having 1 to 4 members. This is in contrast to our study where children in smaller households slept under the ITN the night before the survey when compared to larger households.³⁵ Our study finding may be related to availability of ITNs since the free distribution of ITN is not dependent on the household size.

Universal coverage of ITN is defined as having at least one net for every two household members.^36,37 The universal coverage of ITN was low in this present study. Hence, households without universal ITN coverage may have some household members who sleep outside the ITN without protection from mosquito bites or may resort to having more than 2 people share a net and this may reduce the effectiveness of the ITN.³⁸ This suggests that more net distribution is required if this trend is to be improved across Nigerian households.

With improved net availability in households, more children are likely to sleep under ITNs.³¹ this is evidenced in this study as more children in households with universal ITN coverage slept under the net a night before the survey compared with households with at least one ITN. Therefore, providing more ITNs in households to achieve universal ITN coverage may be a veritable means to increasing the proportion of under-fives that are able to sleep under ITNs,^31,39 thereby reducing their vulnerability to malaria.

However, further qualitative studies are needed to explore the social and cultural factors influencing the use of ITN in Nigerian households and especially among under-fives. Also it is important to assess the factors that influence net retention in Nigerian households and explore household factors that influence the use of ITNs among households with universal net ownership.

A limitation of this study was that only a few socio-demographic variables that may influence ITN use were assessed. This is due to the fact that secondary data analysis was conducted and the parent dataset only collected information about a few relevant socio-demographic variables. The study was prone to social desirability bias as guardians/parents of under-fives may report that children slept under ITNs when actually they did not.

Conclusion

In conclusion, the overall ownership and utilization of ITN still needs to be improved in Nigeria. It is therefore recommended that awareness and distribution of ITN should be increased especially in the southern regions of the country. Also, more health promotion campaigns on the benefits of ITN ownership and its use in malaria prevention particularly for under-fives may be helpful. In addition, free net distribution programs need to focus on larger households, Furthermore, there is a need to provide behavior change communication interventions that will promote ITN use and net retention among households that own ITNs.

Footnotes

Acknowledgements

We wish to acknowledge the DHS program for granting us access to the 2018 NDHS dataset. The first author was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No--B 8606.R02), Sida (Grant No:54100029), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)'s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa's Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the Fellow.

Data availability statement

The 2018 Nigeria DHS dataset can be obtained from the DHS program (ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA) or from The DHS Program—Available Datasets.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Temitope Olumuyiwa Ojo

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