Malaria, age 14, parity 15, education status

caused by protozoa of the genus Plasmodium, is a disease that claimed lives of
approximately 445 000 people globally in 2016 1. The public health concern of malaria goes beyond the
general population to special vulnerable groups such as under-fives and
pregnant women.  The impact of malaria in
pregnancy (MIP) is well documented with effects observed on the women, fetus
and the newborn 2, 3. Sub-Saharan Africa remains the
hardest hit with 85% of the 25 million pregnancies at risk of malaria globally,
occurring in the region 4. This results in
MIP accounting for 20% and 11% of stillborn and neonatal deaths in the region,
respectively 2, 3.

reduce the burden of MIP, World Health Organization (WHO) developed three
strategies namely; Insecticide Treated Nets (ITN), Intermittent Preventive
Treatment use (IPTP) and active case management 5. Despite reports of high ITN coverages in the Sub-Saharan
Africa region, use of the same remains problematic 6-8.

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Malawi, ITN has been at the center of malaria control with a nationwide mass
ITN distribution campaign taking place in 2012 9.  In addition to
the campaign, the ITN policy also recommends that pregnant women should be
given free ITNs at antenatal care (ANC) visits. The policy, coupled with the mass
ITN distribution campaign in 2012 and periodical mass distribution campaigns
conducted in collaboration with other non-organizations has seen ITN use among
pregnant women rise from 35% in 2010 to 62% in 2014 10, 11.  However, a recent Malawian study revealed a
drop in ITN use among women of child bearing visiting ANC age to 53% 12. This is of
concern considering that ITN is one of the most reliable vector control methods
in malaria prevention hence crucial in achieving malaria elimination by 2030 13.

A large body of research has demonstrated that factors such as
women’s age 14, parity 15, education status 15, employment status 14, 16,
household wealth 14, 17, and
religion 14 have significant effects on ITN utilization. For instance, women
who had a higher education were two times more likely to use ITN than women
with no formal education in Kenya 17. In Cameroon, 45% multigravida women as compared to 21% Primigravida
women slept under ITN the previous night before the survey18. However, inconsistent results have been reported elsewhere with
studies revealing education 19, parity 16, and age 15 to have no significant association with ITN use among pregnant

In Rwanda, community factors influenced ITN use among
under-children 20. Under-5 children living in communities with high education and
high wealth were more likely to use ITN in comparison to those living in low
communities 20. Community characteristics have also been previously shown to have
significant influences on health outcomes and health care utilization across Africa
21, 22. However,
little is known about the effects of community on ITN utilization among women.
Few studies have investigated the influence of both individual and contextual factors
on ITN use and whether the community effects still exist after controlling for
individual-level characteristics. Analyzing the contextual
factors is important to ensure that future interventions such as mass
campaigns, and health education messages are tailor-made for both vulnerable
communities and women.

drawing a nationally representative sample, this study aimed to investigate the
individual- and community-level factors on ITN utilization among Malawian
women. Specifically, the study sought to 1) to identify individual- and
community-level factors associated with ITN use among women in Malawi, 2) to
compare factors influencing ITN use among different groups of women (i.e.
pregnant women, non-pregnant women with under-5 children and non-pregnant women
without under-5 children).