Introduction

Globally, malaria is a public health concern, with half of the population at risk of infection [1]. Nearly one million people die each year from malaria [2]. The Plasmodium parasites cause malaria, which is transmitted when one is bitten by anopheles mosquitoes [3, 4]. Globally, malaria cases increased from 227 million in 2019 to 241 million in 2020, with most of this increase occurring in the African region [5]. According to the World Malaria Report, malaria mortality steadily declined from 896,000 in 2000 to 558,000 in 2019. However, malaria deaths increased in 2020 as compared to 2019 (558,000), reaching an estimated figure of 627,000 [5]. WHO’s World Malaria Report for 2021 also reported that 68% (47,000) of the 69,000 extra deaths were caused by problems with service delivery during the COVID-19 pandemic [5].

Due to its high morbidity and mortality rate, malaria poses a major threat to children younger than five years of age [6]. Malaria cases increased from 213 million to 228 million in the WHO African Region between 2019 and 2020, with deaths rising from 534, 000 to 602, 000. Around 95% and 96% occurred in this region, with children under the age of five accounting for 80% of all deaths [5]. In Ghana, malaria is endemic, perennial, and follows a seasonal variation, particularly in the northern part of the country. The rate of spread of malaria differs geographically, conditional on the length of the dry season (December to March), which has little transmission [7]. Ghana is among the 15 countries with the highest malaria cases, accounting for 2% of global malaria cases and 3% of malaria mortality. However, malaria cases and deaths in Ghana decreased between 2016 and 2019. The number of cases decreased by 32% from 237 in 2016 to 161 per 1000 in 2019 [8]. Malaria deaths decreased by 7%, from 0.4 deaths per 1,000 to 0.37 deaths during the same period.

Globally, 18 (58%) out of 31 countries completed the continuous distribution of insecticide-treated mosquito nets (ITNs) campaign, which resulted in 159 million (72%) ITNs being distributed in 2020 [5]. In the Ghanaian setting, both mass and continuous distribution campaigns have been employed in distributing ITN to the entire populace. The recent mass distribution campaign took place in 2018. ITNs are routinely distributed at maternity care centers, child welfare centers, and primary schools as part of the continuous distribution. ITNs are given out free to children aged 18 months or older at their second dose of the measles-rubella vaccine during child welfare visits and pregnant women during their first ANC visit as part of health facility-based distribution [9]. Ghana has 74% of households owning at least one ITN in 2019, but a low usage rate (54%) for children under five years [10]. The global malaria elimination programme classifies Ghana as being in the control phase of malaria elimination [9]. As a result, Ghana and most sub-Saharan African countries have made an effort to attain a reduced level of malaria morbidity [11]. The country’s development and implementation of consecutive strategic action plans, policy interventions, and an enhancement in financial support over the years have contributed to reducing the burden of malaria in the country [12]. However, the National Malaria Control Programme still has a lot more to achieve. It aims at achieving 100% household ownership of at least one ITN, 80% of the general population sleeping under ITNs, and increasing the number of children under five who sleep under ITNs to 85% from current levels [13].

Therefore, this study seeks to identify the determinants of ITN usage in children under five years old, specifically how the use of ITN by mothers is associated with the use by their children under five years of age, in order to improve the implementation of integrated malaria control strategies and interventions in Ghana.

Methods

In this study, the analysis is based on data collected from the 2019 Ghana Malaria Indicator Survey (GMIS). The sampling frame for the 2019 GMIS was based on the 2010 Population and Housing Census (PHC), which was done by the Ghana Statistical Service (GSS) in Ghana. Ghana created six (6) new regions in 2019, totaling 16 regions and 260 administrative districts, municipalities, and smetropolitans [23]. However, the new administrative boundaries were not available during the survey design. As a result, the sampling frame for the 2019 GMIS was based on the ten regional borders set under the 2010 PHC. The GMIS is a nationally representative cross-sectional household survey used to collect information on population-based malaria indicators for the country as a whole, for urban and rural areas separately, and for each of the ten (10) administrative regions (Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West) as defined in the Ghana 2010 Population and Housing Census (PHC). The sampling frame used for the 2019 GMIS is a frame of all census enumeration areas (EAs) created for the 2010 Population and Housing Census (PHC) and provided by the Ghana Statistical Service (GSS) [10].

The 2019 GMIS sample was stratified and selected from the sampling frame in two stages. Each region was divided into urban and rural areas; this yielded 20 strata for sampling. Samples of EAs were selected independently in each stratum in two stages. Implicit stratification with proportional allocation was achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection [10]. This was performed according to administrative units at different levels and by using a probability proportional to size selection in the first stage of sampling. In the first stage, 200 EAs (97 in urban areas and 103 in rural areas) were selected with a probability proportional to EA size and with independent selection in each sampling stratum. In the second stage of selection, a fixed number of 30 households were selected from each stratum to make up a total sample size of 6,000 households. The sampling details for the 2019 GMIS, data collection methods and tools, as well as the quality control measures, have been documented in the full report [10].

This study utilised the children’s file for analysis. A total of 1,876 women aged 15–49 years were included in the study.

Results

The percentage of children under five sleeping under insecticide-treated bed nets by mothers’ background characteristics

In total, 1,876 mothers/caregivers with children under five years of age participated in the study. The results showed that 28.15% of the households did not have children under five years of age sleeping under mosquito bed nets the previous night before the study; 57.94% had all children under five sleeping under bed nets the previous night; and 13.91% had some children under five sleeping under mosquito bed nets the previous night before the interview. We found significant differences in the use of ITN by children under five by all the sociodemographic, economic, and health-related characteristics except respondents’ age group (p-value = 0.275), being pregnant at the time of interview (p-value = 0.120), having a valid national health insurance card (p-value = 0.137), seeing or hearing any messages about malaria in the past 6 months (p-value = 0.289), and mothers/caregivers who would allow their children to be vaccinated against malaria (p-value = 0.198) (Table 1).

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Table 1. The percentage of children under five sleeping under ITN by mothers’ background characteristics.

https://doi.org/10.1371/journal.pone.0280065.t001

Association between children under five sleeping under ITN and background characteristics of their mothers or caregivers

The use of bed nets in children under five was categorised as “no child under 5 slept under ITN the previous night”, “all children under 5 slept under ITN the previous night” and “some children under 5 slept under ITN the previous night (the base outcome).” The results indicate that women who slept under mosquito bed nets were more likely to have their children under five sleeping under mosquito bed nets. In the multinomial logistic regression model, we adjusted for the effect of sociodemographic, and economic factors on children under five sleeping under mosquito bed nets the night before the study. The results showed that mothers/caregivers who slept under a mosquito bed net were less likely to have no child sleeping under a mosquito bed net (RRR = 0.031; 95% CI: 0.015, 0.059). However, they were more likely to have all children sleeping under a mosquito bed net (RRR = 2.468; 95% CI: 1.477, 4.123) compared to having some children sleeping under a mosquito bed net last night.

Again, we found that the mothers/caregivers who made 4 to 7 ANC visits during pregnancy were 19% less likely to have a child sleep under ITN as compared to those who made no ANC visits. Wealthier mothers and caregivers are more likely to allow no child to sleep under ITN.

Moreover, mothers/caregivers with at least two (2) children under the age of 5 were less likely to have no child and all children sleep under ITN. Whereas respondents who are willing to allow their children under five to be vaccinated against malaria were 3.22 times more likely to have no child sleep under ITN last night. On the other hand, the mother/caregiver’s age, education, place of residence, having a valid national health insurance card, being pregnant at the time of the interview, and having seen or heard of any messages about malaria in the past 6 months were not significantly associated with children under 5 sleeping under mosquito bed nets (Table 2).

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Table 2. Association between children under five sleeping under ITN and background characteristics of their mothers or caregivers (Base outcome (reference group) = Some children slept under ITN the previous night).

https://doi.org/10.1371/journal.pone.0280065.t002

Discussion

This study assessed the association between the use of ITN in children under five and their mothers/caregivers using nationally representative data from the 2019 MIS in Ghana. The study found that 58.59% and 61.88% of mothers/caregivers and children under five years old, respectively, slept under a mosquito bed net the night before the interview. This result is similar to a study conducted in Burkina Faso, which found that two-thirds (67.0%) of children under five sleep under the ITN [26]. In contrast, a study conducted in Nigeria that compared the level of usage among mothers/caregivers and children under five indicated that 49.1% of women and 43.1% of children under five slept under ITN the previous night before the conduct of the study [27] and 45.3% of women and 37.5% of children under five slept under ITN the previous night before the conduct of the study [28]. These are substantiated by the fact that, in Ghana and the majority of African nations, the Ministry of Health has made concerted efforts to provide education on malaria prevention with a strong emphasis on the use of ITN as the simplest and most effective method, with the assistance of WHO and UNICEF [29].

In the current study, it was found that the use of ITN in children under five years of age improved over the 2008 and 2014 Ghana Demographic and Health Surveys, which reported 41% and 47%, respectively [30, 31]. This improvement may be attributed to the effort of the malaria control programme in the country towards the universal coverage target of 80% and above [32]. Other studies also reported increases in the usage of ITN [33, 34]. However, about 40.0% of children did not use ITN on the night before the conduct of the interview in the country. This may be due to the high room temperature [35–37]; the use of other malaria preventive methods such as repellants [38]; and the poor quality of ITN [39].

After controlling for a number of factors, our findings showed that mothers/caregivers who slept under a mosquito bed net would also have their children under five sleep under a mosquito bed net. Thus, mothers/caregivers who slept under ITN were less likely to have no child sleep under ITN (RRR = 0.019; 95% CI: 0.009, 0.039). This implies that, in as much as mothers/caregivers sleep under ITN, it is less likely that any child under the age of five of theirs would not sleep under ITN. Similarly, mothers/caregivers who slept under ITN were more likely to have all their children sleeping under ITN (RRR = 2.084; 95% CI: 1.074, 4.044) compared to having some children sleeping under ITN. A previous study reported that children under five whose mothers use ITN are more likely to use them too [20]. Malaria knowledge was associated with the use of ITN among mothers of children under the age of five in Ethiopia [40].

Households with at least two children under five years of age were less likely to have no child and all children sleeping under ITN as compared to some children sleeping under ITN. Our study implies that households with at least two children under five would have at least some children sleeping under ITN. That is, at least there are some households with an unequal distribution of ITN with regard to household size, which significantly lowers the use of ITN [41]. This finding is similar to a study conducted in the Gambia and Ghana [31, 32].

Furthermore, compared to some children, mothers and caregivers who attended ANC visits 4–7 times during pregnancy were less likely to have had no child sleep under ITN. This implies that mothers or caregivers who attended ANC visits four to seven times would have at least one child under the age of five who used ITN. Similar findings have been reported among Senegalese [42]. ITNs are given to pregnant women at no cost during ANC visits as a vital approach for controlling malaria and increasing coverage and use by both pregnant women and their children under five [9, 43–45]. In most areas where malaria is endemic, women sleep with their infants through the first year of life as a protective effect of ITNs delivered to pregnant women during ANC [33, 35].

Moreover, socio-economic status is a key variable in assessing the effect of health interventions or programmes in society. It is an indication as to whether the interventions reach the poor or vulnerable groups relative to the well-to-do people in societies. We found that wealthier mothers/caregivers had a higher chance of letting none of their children under five sleep under ITN compared to some children sleeping under ITN. The finding is also consistent with reports from Ghana [32] and Senegal [42]. Also, the Ghana Statistical Service indicated that the percentage of women who sleep under ITN tends to decrease with wealth [31]. However, Asumah et al. found that increasing average monthly income was associated with the utilisation of ITNs in the Kasena-Nankana East Municipality in the Upper East of Ghana [29]. The distinctiveness of each setting and the ITN deployment interventions and strategies may result in a disproportionate order between the well-off and relatively poor categories. As a result, wealthier households are more likely to have access to other malaria prevention strategies and may not use ITN even if they have them [32, 46]. Mothers/caregivers who would allow their children to be vaccinated against malaria were 3.22 times more likely to have no child sleeping under an TN as compared to some children using an aITN (RRR = 3.22; 95% CI = 1.117, 9.304). That is mothers/caregivers would feel their children under five would be protected from malaria after the vaccination.

Conclusion

The study identified that about three-fifths of both women and children under five slept under ITN. Again, it was found that women who slept under ITN were more likely to have their children under five sleeping under ITN too. ITNs are given to pregnant mothers/caregivers freely during ANC visits as a vital approach for controlling malaria and increasing coverage and use by their children under five. Thus, the target of achieving 85% utilisation of ITN in children under five under the National Malaria Control Programme in Ghana should include usage by their mothers.