Long lasting insecticide bed net utilization and associated factors among pregnant mothers in Fogera district, North West Ethiopia, 2018.

Background: Long lasting insecticide bed net utilization is one of the major vector control intervention to prevent malaria in Ethiopia. Effective utilization of long lasting insecticide bed net has many impacts for decreasing malaria related morbidity and mortality among pregnant mothers. Methods : A community based cross sectional study was conducted from May 1-30, 2018 in Fogera district, North West Ethiopia. Systematic random sampling technique was used to select study participants. A pre-tested and structured questionnaire was used to collect the data. Data was entered into epi-info and analyzed with SPSS software.Bi-variable and multivariable logistic regression with 95% CI at P ≤ 0.05 was used to assess factors associated with net utilization. Result: The mean age of respondent was 28.26 (SD= 5.39). Over all knowledge of pregnant mothers about long lasting insecticide bed net was 68.7 % with 95% CI (64.1%-72.5%). Utilization of LLIN by interview was 88.3% and by observation was 68.3%. Pregnant mothers with secondary school (AOR = 2.449(1.125, 5.33)), had good knowledge about malaria (AOR=2.246(1.508, 3.344)), and had good knowledge about LLIN (AOR=2.1(1.417, 3.119)) were positively associated with LLIN utilization. Conclusion: Observational utilization of LLIN by pregnant mothers was 68.8% which was lower compared with WHO guideline. Those who had good knowledge about malaria and LLIN utilization, and educated mothers were positive significant factors for long lasting insecticide bed net utilization. Continuous health education on the use of long lasting insecticide bed net should be given to pregnant women at to enhance its

health problem and has been consistently reported as one of the three causes of morbidity and mortality (6). In most endemic area of the world pregnant women are the main risk group for malaria; they are four times more likely to suffer for attacks of malaria than non pregnant women (7,8).
Worldwide, an estimated 125 million pregnancies are at risk from malaria each year (9). In Ethiopia pregnant women accounted for 1.7% of all reported outpatients with malaria, 2.9% of reported malaria hospitalizations, and 1.7% of reported inpatient malaria deaths (10). The infection of malaria during pregnancy have many impacts like severe anemia in the mother, increase the risk of maternal mortality and morbidity and it affects the health of the fetus during pregnancy, though it causes still birth and low birth weight of the child(11-13). However, malaria is both preventable and treatable disease, and a combination of treatment and preventive measures can be used to control it (14).
Long lasting insecticide bed net (LLIN) utilization is one of the major vector control intervention to prevent malaria in Ethiopia (15). In malaria risk areas, LLIN distributed through mass campaigns and continuous distribution to achieve and maintain LLIN utilization levels above 80% (10). Effective utilization of long lasting insecticide bed net has many impacts for pregnant mothers such as decrease morbidity and mortality due to malaria, life saving of infants and fetus, economic saving due to medical cost for malaria treatment.
In Ethiopia to improve LLIN utilization among pregnant women different strategies and policies were applied(2, 15). As a result, there is some improvement of LLIN utilization from 2011 to 2015 in pregnant mothers, despite the improvement of utilization of LLIN in pregnant mothers in malaria's areas of Ethiopia, only 44 percent of pregnant women slept under LLIN at night before 2015 survey (16). However, WHO recommends that utilization of long lasting insecticide bed net (LLIN) should be above 80%.
Regardless of this fact, assessing practical utilization of LLIN by observation during in the morning and determinant factors among pregnant mothers have been limited in the study area which is endemic for malaria. In addition to this, there is also variability of factors from one study to another study. Therefore, the purpose of this study is to assess proper long lasting insecticide bed net utilization and associated factor among pregnant mothers in Fogera district, North West Ethiopia.

Sample size determination
The single population proportion formula was used to calculate the sample size considering the following assumptions: proportion of women using long lasting insecticide bed net 44% [16], 95% confidence level, 5% margin of error (absolute level of precision).
In addition we calculated the factors associated with LLIN utilization among pregnant mothers in Adama district Oromia region(37). Since our study was prevalence and factor, we took the largest number of sample size from the three factors and prevalence. So we took the number calculated using single population proportion 626.

Sampling technique/procedure
The study units were identified by two-stage sampling technique. Primarily, from the source population 8 kebeles were selected by simple random sampling. The number of pregnant mothers which was selected from each randomly selected kebeles was determined by the proportion allocation. The total number of pregnant mothers registered in 8 kebeles were 1233. Furthermore, to select the study units (pregnant mothers), systematic random sampling was used with sampling fraction k th which was calculated (k = 1233/ 626 = 1.96 = 2) from the recent antenatal care (ANC) registration list. Out of the 2 pregnant mothers, the initial one was determined by using the lottery method. The next pregnant women to be included in the study was identified systematically through house-to-house visit. For households with more than one eligible woman, interview was done for one of the mothers using simple random sampling technique. Revisits of two to three times were made in case where eligible respondents were not available at the time of the survey by asking the neighbors whether an eligible women in that house was present or not, after all they were considered as nonrespondents.

Data Collection Tools and Procedures
A semi-structured questionnaire was administered by interview method to all pregnant women visited at home. Early in the morning, each pregnant woman was visited to observe the actual practice regarding the use of LLIN during the previous night, and each selected household was revisited on the same day to answer the remaining questions. The data was collected by 8 data collectors and supervised by two supervisors.
Both the data collectors and supervisors were given one day training about the aim of study, procedures and collection techniques going through the questionnaires question by question, art of interviewing and ways of collecting the data.

Data quality control
The questionnaire was prepared originally in English and then translated to local language Amharic then back to English to ensure reliable information. Pre-test of questionnaire was done on 5% of respondents in one neighboring kebele in fogera district for validity and reliability to identify and correct the potential problems encountering during data collection. One day training of data collectors and supervisors was conducted to ensure the quality of data. Data collectors and supervisors were reviewed every questionnaire for completeness and logical consistency, and checked by the principal investigator every day. Finally data cleaning was conducted at the end of data entry.

Data processing and analysis
Data was checked for completeness and any incomplete information was excluded from the entry.
Coded data was entered by using Epi info version 7 and analyzed using SPSS (statistical package for social science) version 21 software. Proportion and percentages were used to describe the socio demographic characteristics and other variables. We used multivariable logistic regression analysis to identify factors associated with LLIN utilization. Adjusted odds ratio (AOR) with 95% confidence intervals and p-value < 0.05 was used to show the association between dependent and independent variables.
In multivariable regression, variables with p-value of < o.o5 were considered as significant.

Ethical consideration
Ethical clearance was obtained from the institutional review board of institute of public health, University of Gondar College of medicine and Health Sciences. Formal letter was written to south Gondar zone from Amhara region. Then official permission letter was obtained from South Gondar zone and Fogera district health office. Prior to interview and inspection of household survey, data collectors had been requested for the respondents' consent. Written informed consent was obtained from each study participant. Respondents were informed about the confidentiality of the information they provide. Participation in the survey was voluntary and they can choose not to participate, but was told that their views was important to strengthen the program. When the data collectors found problems with incorrect use of LLIN, they had educated the study participants about the correct use and maintenance upon completion of the survey. Clinically ill patients found during the survey were advised to consult the nearby health facility to get health service.  (Table 4). 3.5. Utilization of LLIN by pregnant mother previous night of data collection Prior to data collection/interview, the utilization of LLIN by pregnant mothers by interview was (553) 88.3% with 95% CI (85.6%, 90.7%). Those pregnant mothers had given priority by family members in the shortage of LLIN in the house (77%) and perception of pregnant mothers more at risk for malaria than non-pregnant mothers (59.3%).

Over all observation practical utilization of long lasting insecticide bed net (LLIN)
By observational out of five practical long lasting insecticide bed net utilization points, those fulfilled four and above were (68.8%) which was recorded as good utilization practice, which is above the mean score value. The mean and standard deviation of LLIN utilization was 3.92 and 1.192 respectively.

Discussion
In our study self-reported utilization of long lasting insecticide bed net was 88.3%. However, by observation, proper LLIN utilization by pregnant mother was 68.8% with 95% CI (65.1%-72.5%) which is low as compared with the WHO recommendation and the study conducted in Nigeria [20,21]. This might be due to pregnant mothers might not have been provided with appropriate health information regarding the appropriate utilization of LLIN during the provision of the nets and antenatal care (ANC) follow-up time. This suggests that pregnant mother need to know how to hang LLIN properly.
Demonstration and assistant with hanging should also be provided. In addition to verbal communication during distribution, posters with a key message should be available as back up reference. This study was high as compared with the study conducted in Adama Woreda, Oromia Regional State, Ethiopia 18.1% [19]. This difference may be due to the difference in time period; our study is after 10 years of this study, so there might be a knowledge, attitude and behavioral difference in between this time period.
Educational status, knowledge about malaria, knowledge about LLIN was variables significantly associated with LLIN utilization among pregnant mothers. In our study finding more than half (80.5%) of pregnant mothers get information from health institution which is consistent with the previous study in southern Ethiopia [4]. Study conducted in Limmu Seka district showed that participants who had information from health facility was 2 times more likely utilized LLIN than those who had no information from health facility [22]. In our study, the odds of LLIN utilization among pregnant mothers who had good knowledge about malaria (AOR = 2.246(1.508, 3.344)) was 2.246 times more than those who had poor knowledge about malaria. This finding was consistent with study conducted in Damot Pulasa district, Southern Ethiopia [17]. Our study finding showed that study participants who had good knowledge about malaria had good practice of long lasting insecticide bed net (LLIN) utilization. Pregnant mothers who had knowledge about malaria transmition; side effect on pregnancy, preventive methods gave more emphasis to utilize LLIN effectively to prevent themselves as well as their infants from malaria infection.
In this study, the odds of LLIN utilization among pregnant mothers who had good knowledge about LLIN (AOR = 2.1(1.417, 3.119)) was 2.1 times more than those pregnant mothers who had poor knowledge about LLIN. This might be due to lack of follow up by the health authority to the households of pregnant mothers after mass community health education regarding proper and safe utilization of LLIN. This study finding was also consistent with the study conducted in Nigeria (AOR =

Limitations of the Study
There could be social desirability bias during observation of LLIN utilization. Secondly, since the design is quantitative, it doesn't address cultural issues of the respondents.

Conclusion
This study concludes that although self-report utilization of long lasting insecticide bed net was high,