Utilization of Long-Lasting Insecticide Treated Net and Associated Factors Among Pregnant Women in Malarious Kebeles in Awabel District, North-West Ethiopia, 2017

Background: Utilization of long-lasting insecticide treated net (LLITN) is one of the main vector control activities. It has a killing, repellent and physical barrier effects against mosquito. Even if priority is given for pregnant women, not all nets owned by household have been utilized by pregnant women. The objective of the study was to assess utilization of Long-lasting insecticidal net and associated factors among pregnant women in malarious kebeles, Awabel woreda, North-West Ethiopia. Methods: A community-based cross-sectional study was conducted from May 1 to June 30, 2017. A systematic random sampling was used to select 422 households. Two days training was given for data collectors and supervisors. Collected data were coded and entered using epi-data version 3.1, then it was exported to Statistical Package for Social Science (SPSS) version 20. After bivariate logistic regression analysis, all variables with a p-value less than or equal to 0.25was entered into multivariable logistic regression and p value < 0.05 considered as signicantly associated with the outcome variable. Results: Utilization of LLITN was 33.6%. Factors such as attending antenatal care [adjusted odd ratio (AOR) =1.89; 95% CI; 1.04-3.44], traveling <1 hour to reach health facility AOR=4.41; 95% CI; 2.06-9.43], age [AOR= 3.67; 95% CI; 1.36-9.95], knowledge[AOR=11.68; 95% CI; 5.96-22.89] and having positive attitude [AOR=3.12; 95 CI; 1.66-5.88] were signicantly associated with utilization of LLITN. Conclusion: This study showed that low utilization of LLITN. Attending antenatal care (ANC), traveling <1 hour to reach health facility, age , knowledge and attitude had positive association with LLITN utilization. Every concerned body should focus on reducing distance barrier by giving outreach services and increasing ANC, the attitude and knowledge of pregnant women toward malaria and LLITN which increase utilization of LLITN.


Introduction
World Health Organization (WHO) recommends that all risk persons, particularly pregnant women and infants, sleep under Long lasting insecticide treated nets (LLINs) during the night [1] because it reduces miscarriages/stillbirths by one third compared with newborn babies of mothers with no protection, use of LLINs s during rst or second pregnancies was estimated to provide a protective e cacy of 18% against neonatal mortality and of 21% against low birth weight [2]. Women who used LLINs were less likely to have acute malaria, anemia and babies with low birth weight than women who did not use LLINs [3].
Long lasting insecticide treated nets (LLINs) are also effective tools to reduce illness and death due to malaria [4].
Ethiopian national policy aims to provide one LLINs for every sleeping space in malaria-endemic areas <2,000m [6]. According to this policy, more than 64 million nets were distributed between2005 and 2014 by Federal Ministry of health [7]. In early 2015, approximately 4.3 million LLITNs were also distributed to malaria risk area district in Oromia, Amhara and Tigray region [7].
In Africa, malaria causes 10% of direct and indirect maternal death, 35% of preventable low birth weight and 75,000-200,000 infant deaths in each year [2].
Pregnant women are four times as likely to get sick from malaria and twice as likely to die from the disease if they are not using LLINs [1].
In Sub-Saharan Africa, about 23 million pregnant women were unprotected by an insecticide treated net [8]. In this region, educational level, household income, malaria and ITN knowledge and urban residence were the major factors of LLINs utilization [9].
In Ethiopia, despite of giving special emphasis and priority to ITN use among pregnant women [7] not all mosquito nets owned by households are being properly utilized by pregnant women [10]. The gap between ownership and use remains high [2]. The previous studies mainly focused on household and under ve utilizations of LLITN but this study speci cally focusing on utilization of LLITNs and associated factors among pregnant women.

Methods
A community based cross-sectional study was conducted among a total of 422 pregnant women from May 1 to June 30, 2017.in malarious kebeles, Awabel district, North-West of Ethiopia. The district was located at an altitude of 1623 -2570 meter above sea level with the annual rainfall of 1100-1400 and temperature lies 15-21 Degree Centigrade [11].
The required sample size was calculated using a formula for single population proportion. It was calculated considering the utilization of LLIN was 48.4% among pregnant women in Amhararegion [12]. n= Z 2 P(1-P) ÷d 2 Thetotal sample size was 422. The total sample size was proportionally allocated for the nine kebeles based on the number pregnant women who were residing in the study sites. Eligible women in each kebele were selected by systematic random sampling during the study period.
Structured questionnaire was prepared in English and was translated into Amharic language for data collection and translated back into English to check its consistency. Interviewer administered technique was used for data collection by trained data collectors. Training was given for data collectors and supervisors for 2 days on how to collect data. Pre-test was done on 22 pregnant women before actual data collection.
Collected data were coded and entered by epi data version 3.1, and then exported to SPSS version 20 for analysis. Descriptive, bivariate and multivariate analysis was done. Tables, charts and text were used to present the result of the analyzed data. Independent variables with P-value of <0.25 in bivariate analysis was considered for multivariate logistic regressions. P-value less than 0.05 were used as cut off point for presence of statistical signi cance.

Results
Among the total, 417(98.8%) of participants were participated in the study. The median age of the respondent was 29.00±7.089 SD years. About 408 (97.8%) were married. Two hundred sixty-nine (64.5%) of the respondent were unable to read and write. Three hundred seventy-three (89.4%) of the respondents were farmer. The median income of the respondent was 1294.00±769.49 SD Ethiopian birr. Regarding to the family size, 161 (55.3%) and 102 (24.5%) of the respondents had 5-6 and 1-2 respectively (Table 1). no mosquito and cause of skin itching respectively (Figure 1).
In multivariate analysis age, ANC follow up of current pregnancy, time taken to reach health facility, knowledge, attitude and age were statistically signi cance with LLITN utilization among pregnant women (  [19,20]. In this study, utilization of LLITNs is greater than the study conducted in Afar 24.7%, Somali 24.7%, and Oromia region 26.7% [12] and at tertiary hospital in Nigeria 24.6% [24]. The difference might be due to socio demographic, and seasonal variation.
Moreover, this study also identi ed factors that have association with utilization LLINs among pregnant women and found that being knowledgeable, ANC follow up, travelling less than one hour to reach health facility, being age 35 years or above and having favorable attitude toward LLINs utilization were factors that had signi cantly associated with LLINs utilization.
Being knowledgeable on malaria and LLITNs in this study, compared to not being knowledgeable was associated with utilization of LLITNs, which increases the odds of using LLINs during pregnancy by twelve times [AOR = 11.68; 95% CI; 5.96- 22.89]. This is consistent with the study conducted in Sub-Saharan Africa [9] Northern Uganda [23], Nigeria [25,26], Adama woreda and selected malaria prone area in Ethiopia [27,28]. This might be due to knowledgeable pregnant women may know the consequences of malaria in pregnancy if they did not use LLINs. This might impose to use LLINs.
Pregnant women who had ANC follow up for the current pregnancy was almost 2 times more likely to utilize LLITNs than those who had no ANC follow up for current pregnancy [ AOR = 1.89; 95% CI; 1.04-3.44]. This is almost congruent with the study conducted in Uganda [23]. This might lead to increase the opportunity of getting information on how to use LLINs [2].
In this study, pregnant women who travelled less than one hour to reach health facility were almost 4 times more likely to utilize LLITNs than those who travelled more than one hour [AOR = 4.41; 95% CI; 2.06-9.43]. This is almost consistent with the study conducted in Uganda [23]. This might increase the health facility visits which may about malaria and LLITNs.
Pregnant woman whose age were 35 and above were almost 4 times more likely to utilize LLITNs than those whose age was between 15  Permission letter was sought from Awabel district health o ce. Verbal and written informed consent were obtained from each participant. Written consent was obtained from a parent or guardian on behalf of the participants under the age of 18 years. The study participants had the right to refuse in the study or withdraw at any time during the interview was respected. The information obtained from the study participant was maintained its con dentiality by not writing name of the study participants on the questionnaire paper.
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