The ownership of bed nets and sleeping under a bed net the night preceding the survey by SAC was assessed in this survey. The ownership of bed net by the households where SAC were living in the study area was 19.3%. Owning bed net was negatively affected in altitude ranging from 1100 to 1250 meters above sea level and positively influenced by the presence of children aged under-five years in the household. The percentage of children that slept the previous night under a bed net was 7.8% among the total studied and 40.3% in conditional to the presence of a bed net in the household. Bed net utilization by the SAC was positively affected by being a resident in rural areas, age of children below 10 years, mothers with educational status of above grade six and the presence of adequate numbers of bed nets in the households.
The household bed net ownership in the present study was much lower than the universal coverage target of the national malaria control program (26). Not only the ownership but also the adequacy of access to households owning bed net which should be taken as the major indicator of effectiveness of bed nets than ownership alone (27) was also poor. The ownership of bed net was lower than the coverage estimated in the most recent malaria indicator survey in Ethiopia (13) and most other studies conducted in Ethiopia (21, 24, 28, 29) except a study conducted among households of pregnant mothers in Shashogo district in Southern Ethiopia (22). The finding from the present study was also lower as compared to similar studies conducted outside Ethiopia such as national and district level studies in Uganda (30–32),Madagascar (33), Ghana (34, 35), Zimbabwe (36), Equatoria Guinea (37), Yemen(38), among migrant population in Myanmar (39) and in Kenya (40). The higher ownership of bed nets in these countries and specific study localities might be occurred due to difference in the study population since pregnant mothers and children age less than fivers were known to be at higher risk of malaria or timing of data collection relative to the time when the distribution has occurred since some bed nets get lost because of different reasons as time goes on. It might also be related to the level of drug resistant strains circulating in the community as resistant strains had a higher potential to lead to death that in turn might be enabling factor to own bed nets. The difference in finding from Shashogo district in Southern Ethiopia might be difference in the level of endemicity of malaria transmission.
The bed net utilization by SAC in the study area was lower than its utilization by people living in malaria endemic areas in Africa (1). The bed net utilization was lower among this study population (20, 21, 24, 28, 29) as compared to pregnant mothers, children age less than five years in Ethiopia as well as other countries outside Ethiopia like the general population and under five children in Zimbabwe (36), SAC in Uganda, Tanzania and Yemen (31, 38, 40–42), care givers of under five children in Ghana (35), SAC and the general population in Kenya (40) and Nigeria (43). These differences could be due to differences on the level of awareness of the targeted population as pregnant women and children age less than five years were well known high risk population groups than the SAC. The other possible explanations for such differences might be the difference in the level of awareness on the susceptibility of SAC for malaria and its consequences.
There were different factors influencing the bed net utilization among the different target population. From the socio demographic factors, being female and living in urban areas (36, 37, 44) were positively influencing the utilization of bed net by the study population though this was not shown in the present study with respect to residence area. According to this study, the bed net utilization was higher among children in rural area as compared to those in urban area. In Malawi, the bed net utilization was positively associated with being resident in urban areas but not with female gender (45) which was also similar with respect to gender in Yemen (38). In similar to our finding, gender related difference in the utilization of bed net was not seen in a community based cross-sectional study in Katakwi district in Uganda (32). These differences might be related to cultural differences in giving priority to the different population segments in different contexts or ignorance to children mainly aged above nine years.
In most of studies those assessed the influence of presence of pregnant mother or children aged < 5 years, the presence of pregnant mother or children aged less than five years in the household were positively associated with bed net utilization. However, in this study both had positive relation but not significant enough which might be related to low number of bed net owned by the households.
Bed net utilization was significantly associated with the presence of either a pregnant mother or under five years aged children in the household among internally displaced households in the Democratic Republic of Congo (16), household members in the Budondo sub-country in Uganda (28), a national community based survey in Madagascar (30). In agreement with our finding, bed net utilization by SAC was not affected by the presence of pregnant mother or children aged less than five years in the household in Malawi (45) and general population in Yemen (38). In addition to the above explanation, these disparities between studies could be due to differences in the culture as pregnant women or young children might share the same sleeping place with the SAC.
The other factors affecting utilization of the bed net by the SAC in the present study area were maternal level of education and the ratio of bed nets to the household size. In Uganda and Zimbabwe, bed net utilization was significantly influenced by the density of bed nets in the households (14, 36). This was also corroborated by the 2007 national malaria indicator survey in Ethiopia (44), 2009 community based Survey in Madagascar (33). However, the proportion of bed nets in Adami Tulu did not influenced utilization of bed nets by children aged less than 5 years (29) and this difference might be related to difference in the attitude towards the bed net utilization on the prevention of malaria.
The bed net utilization was also influenced by the economic status of the population as it could give an opportunity to buy in areas where there was access. The review of the national malaria indicator survey revealed this in Countries of SSA (46). The finding of the present study was in contrast to this where socioeconomic status of the household had no significant impact on the utilization of bed net. In similar with studies conducted in Adami Tulu, utilization of bed net among the study population was higher when the mother of children had higher level of education [36]. The same thing was true for study population in Equatorial Guinea (37). However, the educational status of caregiver of children aged bellow five years was not influenced by their educational status in Ghana (35) which could be related to differences in decision making capacity by the caregivers where non parental care givers might had low influence in ordering the children to sleep under the bed net or low decision making power in the household.
Finally, the readers of this manuscript shall interpret the finding of this research by taking the following limitations and strengths of the study. The 1st limitation was due to involving only school enrolled children as the situation could be different for those non-enrolled to the school. The 2nd limitation was due to study design used since cross-sectional studies are not strong in generating evidence for cause and effect relationship. The strengths of this study is that we were able to do research in a hard to reach study setting and underexplored area, the sample size was large enough, making the power of the study high.