Predictors of Insecticide-Treated Nets Utilization among Children under five years in Refugee Settlements in Uganda: Analysis of the 2018-19 Uganda Malaria Indicator Survey

doi:10.21203/rs.3.rs-4812528/v1

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Research Article

Predictors of Insecticide-Treated Nets Utilization among Children under five years in Refugee Settlements in Uganda: Analysis of the 2018-19 Uganda Malaria Indicator Survey

https://doi.org/10.21203/rs.3.rs-4812528/v1

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Background

Despite significant distribution of insecticide-treated net (ITNs) by the Government of Uganda to refugees, malaria is major cause of mortality and morbidity among children under five years in refugee settlements. This highlights the persistent challenges and complexities surrounding malaria control and prevention efforts in these settings. Studies that focus on the determinants of ITN utilization among children under five years in refugee settlements in Uganda are not available. Using the 2018–2019 Uganda’s Malaria Indicator Survey (UMIS) data, analysis of the individual and household factors associated with utilisation of ITN among children under five in refugee settlements of Uganda was conducted.

Methods

This study focused on 589 children under five staying in refugee settlements located in Uganda. The extracted variables from the UMIS included social-economic factors associated with ITN utilisation. Descriptive analysis was performed to generate summarized statistics, while inferential statistics by way of bivariate analysis were performed to assess the association between the outcome and the independent variables using the chi-square test, and multivariable logistic regression modelling to assess the magnitude of the associations after controlling for other covariates. All analyses considered the survey sampling design and sampling weights, and are conducted in Stata version 18.

Results

The odds of children sleeping under ITN were higher if their mothers had secondary and higher education (8.1 times) as well as primary education (1.5 times). The odds of children sleeping under ITN reduced by 50% if their mothers were pregnant. Interestingly, the odds of children sleeping under ITN were 70% lower if their mothers knew that ‘not sleeping in nets’ caused malaria. Mothers who were exposed to malaria messages had lower odds of their children sleeping under ITNs. Besides, households with televisions had lower odds of their children sleeping under ITNs.

Conclusions

The results highlight areas of intervention that can increase ITN use in refugee settlements of Uganda. Improving access to education for mothers, providing targeted health education on the importance of ITN usage during pregnancy, dispelling misconceptions about malaria transmission, facilitating the proper installation of ITNs among others, can all contribute to increased ITN utilization among children under five.

Children under five

insecticide-treated nets

malaria

malaria indicator survey

refugees

settlements

Uganda

Malaria, a vector borne and a climate sensitive disease, is still a major cause of mortality and morbidity worldwide. By 2022, an estimated 249 million malaria cases in 85 malaria endemic countries were recorded globally, with over 233 million cases (94%) documented in the WHO African Region[1]. It is further revealed that in 2022, the WHO African Region accounted for about 95.4% of deaths globally and approximately 78.1% of all deaths in this region, were among children aged under 5 years. The African countries which accounted for almost half of all malaria cases globally, include Nigeria (27%), the Democratic Republic of the Congo (12%), Uganda (5%) and Mozambique (4%). Although Uganda accounts for 5% of the 249 million global malaria cases[1], it is also a leading host country for refugees in Sub-Saharan Africa (SSA), accommodating over 1.7 million refugees, of which 57% are children[2]. The refugees in Uganda come from various neighboring countries in East Africa and the Great Lakes region, primarily due to political instability, persecution, ethnic tensions, human rights abuses, and calamities.

By 2023, South Sudan made up the largest refugee population in Uganda (57%), followed by the Democratic Republic of Congo (D.R. Congo) (31%), while other refugees constituting 12% came from Somalia, Rwanda, Burundi, and Sudan[2]. Most of the refugees (92%) live in settlement camps, while 8% live in Kampala, the capital city of Uganda. Refugee settlements in Uganda are associated with overcrowding, inadequate and temporary shelters, limited vector control efforts, and poor access to water and sanitation which enable rapid malaria spread[3]. This situation makes children in refugee settlements vulnerable to malaria infections. A recent study conducted across nine refugee settlements in Uganda utilizing the 2018–2019 Malaria Indicator Survey (UMIS) dataset, indicates that malaria prevalence among children under five years is 32.8%.[3] and this constitutes an emerging challenge for humanitarian response which requires urgent attention.

The malaria burden in endemic countries is further being amplified by climate change. The individual and complex interacting effects of temperature, rainfall and humidity have been shown to expand the geographical limit of malaria, increase transmission intensity, reintroduce malaria in areas where malaria was eliminated recently, enhance larval development, mosquito survival, human biting rate and parasite development rate among others[1, 4, 5]. There is increasing evidence that refugee settlements in Uganda are highly exposed to extreme weather conditions, particularly high temperatures, extreme and erratic precipitation [6]. This high level of exposure in combination with their limited abilities to cope and adapt to climate change has heightened malaria risks in these already marginalized populations. Children in refugee settlements are already experiencing multiple life threatening risk including high rates of malnutrition, public health emergencies such, measles, cholera, typhoid fever, and hepatitis. Since the refugee population is steadily increasing in Uganda, malaria prevention among children must be given urgent attention to reduce any potential malaria humanitarian crisis.

The use of insecticide treated nets (ITNs) is one of the most effective ways to prevent malaria transmission and has proven to show significant reduction in malaria morbidity and mortality across a range of transmission settings in Africa [7–9]. By 2022, a total of 254 million ITNs were distributed in all malaria endemic countries with about 235 million (93%) distributed in sub-Saharan Africa (SSA)[1]. Half of the ITNs distributed to SSA were received by six countries which include the Democratic Republic of the Congo (33.6 million), Nigeria (28.4 million), Ethiopia (21.4 million), Sudan (18.9 million), Uganda (13.8 million) and Mali (12.5 million)[1].The Government of Uganda adopted the policy of mass distribution of ITNs as one of the significant interventions for malaria prevention. Three mass campaigns across Uganda including refugee settlements, have already been implemented in 2013–2014, 2017–2018, and 2020–2021[10]. On arrival, the refugees are given free ITNs by United Nations High Commissioner for Refugee (UNHCR) in collaboration with Uganda’s Malaria Control Division of the Ministry of Health. Since 2023, over, 1.1 million ITNs have successfully been distributed to refugees[11]. This effort has further led to free distribution of ITNs in homes, health centres, antenatal clinics and children’s clinics to promote access and increase utilization among refugees and the general population. ITNs have the ability to kill or repel mosquitoes which feed and rest indoors as well as preventing night mosquito bites.

Despite this high level of investment in ITN distribution in SSA, incidences of malaria infections and associated deaths have continued to be a significant development challenge among vulnerable populations in SSA[12]. Two recent studies conducted on refugee settlements of Uganda based on the 2018–2019 MIS data [3, 13] identified various malaria risk factors including (1) age of child; (2) roof materials (i.e., thatch roofs); (3) wall materials (i.e., poles with mud and thatch walls); (4) lack of insecticide-treated nets; (5) type of toilet facility used (i.e., no toilet facility, (6) distance to water sources, limited knowledge on the causes and prevention of malaria, mother’s level of education among others. It should be noted the utilisation of ITNs in any community is influenced by varied individual, household, and community-level factors that probably have not been adequately considered during the distribution of ITNs. Studies have shown that the key determinants of ITN utilization in SSA include hot weather, absence of visible mosquitoes, poor attitude to use ITNs, lack of ownership of ITN, negligence among households, suffocation caused by ITNs, and unpleasant odor associated with ITNs among others [12]. In Uganda, the factors influencing the use of ITNs include: access to ITNs, age of household head, sex of household head, number of sleeping rooms, wealth, malaria prevalence, mother’s level of education, mother’s knowledge of malaria transmission, residence, and region [14–16].

Although these, and recent studies provide valuable insights on the factors influencing the utilization of ITN, they provide no evidence on the determinants of ITN usage in refugee settlements of Uganda, yet context specific behavioral and social cultural information are key in understanding the interactions that propel the utilization of ITNs within these unique local dynamic settings. Given the fact that malaria remains a significant health threat in refugee settlements, where resources are often limited and vulnerable populations face heightened risks, exploring ITN utilization among children under five years is essential. In refugee settings, where access to healthcare services may be constrained and living conditions can exacerbate the risk of malaria transmission, the effective use of ITNs can be a life-saving intervention. It should also be noted that refugee populations in Uganda are structurally disadvantaged which could potentially influence their access to ITN and their utilisation. Additionally, the diverse social, cultural, and economic backgrounds of refugee populations can influence perceptions, beliefs, and practices related to malaria prevention, including ITN usage. Studying ITN utilization among children under five in refugee settlements provides valuable insights into the effectiveness of interventions and helps identify barriers to ITN utilization specific to this vulnerable group. By understanding these barriers and tailoring interventions to address them, we can improve ITN coverage and compliance among children in refugee settings, ultimately reducing the burden of malaria and improving health outcomes within these populations. Specifically, this study aimed to analyse the individual and household level factors are associated with ITNs utilization among children under five in refugee settlement of Uganda.

This study has contributions to the growing body of literature on malaria and has some policy implications. This is the first study to concentrate on the utilization of ITN in refugee settlements of Uganda based on nationally representative datasets. Studying the factors that determine ITN utilisation in these unique communities characterized by overcrowding, inadequate and temporary shelters, limited vector control efforts and being occupied by people from diverse socio-economic and cultural backgrounds, can lead to a better understanding of the actions that can increase ITN use in these settings. Well informed targeted actions will make it possible to improve the fight against malaria, which is the leading cause of mortality and morbidity in these refugee settlements. The results of this study will provide important answers on ITN usage, and will inform decisions on ITN distribution, access and utilisation campaigns, the development of ITN replacement strategies, and the development and deployment of tools that include behavior change communication activities. The results of this study will further form a basis on assessing the kinds of behavior change strategies that might provide health co-benefits of ITN utilisation in refugee settlements.

Conceptual framework

The variables used to construct the conceptual framework for this study were chosen from a review paper which focused on identifying factors associated with ownership and utilization of ITNs among children under five years in SSA [12]. The identified variables were categorized into two levels; that is individual and household as shown in Fig. 1.

Data source and study location

The study is a secondary analysis of the 2018–2019 Malaria Indicator Survey of Uganda focusing on 12 refugee settlements in Uganda (Fig. 2)

The 2018–2019 MIS is the third malaria survey conducted in Uganda. The MIS is among The DHS Program surveys, also a household based survey designed to collect data focused on internationally accepted malaria indicators. This survey has specific malaria questions and malaria parasitemia testing. The survey was conducted during the high malaria transmission period shortly after the rainy season. The MIS collected data on the availability and use of ITNs in households, and several other malaria indicators in refugee settlements of Uganda. The sampling frame was based on Uganda’s Population and Housing Census frame for 2014 and this survey employed a two-stage stratified sampling procedure. In the first stage, stratification of the sampling frame by geographic area (Urban, rural and refugee) was conducted. The stratification was based on the enumeration areas of Uganda’s population census of 2014. Within the first stage, two activities were done: selection of clusters from each strata and listing of households in the selected clusters. In the second stage, selection of households to be interviewed was accomplished. In this study, the unit of analysis was children. The Kids Recode (KR file) was downloaded from The DHS Program website (https://dhsprogram.com/). A total of 7,124 children were included in this survey. Since our focus was children in refugee settlements, other children in non-refugee camps where excluded. After weighting and excluding children with missing responses (67), the sample size for our study was 589 children.

Variables

Dependent variables

Our outcome variable was whether a child slept under ITN last night. In the KR file, this variable was coded as ml0 and three categories were given: no net, only treated nets, and only untreated nets. We made this outcome variable binary showing whether or not a child slept under a bed net last night before the survey (No = 0, Yes = 1).

Independent variables

With our conceptual framework (Fig. 1), two level variables (individual and household) that are associated with utilisation of ITNS were identified from empirical evidence [12]. Both the individual and household level factors shown in Table 1. Household wealth was excluded from the analysis since it was highly correlated with variables of possession of television and radio.

Table 1

Categorization of the Independent variables
Independent variables	Description
Individual level factors
Age in months	This variable was grouped into 3 categories: 0–11 months, 12–24 months, 25–60 months
Sex of the child	This variable is binary in nature taking on 2 categories: Male and Female
Age of mothers (Years)	This was recoded into 3 categories: < 24, 25–34, 35–49
Mother's educational level	This was recoded into 3 categories: No education, Primary level, secondary and above
Pregnancy status	This was categorized as Pregnant and Not pregnant
Not sleeping in net causes malaria	This variable was intended to understand whether women knew the cause of malaria and how to prevent it. This variable was categorized as Yes and No
Exposure to malaria messages	This was categories as Yes and No
Mosquito bites cause malaria	This variables was categorized as Yes and No
Mother's Religion	This was recoded into 2 categories. Christians (Catholics, Anglican, Orthodox, Pentecostal, Jewish, Baptist) and Muslim.
It’s easy for mother to hang a bet net	This variable was grouped into 2: Yes and No
Has a bed to sleep on	This variable was grouped into 2: Yes and No.
Household characteristics
Sex of household head	This variables was Categorized as Male and Female
Age of Household head (Years)	This variable was grouped into 3 categories: less than 30 years, 31–39 years, above 40 years
Household has television	This is a binary variable and was categorized as Yes and No
Household has radio	Categories included Yes and No
Household has electricity	Categories included Yes and No
Region of residence	All households located in Adjumani, Arua, Moyo, Yumbe and Lamwo districts were put under the Northern region. All households in Kamwenge, Isingiro, Kiryandongo, and Kyegegwa districts, were put under the Southern region.
Number children staying in household	This variable was grouped into 3 categories: One child, 2–3 children, 3 above

Statistical analysis

In this paper, three types of analyses were performed. These included descriptive analysis of the data resulting into summarized statistics, bivariate analysis to assess the association between the outcome and the independent variables using the chi-square test, and multivariable logistic regression modelling to assess the magnitude of the associations after including controls. Three multivariable logistic regression models were performed to cater for 1) individual level factors, 2) household level factors and 3) a combination of both the individual and household level factors. The multivariable logistic results were presented with adjusted odds ratios (OR) with 95% confidence intervals (CI). The p-values of < 0.001, < 0.01, < 0.05 were set for statistical significance. The data were weighted to account for disproportionate sampling and nonresponse. The analysis also adjusted for the effect of the complex survey design. All statistical analyses were conducted in Stata version 18 (StataCorp, College Station, TX, USA).

Descriptive statistics of the respondents

A total of 589 children living in refugee settlements were included in this study. Table 2 presents the basic characteristics of the studied population.

Table 2

Characteristics of the study population
Variables	Number	Percent
Child's characteristics
Age in months
0–11	143	24.3
12–24	219	37.2
25–59	227	38.5
Sex
Male	279	47.4
Female	310	52.6
Children slept under the net last night
No	184	31.2
Yes	405	68.8
Number children staying in household
One child	98	16.6
Two children	413	70.1
Three children and above	78	13.2
Mother's characteristics
Age of mothers (Years)
Less than 24	153	26.0
25–34	310	52.6
35 and above	126	21.4
Mother's educational level
No education	278	47.2
Primary	263	44.7
Secondary and higher	48	8.2
Pregnancy status
Not pregnant	544	92.4
Pregnant	45	7.6
Not sleeping in net causes malaria
No	553	93.9
Yes	36	6.1
Exposure to malaria messages
No	446	75.7
Yes	143	24.3
Mosquito bites cause malaria
No	465	78.9
Yes	124	21.1
Mother's Religion
Muslim	56	9.5
Christians	533	90.5
It’s easy for mother to hang a bet net
No	13	2.2
Yes	576	97.8
Has a bed to sleep on
No	265	45.0
Yes	324	55.0
Household characteristics
Sex of household head
Male	235	39.9
Female	354	60.1
Age of Household head (Years)
Less than 30	266	45.2
31–39	195	33.1
40+	128	21.7
Household has television
No	583	99.0
Yes	6	1.0
Household has radio
No	508	86.3
Yes	81	13.8
Household has electricity
No	467	79.3
Yes	122	20.7
Region of residence
Northern districts	404	68.6
Southern districts	185	31.4
Total	589	100.0

For the outcome variable, 68.8% of the children in refugee settlements slept under an ITN on the night before the survey. Children aged less than 11 months were 24.3%, those between 12–24 months were 37.2% and those above 25 months were 38.5%. In this study, 52.6% of the children were females while 52.6% of the mothers to the children were aged between 25–34 years. Additionally, 47.2% of the mothers had no formal education. Mothers who did not know that ‘not sleeping in nets’ caused malaria were 93.9%. Besides, 75.7% of the mothers were exposed to malaria messages. Although majority of the mothers were exposed to malaria messages, while 78.9% didn’t know that mosquito bites cause malaria infection. Six in 10 of households were headed by women. Most of the households had two children (70.1%). Moreover, 45.2% of the household heads were less than 30 years of age while others aged between 31–39 and above 40 years, were 33.1% and 21.7% respectively. Majority of the households (94.4%) were categorized as poor. Most of the households (68.6%) were located in refugee settlements found in the Northern districts of the country.

Bivariate analysis

The test of association between the dependent variable (ITN use) and the independent variables was performed using the Chi-square test and the results are shown in Table 3.

Table 3

Association between child slept under net last night and child's, mother's and household's level characteristics
Variables	%	CI	P value
Child's characteristics
Age in months			< 0.001
0–11	76.7	[63.7,86.1]
12–24	69.6	[60.0,77.7]
25–59	58.1	[46.0,69.2]
Sex of the child			0.488
Male	65.1	[54.3,74.4]
Female	68.1	[55.9,78.2]
Mother's characteristics
Age of mothers (Years)			0.737
Less than 24	65.7	[45.7,81.3]
25–34	69.4	[56.4,79.8]
35 and above	61.9	[40.2,79.7]
Mother's educational level			0.004
No education	62.3	[50.9,72.5]
Primary	67.8	[57.5,76.6]
Secondary and higher	90.8	[67.7,97.9]
Pregnancy status			0.003
Not pregnant	69.5	[60.6,77.0]
Pregnant	44.4	[26.4,64.0]
Not sleeping in net causes malaria			0.003
No	68.5	[58.8,76.9]
Yes	45.9	[31.0,61.6]
Exposure to malaria messages			0.548
No	67.2	[57.6,75.6]
Yes	63.7	[45.8,78.5]
Mosquito bites cause malaria			0.427
No	65.3	[54.0,75.1]
Yes	71.4	[55.6,83.3]
Mother's Religion			0.623
Muslim	71.1	[50.5,85.5]
Christians	66.2	[55.1,75.8]
It’s easy for mother to hang a bet net			0.528
No	56.7	[26.1,83.0]
Yes	66.8	[56.3,75.9]
Has a bed to sleep on			0.125
No	61.1	[47.1,73.5]
Yes	72.6	[62.2,81.0]
Household characteristics
Sex of household head			0.644
Male	65.6	[53.9,75.6]
Female	68.1	[55.8,78.4]
Age of Household head (Years)			0.506
Less than 30	68.9	[57.5,78.4]
31–39	68	[54.8,78.8]
40+	60.2	[41.6,76.4]
Household has television			0.024
No	67.4	[57.3,76.2]
Yes	33.1	[11.6,65.2]
Household has radio			0.512
No	66.2	[55.7,75.3]
Yes	69.6	[55.6,80.7]
Household has electricity			0.876
No	66.3	[57.6,74.0]
Yes	67.6	[45.0,84.2]
Region of residence			0.126
Northern districts	73.1	[61.7,82.0]
Southern districts	59.4	[44.1,73.1]
Number children staying in household			0.837
One child	67	[48.4,81.5]
Two children	67.4	[57.4,76.1]
Three children and above	61.1	[32.2,83.9]

From Table 3, only five independent variables (Child’s age, mother’s education, pregnant status, knowledge on causes of malaria and ownership of television) were significantly associated with the dependent variable (child slept under ITN last night). Utilisation of ITN was most common among children less than 11 months (76.7%) and children between 12–24 years. Besides, the use of ITN among children less than five years was higher among women with secondary and higher levels of education compared to those who didn’t have any formal education (62.3%). It is surprising that the use of ITN among children was higher among women who were not pregnant (69.5%) compared to those who were pregnant (44.4%). Additionally, the use of ITN of children under 5 was also highest among mothers who didn’t know that ‘not sleeping in nets’ caused malaria (68.5% compared to those who knew (45.9%). Finally, the level ITN utilization was highest among households which had no television (67.4%) compared to those which had (33.1%).

Determinant of ITN utilisation among children less than five years

A multivariable logistic regression analysis was performed to determine the magnitude of the associations between the independent variables and the outcome variables and results are captured in Table 4.

Table 4

**Adjusted logistic regression for the predictor of ITN utilization among children in refugee settlements**
	Dependent variable: Child slept under net last night
Variables	Combined Individual and Household Characteristics		Individual Characteristics		Household Characteristics
Variables	⸶AOR	95% CI	⸶AOR	95% CI	⸶AOR	95% CI
Age in months (Ref. less than 11)
12–24	0.6	0.4–1.0	0.7	0.5–1.2	-	-
25–59	0.4***	0.3–0.5	0.4***	0.3–0.6	-	-
Sex of the child (Ref. Male)
Female	1.5	1.0–2.2	1.3	0.9–2.0	-	-
Age of mothers (Years) (Ref. Less than 24)
25–34	1.5	0.5–4.3	1.4	0.5–4.3	-	-
35–49	1.9	0.5–7.1	1.2	0.4–3.6	-	-
Mother's educational level (Ref. None)
Primary	1.5*	1.0–2.3	1.5*	1.0–2.1	-	-
Secondary and higher	8.5***	2.7–26.8	8.1***	2.9–22.8	-	-
Pregnancy status (Not pregnant)
Pregnant	0.5	0.2–1.2	0.5*	0.2–1.0	-	-
Not sleeping in net causes malaria (Ref. No)
Yes	0.3*	0.1–0.8	0.3*	0.1–0.9	-	-
Exposure to malaria messages (Ref. No)
Yes	0.5*	0.3–1.0	0.7	0.5–1.1	-	-
Mosquito bites cause malaria (Ref. No
Yes	1.1	0.5–2.6	1.1	0.5–2.5	-	-
Mother's Religion (Ref. Muslim)
Christians	0.7	0.2–3.1	0.9	0.3–2.6	-	-
Its easy for mother to hang a bet net (Ref. No)
Yes	5.9**	1.6–21.5	3.7*	1.2–11.3	-	-
Has a bed to sleep on (Ref. No)
Yes	1.2	0.6–2.5	1.4	0.7–2.7	-	-
Sex of household head (Ref. Male)
Female	0.5	0.3–1.0	-	-	0.6*	0.3–1.0
Age of Household head (Years) (Ref. <30)
31–39	0.9	0.5–1.7	-	-	1	0.5–2.1
40+	0.5*	0.2–1.0	-	-	0.6	0.3–1.1
Household has television (Ref. No)
Yes	0.1*	0.0–0.8	-	-	0.0*	0.0–0.5
Household has radio (Ref. No)
Yes	1.3	0.6–2.6	-	-	0.9	0.6–1.5
Household has electricity (Ref. No)
Yes	1.8	1.0–3.4	-	-	1.5	0.8–2.7
Region (Ref. Southern districts
Northern districts	2.4*	1.2–4.7	-	-	2.4*	1.2–4.7
Number children (Ref. One Child)
Two children	0.9	0.4–1.6	-	-	0.9	0.4–1.7
Three children and above	0.4	0.1–1.6	-	-	0.6	0.2–1.9
⸶AOR = adjusted odds ratio, *p < 0.001, p < 0.01, *p < 0.05

In Table 4, children aged between 25–59 months had 60% lower odds of sleeping under ITN compared to the reference category (less than 11 months). The odds of children sleeping under ITN were higher if their mothers had secondary and higher education (8.5 times) as well as primary education (1.5 times) compared to children whose mothers had no education. The odds of children sleeping under ITN reduced by 50% if their mothers were pregnant, compared to children whose mothers were not pregnant. Surprisingly, the odds of children sleeping under ITN were 70% lower if their mothers knew that ‘not sleeping in nets’ caused malaria compared to those who didn’t know. Higher odds of children sleeping under ITN were observed if their mothers were able to hang the net with ease (5.9 times). The odds of children sleeping under ITN reduced by 40% among female headed households compared to male headed households. Besides, the odds of children sleeping under ITN were 2.4 times higher in households located in refugee settlements of the northern districts of the compared to households located in the refugee settlements in the southern districts.

This study aimed to provide an overview of the determinants of ITN utilization among children under 5 in refugee settlements of Uganda using the 2018–2019 Malaria Indicator Survey datasets which is nationally representative. Overall, 68.8% of children under five years slept under an ITN in households on the night before the survey. This percentage is moderate given the high levels of ITN distribution in Uganda, through various universal coverage campaigns in 2013–2014, 2017–2018, and 2020–2021[17]. This percentage finding is however lower than that of a study conducted in Soroti District, North Eastern Uganda ,where it was observed that 89.4% of children slept under the bed net the previous night to the survey, a figure that is far much higher than the national estimates[16]..The absence of 100% ITN utilisation among refugee children under five years explains the observed 32.8% malaria prevalence among them[3].

The study established significant factors associated with the use of ITNs for malaria control among children under 5 years in refugee settlements in Uganda. Age of the child was key in influencing ITN utilization. The results show that older children (25–59 years) had a 60% lower odds of utilizing ITN and this is in-line with findings by another study done to evaluate bed net use in Soroti District, North Eastern Uganda [16]. Possible explanations to this results could be that older children in refugee settlements are viewed as being immune to malaria infections and as such, don’t require ITN for sleeping at night. Besides, in cases of fewer ITNs, young children could be given priority compared to older one. This finding is also consistent with other studies done in sub Saharan Africa in regard to factors influencing the use of bed nets by children under 5 years [12].

Our results further indicate that children whose mothers had some formal education had higher odds of sleeping under ITNs compared to children whose mothers had no education. Similar significant association between formal education and ITN utilization in under five has also been observed in other studies[12, 15, 18]. This result is not surprising because educated mothers can make better decisions about health outcomes of children compared to uneducated ones. Investing in education initiatives for mothers in these populations can potentially improve ITN coverage and contribute to the prevention of malaria and other vector-borne diseases.

Our results further indicated that children whose mothers were pregnant had lower odds of sleeping in ITN compared to children whose mothers were not pregnant. This finding highlights a potential gap in ITN utilization among children under five in refugee settings and underscores the importance of targeted interventions to promote ITN use among this vulnerable group. This result could be attributed to the fact that when pregnant women go for antenatal care (ANC), a lot of emphasis is put on both maternal and fetal health rather than their children under five years. Thus, health workers in ANC health facilities should also emphasis the importance of ITN for children of pregnant mothers.

It's indeed surprising that the odds of children sleeping under ITNs were 70% lower when their mothers were aware that ‘not sleeping under ITN’ could cause malaria, compared to mothers who were unaware of this fact. This finding underscores the importance of understanding the complex factors influencing ITN usage among children in refugee settings. It suggests that maternal knowledge and beliefs about malaria transmission and prevention play a significant role in shaping mothers’ behaviors related to ITN use among their children. Addressing misconceptions and promoting accurate knowledge about malaria transmission and the effectiveness of ITNs could be crucial strategies for improving ITN utilisation and reducing the burden of malaria among children under five years in refugee settlements of Uganda.

Our findings suggest that the ease with which mothers were able to hang ITNs contributed to increased usage of these nets among their children. This highlights the importance of considering practical factors such as accessibility and convenience when implementing malaria prevention interventions, particularly in refugee settings. Providing support and resources to facilitate the proper installation and maintenance of ITNs can enhance their effectiveness as a tool for preventing malaria transmission among children under five years.

Our findings suggest that mothers who were exposed to malaria messages had lower odds of their children sleeping under ITNs. This unexpected result may indicate a potential discrepancy between the messaging content or delivery and its effectiveness in promoting ITN use among mothers in refugee settings. Further exploration is needed to understand why exposure to malaria messages did not translate into increased ITN usage and to identify potential barriers or factors influencing this relationship. Adjustments to messaging strategies or targeted interventions may be necessary to improve the uptake of ITNs among children in these populations.

Our findings suggest that households with televisions had lower odds of their children sleeping under ITNs. This unexpected result may raise questions about the potential influence of television ownership on household priorities or behaviors related to malaria prevention. Further investigation is warranted to understand the underlying factors contributing to this association and to explore potential avenues for promoting ITN usage among households with televisions. Adjusting communication strategies or integrating malaria prevention messages into television programming may be necessary to address this discrepancy and improve ITN coverage among children in these households.

In addition, the odds of children sleeping under Insecticide Treated Nets (ITNs) were 2.4 times higher in households located in refugee settlements of the northern districts compared to households located in refugee settlements in the southern districts. This significant difference underscores the importance of considering regional factors and geographical location when implementing malaria prevention interventions within refugee populations. Understanding the specific challenges and barriers to ITN utilization in different areas can inform targeted strategies to improve coverage and promote consistent use of ITNs among children living in refugee settings across Uganda.

Our study has some strengths and limitations. This is the first study to provide an overview of ITN utilization among children in refugee settlement of Uganda using the MIS data which is nationally representative. The study uses an adequate sample size, which renders the findings generalizable to the refugee children in Uganda. Despite these strengths, our study was not devoid of limitations.

The cross-sectional nature of the study design did not allow a causal-effect relationship to be established with certainty among the identified predictors; moreover, malaria incidence follows a seasonal pattern which the UMIS did not account for. Despite these limitations, the study was adequately powered to detect several important determinants of ITN utilisation among children under five years.

Despite the increased distribution of ITNs in refugee settlements in Uganda, malaria infections among children under five years have persisted. While ITNs are effective in preventing malaria when used correctly and consistently, the challenge lies in enhancing their consistent use in refugee settlements. This study has identified several factors associated with ITN utilization, including age, maternal education, pregnancy status, knowledge of malaria causes and prevention, household head gender, and refugee household location. These findings underscore the importance of considering these factors in the distribution and promotion of ITNs within refugee settlements. Tailored interventions that address specific barriers to ITN use, such as providing targeted health education, ensuring equitable access to education, addressing gender dynamics within households, and adapting distribution strategies to suit local contexts, are essential for improving ITN utilization and ultimately reducing malaria burden among children in refugee settings. Future studies should explore additional factors, such as seasonality and other socio-environmental determinants that may influence ITN utilization in refugee settlements. By gaining a deeper understanding of the complex interplay of factors affecting ITN use, stakeholders can develop more effective strategies to combat malaria and improve health outcomes in refugee populations.

DHS: Demographic and Health Surveys; ITNs: Insecticide-treated bed-nets; SSA: sub-Saharan Africa; UMIS: Uganda Malaria Indicator Survey; WHO: World Health Organization.

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles stated in the Helsinki Declaration. The launch of MIS (phase DHS-VII) data collection was conditional on the authorisation of the National Statistical Council and the approval of the National Committee on Health Research Ethics. During data collection, the informed consent of eligible respondents was sought before starting the interviews. The dataset used was fully anonymised.

Consent for publication

Not applicable.

Availability of data and materials

The data used in this study can be obtained by sending a request via the DHS Program website and upon approval data can be obtained from https://dhsprogram.com/data/dataset/Uganda_MIS_2018.cfm?flag=1

Competing interests

Neither of the authors discloses any potential or actual conflict of interest. No financial or nonfinancial benefits have been or will be received from any party related directly or indirectly to the subject of this article.

Funding

This study was carried out with support provided by the United States Agency for International Development (USAID) through The DHS Program (#720-OAA-18C-00083).

Authors' contributions

H.M.S. contributed to conceptualisation, methodology, data acquisition, formal analysis, validation, preparation, revision, and editing of the original draft. F.M, helped
with the conceptualisation, methodology, manuscript preparation, revision of the original draft. All authors approved the final manuscript. All authors read and approved this version of the manuscript.

Acknowledgements

We would like to thank the DHS program for authorising us to use the data used in this study. We are very grateful to USAID for supporting our research project. We acknowledge and thank the high-quality team of the ICF International and the DHS Fellows Program. Particular thanks to Sara Riese, Elma Laguna and Azaz Bin Sharif for sparing their precious time in the preparation of this paper. Their commitment and valuable contributions helped to shape and uplift the quality of this paper. We are also grateful for the extensive review by Taylor Cameron and appreciate all the hard work and time devoted to this publication.

Authors' details

¹Department of Geography, Geo-informatics and Climatic Sciences, Makerere University, P.O Box 7062, Kampala, Uganda.

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No competing interests reported.

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Predictors of Insecticide-Treated Nets Utilization among Children under five years in Refugee Settlements in Uganda: Analysis of the 2018-19 Uganda Malaria Indicator Survey

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Abstract

Background

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Results

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Background

Methods

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Data source and study location

Variables

Dependent variables

Independent variables

Statistical analysis

Results

Descriptive statistics of the respondents

Bivariate analysis

Determinant of ITN utilisation among children less than five years

Discussion

Conclusion

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