Description of the study area
This study was household based and was carried out in Kimilili Sub-County which lies in Western Kenya Region which is a Malaria holo-endemic area. The Sub-County has two administrative Divisions, eight administrative locations and 16 administrative sub-locations. The study area has only one major referral health facility with a fully-fledged Comprehensive Care Centre - Kimilili Sub-County Referral Hospital. The hospital is served by small public health facilities located in each of the eight administrative locations plus several other private and mission health facilities. The population of Kimilili Sub-County according to the 2009 housing and population census was 320,300 people of which 155,771 were males and 164,529 females and 101000 under-five children. The population density is 572.44 with 61,486 households. Kimilili has two rainy seasons; long rains from March to June and short rains from September to December . Malaria endemicity peaks up during the long rains season. The annual temperature range of Kimilili is between 18°C to 29°C with an average humidity of 80 %. The main economic activity in the area is agriculture involving farming of coffee, maize, beans, sugarcane, bananas, potatoes plus horticulture crops
The study subjects were 222 under-five HIV positive children, randomly and proportionately recruited from eight administrative locations of Kimilili Sub-County. The parents/caretakers/guardians acted on behalf of the under-five children as respondents.
The study was a household based cross-sectional survey, conducted between March to August 2016, using a pre-tested structured questionnaire as data collection tool. The researcher and his fellow co-researchers trained a team of three research assistants for one week on how to collect data using the data collection tools, the local cultural norms were adopted in the approach of the respondents’ households and the consenting procedure before commencement of face to face interviews with respondents to collect data was undertaken.
Data was collected at a household level and hence we defined a household as: a unit with a married man and his wife/wives plus all of his dependants currently living with him . The under-five parent/caretaker who was a household head was identified and acted as a respondent on behalf of his/her participating under-five child. The researcher and his research assistants outlined in details the purpose of the study to respondents, the rights of participants, benefits and risks associated with the study. The respondents were then allowed an opportunity to either accept to participate in the study through voluntary written informed consent before the questionnaire was administered or alternatively decline to grant consent and hence excluded from the study.
The study questionnaire had two parts; the first part was primarily for collection of demographic variables of both study subjects and respondents (parents/caretakers/guardians) which included age and sex of child; age and sex of respondent, level of education, marital status, occupation and type of house. The second part was designed to capture data on ITN ownership, ITN usage and household Malaria attacks.
A sample size of 226 was calculated using Yemane’s formula . However, the response rate among respondents was 98.2%, which translated to only 222 under-five HIV positive children participating in the study.
Stratified random-sampling technique based on eight administrative locations in Kimilili Sub-County was used to proportionately select under-five HIV positive children to be included in the final study sample. HIV positive status of study subjects was well known in advance, as it was on the basis of their HIV positive status that they were recruited at the Comprehensive Care Centre; they were re-tested and confirmed positive by the Comprehensive Care Centre as described by Rutto et al  and hence started on anti-retroviral therapy. The randomly selected study participants were traced to their households based on special forms called client household locator forms and records held at Kimilili Sub-County Hospital’s Comprehensive Care Centre. These household locator forms and records had details of the names of all children enrolled in Comprehensive Care Centre; names of their parents/caretakers; physical location of their homes; Chiefs and Other fine details. Therefore using the locator forms it was easy to trace the eligible study homes.
Ethical clearance was sought from Great Lakes University of Kisumu (GLUK) Research Ethics Review Committee and Certificate of Approval of Research Protocol was granted under reference number, GREC 065/11/2012.
The hospital and local administration gave consent to the study. The research respondents granted written informed consent on behalf of their participating under-five year old children. The consenting process was done using Informed Consent Agreement Form, that were available in both English and local Luhya languages, therefore respondents were consented in the languages of their choices and which they understood best.
The study ensured the coding of its participants data and that their identity remained anonymous from the time of recruitment into the study up to the conclusion of the study. All information relating to study subjects was kept confidential with no access to third parties.
The research tools were pre-tested to guarantee accuracy and validity before being used.
Data was collected directly on the study questionnaires, checked for validity and entered onto computer excel spreadsheet by two data entry clerks. This was then merged into one spreadsheet by a third clerk and inconsistences corrected using original data collection questionnaires.
The excel spreadsheet was then scored for each primary variable of investigation, rated and coded manually. The data was exported into Statistical Package for Social Sciences (SPSS) version 11.5 and analyzed. Chi-square and 95% confidence interval analysis were used as statistical tools to determine statistical significance to declare an association between different variables at a cut-off value of 95% (P = 0.05). The results were presented in frequencies, percentages and descriptive statistics.
The appropriate responses which included routine and consistency use of ITN implied correct utilization of ITN at household level; this was rated good and coded 1. The responses that were a mixture of both haphazard and consistency ITN utilization implied median ITN use and were rated fair and coded 2; while the inappropriate responses which implied haphazard and inconsistency use of ITNs were scored low, rated poor and coded 3.
Limitations of the study
The following were the major limitaions of this study; Firstly, the study was localized in Kimilili Sub-County yet Malaria is a national and a global problem. A study of this kind should have covered at least a whole region to justify inference of its findings to general population. Secondly, This study may have also been limited by recall bias in its attempt to establish the facts as to the utilization of ITN without misqivings. Not all respondents may have clearly recalled how they utilized ITN during administration of the questionnaire. Thirdly, the validity and accuracy of tools of data collection may not have been 100% guaranteed despite having been pre-tested and validated during pilot study.