Linking insecticide mosquito nets to malaria: the roles of malaria Knowledge 1 and household-income

: 7 Background: Drawing on the theory of the health belief model, this study examined the interplay 8 of insecticide mosquito nets, malaria-knowledge, household income, and malaria. The study 9 premised on the notion that insecticide mosquito nets proposed to be positively related to malaria, 10 and knowledge was proposed to mediate the relationship between insecticide mosquito nets and 11 malaria. Furthermore, household-income was anticipated to have a moderating effect on the direct 12 and indirect relationships (through malaria knowledge) between insecticide mosquito nets and 13 malaria. 14 Methods: The hypothesized relationships were examined using the panel data collected from 10 15 regions of Ethiopia during 2011 – 2015. Structural equation modeling and random effect model 16 used to test the articulated hypothesis. Statistical analyses were performed using Stata version 13.0. 17 Results: The results were consistent with our proposed hypotheses, showing a significant and 18 positive relationship between the research variables. Accordingly, our estimate suggests that 19 malaria knowledge contributed to improving insecticide mosquito nets and malaria disease 20 relationships. The result revealed a significant and positive effect (β = 0.47, p = 0.003) of the 21 indirect effect where the direct effect coefficient is also positive (β = 0.28, p = 0.001). The study 22 also reported a positive impact of household-income in strengthening the relationship between 23 insecticide mosquito nets and malaria via knowledge with considerable value (β = 0.13, p = 0.000). 24 Conclusion: The findings are potentially useful for the health sector to assure the success 25 regarding infectious disease prevention and control, particularly malaria, explaining how such 26 factors contribute to the relationship.

followed by South-East Asia Region of WHO (6%) and the Eastern Mediterranean Region of 48 WHO (2%). Malaria generally reflects a significant burden on health systems and the broader 49 economy, particularly in Africa, which represents a significant economic burden for households 50 to pay for prevention and treatment (6). 51 African heads of governments set a target of 60% coverage of bed nets for use by pregnant women 52 and children U5 by 2005 following the Abuja summit in 2000 (7). Ethiopia set an objective to have 53 had a community with appropriate knowledge and health-seeking behaviors regarding malaria 54 prevention and control by 2020 (8). Also, ownership and utilization, net care and repair via demand 55 creation and familiarity is the critical point to implement. The universal coverage of mosquito net 56 is one of Ethiopia's primary vector control and prevention initiatives for ensuring unlimited access 57 to an insecticide mosquito net, and spraying households with indoor residual spray in targeted 58 areas (4,9). The cumulative number of ITNs exceeded 65 million, and about 6 million households 59 in malaria-prone areas are sprayed yearly with indoor residual sprays in 2015 (10). However, 60 Page 3 of 32 malaria continued as a significant public health challenge in Ethiopia (11). Insecticide mosquito 61 net identified as the most effective malaria prevention approach (12). Insecticide mosquito net 62 decreases malaria incidence in a variety of settings by 50% and malaria mortality rates by 55% in 63 children under 5 in Sub-Saharan Africa (2). Since the introduction of the intervention strategy, 64 significant success attained in the malaria program, and from 2000 and in the year 2015, malaria 65 decreased by 48% worldwide (3). Yet, malaria disease remains the leading cause of maternal and 66 child morbidity and mortality in low-resource countries. And Ethiopia accounts for 6% of malaria 67 cases worldwide, and about 12% of global affairs and deaths from Plasmodium vivax (13). In 68 Ethiopia, more than 50 million people are at risk, representing nearly two-thirds of the population  To the best of our knowledge, none of the previous work takes into account the role of malaria 84 knowledge to the relationship between insecticide mosquito net and malaria. Besides, none of the 85 previous research tests the moderating role of household-income in strengthening the relationship 86 between strategic interventions and malaria through malaria-knowledge. This study, therefore, 87 measures the influence of malaria knowledge and household-income in the relation aimed to 88 investigate the effect of insecticide mosquito nets on malaria as knowledge and income of the 89 household as a mediating and moderating role, respectively.

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Apart from this fundamental contribution, we contribute to the existing literature in numerous 91 ways. First, we observed the changes in the outcome with the direct relationship between ITN and 92 malaria, besides with moderation-mediation effect. Second, we considered a national-level 93 aggregate panel data with a considerable number of observations. Third, this is the first study in 94 Ethiopia to evaluate the ITN-malaria relationship in the context of malaria knowledge and income 95 of the household as a mediation-moderation effect. Finally, we conducted our analyses using 96 structural equation modeling in line with a random effect model of panel data estimation technique.

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The rest of the paper organized as follows. Section 2 explains the theoretical background. Section (29). The health belief model hypothesizes that health-related action depends upon the 107 simultaneous occurrence of three classes of factors: (1) The existence of sufficient motivation (or 108 health concern) to make health issues salient or relevant. (2) The belief that one is susceptible 109 (vulnerable) to a severe health problem or to the sequelae of that illness or condition, which often 110 termed as a perceived threat. (3) The belief that following a particular health recommendation 111 would be beneficial in reducing the perceived threat, at a subjectively-acceptable cost. Furthermore, 112 the theory based on the understanding that a person will take a health-related action if that person 113 believes s/he is susceptible to the condition (perceived susceptibility), the condition has serious 114 consequences (perceived severity), believes taking action would reduce their vulnerability to the 115 condition or its severity (perceived benefits), and these benefits outweigh the cost of taking action 116 (perceived barriers) (30). Action is taken more easily if the person exposed to factors that prompt 117 action (cues to action) and is confident in her/his ability to successfully perform an action (self-       Likewise, the study revealed the association between income and practice of malaria preventive 228 actions, where higher income groups are more likely to practice two times higher than low-income 229 groups (69). Besides, the report shows access to intervention influenced by household income (7). 230 Similarly, the study reported that, though ITN suggested as a means of malaria reducing approach, 231 the communities with large families and low-incomes more affected by malaria disease (70). The 232 other study also showed the significant predictor variables for knowledge on malaria using IRS as 233 a control tool were age, educational level, occupation, and income levels (71). Therefore, we 234 hypothesized that: 235 Hypothesis 5: Income of the house-hold moderates the mediated relationship between Insecticide 236 mosquito nets and malaria through knowledge. In such a way that the mediated relationship will 237 be stronger for those societies who are better in owning income.  Insecticide-treated nets and malaria. Such that the relationship will be stronger for an advanced 240 community than for those who are lower-income level.

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Descriptive statistics 320 The means (M), standard deviations (SD), minimum, maximum, and number of observations of 321 the study variables provided in Table 1.   Testing the direct and indirect relationship (hypothesis 1-6) 347 The proposed direct and indirect relationships for all hypotheses simultaneously tested under 348 structural equation modeling. The results depicted in Table 3. Accordingly, the results showed a

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As seen in Table 3, the effect of the interaction between insecticide mosquito nets and household  Table 3 for 378 results. These results were consistent with our proposed hypothesis 6. Our study also shows a  The goal of the present study was to examine the interplay of insecticide mosquito nets, malaria health, which may inspire cerebral rationalizations. We also found that insecticide mosquito net 412 was positively related to malaria knowledge, and knowledge was positively related to malaria.