Utilization of insecticide-treated nets for malaria prevention among children in Africa: a systematic review and meta-analysis

(2025) 24:358 Basiru et al. Malaria Journal https://doi.org/10.1186/s12936-025-05599-w Malaria Journal Open Access REVIEW Utilization of insecticide‑treated nets for malaria prevention among children in Africa: a systematic review and meta‑analysis Afisu Basiru1*, Uchenna B. Alozieuwa2, Mercy I. Aboh3, Umar Y. Usman4, Ogochukwu N. Nwaefulu5, Oluchukwu P. Okeke6, Folahanmi T. Akinsolu7,8 and Olajide O. Sobande6 Abstract Background Despite the proven effectiveness of insecticide-treated nets (ITNs) in reducing malaria incidence and mortality, their usage among children in Africa remains inadequate. This systematic review and meta-analysis aimed to ascertain the prevalence of ITN usage for malaria control among children in Africa. Methods This review was registered with Prospero (CRD42023474978). A search was conducted in Scopus, PubMed, and Google Scholar for publications between 2013 and 2023. The study population was children in Africa, the intervention was ITN utilization, and the prevalence of ITN use was the outcome. The Jonna Briggs Institute (JBI) criteria were used to evaluate the quality of the included studies. A random effects model determined the overall pooled prevalence of ITN utilization. A sub-group analysis was carried out based on regions of Africa. Egger’s Regressionbased test was used to identify publication bias. Results This review included 30 studies with 76,045 children, 50 households, and 1009 caregivers. Among the 30 included studies, 26 (86.7%) determined the ITN utilization in children, three (10%) evaluated the use of ITN by caregivers of children, and one (3.3%) article reported ITN utilization in households with children. In addition, 28 (93.3%) studies were cross-sectional. The pooled prevalence of ITN utilization was 69.50% with a 95% CI (64.5–74.5%). Statistically significant heterogeneity was observed (I2 = 100%, p = 0.001). ITN utilization was highest in Central Africa (85.44%, 95% CI 85.3–85.6), followed by Southern Africa (80.7%, 95%CI 80.6–80.9) and Eastern Africa (69.2%, 95%CI 63.8–74.6), and lowest in West Africa (67.0%, 95% CI 56.2–77.8). Conclusion The prevalence of ITN utilization among children in Africa is low and varies by region. This utilization needs to be improved. Keywords Child health, Public health, Malaria control, Africa, Health intervention *Correspondence: Afisu Basiru Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Basiru et al. Malaria Journal (2025) 24:358 Background Malaria remains a major global health challenge, with an estimated 299 million cases and 409,000 deaths recorded worldwide in 2019 [1, 2]. Sub-Saharan Africa (SSA) bears the heaviest burden, accounting for 85% of global cases. Nigeria alone is responsible for 27% of all cases and 23% of malaria-related deaths globally [1]. This disease disproportionately affects populations in low- and middle-income countries (LMICs), where over half of the global population remains at risk [2]. In LMICs, malaria contributes significantly to morbidity, mortality, poverty, and reduced productivity [3–5]. Children in endemic regions, particularly those without yet developed sufficient immunity, are especially vulnerable. In SSA, this vulnerability can result in severe outcomes such as cerebral malaria [6–9]. Various global and regional efforts have been implemented to reduce malaria-related morbidity and mortality [10–12]. For example, Nigeria’s National Malaria Strategic Plan (NMSP) aims to ensure that 80% of the population can access vector control interventions by 2025 [13]. Malawi and countries in Southern Africa have also developed strategic plans emphasizing burden stratification and vector control as key approaches [14, 15]. Malaria control typically requires a multifaceted strategy. Key interventions include the use of insecticidetreated nets (ITNs), indoor residual spraying, seasonal malaria chemoprevention (SMC) for children aged 3–59 months, timely diagnostic testing followed by artemisinin-based combination therapy (ACT), and focused treatment during pregnancy [16–24]. Among these, ITNs have emerged as the most cost-effective method for malaria prevention, averting more than 50% of malaria cases and reducing child mortality by 27% [25–27]. Many African countries, including Nigeria, Kenya, Ethiopia, and Rwanda, have undertaken mass ITN distribution campaigns to expand access and coverage [28– 30]. Ownership is a major determinant of ITN use, and distribution during antenatal care and immunization visits has been instrumental in improving coverage [31–33]. ITNs function by creating a physical barrier that repels or kills mosquitoes, thereby reducing human-vector contact and malaria transmission [34–36]. In high-transmission areas, ITNs can reduce severe malaria by up to 45% and mortality in children under five by up to 55% [37]. Despite their proven effectiveness, ITN usage among children under five in Africa remains suboptimal, with reported usage at just 57.4% [38]. Barriers such as limited access, cultural beliefs, seasonal variations, and low awareness contribute to this gap [39–43]. In some regions like Kenya, awareness is high, yet usage remains low due to practical challenges [44]. Maternal education Page 2 of 10 and occupation are also strongly associated with ITN ownership and use [45–49]. Notably, recent malaria control successes have led to a shift in disease burden from younger to older children. Historically, pregnant women and children under five were the primary focus of malaria interventions due to their high vulnerability [50, 51]. However, with reduced transmission in many areas, school-aged children (6–15 years) are now experiencing more clinical cases [52–54]. Up to 70% of school-aged children in hightransmission settings harbour malaria parasites, representing a significant reservoir for continued transmission [55, 56]. Despite this, few malaria control programmes specificall (...truncated)