Factors associated with the non-use of insecticide-treated nets in Rwandan children

Malaria Journal Ruyange et al. Malar J (2016) 15:355 DOI 10.1186/s12936-016-1403-6 Open Access RESEARCH Factors associated with the non‑use of insecticide‑treated nets in Rwandan children Monique Murindahabi Ruyange1*, Jeanine Condo5, Corine Karema1, Agnes Binagwaho2,3,4, Alphonse Rukundo1 and Yvette Muyirukazi1 Abstract Background: Insecticide-treated bed nets (ITNs) are highly effective in reducing malaria burden when used properly. However, factors related to individuals, households and community may influence how ITNs are used for malaria control. The study examined influences exerted at these levels to determine if they are associated with ITN non-use among children under 5 years of age in Rwanda. Methods: Using data from the 2010 Rwanda Demographic Health Survey, the investigation was done on the factors associated with ITN non-use among children under 5 years. Descriptive statistics as well as univariate and multilevel logistic regression analyses were used to identify factors associated with ITN non-use. Results: Responses from a total of 6173 women aged 15–49 years living in 492 villages were included in the analysis. Risk factors for children not utilizing ITNs (25 %) included: (Odds ratio [95 % confidence interval]) households with more than five members (1.42 [1.23–1.63]), employed mother (1.33 [1.06–1.66]), and lower household altitude (1.36 [1.14–1.61]). Protective risk factors for ITN use included households with more than three nets (0.39 [0.33–0.47]), mothers who attended one to four visits at antenatal clinics during pregnancy (0.45 [0.29–0.69]), more than four antenatal clinic visits during pregnancy (0.39 [0.21–0.70]), mothers married or living with partner (0.43 [0.36–0.52]), mothers with any education level (0.77 [0.65–0.91]), and households with higher community wealth quintile (0.71 [0.59–0.84]). Conclusions: Rwanda has achieved high coverage of ITN use and proper use has contributed to a decline in malaria in Rwanda; however, maintaining universal ITN coverage is not enough to protect citizens from this disease. Risk factors related to ITN non-use at individual, household and community level include poverty, education, birth spacing, and antenatal clinic attendance. There is a need to address findings with strategies to mitigate the non-use of ITNs for effective malaria prevention in Rwanda. Keywords: Malaria, Prevention, ITN, Children under 5 years Background Malaria is the leading cause of morbidity and mortality in sub-Saharan Africa for children under 5 years of age (U5) and was responsible for approximately 6.5 % of deaths among U5s in Rwanda in 2011 [1, 2]. Following the scale-up of comprehensive malaria control interventions between 2007 and 2010, the prevalence of malaria parasitaemia measured by household surveys declined from 2.6 to 1.4 % in children between six and 59 months of age, *Correspondence: 1 Malaria and Other Parasitic Diseases Division‑RBC, Ministry of Health, Kigali, Gasabo, Republic of Rwanda Full list of author information is available at the end of the article and U5 mortality declined by 42 % from 133 deaths to 76 per 1000 live births [3]. Insecticide-treated bed nets (ITNs) are an important malaria prevention intervention in reducing childhood malaria morbidity and mortality. Repeated studies have been shown that ITNs are the most cost-effective measure to reduce malaria transmission in developing countries [4, 5]. In 2010, Rwanda distributed approximately 4.1 million ITNs during a universal coverage campaign with the goal of one ITN per two people, thereby covering all sleeping areas in each household. This campaign resulted in an increase of 25 % of U5 sleeping under an ITN compared to 2007–2008 [3, 10, 15]. The 2010 © 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ruyange et al. Malar J (2016) 15:355 universal ITN campaign resulted in 75 % of U5 sleeping under a mosquito net, relatively high compared to other sub-Saharan countries, but nonetheless below Rwanda’s national and international target of 80 % [3]. A number of studies have examined factors associated with ITN non-use among U5 in sub-Saharan Africa [6, 8–13]. However, the focus of these studies have been on individual-level factors, and only a few have examined community-level factors [7]. The 2010 Rwanda Demographic Health Survey (DHS) data were analysed to identify social and ecological factors, including individual, household and community factors associated with non-use of ITNs among U5s in order to inform national malaria control programmes on areas of focus for increase of ITN use among U5s. Methods Study setting Rwanda is situated in East Africa, immediately south of the Equator [3]. Uganda is to the north, Tanzania to the east, the Democratic Republic of the Congo to the west, and Burundi to the south of the country. Rwanda’s average elevation varies between 1500 and 2000 m. Rwanda enjoys a temperate, sub-equatorial climate with average yearly temperatures of around 18.5 °C. The average annual rainfall is 1250 mm and occurs in two rainy seasons of differing lengths (February to June and September to December), alternating with one long (June to September) and one short dry season (December to February). Rwanda has a dense network of rivers and streams, and several lakes surrounded by wetlands [3]. Study design and sample size The 2010 Rwanda DHS, conducted by the Rwanda National Institute of Statistics in collaboration with the Ministry of Health, collected data on 13,671 women of reproductive age and 6329 men aged 15–59 years. Methods and data collection procedures have been published previously [3]. Sites were selected at random and comprised 492 sampling clusters. In selecting sites, the sampling scheme accounted for rural and urban areas and for different regions in the country. For this study, communities were based on sharing a common primary sample unit (PSU) within the Rwanda DHS data. Data from female respondents were aggregated and used for statistical analysis as described below. Measures Individual child, parent, household, and community characteristics were examined to identify factors that may affect the non-use of ITNs among U5s. The term community was used to describe clustering within the same geographical living environment. These characteristics Page 2 of 7 included: (1) the age and sex of the child; (2) the age, education level, employment status, marital status, and ante (...truncated)