Factors associated with insecticide-treated net usage among women of childbearing age in Malawi: A multilevel analysis

Background: This study aimed to identify factors at individual and community level influencing insecticide-treated net (ITN) usage among groups of women of childbearing age (WOCBA) in Malawi. Methods: Factors influencing ITN usage in Malawi were assessed through interviews with 16,130 WOCBA (15-49 years) across 850 communities who participated in the 2015-2016 Malawi Demographic Health Survey. Multilevel logistic regression analysis was used. Results: ITN use was similar between pregnant women and non-pregnant women with children under 5 years (45.9% and 46.9%, respectively), but slightly lower among non-pregnant women without children under 5 years (39.1%). Both individual and community characteristics were associated with ITN use among WOCBA and varied significantly across subgroups. Specifically, non-pregnant women with children under 5 years living in communities where women had high autonomy in health care decisions had an 18% greater odds of using an ITN compared with those from communities where women had low health care autonomy (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] 1.00-1.38). Distance to health care facility influenced ITN usage among pregnant women; those who did not regard distance as a problem had a 44% greater odds of using an ITN than those for whom distance was seen as a problem (aOR = 1.44; 95% CI 1.09-1.89). Number of household members, region, urbanization, and community ITN coverage influenced ITN usage across all WOCBA groups. Conclusion: The findings confirmed the importance of assessing various factors affecting ITN usage among groups of WOCBA. Both individual- and community-level factors should be considered when designing and implementing ITN programmes in Malawi.