The study revealed that about two third of the surveyed households had at least one LLIN, but only one third of them used at least one of their LLIN in the previous night of the survey. This is lower than survey results in other similar studies in the country. They reported that 91.0% of the households had at least one ITN and 65% of them used at least one ITN [6
]. A similar study in Wonago district, southern Ethiopia, reported 75.5% usage [16
]. It was also lower than results found in other sub-Saharan countries [21
]. But, it is almost similar with a report of other study in the country, which reported 37.0% and 19.6% of the households had used at least one mosquito net and LLIN, respectively [24
]. Moreover, the study identified individual, household, socio-economic, environmental, and LLIN related characteristics as barriers to LLIN use.
In this survey, there could be a potential bias in measuring LLIN use among the entire household members of the respondent. It was found to be less likely to observe LLIN use of all the household members in the household, even if the net was available in the house and in hanged position. This may not be a problem at least to ensure use of at least one LLIN at least by one of the household members, including the young children and the respondent herself. In addition, the presence of hanged LLIN above the bed or sleeping place in the room was considered as a proxy indicator to LLIN use. The study also relied on a cross sectional survey conducted after the main rainy season when mosquito density and malaria transmission is high which LLIN use may be more likely to be higher than during the dry season. But, it may be useful for understanding of the reasons why LLIN owned households did not use it.
Though the women’s awareness on malaria prevention was moderate (68.2%), it was not translated into LLIN use in the study area, which is consistent with the other study in the country [16
]. Similarly, several cross sectional studies have shown that women in some African countries have reasonably good knowledge on the cause and prevention of malaria. However, the extent of mosquito net use is not as good as their knowledge [25
]. It may be due to the differences on the burden of mosquito bite and malaria infection and access to health information [26
More urban households (72.1%) owned LLINs than rural (64.6%) ones (COR=1.42, 95%CI 1.10, 1.82). This is lower than Kafta-Humera district, Ethiopia where the study reported 91.1% in urban and 80.0% in rural households [27
]. But higher than the 2007 MIS report, 39.5% of urban and 56.2% rural [9
]. When the confounding factors are controlled, LLIN use was lower in urban (27.6%) than rural (34.4%) households (Adjusted OR=0.51; 95%CI, 0.34, 0.76). This is in contrary with Haileselassie et al.
and the 2007 MIS survey reports, though both studies assessed ITNs use among selected household members only. There would be a couple of explanations for this difference: difference in housing construction and use, like using a separate room for cooking, presence of separate bed rooms, and expansion of health extension program in the rural part of the country could be among the reasons. The LLINs use was higher among residents of malaria endemic zone than fringe zone residents, and this is consistent with other studies in the country [6
]. This may be attributed to low mosquito population and malaria infections in the malaria fringe zone than the malaria endemic areas. It would also be more likely that health extension workers may give more messages on malaria prevention and control methods and LLIN use to malaria endemic area residents.
Absence of separate sleeping room, sharing rooms with domestic animals and putting fire place in the room were household barriers to LLIN use. This is similar with a cross sectional study conducted in the country [16
]. Sharing of one common sleeping place in the house may not be convenient to use LLIN for all of the household members. Observation also showed that most rural residents had non partitioned single room and had a fire place in the same room which may not be convenient to hang LLINs regularly. However, the sleeping habit of the community favoured the young children to share the available LLIN with their mother or father. LLIN ownership was not different between households that had children under five years (66.8%) and those did not have (63.8%). This is may be due to the universal target to LLINs coverage to all malaria risk residents. However, the presence of young children in the household and living in recognized endemic zone were independent predictors of LLIN use (Table ).
The study also identified that LLINs colour and shape preference were barriers to bednets use. The blue and cylindrical shape LLINs were more preferable than the white and rectangular. The study also showed that the majority (91.8%) of the households had either one or two LLINs, which may be inadequate to use for big household members.
The qualitative part of the study also supported that hanging of rectangular net is inconvenient and hard to keep for a long time in hanged position in small multipurpose room. It was also mentioned that the white nets may be coated or soiled with soot and may be unsightly to use for a long time. Recent studies in Ethiopia [6
] and in Kenya [28
] have also demonstrated that ITNs size, shape, colour and the availability of ITNs in the household as the barriers to mosquito nets use. The qualitative open ended questions and the observations showed that several LLINs were in a poor condition and handled improperly. Some households had used LLINs to cover some household properties which may shorten the service years of the LLINs and may make the nets conditions poor.