Exploring a moderation analysis in the interaction between determinants of ITN use in Ghana. A multi-level analysis based on the DHS 2020 /2019 malaria indicator survey
Authors: Awoonor-Williams Kelvin Edem , Urke Helga Bjørnøy 
Published: February 2024

Abstract
Background
Insecticide-treated mosquito net (ITN) use is considered a highly efficient vector-control strategy in reducing malaria transmission and while this tool is significantly available to vast malaria-endemic areas, there persists a gap in determining its effective use given households´ access and ownership. Malaria analysis posits that although the availability of ITNs in a household is a prerequisite for use, it does not determine its effective use. Rather, determinants of ITN use are a result of the complex interplay of factors at the various socio-ecological levels (i.e., individual, household, community, and net level). These complexities are context-specific which shape the behavior choices of ITN use. This study explores the context-specific factors associated with ITN use that focus on the interactive relationship among individual determinants of ITN use. A conceptual approach is developed to test the interactive effect of ITNs in the household on the relationship between the number of children under five years and ITN use by household members in Ghana.
Method
Survey data with a sample size of 10,997 was drawn from the Ghana 2019 Demographic and Health Survey and the 2020 Malaria Indicator Survey to analyze an interactive relationship between individual, household, community, and net level variables. The relationship between these variables was assessed in a multivariate setting via a linear regression model. A further analysis involved a moderation effect of the number of ITNs on the relationship between the number of children under five years and household members´ ITN use using a single moderation model.
Results
From the data analyses, the number of children under five years was positively associated with household members' ITN use (OR = 0.29, p < .001), number of ITNs was negatively associated with ITN use (OR = -06, p < .05) and was positively associated with number of children under five years (OR = .23, p < .05). Gender was positively associated with ITN use and number of children under five years and negatively associated with number of ITNs. Increasing age was associated with decreased ITN use, number of children, and number of ITNs respectively. Increasing wealth index was associated with decreased ITN use, the number of children under five years, and the number of ITNs. The region was not significant with ITN use but associated with the number of children under five years. Place of residence was associated with ITN use, number of children under five years, and number of ITNs. A moderation effect of the number of ITNs (OR = − .05, p < .001) on the relationship between the number of children under five years and household members' ITN use was reported.
Conclusion
The number of children under five years influenced household members ITN use but this relationship was moderated by the number of ITNs in the household. The proportion of the number of children under five years was moderately different for a high and low number of households ITN availability whereby ITN use decreased with higher ITN ownership and increased with lower ownership. Future research should focus on more moderation analysis to better understand the complexity of interactions between individual, household, community, and net-level factors that determine ITN use. This might help to better understand and engage better-targeted action in increasing effective ITN use in households relevant to their needs.