Ideational factors associated with consistent use of insecticide-treated nets: a multi-country, multilevel analysis
Authors: Babalola S , Kumoji EK , Awantang G , Oyenubi O , Toso M , Tsang S , Bleu M , Achu D , Hedje J , Schnabel D , Cash S , Lith L , McCartney-Melstad A , Nkomou Y , Dosso A , Hunter G 
Published: June 2022

Abstract
Background: Malaria remains a major cause of morbidity and mortality in many countries in Africa. Insecticide-treated nets (ITNs) are highly effective at preventing malaria. Sleeping under an ITN every night and year-round is critical to maximize its benefits. Using household survey data, this manuscript examines the sociodemographic, psychosocial (ideational) and household factors associated with consistent ITN use in Cameroon, Côte d’Ivoire and Sierra Leone.Methods: The data came from Malaria Behavior Surveys conducted in Cameroon (2019), Côte d’Ivoire (2018), and Sierra Leone (2019). The targeted population, sampling procedures, and data collection tools were similar in the three countries although geographic coverage of the surveys differed. The sample was nationally representative in Côte d’Ivoire, representative of two regions (North and Far North) in Cameroon, and of two districts (Bo and Port Loko) in Sierra Leone. The analyses were limited to households with at least one ITN and included 6092 in Côte d’Ivoire, 2940 men and women in Cameroon, and 2721 in Sierra Leone. The main analytic method was multilevel logistic regression that included sociodemographic, ideational, and household independent variables while adjusting for random effects at the cluster level. The dependent variable was consistent ITN use, defined as sleeping under an ITN every night (during the week preceding the survey) as reported by the respondent.Findings: The findings revealed the importance of sociodemographic and ideational variables as correlates of consistent use of ITN although the significant variables varied across countries. Results of the multilevel logistic regression showed a strong positive association of age with consistent ITN use in Cameroon and Côte d’Ivoire; in Sierra Leone, the relationship was curvilinear. The association with education level was significant and negative in Côte d’Ivoire and Sierra Leone but not significant in Cameroon. Perceived self-efficacy to use ITNs was the only ideational variable that demonstrated a positive association with consistent ITN use across the three countries. Positive attitudes towards ITN use and the perception of ITN use as a community norm were positively linked with consistent ITN use in Cameroon and Côte d’Ivoire but neither was significant in Sierra Leone. Perceived vulnerability to malaria was positively linked with consistent ITN use in Cameroon and Sierra Leone, but negatively correlated with the outcome in Côte d’Ivoire. Household net sufficiency was strongly and positively associated with consistent ITN use in the three countries. Finally, the findings revealed strong clustering at the enumeration area (EA) level, suggesting there are similarities in net use pattern among repondents of the same EA, possibly due to factors operating at the EA level. Conclusions: There are similarities and differences in the variables associated with consistent ITN use across the three study countries and several ideation model variables are signficiant. The findings suggest that a social and behavior change strategy based on the ideation model is relevant for increasing consistent ITN use and can inform specific strategies for each context. Finally, ensuring household net sufficiency is essential.