Assessment of Long-Lasting Insecticidal Net (LLIN) ownership, utilization, and associated barriers in malaria-endemic communities of Ethiopia

Abstract

BACKGROUND: Malaria remains a critical global health challenge, with over 68% of Ethiopia's population living in at-risk areas. While Long-Lasting Insecticidal Nets (LLINs) are a cornerstone of prevention, their effectiveness depends on consistent use. This study aimed to assess LLIN ownership and utilization patterns and identify socio-behavioral and physical determinants of their effectiveness in endemic communities. METHODS: A community-based, cross-sectional survey was conducted from October 2024 to January 2025 across 11 administrative regions in Ethiopia. Using a two-stage stratified cluster sampling technique, data were collected from 9,222 households (34,427 individuals) through face-to-face interviews and direct physical observations. Data analysis was performed using the SPSS Complex Samples module and hierarchical multivariable logistic regression. RESULTS: The survey found a household LLIN ownership rate of 71.5%, while the proportion of sufficient LLINs for every two people was 58.3%. Among those who owned nets, the overall utilization rate was 59.9%, with significantly higher rates in rural areas (72.7%) than in urban areas. Vulnerable groups achieved higher usage levels, specifically pregnant women (78.5%) and children under five (67.2%). Multivariable analysis identified age and pregnancy status as significant predictors of LLIN use. Pregnant women had the highest utilization rate (78.5%), with about twice the odds of net use compared with non-pregnant women (OR = 2.03, 95% CI: 1.7-2.38, p < 0.001). Similarly, adults aged 25-49 years had 1.8 times higher odds of net use compared to individuals in the baseline age group (OR = 1.81, 95% CI: 1.63-2.02, p < 0.001). Major barriers to consistent utilization included limited confidence in hanging nets (60.5%, p < 0.001) and the widespread misconception (64.1%) that malaria risk is confined to the rainy season. CONCLUSION: Although Ethiopia has made strides in LLIN ownership and prioritized protection for vulnerable demographics, overall utilization remains below the 80% threshold required for community-wide protection. To bridge the gap between ownership and consistent use, national strategies should transition toward skill-based interventions and targeted communication to address practical barriers and seasonal misconceptions.