This first comprehensive assessment of the coverage of the key malaria indicators in Iran highlights several important areas that need to be addressed urgently by Ministry of Health and Medical Education to achieve malaria control targets set by RBM partnership as well as national strategic plan for malaria elimination.
The current study confirmed low access to mosquito net among surveyed households. Based on findings in this report, only one-fifth of households owned at least one bed net (treated or untreated). Accordingly, tiny proportion of children under five years of age (6%) and pregnant women (6%) slept under any net the night before the survey. Net possessions among previous studies mainly come from African countries [10–14, 18–25] ranged from 4% to about 80%. Correspondingly, reported use during the preceding night by vulnerable groups in these regions was between 1 to 75% for any net. Hence, the results of the present study in line with some of the previous studies are too far from expected coverage of Abuja (60%)  and RBM (80%)  announcements. However, some countries including Ethiopia , Tanzania , Zambia , Rwanda , Eritrea , Liberia  and Djibouti  have closed or exceeded the Abuja targets. Importantly, the proportion of children and pregnant women who slept under a net during the night before the survey was considerably lower than the proportion of households that possess a net in the current study. This discrepancy between possession and utilization are consistent with the available evidence from other countries  and could be a matter of concern as well. The relationship between ownership and use of net might be possibly associated with the distribution of children and women of reproductive age among households owning nets. For example, among extended family owning one net, each individual may be less likely to sue a net because there are not enough nets available for everyone in the households. Unquestionably, increase access and utilization of mosquito net require assuring that all households have adequate numbers of bed net to be used by all household members, particularly children and pregnant women. Several epidemiological studies [24, 25, 27] have demonstrated that free or voucher scheme of insecticide-treated nets may well contribute to the household net ownership and its utilization. The experiences come from these studies might be applicable for Iran, too.
The current study also suggests that one out of every ten households reached by indoor residual spraying in the year preceding the survey. These findings are consistent with data from Angola , Ethiopia  and Djibouti , but considerably lower than those reported form Zambia (40%)  and Mozambique (52.4%) . The RBM declaration  includes a target that 80% households in areas at risk from malaria should be sprayed with insecticide. Therefore, the IRS coverage in Iran is much lower than the level required for controlling effectively the malaria vector.
Additionally, the present study indicates that knowledge of interviewees concerning malaria symptoms and transmission are relatively modest, but mosquito net as an effective prevention method against malaria was known by an unacceptably small proportion of participants (one-third). These results are roughly similar to the existing data from the prior National surveys [10–13, 18–25] with an exception for Zambia  where more than 80% of women reported that use of mosquito nets could prevent malaria. This lower awareness of inhabitants about preventive measures of malaria might explain some of the discrepancy between possession and use of net by vulnerable groups. Therefore, the survey suggests developing, and implementing effective health promotion policies to increase the awareness of households about the symptoms, transmission route and in particular control measures of malaria. Strong and sustainable interventions efforts including information, education, and communication activities not only maximize mosquito net use, but also improve health-seeking behaviors at community levels. Awareness of families possibly will lead them to react properly when having fever and shivering as well. More importantly, emphasis on girl's education may be probably effective to address lack of satisfactory knowledge about malaria over the long term.
Data also suggests variation by region and residency. In this study, residents in Sistan & Baluchestan province showed better knowledge and higher rate of mosquito-net use compared with other provinces. Likewise, vulnerable groups in rural areas were more likely to have or use a net compared to the urban areas. This discrepancy might be attributed to higher experience rate of malaria cases and exposures and accordingly more sensitized to malaria problem.
There are several limitations that warrant interpretation of the results. The use of mosquito net by children under-five and pregnant women was analysed only for the night prior the survey and may, therefore, not reflect the long-term pattern of net usage. Self-reported use of mosquito net as well as indoor residual spraying may also introduced bias. However, large number of included clusters, combined with well-trained local interviewers and extensive supervision, minimized these effects. Furthermore, this is the first comprehensive survey of this highly malarious region in Iran.