The current study, carried out in three villages of central Côte d'Ivoire, determined whether social and economic factors influence the knowledge and preventive measures against malaria, placing particular emphasis on the use of LLINs. In two of the villages, LLINs were freely distributed by the national malaria control programme before the current investigation, whereas the third village did not benefit from this free bed net distribution campaign. A clear relationship was found between SEP and reported malaria symptoms, treatment behaviour and measures taken against mosquitoes. It was found that the education attainment of the household heads and whether children are present in a household are associated with LLINs utilization.
The main malaria symptoms reported by the heads of households or adult substitutes were fever or hot body. However, compared to previous studies carried out in central Côte d'Ivoire  and south-western Ethiopia , the frequency of these specific symptoms was lower. Convulsion was rarely mentioned as a symptom for malaria in the current setting. This observation confirms results obtained by Esse and colleagues, who described convulsion as a childhood health problem rather than a malaria-related symptom . In other parts of Africa, convulsion was also not associated with malaria. For example, in the United Republic of Tanzania  and in Zambia , people recognized convulsions as a disease entity within the broad concept of epilepsy caused by supernatural forces, thus, requiring traditional healers for case management. In Ethiopia some caregivers associated convulsion to childhood malaria, which may indicate recognition of some features of severe malaria . A history of fever is a widely used symptom in health facilities and at home that serves as an indicator for clinical malaria, and hence for initiating malaria treatment .
Household heads reported more often to use traditional medicine as first-line treatment before seeking care at a dispensary or a hospital. An important explanation of this observation is the lack of cash (traditional facilities often only require in-kind payments) . The current results confirm this practice; wealthier households were more likely to report using modern pharmaceutical remedies and seeking care at official health services, whereas poorer households tended to use a broad range of traditional remedies. In general, modern medicine is more often used if it is readily available at home or if there is sufficient cash to purchase it. When positive experiences have been made with a specific drug before, it is likely to be used again. This is a common observation: home treatment is frequent, reaching up to 94% in rural Ghana and people - irrespective of SEP - use drugs within their immediate environment first, before seeking help/care and purchasing treatments [29, 30]. In this context, the close proximity of one of the study villages (i.e., N'Dakonankro) to the capital of Yamoussoukro might have influenced people's practice with regard to treatment explaining the increased use of modern drugs sold by street vendors compared to traditional plants used in Yoho. Nonetheless, the results of this study suggest that there is still a major problem, particularly among poor population segments with the knowledge and adoption of the key malaria control strategy of early diagnosis and effective treatment.
More than two thirds of the household heads (69.9%) mentioned mosquitoes as the main cause of malaria in children. Mosquitoes were more frequently mentioned by wealthier households, suggesting better access to health information and education. This is in accordance with other studies pursued in Africa where mosquitoes were identified as a cause of malaria by people with better formal education and from better-off households [18, 31, 32]. Furthermore, findings presented here show that the use of LLINs was influenced by SEP, educational attainment of the heads of household and children under five years concurrently living in a household. In a study from Kenya, ITN use by children under the age of five years was positively associated with the caregiver's knowledge of ITNs, marital status and occupation . In the current study from central Côte d'Ivoire, the better-off reported to have received information mainly through television and radio and their better formal education facilitated the understanding of the information provided. Actions against mosquitoes differed between socioeconomic groups. To fight against mosquitoes, almost half of the households reported to use ITNs, of which two thirds for protection against mosquitoes and one third for protection against malaria. The least poor mentioned more often to use LLINs to protect themselves. Thus, knowledge about mosquitoes as cause of malaria correlated with bed net use. In a study from western Ethiopia, the possession of bed nets, the willingness to pay for the nets and their actual use was associated with wealth status . In another study from Ethiopia not owning ITNs was associated with unaffordability and no availability . Conversely in Gabon, SEP was inversely related to bed net use . This observation has been explained by the poorest being more bothered by insect nuisance than their richer counterparts, so they were more likely to use bed nets to protect themselves.
Two studied villages, namely Bozi and Yoho, received free LLINs from the national malaria control programme, whereas N'Dakonankro did not. Interestingly, N'Dakonankro and Yoho had approximately the same LLINs coverage, which was rather low (7.1% and 10.7%, respectively). The low and comparable rates of coverage can be explained by the large number of pregnant women of N'Dakonankro who visited hospitals in the city (Yamoussoukro) where they were given LLINs free of charge, while no such action was in place in the other study villages. Nonetheless, the utilization rate was higher (almost 50%) in the villages Bozi and Yoho, where the intervention by the national malaria control programme took place, compared to only 8.8% in N'Dakonankro. Furthermore, the mean number and use of LLINs in the current study was influenced by the education level of the head of households. This finding confirms results from Dike and colleagues , who observed that higher educational attainment was associated with a higher likelihood of households purchasing both treated and untreated bed nets, although in a study from western Côte d'Ivoire, Fürst and colleagues  found that the educational level of the respective heads of households had no influence. The current study further confirms that the mean number of LLINs in the household is governed by the presence of children younger than five years of age . Results presented here further suggest that preventive measures against malaria (i.e., free distribution of LLINs) targeting particularly vulnerable groups, facilitated by the national malaria control programme might also have increased the malaria knowledge, and hence the use of LLINs.