Using simple methodologies, the authors have shown that distance to health services is associated with ITN possession. Interestingly, this analysis uncovered the same relation with reported household use of any type of nets, even among those households who possess at least one. This finding provides further evidence to suggest that health services may play an important role in providing not only material resources, but also promoting use of health interventions within the home. Although data on maternal attitudes toward local health workers and preferred sources of health information were not available in this study, the results support the inference that regular contact between citizens and health workers or health intervention distribution sites help promote and reinforce beneficial household health behaviours.
In Malawi, present strategies of ITN distribution centre on antenatal and under-five clinics. Given the results of this study, which suggest that possession of ITNs decreases with increasing distance from health facilities, there may be a need to enhance community-centred ITN distribution models, to achieve the same level of coverage as existing community-based vaccination strategies. ITNs could be distributed widely within communities, utilizing present community health workers to deliver them directly to households. Information on appropriate use should then be disseminated directly to caregivers, reinforcing proper protective behaviors. Other studies have shown that community based malaria education programs result in more consistent patterns of households ITN use . An emphasis on a community-based model over facility-based distribution strategies could address the problem of low ITN possession particularly among communities distant from health services, but could also serve to encourage consistent levels of use within households in isolated communities that have little access to malaria educational programmes.
The mechanisms of household-level decision-making as they relate to HF access are largely unknown. More frequent trips to HFs might result in more opportunities for health messages to reach households, reinforcing pro-active efforts to protect the health of family members and increasing awareness of the causes and prevention of malaria. This study lacked a quantified measure of education of female household heads, preventing formal examination of this possibility. Other studies have indicated that knowledge and perceptions of malaria sources varied among education levels , with better educated mothers having greater malaria knowledge than those who were less educated. In addition, Dyke, et al  demonstrated in Nigeria that higher levels of education are not only associated with malaria knowledge, but also with actual ITN use.
Health services tend to be located near markets, schools and other important areas of infrastructure. Thus, households near HFs are also likely to be of greater SES through participation in market economic activities, better educational opportunities and greater chances for employment. Residents living further away from health services, and thus from market centres, may tend to be less educated, less likely to participate in cash-based economic activities, and less prone to taking advantage of health services and interventions. However, because education level and SES are intertwined, the lack of significance of SES (wealth quintiles) in the regression model for household ITN use suggests that education plays less of a role in ITN use than health messages and access to services than might be assumed. While the insignificance of SES in the multivariate possession model may be the result of ITN distribution programmes that specifically target low SES households, the lack of significance in a model of ITN use given possession suggests the need for further exploration of determinants of ITN use beyond material wealth.
The authors recognize that there may have been systematic over-reporting of ITN use or variability in reports of ITN use among SES groups, for example. Respondents may have been concerned about self-implicating themselves if they believed that they neglected to protect their children from disease. Similarly, no clear attempt was made to disentangle actual practices from reported habits through structured verification of responses and the data prevented validation of responses of ITN use. However, misreporting of ITN use was probably unrelated to distance to nearest HF, suggesting no systematic bias that would influence statistical estimates of ITN use and health facility proximity associations. While absolute percentages of ITN use may be overestimated in the present survey, the reported patterns with proximity to health services are valid and representative.
Equitable distribution of ITNs with strategies that maximize coverage of high risk areas should be of uppermost priority among health officials. The authors recommend that health workers take proactive steps to help communities that are remotely situated (particularly those beyond 5 km) from health services. Although nothing in these results allows one to test the hypothesis that direct, community-based health initiatives reinforce health behaviors, future research should attempt to measure the public health impact of community workers. Studies that assess community attitudes toward those workers could direct policy makers to upgrade current strategies which could, in turn, help improve the level of trust in the information and services that they deliver.
Clearly, though, community based malaria programmes should not be limited to ITNs, but should include other methods such as indoor residual spraying (IRS) and home-based treatment methods. Promoting a comprehensive approach in the fight against malaria should be of the utmost importance to both researchers and policy makers . IRS initiatives may obviate the need for regular, nightly use of ITNs and home treatment strategies for isolated areas may mitigate transmission levels. To this end, future research efforts should include other intervention methods, access to which may also be associated with distance to health services. Future research could utilize the methods presented here, to assess the potential role that access to health services can play in an interdependent system of interventions and work to target underserved geographic areas of significant risk for malaria. It is possible that within this system of interventions, some may be more effective than others and the correct 'recipe' for a sustainable strategy balanced with logistical costs may be geographically dependent on access to health services.