Several studies have established the critical role of ITNs in malaria prevention, particularly in sub-Saharan Africa and Ghana [17, 18]. Yet, there are existing inequalities in terms of ITNs utilization, thereby putting some sub-populations at a disadvantage. The study examined the inequalities in ITNs by pregnant women in Ghana. The findings revealed that ITNs by pregnant women has increased from 32.6% in 2011 to 49.7% in 2017. This figures are greater than the prevalence recorded in sub-Saharan Africa (30.6%) and Madagascar (10.1%) [17]. The results, however, corroborate an earlier study conducted in Ghana [19] which reported a prevalence of 49.2%. Probably, the increase in the utilization of ITNs between 2011 and 2017 could be attributed to the implementation of the National Malaria Control Programme (NMCP), which provides free mass and continuous distribution of ITNs in hospitals and schools [20, 21]. Although the results suggest an increase in the utilization of ITNs in Ghana between the period under study, the current prevalence of ITNs utilization (49.7%) raises concerns as to whether Ghana would be able to achieve the WHO target of 90% decline in the incidence of malaria infections and mortality due to malaria by the year 2030 [22]. Hence, there is the need for policy and intervention reviews in order to identify and forge new strategies to improve ITNs utilization in Ghana.
Across both survey, the utilization of ITNs was higher among women from poorer households as compared to women from richer households. This finding is somewhat surprising because previous studies have revealed that women from higher wealth indexed households are more likely to own ITNs and consequently, being more likely to utilize it [23,24,25]. Nevertheless, the result is analogous to the findings of a related study conducted in Ghana which found that although women from higher wealth indexed households were more likely to own ITNs, the utilization was rather higher among women from poorer households [10]. A plausible explanation for this finding could be that, unlike women from richer households, women from poorer wealth households are unable to afford alternative preventive methods such as intermittent preventive treatment, repellents and aerosol sprays [10, 26]. The inequality estimate revealed that there was marginal inequality in the utilization of ITNs between 2011 and 2017. Probably, this could be as a result of the pro-poor nature of the NMCP which mostly target poorer households with free ITNs distribution.
Contrary to findings from previous studies that found higher ITNs utilization among women in urban areas [27, 28], the study found that rural dwelling pregnant women had higher ITNs utilization in both 2011 and 2017 as compared to their counterparts in rural areas. The result is, however, consistent with the findings from studies conducted in Ghana [29, 30] and Myanmar [31]. The reasons for this finding is unclear, however, it could be that rural dwelling women struggle to afford malaria treatment and, therefore, prioritize preventive measures such as ITNs use, far more than their counterparts residing in urban areas [32]. With respect to inequality analysis, the study revealed that there was marginal inequality in the utilization of ITNs. Thus, suggesting that Ghana has been able to narrow the rural–urban inequalities in terms of ITNs utilization over time.
Concerning the education dimension, it was revealed that ITNs utilization was higher among women who had no formal education compared to those who had formal education across both survey points. Similar findings have been reported by a related study from Ghana [30]. A plausible explanation for this could be that, women with no formal education often perceive themselves to be highly vulnerable to malaria infection, possibly receiving encouragement to utilize ITNs as compared to those with formal education. Dadzie et al. [30] also argue that women with formal or higher education have greater access to information about alternative malaria prevention methods. Consequently, they tend to practice better environmental hygiene and/or adopt alternatives to ITNs, hence, explaining the lower ITNs utilization among women with no formal education, and the corresponding higher ITNs utilization among those with formal education. However, there was marginal educational-based inequality with regards to the utilization of ITNs over time.
Regarding the region of residence, the findings indicate that women from Greater Accra region were the least to utilize ITNs in both the 2011 and 2017 survey points. However, in 2011, the utilization of ITNs was higher among women in the Eastern region; whilst women in the Volta region dominated in terms of ITNs use in 2017. There was substantial inequality in utilization of ITNs in both 2011 and 2017. The reasons for the substantial regional inequalities in ITNs utilization and the differences over time are unclear. However, it is possible that the low ITNs utilization in the Greater Accra region may be due to the characteristics of the region. Women in the Greater Accra region tend to be urbanites and also have higher formal education; all of these factors have been found to be associated with lower utilization of ITNs [27,28,29,30]. Another possible explanation could be that, Ghana’s ITNs programme has generally be pro-poor and pro-rural in nature, hence, explaining the low utilization of ITNs in the Greater Accra region.
Policy implications
From a policy perspective, there is the need for Ghana to review the free, mass distribution of ITNs component of the NMCP. The study reveals that the current pro-poor and pro-rural nature of ITNs utilization may be triggering inequalities in the utilization of ITNs. Therefore, a second look and revision in the current NMCP could improve ITNs utilization in Ghana. The findings also underscore the need to enhance health educational messages about the importance of using ITNs in urban areas and in the Greater Accra region.
Strengths and limitations
The study used nationally representative data, hence, making the findings generalizable to the entirety of Ghana. Also, the use of the HEAT software was appropriate for estimating various inequality estimates for the various dimensions. This adds to the rigor and validity of the study methodology. Nonetheless, there are some limitations that should be considered when interpreting the study findings. As a study that relied on secondary data, it was not possible for us to account for other important factors such as cultural norms that could play key role in women’s utilization of ITNs. Also, given that information on ITNs was self-reported, there is the possibility of recall and self-reporting bias.