Malaria continues to be a major public health problem globally with high mortality and morbidity in Africa. As at December 2015, the disease accounted for 214 million cases and 438,000 deaths globally with sub-Saharan Africa (SSA) accounting for 88% and 90% of cases and deaths respectively 1. Pregnant women and children are the most vulnerable groups to Malaria 2. Malaria in pregnancy exposes women to an increased risk of severe anaemia, spontaneous abortion, premature delivery or death while subjecting the foetus to the risk of stillbirth or low birth weight 34 . Children are particularly susceptible to the disease due to their poorly developed immune system. Despite the decline in morbidity and mortality, malaria remains the fourth leading cause of under-five mortality in the sub-region 56.

Considering the closeness between mother and child, effective measures put in place to protect the mother from malaria could also protect the child and hence reduce the morbidity and mortality related to malaria 7. In 1992, the World Health Organization (WHO) during its global ministerial conference on malaria in Amsterdam approved a number of control measures, which include early diagnosis and prompt effective treatment, chemoprophylaxis in susceptible groups, reduction of man-vector contact, information, education and communication (IEC), surveillance and research 8.

In order to reduce the burden and mortality of malaria in the region, African leaders committed to implementing strategies of the Roll Back Malaria Initiative (RBM). The commitment was to be realized by 60% coverage of populations at risk with anti-malaria interventions 9. The 60% coverage was subsequently redefined to 80% coverage by 2010 and further raised higher with the introduction of the Global Malaria Action Plan for universal coverage 10. Mosquito nets, treated with insecticides were found as one of the major breakthroughs in the fight against malaria. They were found to give a much higher degree of protection against malaria 11. The use of mosquito nets was one of the primary interventions recommended by WHO Global Programme (WHO/GMP) for effective malaria control 12.

However, reports have shown that caregivers and mothers use other preventive measures in addition to LLIN in preventing malaria. A study conducted in Ekiti, Nigeria revealed that, 28% of the respondents used LLIN alone, others used other malaria preventive methods such as mosquito coil (21%), 21% used gauze wire in windows and 30% used other methods such as mosquito repellent, brooms and burning of cow dung 13.

In Ghana, according to the Ghana Demographic Health Survey (GDHS), overall LLIN ownership was 68.3% with 60.7% ownership in urban and 78.3% in rural settings. The overall usage of LLIN was 46.6% with 35.8% in urban and 56.1% in rural settings. In the Volta Region LLIN ownership was 76.3% and usage was 66.3% 14. No studies have been conducted to show the preferred malaria control measures in the Volta region. This report assessed preferred methods of controlling malaria among mothers with children under five years in the Hohoe Municipality of Ghana.

Table 1 shows that a total of 418 mothers (respondents) with their mean age and that of their children was 28.84±6.7 years and 13.8±10.0 months respectively were recruited for the study. Most of the respondents, 46.2% attained primary/Junior High School (JHS), and most, 35.1% were traders. The majority, 86.5% were married/co-habiting, and most, 97.4% were Christians. The main ethnic groups were the Ewes (82.6%), and more than half (51.4%) of the respondents were residing in urban areas. The majority, 71.5% delivered their babies at the hospital.

This study assessed methods used by mothers to prevent malaria infection among children under five years in the Hohoe Municipality of Ghana. The current study revealed that the use of LLINs only by mothers to prevent malaria was 28.5%. This is in agreement with what was reported from Ekiti, Nigeria which also found only 28% respondents using only LLINs to prevent malaria 13. It was also found that older mothers aged between 30-39 and 40-49 years were 3.87 and 5.55 times more likely to use LLINs only rather than OMs as compared to mothers aged less than 20 years (p=0.019) and (p=0.029) respectively. Mothers who resided in rural areas were 2 times more likely to use LLINs only rather than other methods as compared to mothers in urban areas (p=0.002). The possible reasons why older mothers used LLINs only could be that they might have obtained more information on the use of LLINs during their previous pregnancies and might have used LLINs with their children before and experienced the effectiveness of the nets.

This current study also found that 50.7% of mothers combined LLINs with other methods and older mothers aged between 30-39 and 40-49 years were 3.08 and 4.02 times more likely to combine LLIN with and other methods rather than OMs only as compared to mothers aged less than 20 years (p=0.023) and (p=0.050) respectively. Mothers in this study preferred using a combination of LLIN with other methods because they might have the perception that LLINs alone cannot give them maximum protection since they are not always sleeping except in the night. However, mosquitoes are seen around the homes in the evenings when they are not sleeping. This may compel them to use other methods to complement the LLIN. Another reason could be that mothers may not use LLINs all the time because sometimes the net may be washed and not be hanged or may not use it because of heat and may use OMs to complement LLIN.

The current study also found that mothers with a higher (SHS/tertiary) educational attainment were 2.08 times more likely to use a combination of LLIN while other mothers preferred using LLIN and other methods rather than OMs only as compared to those with no formal. It is possible that mothers with higher educational attainment could read and understand information and instructions on the use of LLIN and adverts on other methods and are therefore attracted to using other methods.

The current study found that mothers who resided in rural areas were 2 times more likely to use LLINs only as well as 2 times more likely to combine LLIN with other methods as compared to those in urban areas (AOR=2.00, p=0.002) and (AOR=2.00, p=0.013) respectively. The GDHS, (2014) also reported that 56.1% of children under five years residing in rural areas used LLINs as against 35.8% urban areas 14. The difference in usage could have been as a result of the nature of buildings found in rural and urban areas. Mothers in urban areas may living in houses with trap doors, wire gauze mess, fans and even air conditioners, which may make them feel protected against malaria, hence the disparity in usage. Another reason for the lower usage of LLINs in urban areas could be due to a lot of advertisement on the radio television, bill boards and posters on the effectiveness of other methods in preventing malaria. Other methods such as mosquito coil, repellents and paints are readily available in the shops and markets in urban areas and are not expensive. Therefore, mothers could be attracted to using them.

Even though LLINs are distributed free of charge to pregnant women and children under five years and the coverage in the Hohoe Municipality is above 95% reported by Kwekeu et al, (2017) (Unpublished), this current study found that 20.8% of mothers used OMs only to prevent malaria. This was found to be higher among younger mothers less than 20 years and mothers with no formal education and those residing in urban areas. The possible reason could be that younger mothers may not have experienced the effectiveness of LLINs before. Those with no formal education may be aware of the importance of LLINs. It is also possible that mothers in urban areas may have the LLINs but because they have other methods which they think are equally effective, the LLIN is not being used.

Limitations of this study included the fact that the study was done for only one month and the results may not reflect what happens throughout the year. Also, Information on the preferred method to prevent malaria may not be accurate because it was only collected from the respondents but not observed.

This study has revealed that the proportion of mothers who used LLINs alone for preventing malaria was low. One out of 3 mothers used LLINs only while more than half of mothers preferred using a combination of LLINs with other methods. Despite the free distribution of LLINs at the antenatal care and CWC with a coverage of over 95%, one out of 5 mothers use OMs only to prevent malaria. Older mothers, higher educational attainment and place of residence were significantly associated with methods used to prevent malaria. This could be a reflection of how LLINs are used in Ghana. Targeted educational interventions on LLINs in order to improve usage among younger mothers and mothers residing in urban areas would be required. Further studies are needed to find out reasons for using OMs only and also the reasons for the combination of LLIN with other methods. There is also the need to determine the added values of OMs to LLINs in preventing malaria.

LLIN: Long Lasting Insecticide Treated Net, LLIN+: Long Lasting Insecticide Treated Net plus other methods, OMs: Other methods, GDHS: Ghana Demographic Health Survey; GMP: Global Malaria Programme, RBM: Roll Back Malaria, GHS: Ghana Health Service, ERC: Ethical Review Committee, WHO: World Health Organization; CWCs: Child Welfare Clinics, GHS-ERC: Ghana Health Service-Ethics Review Committee, GHS: Ghana Health Service, LLINs: MoH: Ministry of Health, MCP: National Malaria Control Program, JHS: Junior High School, SHS: Senior High School. HMMD: Hohoe Municipal Meteorological Department, HMHD: Hohoe Municipal Health Directorate. SPH: School of Public Health, UHAS: University of Health and Allied Sciences, SES: Socio-Economic Status.

Available upon request

None

MK conceived the study. MK and WA, WT, RO, MA did the data analysis and wrote the methods section. MK, MA, WT, PP and ET were responsible for the initial draft of the manuscript. All authors reviewed and approved the final version of the manuscript.