Main findings
The findings of this study showed that there is need for improvement in using ITN regularly and taking antimalarial drugs during pregnancy. Striking variances were observed in the prevalence of ITN use among the eight countries. While Sierra Leone, Mali, Burkina Faso, attained coverage of over four-fifth among the adult women population, the situation seems to be far more challenging for other countries including Nigeria, Ghana, Kenya, and Malawi where about two-fifth to three-fifth of the women are not using ITNs. Similarly, some countries are clearly far behind than others in achieving optimum coverage for utilisation of antimalarial drug during pregnancy.
Except for women aged 15–19 years and antimalarial drug use, younger women were more likely to use both the services compared to those aged 40 years and above. The increase in antimalarial drug use during pregnancy could be as a result of the fertility level among the young women, which is generally known to outscore the older counterpart. Again, it is probable that the younger generations are enjoying a higher exposure to mass media and health related information, which could help them to become more aware of their health needs and environmental conditions. Women in the rural areas, those with low educational qualification and poor households were found to be less adherent to malaria prevention behaviour. Majority of the African population are living in rural areas where grid connectivity is still a serious problem, and more so the communities remain deprived of the benefits of health communication offered by fast expanding digital media technologies [22]. As the results further describe, television and radio were the most commonly reported sources of malaria information after direct communication with healthcare workers.
Percentages of women sleeping under ITN and taking antimalarial drugs in last pregnancy were higher among participants who reported receiving malaria information from TV, radio, poster/billboard, religious institutions, community events and healthcare workers. In the model that adjusted for potential confounders, receiving malaria information through radio, poster, community event and health worker turned out to be significant predictors of using ITN. However, not receiving malaria information through the mass media including radio amongst others, significantly resulted to reduction in the odds of ITN and antimalarial drug use during pregnancy.
Previous studies
Country representative studies on the use of ITN among women are still scarce, however there are evidences of appreciable success in increasing ITN coverage in the general population for several countries. In Burkina Faso, for instance, household ownership of ITN has increased dramatically from 5.6 to 89.9% between 2003 and 2014, a success that is largely attributable to the free mass distribution of ITNs in the years 2010 and 2013 [29]. At sub-national levels the prevalence of ITN use varies from 56.3% in Western Kenya [30], 90% in Malawi [31], and 27% in northern Nigeria [17]. These variations are hard to account for in light of the present analysis. Some possible explanations might include socioeconomic inequalities and the coverage and efficacy of the respective programs. For example, although Mali introduced its first IPTp and ITN policy (in 2003 and 2006 respectively) only a few years after Kenya (in 1999 and 2001 respectively) [32], a considerable disparity can be seen in the prevalence of ITN and IPTp use between these two countries.
In the current literature the evidence on the association between mass media exposure malaria prevention practices are scarce. However, studies in Cameroon [33], Gambia [34], Ghana, Malawi Nigeria [22], highlighted the importance of targeting the dissemination of health knowledge through traditional media. In Gambia, songs performed by community members were found to be effective in encouraging people to repair bed nets [34].
General discussion and policy implications
In the last 10–15 years tremendous efforts have been made to attain universal coverage of ITN and gestational use of antimalarial drugs, the two most cost-effective tools of prevention of malaria. Several countries in SSA have received free ITN campaign and distribution, thereby succeeded in increasing household ownership of ITNs. However, there are evidences on the gap between ownership and optimum use of the preventive services [35], addressing which could help the programs attain the full potential of the services being provided [36]. Achieving the universal coverage and utilisation goal of ITN and IPTp, can be greatly enhanced by improving people knowledge and awareness about malaria and encouraging adoption of preventive behaviour among the population. Social media strategies have proven to be useful in promoting health knowledge among adult populations in all settings, and can be leveraged by malaria elimination programs in Africa as well. Health policy making should focus on empowering women with health knowledge as it can help women develop their own perceptions and knowledge base of the particular disease and enable them to better communicate their health issues with physicians.
For long-terms success, the broader macroeconomic conditions e.g. research and funding, should also be given special attention. As more countries are progressing towards malaria elimination, the donor financing malaria programs has also been declining since 2010 [37, 38]. Many malaria-eliminating countries have projected national declines in funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), which has been the largest financial supporter of malaria since 2002 [39]. The changing priority of donor agencies can put the countries in SSA in a difficult situation with respect to their pursuit of malaria elimination. Since these are the least wealthy of all countries who are experiencing the highest incidence, it is very unlikely that national funding alone will be able to keep up with intervention and elimination efforts. National leaders in Africa need to gather efforts to reduce dependency on foreign donors and develop regional partnership for addressing local challenges.
Strengths and limitations of the study
Among the strengths of the present study is the large sample size, generalizability of the findings, women aged 15–49 years, and comparative presentation of the data that allows understanding of the situation in a particular country relative to others. However, there are several limiting points including the secondary nature of the data which means that authors had no control over the measurement and selection of the variables. Although the incidence of malaria is perennial in some regions, for certain there is a factor of seasonality. Therefore, not being able to account for high or low transmission period of the surveys might have affected the prevalence of ITN use. For instance in Kenya, the prevalence of ITN use was found to be significantly higher during the rainy season compared to that in dry season [30]. Apart from the seasonal variation in ITN use, another potential confounder for the prevalence might be the use of unobserved protective behaviour or mechanisms e.g. better housing environment, insecticide sprays, and traditional methods. Information on antimalarial drug use for the last pregnancy is subject to some degree of recall error. We were also unable to deduce the variation in the predictability of different types of mass media (digital, paper, health worker) on ITN use and uptake of antimalarial drug. There was no information on the exact contents of the messages women received through the above mentioned sources. Lastly, data were cross-sectional and therefore no causal relationship can be made from our analysis.