The Universal Access Paradox: A Cross-Sectional Evaluation of Long-Lasting Insecticidal Treated Net Ownership and Utilization Discrepancies among Pregnant Women in Nkoranza South District, Ghana

The Universal Access Paradox: A Cross-Sectional Evaluation of Long-Lasting Insecticidal Treated Net Ownership and Utilization Discrepancies among Pregnant Women in Nkoranza South District, Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Universal Access Paradox: A Cross-Sectional Evaluation of Long-Lasting Insecticidal Treated Net Ownership and Utilization Discrepancies among Pregnant Women in Nkoranza South District, Ghana Richmond Yaw Osei, Ishmael Awini Aburi, Abigail Boatemaa, Gabriel Osei Forkuo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9223820/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Malaria in pregnancy remains a leading cause of maternal and neonatal morbidity in sub-Saharan Africa. While long-lasting insecticidal treated nets are highly efficacious and cost-effective, consistent utilization often falls short of programmatic targets even when ownership is high. This study evaluated factors associated with the access to and utilization of these nets among pregnant women in Bonsu Sub-Municipality, Ghana. Methods A descriptive cross-sectional study was conducted among 60 purposively selected pregnant women. Structured questionnaires and direct observation of the sleeping environment were used to collect data on socio-demographic characteristics, knowledge levels, and usage practices. Results Access was near-universal, with 98.3% of respondents obtaining nets primarily through antenatal care clinics. However, a significant "Universal Access Paradox" was observed: while ownership was nearly 100%, only 43.3% of respondents had their nets correctly hung and in active use. Significant knowledge deficits were identified, with 45.8% of women incorrectly believing the insecticide was effective for only one year. Furthermore, 65.0% reported itchiness as a major adverse effect, contributing to a 35.0% non-utilization rate among owners. Conclusions The ownership-utilization gap is driven by a knowledge-efficacy deficit and physical discomforts rather than supply-side barriers. Consistent biological protection is hindered by "perceived obsolescence" of the nets and a lack of pre-emptive counseling regarding transient side effects. Limitations include the small purposive sample size and the cross-sectional design, which captures only a temporal snapshot of behavior and may be subject to social desirability bias in self-reported data. The outlook for future work necessitates a shift from passive distribution to a "Distribution Plus" model that prioritizes longitudinal behavioral tracking, male partner engagement, and the development of low-irritant insecticide coatings to ensure consistent person-nights of protected sleep. antenatal care bed net adherence knowledge-attitude-practice malaria prevention maternal health sub-Saharan Africa socio-behavioral determinants Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Introduction Malaria continues to represent one of the most consequential and persistent infectious disease burdens confronting global public health, with the heaviest toll borne disproportionately by sub-Saharan African countries. According to the World Health Organization (WHO, 2015), an estimated 214 million cases of malaria were recorded worldwide in 2015, resulting in approximately 438,000 deaths, of which over 90% occurred on the African continent. More recently, Kokuhennadige et al. ( 2026 ) have documented a troubling resurgence of malaria in pregnancy across Africa, underscoring the fragility of gains achieved through decades of control efforts and the urgency of renewed programmatic investment in evidence-based preventive interventions. In Ghana, malaria is hyperendemic and perennial across all ecological zones, with seasonal variation that is particularly pronounced in the northern and transitional savannah regions. The entire Ghanaian population of approximately 24.2 million is at risk, yet pregnant women and children under five years of age carry a disproportionate burden owing to compromised immunity and heightened physiological susceptibility (WHO/Ghana Health Service [GHS], 2003). The pathophysiology underlying the vulnerability of pregnant women to malaria is well characterized in the literature. Pregnancy substantially impairs a woman’s immune response to Plasmodium falciparum , the dominant malaria parasite species in West Africa, rendering her significantly more susceptible to infection, severe anaemia, and febrile illness (Brabin et al., 2001 ; Desai et al., 2007 ; Minwuyelet et al., 2025 ). The consequences extend beyond maternal health: maternal malaria infection is independently associated with intrauterine growth restriction, low birth weight (LBW), premature delivery, spontaneous abortion, and neonatal mortality (Guyatt & Snow, 2004 ; Kabalu Tshiongo et al., 2024 ; McCormick, 1985 ; Steketee, Nahlen, Parise, & Menendez, 2001 ). Globally, malaria in pregnancy is estimated to account for over 10,000 maternal deaths and 200,000 neonatal deaths per year (Schantz-Dunn & Nour, 2009 ), while in Africa alone, approximately 30 million pregnancies annually are exposed to malaria risk (Sachs & Malaney, 2002 ). Primigravid women bear the greatest immunological burden owing to the absence of acquired immunity to placental malaria mediated through VAR2CSA-binding antibodies, which are developed only following repeated gestational exposures (Desai et al., 2007 ; Kokuhennadige et al., 2026 ). Among the arsenal of malaria prevention and control tools, long-lasting insecticidal treated nets (LLITNs) have emerged as a cornerstone intervention of proven efficacy. An LLITN is a factory-treated bed net incorporating a synthetic pyrethroid insecticide that retains its biological efficacy for a minimum of three years under normal field conditions of use, without the need for re-treatment (WHO, 2007). Unlike conventional insecticide-treated nets (ITNs) that required periodic chemical re-impregnation, LLITNs offer a logistically simpler and more durable protective barrier against vector mosquitoes, particularly Anopheles gambiae and related species responsible for malaria transmission in sub-Saharan Africa. The physical barrier function of the net reduces human–vector contact, while the residual insecticide kills or repels mosquitoes that make contact with the net surface, thereby providing both personal and community-level protection (Lengeler, 2004 ; Pluess et al., 2010 ). The global scale-up of LLITN distribution has been underpinned by compelling evidence from randomized controlled trials and systematic reviews demonstrating reductions in all-cause child mortality of 17–38% and reductions in malaria-attributable morbidity of up to 50% in high-transmission settings (Lengeler, 2004 ). Emerging evidence from quasi-experimental and prospective study designs further confirms that ITN effectiveness under routine programmatic conditions remains substantial, with Osei et al. ( 2026 ) demonstrating significant reductions in malaria among children under five in Ghana even under conditions of imperfect adherence. The WHO has accordingly recommended universal LLITN coverage — defined as access to and use of LLITNs by all persons at risk — as a central pillar of the Global Technical Strategy for Malaria 2016–2030 (WHO, 2015), encompassing free mass distribution campaigns and continuous distribution through multiple channels, including ANC clinics, child welfare clinics (CWCs), and community-based platforms (Zhou et al., 2014 ). In Ghana, the National Malaria Control Programme (NMCP) has implemented a multi-channel LLITN distribution strategy aligned with these global recommendations. Between 2010 and 2015, the programme achieved an 80% increase in LLITN coverage among populations at risk (WHO, 2015). Coverage of LLITNs among pregnant women attending ANC services rose from 22.9% in the first quarter of 2016 to 74.3% by 2017 (NMCP, 2017). Under the ANC protocol, all registered pregnant women are entitled to receive one LLITN free of charge at their first antenatal visit. However, national population-based survey evidence compiled by Awunyo et al. ( 2025 ) confirms a persistent and statistically significant discrepancy between LLITN ownership and effective utilization among pregnant women across Ghana, a pattern that mirrors findings from a longitudinal analysis by Okova et al. ( 2025 ), who documented widening within- and between-group socioeconomic inequalities in malaria prevention uptake over the period 2003–2022. Notwithstanding these programmatic advances, a persistent disconnect between LLITN ownership and consistent utilization has been documented extensively in the literature. High coverage rates do not automatically translate into high usage rates, as actual protective benefit is contingent upon correct and consistent use — specifically, sleeping under a properly hung net every night during peak vector-biting hours (Atkinson et al., 2012 ; Cottrell et al., 2025 ; Mwebesa et al., 2025 ). Barriers to utilization are multifactorial and operate at individual, household, and community levels. These include poor knowledge of malaria transmission and LLITN efficacy duration, perceived or experienced side effects — including cutaneous irritation, respiratory discomfort, and headache associated with the pyrethroid insecticide — socioeconomic constraints, cultural beliefs, inadequate sleeping space, and the influence of spousal and community norms on health behaviours (Bardoe et al., 2025 ; Binka & Adongo, 1997 ; Donacho et al., 2025 ; Eisele et al., 2009 ; Grabowsky et al., 2005 ; Ibeagha et al., 2025 ; Macintyre et al., 2012 ; Nuwaha, 2001 ). Recent systematic review evidence by Carshon-Marsh and Di Ruggiero ( 2025 ) has further highlighted that inadequate behaviour change communication and absent post-distribution follow-up are modifiable system-level barriers that directly predict low utilization in contexts where ownership is already high. In the Nkoranza South Municipality of the Brong Ahafo Region, malaria constitutes the foremost cause of outpatient department (OPD) attendance, accounting for 47% of OPD visits, 16.2% of hospital admissions, and 17.4% of hospital deaths (GHS, 2009). Annual district health reviews have consistently identified malaria among pregnant women as a leading cause of maternal morbidity, despite the systematic distribution of LLITNs through ANC services. In 2015, the municipality distributed 100 LLITNs to pregnant women, achieving a coverage of 41.2%; by 2016, 162 nets were distributed, raising coverage to 67.8%, yet malaria in pregnancy remained at 60% (Nkoranza South District Health Management Team [DHMT], 2016). This paradox — of rising LLITN coverage coexisting with persistently high malaria prevalence — underscores the inadequacy of measuring programme success solely by distribution metrics and points to critical deficiencies in utilization and adherence, consistent with national data reported by Abesig et al. ( 2025 ) documenting sustained malaria test positivity among pregnant women in northern Ghana despite programmatic scale-up. No systematic research had previously been conducted within Nkoranza South District to rigorously evaluate the factors associated with LLITN access and utilization among this vulnerable group. This evidence gap limits the capacity of the District Health Management Team (DHMT) and other stakeholders to design and implement evidence-based, targeted interventions. In the global context, malaria imposes an estimated annual economic burden exceeding USD 12 billion on sub-Saharan African economies and is estimated to reduce economic growth by up to 1.3% per year (Gallup & Sachs, 2000 ; WHO, 2005). The indirect costs — reduced labour productivity, impaired child cognitive development, increased school absenteeism, and diminished household welfare — further compound its developmental consequences (Chima, Goodman, & Mills, 2003 ). The present study was therefore conducted to generate district-specific, actionable evidence to guide targeted malaria prevention programming in this high-burden setting. 1.1 Aim of the study The aim of this study was to evaluate the factors associated with the access to and utilization of long-lasting insecticidal treated nets (LLITNs) in the prevention of malaria among pregnant women in Bonsu Sub-Municipality, Nkoranza South District, Brong Ahafo Region, Ghana. 1.2 Specific objectives The study was guided by the following specific objectives: 1. To assess the level of knowledge of pregnant women regarding LLITNs and their role in malaria prevention. 2. To evaluate the common practices associated with the use of LLITNs among pregnant women in the study area. 3. To identify factors associated with access to LLITNs among pregnant women attending antenatal care services. 1.3 Research questions The following research questions guided the study: 1. What is the level of knowledge of pregnant women in Bonsu Sub-Municipality regarding the use and benefits of LLITNs? 2. What are the common practices associated with LLITN use among pregnant women in the study area? 3. What factors are associated with access to LLITNs among pregnant women attending antenatal care services in the study area? 2. Literature Review 2.1 Global and regional burden of malaria in pregnancy Malaria in pregnancy constitutes a global public health emergency with disproportionately severe consequences in sub-Saharan Africa. Sachs and Malaney ( 2002 ) demonstrated that approximately 30 million pregnancies in malaria-endemic Africa are exposed to the risk of infection annually, with maternal and foetal consequences including severe anaemia, low birth weight, premature delivery, and neonatal death. These findings were corroborated and extended by Schantz-Dunn and Nour ( 2009 ), who estimated that malaria is responsible for over 10,000 maternal deaths and 200,000 neonatal deaths each year globally, with the African continent bearing the overwhelming majority of this mortality burden. More recently, Minwuyelet et al. ( 2025 ), in a comprehensive systematic review of malaria in pregnancy, confirmed that the disease remains a critical public health threat across sub-Saharan Africa, with profound and often underappreciated effects on placental function, foetal growth, and neonatal survival. Kokuhennadige et al. ( 2026 ) have further documented a resurgence of malaria in pregnancy in parts of Africa, attributing this reversal to insecticide resistance, COVID-19-related disruptions to malaria services, and stagnating utilization of preventive interventions including LLITNs. The immunological basis of pregnant women’s vulnerability to malaria has been extensively characterized. Desai et al. ( 2007 ) conducted a comprehensive systematic review of the global epidemiology of malaria in pregnancy and documented that primigravid women — those experiencing their first pregnancy — are most susceptible to placental malaria, attributed to the unique immunological tolerance mechanisms of early pregnancy and the absence of VAR2CSA antibody-mediated immunity. Brabin et al. ( 2001 ) further demonstrated that severe anaemia resulting from malaria infection in pregnancy significantly elevates maternal mortality risk, particularly in settings with limited access to emergency obstetric care. Steketee et al. ( 2001 ) provided compelling evidence linking maternal malaria infection to low birth weight — itself the single greatest risk factor for neonatal death, as originally identified by McCormick ( 1985 ) — establishing a clear causal pathway from inadequate malaria prevention to adverse perinatal outcomes. Kabalu Tshiongo et al. ( 2024 ) have provided recent corroboration of these mechanisms, demonstrating in a facility-based study in the Democratic Republic of Congo that combined use of ITNs and IPTp is associated with significantly improved birth weight and maternal haemoglobin outcomes compared to either intervention alone. In the specific context of Ghana, malaria in pregnancy remains hyperendemic and perennial across all regions. The Ghana Demographic and Health Survey (GDHS, 2008) documented that nationally, only 19.9% of pregnant women slept under a treated net the night preceding the survey, highlighting the persistent and substantial gap between net availability and consistent protective use. More recent data from Awunyo et al. ( 2025 ), based on a national population-based survey of Ghanaian pregnant women, confirm that while LLITN ownership has improved substantially over successive programme cycles, effective utilization remains low and is differentially distributed across socioeconomic strata. Abesig et al. ( 2025 ), in a trend analysis of malaria test positivity rates among pregnant women in the Savannah Region of Ghana over 2018–2022, documented that malaria positivity among ANC attendees remained high despite programmatic efforts, underscoring the need for targeted utilization-promoting interventions. Similarly, Bonsra et al. ( 2025b ) identified age, educational attainment, income, and ITN use as significant predictors of malaria prevalence in pregnancy across selected districts of the Ashanti Region, while Bonsra et al. ( 2025a ) further confirmed these patterns in a health facility-based study in Kwadaso Municipality, Ghana. 2.2 Efficacy and effectiveness of long-lasting insecticidal treated nets The evidence base for the efficacy of LLITNs and their precursor ITNs in reducing malaria transmission, morbidity, and mortality is among the most robust in the field of global health. Lengeler ( 2004 ) conducted the landmark Cochrane systematic review and meta-analysis of randomized controlled trials of insecticide-treated nets, documenting reductions in all-cause child mortality of 17–38% and reductions in uncomplicated clinical malaria episodes of approximately 50% in areas of stable transmission. Pluess et al. ( 2010 ) subsequently reviewed the community-level protective effect of ITNs, demonstrating that high population-level coverage confers a mass effect that reduces vectorial capacity and transmission intensity beyond the direct protection afforded to individual net users. Osei et al. ( 2026 ) provided recent quasi-experimental confirmation that ITN use under routine programmatic conditions in Ghana remains associated with significant reductions in malaria among children under five, affirming the programmatic relevance of effectiveness data to the Ghanaian context. Madukwe et al. ( 2025 ) demonstrated in a Nigerian ANC-based study that women who used both IPTp and slept under an ITN had significantly lower Plasmodium falciparum prevalence than those who used IPTp alone, providing direct evidence for the additive protective effect of LLITN use alongside pharmacological prevention. Okoro et al. ( 2025 ) further confirmed in a cost-effectiveness analysis in Jos North, Nigeria, that combined ITN and IPTp prevention is the most cost-effective strategy for malaria prevention in pregnancy, with ITNs providing the greatest marginal benefit at lowest additional cost. Cottrell et al. ( 2025 ) documented that suboptimal distribution and underutilization of ANC-given bed nets in Benin compromised pregnant women’s protection substantially, with a prospective field study demonstrating that actual net utilization rates fell to less than 50% within weeks of distribution despite near-universal ownership, a pattern directly mirroring the present study’s context. Zhou et al. ( 2014 ) examined the role of universal LLITN coverage as a programmatic strategy, affirming the WHO recommendation that universal access — defined as at least one LLITN per two persons at risk within each household — should be pursued through a combination of mass free distribution campaigns and continuous distribution channels, including ANC clinics and community-based platforms. These authors emphasized that the effectiveness of distribution channels is contingent upon the quality of accompanying health education and the degree to which community members internalize the importance of consistent net use, rather than merely possessing a net — a conclusion of direct relevance to the present study’s findings. 2.3 Knowledge, attitudes, and practices regarding LLITNs A substantial and growing body of literature has examined the relationship between knowledge, attitudes, and practices (KAP) pertaining to LLITNs and actual utilization behaviours. Atkinson et al. ( 2012 ) conducted a systematic review of barriers to LLITN use in sub-Saharan Africa and identified knowledge deficits — including misconceptions about the mechanism of net action, the duration of insecticide efficacy, and the consequences of improper net maintenance — as significant determinants of low utilization. Ibeagha et al. ( 2025 ), in a recent review of factors contributing to inconsistent ITN use in tropical Africa, confirmed that inadequate knowledge depth, perceived adverse effects, socioeconomic constraints, and absent BCC remain the predominant modifiable drivers of underutilization across the region, and specifically identified knowledge of chemical efficacy duration as a critical and underaddressed knowledge gap in existing health education programmes. Zuuri et al. ( 2025 ) conducted a cross-sectional KAP study among pregnant women in Sekyere South District, Ghana — a setting comparable to the present study area — and documented that gaps in malaria prevention stemmed primarily from misconceptions and incomplete adherence rather than supply shortages, concluding that strengthened ANC counselling, myth correction, and expanded outreach with ITN replacement are priority interventions. Salifu et al. ( 2026 ) assessed malaria knowledge and preventive practices among pregnant women in the Savannah Region of Northern Ghana and identified inadequate knowledge of ITN efficacy duration, inconsistent use practices, and limited ANC attendance as key barriers to effective malaria prevention among marginalized pastoral communities. Bardoe et al. ( 2025 ), in a qualitative exploration of psychological barriers to preventive interventions in Ghana, identified motivational inertia, fatalistic health beliefs, and the perceived burden of consistent preventive behaviour as underappreciated psychological determinants of LLITN non-use that are not adequately captured by quantitative KAP instruments. Binka and Adongo ( 1997 ) investigated factors influencing ITN use in northern Ghana and identified household-level decision-making dynamics, including the role of male household heads in determining whether family members sleep under nets, as a significant structural barrier to utilization among women and children. Eisele et al. ( 2009 ) provided a multi-country analysis of the determinants of ITN use in sub-Saharan Africa, documenting that education level, household wealth, and exposure to malaria-prevention messaging were the strongest predictors of consistent net use. Grabowsky et al. ( 2005 ) demonstrated that free distribution of ITNs substantially increased ownership rates but did not automatically translate into increased use, emphasizing the indispensable role of behaviour change communication (BCC) in achieving utilization gains. Mwebesa et al. ( 2025 ), in a multilevel pooled analysis of ITN use among pregnant women across high-burden sub-Saharan African countries, identified ANC attendance frequency, household wealth, women’s education level, and partner support as the strongest multilevel predictors of consistent ITN use in pregnancy, after controlling for access. 2.4 Access to LLITNs through antenatal care services The integration of LLITN distribution into ANC services is widely recognized as a highly cost-effective strategy for reaching pregnant women with preventive interventions. Nkuo-Akenji et al. ( 2009 ) evaluated LLITN coverage and utilization among pregnant women in Cameroon and documented that ANC attendance was the strongest predictor of LLITN ownership. Ajonina et al. ( 2024 ), in a recent cross-sectional study in the Littoral Region of Cameroon, confirmed that LLIN use among pregnant women attending ANC remained below national targets and was independently associated with age, religion, and gestational period, highlighting the importance of tailoring ANC-based interventions to the specific determinants operative within each setting. Cottrell et al. ( 2025 ) highlighted in Benin that even where ANC-based distribution achieves near-universal net provision, actual utilization rates within weeks of distribution can fall to critically low levels without concurrent post-distribution follow-up and counselling. Ye et al. ( 2012 ) found in Burkina Faso that ANC-based distribution substantially increased LLITN ownership among pregnant women, but that free distribution alone was insufficient to drive utilization without concurrent community sensitization and follow-up counselling. Sumaila et al. ( 2025 ), in a study of ITN use determinants among pregnant women in Kintampo North Municipality — a district in the Bono East Region of Ghana directly adjacent to Nkoranza South — identified ANC attendance frequency, knowledge of ITN efficacy, and spousal encouragement as the strongest predictors of consistent ITN use, providing directly comparable contextual evidence for the present study. In Ghana, the NMCP’s continuous distribution strategy through ANC and CWC channels has produced significant increases in LLITN coverage. However, as Okova et al. ( 2025 ) demonstrated, persistent socioeconomic inequalities in both ownership and utilization undermine the equitable protective benefit of this strategy across the population. Opara, Ismail, and Mohd Nazan ( 2024 ), in a systematic review of health education intervention programmes targeting ITN use in pregnancy, demonstrated that structured, interactive, and pictorial health education delivered at ANC visits significantly improved both knowledge depth and utilization rates compared to routine passive counselling, with gains sustained at three- and six-month follow-up. These findings provide a strong evidence base for the recommendation, emerging from the present study, to strengthen ANC-based LLITN counselling through standardized, evidence-informed protocols. 2.5 Factors influencing LLITN utilization among pregnant women in Ghana Context-specific evidence from Ghana underscores the multidimensional nature of LLITN utilization barriers. Anto et al. ( 2009 ) evaluated malaria prevention practices in the Kassena-Nankana district of northern Ghana and documented that household ownership of LLITNs was substantially higher than actual use, attributing this discrepancy to knowledge deficits, competing household priorities for net use, and structural factors including roof height and sleeping arrangement configurations that compromised proper net hanging. Akuffo et al. ( 2021 ) confirmed in a nationally representative Ghanaian dataset that ITN non-use was strongly associated with inadequate knowledge of net maintenance, perceived side effects, and absence of partner encouragement, while Alhassan ( 2021 ) documented similar patterns in a facility-based study at Tamale Teaching Hospital, noting that single women and women with lower educational attainment were disproportionately represented among non-users. Ansah et al. ( 2024 ), in a study of treated bed net use and anaemia among pregnant women in Ghana, demonstrated a statistically significant association between LLITN non-use and elevated anaemia risk, providing direct haematological evidence for the clinical consequences of utilization gaps in the Ghanaian context. The NMCP’s 2017 annual review documented that despite significant increases in LLITN distribution, malaria in pregnancy remained a leading cause of ANC attendance and maternal hospital admission across all regions (NMCP, 2017). In Nkoranza South Municipality specifically, the 2009 district health report (GHS, 2009) documented that malaria accounted for 47% of OPD visits, 16.2% of hospital admissions, and 17.4% of hospital deaths — figures that collectively situate the present study within a context of well-documented programmatic need. 3. Methodology 3.1 Study design A descriptive cross-sectional study design was employed. This design is widely used in public health research for estimating the prevalence of health behaviours and associated factors at a specific point in time within a defined population (Bowling, 2002 ; Creswell, 2009 ; Kelsey et al. 1996 ). The cross-sectional design was considered appropriate for this study because it enabled the simultaneous assessment of multiple variables — including knowledge, access, and practice — within the study population without requiring prospective follow-up, thereby providing a cost- and time-efficient approach to generating baseline evidence for programme planning purposes. 3.2 Study area The study was conducted in Bonsu Sub-Municipality, which is located within the Nkoranza South Municipality of the Brong Ahafo Region of Ghana. Nkoranza South Municipality was carved out of the former Nkoranza District in February 2008 under Legislative Instrument (LI) 1899, and was formally accorded municipality status in May 2012 under LI 2089. Bonsu Sub-Municipality lies within longitudes 1°10″W and 1°55″W and latitudes 7°20″N and 7°55″N, covering a total land area of 923 square kilometres. The municipality shares boundaries with the Nkoranza North District to the north, Techiman Municipality to the west, and the Ejura-Sekyedumase and Offinso North Districts to the south-east and south. The predominant economic activity is subsistence and small-scale commercial agriculture. Malaria is hyperendemic throughout the municipality and represents the leading cause of OPD attendance, hospital admission, and hospital mortality (GHS, 2009). 3.3 Study population The target population comprised all pregnant women registered for ANC services at health facilities within Bonsu Sub-Municipality during the study period. Inclusion criteria required participants to be currently pregnant, aged 16 years or older, residing within the sub-municipality, and willing to provide informed consent. Women who were unable to communicate in either English or the local Twi/Brong dialect, even with the assistance of a trained interpreter, were excluded from the study. 3.4 Sample size and sampling procedure A total of 60 pregnant women were selected using purposive sampling. Purposive or judgement sampling involves the deliberate selection of participants who are considered most representative of or informative about the phenomenon under study and is a widely accepted approach in descriptive health studies where the research objective is to characterize a specific and relatively homogeneous population (Patton, 2002 ; Polit & Beck, 2010 ). All ANC registrants present at participating facilities during the designated data collection periods who met the inclusion criteria were invited to participate, and the sample was augmented by visiting outlying communities within the sub-municipality to ensure adequate geographic representation. 3.5 Data collection instrument and procedure Data were collected using a structured questionnaire developed by the principal investigator on the basis of a comprehensive review of the existing literature on LLITN knowledge, access, and utilization (Atkinson et al., 2012 ; Eisele et al., 2009 ; Macintyre et al., 2012 ; Mwebesa et al., 2025 ; Nkuo-Akenji et al., 2009 ; Opara et al., 2024 ). The questionnaire comprised four sections: (1) socio-demographic characteristics, including age , level of education , occupation , and marital status ; (2) knowledge items assessing awareness of LLITN benefits, chemical efficacy duration, processing procedures, and perceived side effects; (3) items assessing LLITN access, including source of net and ease of access ; and (4) items assessing common practices, including frequency of use , method of net hanging , and confirmation of actual use . The questionnaire was pre-tested with a small group of non-participant pregnant women to assess clarity and face validity, and revisions were made accordingly before formal data collection commenced. Questionnaires were administered through face-to-face interviews conducted by the principal investigator and a trained female research assistant fluent in both English and the local dialect. For physical confirmation of net use status, the research assistant conducted direct observations of the sleeping environment. All interviews were conducted in a private setting to ensure confidentiality and minimize social desirability bias. 3.6 Data analysis Data were entered, cleaned, and analysed using Python 3.12 with appropriate statistical and data‑processing libraries such as pandas, NumPy, and SciPy. Descriptive statistics such as frequencies and percentages were calculated for all categorical variables and are presented in tabular and graphical form. Findings were organized thematically in alignment with the three study objectives: (1) knowledge, (2) access, and (3) common practices. All percentages are rounded to one decimal place. For items permitting multiple responses, percentages were reported as proportions of the total sample ( N = 60) and may therefore sum to values exceeding 100%. 3.7 Ethical considerations Prior to data collection, ethical approval was obtained from the appropriate institutional review board, and administrative permission was sought from the Nkoranza South District Health Directorate. All participants provided verbal informed consent prior to their inclusion in the study. Participants were informed of the voluntary nature of their participation, their right to withdraw at any time without consequence, and the confidentiality of their responses. No personally identifying information was recorded in the data collection instruments. The principles of beneficence, non-maleficence, autonomy, and justice as outlined in the Declaration of Helsinki (World Medical Association, 2013 ) were adhered to throughout the study. 4. Results 4.1 Socio-demographic characteristics of respondents A total of 60 pregnant women participated in the study. As shown in Table 1 and Fig. 1 , the majority of respondents (38.3%) fell within the 26–30 year age group, followed by the 21–25 year category (23.3%), with only 3.3% of respondents aged 41 years or above. This age distribution is consistent with the typical reproductive age pattern in rural Ghanaian communities and reflects the broader demographic profile of ANC attendees in the district (GHS, 2009). The predominance of women in the mid-reproductive age range is epidemiologically significant, as multigravid women in this age bracket may possess some degree of acquired immunity to placental malaria, yet remain at risk of anaemia and other pregnancy complications associated with malaria infection (Desai et al., 2007 ; Kokuhennadige et al., 2026 ). Table 1 Socio-demographic characteristics of respondents ( N = 60) Parameter Category n % Age of Respondents (years) 16–20 11 18.3 21–25 14 23.3 26–30 23 38.3 31–35 6 10.0 36–40 4 6.7 ≥ 41 2 3.3 Total 60 100.0 Level of Education No formal education 16 26.7 Primary 10 16.7 Middle/JSS/JHS 29 48.3 Secondary/SHS 1 1.7 Tertiary 4 6.7 Total 60 100.0 Occupation Farmer 27 45.0 Trader 13 21.7 Others 9 15.0 Housewife 5 8.3 Civil servant 4 6.7 Unemployed 2 3.3 Total 60 100.0 Marital Status Married 37 61.7 Co-habiting 17 28.3 Single 6 10.0 Total 60 100.0 Note. JSS = Junior Secondary School; JHS = Junior High School; SHS = Senior High School. Regarding educational attainment , the largest proportion of respondents (48.3%) had completed Middle/Junior High School (JHS) or its equivalent, while 26.7% had received no formal education. Only 1.7% had attained secondary school (Senior High School [SHS]) education, and a further 6.7% had received tertiary-level education. The high proportion of respondents with no formal or basic education has important implications for health literacy and the capacity to comprehend and act upon LLITN health education messages, and is consistent with findings from Bonsra et al. ( 2025b ) and Eisele et al. ( 2009 ) regarding the inverse relationship between educational attainment and malaria prevention knowledge deficits in Ghana and the broader sub-Saharan African region. Occupational distribution revealed that farming was the primary livelihood activity, with 45.0% of respondents identifying as farmers, followed by trading (21.7%), other unspecified occupations (15.0%), housewifery (8.3%), civil service (6.7%), and unemployment (3.3%). The predominance of agricultural livelihoods is characteristic of rural Brong Ahafo communities and is relevant from a malaria epidemiological standpoint, as agricultural workers engaged in outdoor fieldwork during the evening and early morning peak biting hours of vector mosquitoes face substantially elevated exposure risk. Marital status data revealed that the majority of respondents (61.7%) were married, while 28.3% reported co-habiting with a partner, and 10.0% were single. The predominance of married respondents has potential implications for LLITN utilization, as household-level decision-making regarding net use may be influenced by the attitudes and behaviours of male partners (Binka & Adongo, 1997 ; Grabowsky et al., 2005 ; Mwebesa et al., 2025 ). 4.2 Knowledge of respondents regarding LLITNs The findings pertaining to respondent knowledge of LLITNs are presented in Table 2 . All 60 respondents (100%) correctly identified that LLITNs prevent malaria in pregnancy, reflecting a high level of awareness of the primary protective benefit of the intervention. This finding is consistent with evidence from comparable settings documenting near-universal awareness of the malaria-prevention function of bed nets following sustained mass distribution campaigns (Eisele et al., 2009 ; Nkuo-Akenji et al., 2009 ; Zuuri et al., 2025 ). However, knowledge was considerably less robust regarding more nuanced aspects of LLITN function and maintenance. Specifically, only 27.1% of respondents correctly identified the three-year effective lifespan of the chemical insecticide as the correct expiry period for the net, while the largest single group (45.8%) incorrectly believed the chemicals expired after only one year, and a further 8.5% reported having no knowledge of the expiry period. This widespread misconception about chemical efficacy duration has significant practical implications: respondents who believe the insecticide expires after one year may prematurely discontinue LLITN use, a finding consistent with knowledge gaps documented by Ibeagha et al. ( 2025 ) across tropical Africa and by Salifu et al. ( 2026 ) among Ghanaian pregnant women. The findings pertaining to respondent knowledge of LLITNs are presented in Table 2 and Fig. 2 . Regarding perceived benefits of LLITNs to the foetus, 70.0% of respondents indicated awareness that net use prevents foetal death, 53.3% identified the prevention of low birth weight (LBW), 43.3% mentioned the prevention of anaemia, and 16.7% cited the prevention of stillbirth. ANC clinics were identified as the primary source of LLITN knowledge by 91.7% of respondents, with radio identified as a secondary source by 46.7% and market sources by 13.3%. These patterns reinforce the critical gatekeeping role of ANC services as the dominant knowledge dissemination channel (Nkuo-Akenji et al., 2009 ; Ye et al., 2012 ). Table 2 Knowledge of respondents regarding LLITNs ( N = 60) Parameter Category n % Perceived chemical expiry period 1 year (incorrect) 27 45.8 2 years (incorrect) 10 16.9 3 years (correct) 16 27.1 4 years (incorrect) 1 1.7 Do not know 5 8.5 Total 59 100.0 Benefit of LLITN to pregnant woman Prevents malaria 60 100.0 Perceived benefits to foetus (multiple responses) Prevents death 42 70.0 Prevents low birth weight 32 53.3 Prevents anaemia 26 43.3 Prevents stillbirth 10 16.7 Source of knowledge (multiple responses) ANC 55 91.7 Radio 28 46.7 Market 8 13.3 Overall knowledge level Moderate knowledge 51 85.0 Poor knowledge 5 8.0 Good knowledge 4 7.0 Total 60 100.0 Note. ANC = Antenatal Care. Percentages for multiple-response items may sum to values exceeding 100%. The overall knowledge level of respondents was classified as moderate in 85% of cases, with 8% demonstrating poor knowledge and only 7% demonstrating good knowledge. This pattern is consistent with findings from analogous KAP studies conducted in Ghana and other sub-Saharan African settings (Anto et al., 2009 ; Atkinson et al., 2012 ; Binka & Adongo, 1997 ; Zuuri et al., 2025 ), and supports the conclusion that while awareness of the primary malaria-prevention function of LLITNs is nearly universal, deeper understanding of net maintenance, correct processing procedures, and the duration of insecticide efficacy remains inadequate among a substantial proportion of the study population. Figure 3 presents knowledge pertaining to the processing and maintenance of LLITN effectiveness. Regarding the appropriate first-time processing procedure, 71.2% of respondents correctly reported that the net should be dried in the shade, while 15.3% reported merely drying it in direct sunlight — an incorrect practice that may accelerate photodegradation of the pyrethroid insecticide coating. A further 8.5% reported washing and drying the net in sunlight, and 5.1% reported washing and drying in the shade. The predominance of correct processing behaviour (shade drying) suggests that ANC health education messages on this aspect of net care have been relatively effectively communicated and retained. With respect to maintenance of insecticide effectiveness, 83.1% of respondents correctly identified that retreatment is not necessary for LLITNs — an important distinction from conventional ITNs and a finding that indicates satisfactory awareness of this critical differentiating feature of the LLITN technology. Only 5.1% each reported that retreatment could be performed at home or at a health facility, and 3.4% mentioned community-based retreatment, with a further 3.4% indicating no knowledge of the maintenance requirements. 4.3 Access to LLITNs Findings on the access of respondents to LLITNs are presented in Table 3 and illustrated in Fig. 4 Access to LLITNs was overwhelmingly through the public health system. Of the 59 respondents who owned a treated net (constituting 100% of net owners), 98.3% had obtained their primary LLITN from an ANC clinic. A noteworthy proportion (21.7%) also reported receiving LLITNs as donations from friends or family members. Purchase from market vendors was reported by 6.7% of respondents. Table 3 Access to LLITNs among respondents ( N = 60) Parameter Category n % Type of net possessed Treated (LLITN) 59 100.0 Source of LLITN (multiple responses) Antenatal care (ANC) clinic 59 98.3 Donation from a friend 13 21.7 Market 4 6.7 Ease of access to LLITN Free and easily available at ANC 54 90.0 Free but with difficulties 3 5.0 Cheap (purchased) 2 3.3 Expensive (purchased) 1 1.7 Total 60 100.0 Note. ANC = Antenatal Care; LLITN = Long-Lasting Insecticidal Treated Net. Percentages for multiple-response items may sum to values exceeding 100%. The overwhelming majority of respondents (90.0%) reported that their LLITN was freely and easily available through the ANC service, with only 5.0% reporting free availability but with associated difficulties. The near-universal experience of free and convenient ANC-based net access reflects the effectiveness of the NMCP’s continuous distribution strategy (Grabowsky et al., 2005 ; Zhou et al., 2014 ) and confirms that financial or logistical barriers to LLITN acquisition are not the primary impediment to effective malaria prevention in this population. As Carshon-Marsh and Di Ruggiero ( 2025 ) and Cottrell et al. ( 2025 ) have argued, high ownership rates in such settings must not be conflated with adequate protection: the principal challenge lies in translating net ownership into consistent and correct use through robust post-distribution behavioural support. 4.4 Common practices of LLITN use Data on common practices relating to LLITN use are presented in Table 4 and Fig. 5 . The data reveal a notable discrepancy between net ownership and consistent protective use. While 60.0% of respondents reported always using their LLITN — but exclusively at night — a significant proportion (18.3%) reported not using the net at all, and a further 11.7% reported using it only occasionally. The 10.0% who reported using the net both during the day and at night demonstrate an exemplary level of consistent protection. Table 4 Common practices of LLITN use among respondents ( N = 60) Parameter Category n % Frequency of LLITN use Always – night only 36 60.0 Not at all 11 18.3 Occasionally 7 11.7 Always – day and night 6 10.0 Total 60 100.0 Method of net use Hangs net above the bed 58 100.0 Side effects experienced (multiple responses) Itchiness 39 65.0 Other effects 8 13.3 Difficulty in breathing 5 8.3 Vomiting 4 6.7 Confirmation of LLITN use status Net hanged appropriately and in use 26 43.3 Has net but not currently in use 21 35.0 Has net but not hanged appropriately 13 21.7 Total 60 100.0 The combined observation that 35.0% of respondents possessed a net but were not currently using it, and a further 21.7% possessed a net that was not correctly hung, yields a striking composite finding: 56.7% of LLITN owners were either not using their net at all or were using it suboptimally. This high rate of ownership–utilization discordance echoes findings from Cottrell et al. ( 2025 ), Gikandi et al. ( 2008 ), Grabowsky et al. ( 2005 ), Iwueze et al. ( 2014 ), and Mwebesa et al. ( 2025 ), who collectively documented similar patterns across East and West Africa. Only 43.3% of respondents had their net appropriately hung and actively in use, representing the proportion of the study population deriving full preventive benefit from their LLITN. Adverse effects associated with LLITN use were reported by a substantial proportion of respondents. Itchiness was the most prevalent complaint, identified by 65.0% of respondents, followed by unspecified other effects (13.3%), difficulty in breathing (8.3%), and vomiting (6.7%). The high prevalence of reported itchiness is consistent with evidence from Atkinson et al. ( 2012 ) and Macintyre et al. ( 2012 ) identifying cutaneous irritation as the most common adverse reaction to pyrethroid-impregnated nets. Ibeagha et al. ( 2025 ) specifically identify perceived side effects — including itchiness, heat discomfort, and chemical odour — as among the most prevalent and modifiable drivers of ITN discontinuation across tropical Africa, and recommend proactive adverse effect counselling as a priority intervention to prevent utilization abandonment. 4.5 Summary of key findings Figure 6 provides a synthesized visual summary of the eight most salient findings from the study, integrating data across the knowledge, access, and practice domains. The juxtaposition of near-universal malaria-prevention awareness (100%) and high ANC-based access (98.3%) against the 35.0% non-utilization rate underscores the critical gap between LLITN ownership and effective use in this population. Critical knowledge deficits — particularly regarding the three-year chemical efficacy period, misidentified by 72.9% of respondents — combined with a high prevalence of adverse effect experience (65.0% reporting itchiness) and a composite suboptimal use rate of 56.7%, collectively characterize the LLITN utilization challenge in Bonsu Sub-Municipality. 5. Discussion This study aimed to evaluate the factors associated with the access to and utilization of long-lasting insecticidal treated nets (LLITNs) in the prevention of malaria among pregnant women in Bonsu Sub-Municipality, Nkoranza South District, Brong Ahafo Region, Ghana. The findings of this study provide a comprehensive, district-specific characterization of the factors associated with LLITN access and utilization among pregnant women in Bonsu Sub-Municipality, Nkoranza South District, and yield several important insights for programme planning and health policy. The study is set within a context of well-documented and locally persistent tension between rising LLITN ownership and persistently high malaria prevalence in pregnancy — a paradox that has been documented nationally by Awunyo et al. ( 2025 ) and regionally by Abesig et al. ( 2025 ) and is explained, in large part, by the findings of the present investigation. 5.1 Knowledge of LLITNs: Depth, gaps, and programmatic implications The finding that all respondents (100%) recognized malaria prevention as a primary benefit of LLITN use is encouraging and consistent with the documented success of the NMCP’s health promotion activities at ANC facilities (Eisele et al., 2009 ; NMCP, 2017; Zhou et al., 2014 ). However, the predominance of moderate rather than good knowledge — with 85% of respondents in the moderate category and only 7% demonstrating good knowledge — highlights the limitations of surface-level awareness as a driver of behaviour change. As Atkinson et al. ( 2012 ) and Ibeagha et al. ( 2025 ) have argued, awareness of the primary malaria-prevention function of nets does not necessarily translate into the deeper, operational knowledge required to support consistent and correct use. The finding that only 27.1% of respondents correctly identified the three-year chemical expiry period — while 45.8% believed it to be only one year — has particular practical significance and represents one of the most actionable findings of this study. Respondents who underestimate the durability of the LLITN insecticide may prematurely discontinue use or engage in unnecessary retreatment attempts, potentially reducing the insecticide load to subtherapeutic levels and compromising net efficacy (Binka & Adongo, 1997 ; Grabowsky et al., 2005 ). This specific misconception has been documented in comparable Ghanaian settings by Salifu et al. ( 2026 ) and Zuuri et al. ( 2025 ), who both recommend targeted ANC counselling to address the prevalent confusion between LLITNs and conventional retreatable ITNs as a high-priority intervention. The 91.7% who identified ANC as their primary source of LLITN knowledge simultaneously underscore the pivotal role of antenatal health education sessions in shaping knowledge and practices, and highlight the consequences of inadequate depth or coverage of LLITN health education at these contact points. Strengthening the quality, consistency, and depth of ANC-based LLITN counselling through standardized protocols and pictorial materials — as advocated by Opara et al. ( 2024 ) — is therefore a priority recommendation emerging from this study. The relatively low proportion recognizing the stillbirth-prevention benefit of LLITN use (16.7%) is particularly noteworthy, given the well-established causal chain linking placental malaria to foetal growth restriction and stillbirth documented by Desai et al. ( 2007 ), Kabalu Tshiongo et al. ( 2024 ), and Minwuyelet et al. ( 2025 ). This finding suggests that health education at ANC visits may be emphasizing the fever-prevention and direct anti-malaria benefits of LLITNs at the expense of communicating the more distal but equally important foetal outcomes. Communicating the foetal consequences of malaria — including stillbirth, LBW, and neonatal death — may enhance the perceived relevance and urgency of LLITN use for pregnant women, thereby strengthening motivational drivers of consistent utilization, consistent with the behavioural change communication principles advanced by Bardoe et al. ( 2025 ). 5.2 Access to LLITNs: High ownership, persistent inequalities Access to LLITNs in the study population was uniformly high and predominantly through the public ANC delivery channel, with 98.3% of net-owning respondents obtaining their LLITN free of charge from an ANC clinic, and 90.0% reporting free and easy access. These findings affirm the effectiveness of the Ghana NMCP’s free distribution policy and ANC-integrated delivery mechanism in eliminating financial and logistical barriers to LLITN ownership among pregnant women in this rural setting. This is consistent with evidence from Grabowsky et al. ( 2005 ), Sumaila et al. ( 2025 ), and Zhou et al. ( 2014 ), who collectively demonstrated that free distribution strategies substantially increased net ownership compared with subsidized or full-price market distribution. The 21.7% of respondents who reported obtaining a net through donation from a friend or family member suggests the existence of informal inter-household sharing and redistribution mechanisms. While reflective of community solidarity, this pattern carries the risk of concentrating multiple nets in households with surplus ownership while leaving more isolated households under-covered — a risk documented by Okova et al. ( 2025 ) in their analysis of within-group socioeconomic inequalities in LLITN distribution across Ghana over 2003–2022. The small proportions reporting market purchase (6.7%) and cost-related access difficulties (combined 5.0%) confirm that financial access barriers are not a primary driver of LLITN under-utilization in this population. As Carshon-Marsh and Di Ruggiero ( 2025 ) and Cottrell et al. ( 2025 ) have argued, this finding shifts the programmatic imperative squarely toward post-acquisition utilization promotion rather than further ownership expansion. 5.3 LLITN utilization practices: The ownership–use gap as the central challenge The most critical finding of this study concerns the substantial gap between LLITN ownership and consistent, correct utilization. Only 43.3% of respondents had their net correctly hung and actively in use at the time of observation, while 35.0% possessed a net but were not using it, and 21.7% had a net that was not correctly hung. This composite non-utilization and suboptimal use rate of 56.7% represents a major programme implementation gap and implies that more than half of the pregnant women who received an LLITN through the ANC system were not benefiting from its protective function at the time of the study. This magnitude of ownership–utilization discordance is consistent with findings from Cottrell et al. ( 2025 ) in Benin, Gikandi et al. ( 2008 ) and Teym et al. ( 2025 ) in East Africa, Getnet et al. ( 2024 ) in Ethiopia, and Mwebesa et al. ( 2025 ) across multiple sub-Saharan African countries, and underscores the global inadequacy of measuring programme success by distribution coverage alone. The high prevalence of itchiness as a reported side effect (65.0%) is a particularly salient finding, given the documented relationship between perceived adverse effects and LLITN use discontinuation. Ibeagha et al. ( 2025 ) identified pyrethroid-related adverse effects as among the most prevalent modifiable barriers to consistent ITN use in tropical Africa, and specifically note that women who experience itchiness in the first nights of net use are significantly more likely to permanently discontinue use without prior counselling about the expected transient nature of these reactions. Macintyre et al. ( 2012 ) identified cutaneous irritation as the most common adverse reaction to pyrethroid-impregnated nets across multiple African settings. The mechanism underlying this reaction is likely a type IV delayed hypersensitivity response to permethrin or other pyrethroid compounds, which manifests as localized pruritic dermatitis on skin areas in direct contact with the net material. Proactive, empathetic counselling regarding expected adverse effects — framed within a clear communication of the net’s substantial protective benefits — is therefore an essential component of comprehensive LLITN health education, as advocated by Bardoe et al. ( 2025 ) and Carshon-Marsh and Di Ruggiero ( 2025 ). The finding that 35.0% of respondents possessed a net but were not using it at the time of observation, despite living in a setting of high malaria endemicity and attending a health service that endorses net use, suggests the operation of motivational, contextual, and social factors that are not adequately addressed by distribution-focused programme strategies. These include spousal influence on net allocation decisions (Binka & Adongo, 1997 ; Mwebesa et al., 2025 ), sleeping space constraints, habitual behavioural inertia (Bardoe et al., 2025 ), and the perceived burden of nightly net setup — factors collectively identified as targets for community-based behaviour change communication by Zuuri et al. ( 2025 ) and Salifu et al. ( 2026 ) in Ghanaian contexts. The present study’s finding that all net-using respondents employed the correct method of hanging the net above the bed indicates that the basic mechanics of correct usage are well understood among active users: the primary barrier is motivational and contextual, not procedural, a distinction with important implications for intervention design. Aoki et al. ( 2025 ), in a study of ITN use determinants among pregnant women in Angola, and Donacho et al. ( 2025 ), in a community-based cross-sectional study among pregnant women in Southwest Ethiopia, both identified marital status, spousal support, educational attainment, and knowledge of LLITN efficacy duration as the strongest independent predictors of consistent LLITN use in multivariate analyses, reinforcing the centrality of these factors in the present study’s context. Baykemagn et al. ( 2025 ), applying machine learning algorithms to predict mosquito bed net utilization among women of reproductive age across sub-Saharan Africa, identified ANC attendance frequency, household wealth, women’s empowerment, and regional malaria transmission intensity as the most important predictors of utilization, highlighting the multilevel, structural dimensions of the utilization gap that require system-level as well as individual-level responses. The cost-effectiveness evidence advanced by Okoro et al. ( 2025 ) and Madukwe et al. ( 2025 ) further strengthens the case for sustained investment in LLITN utilization-promoting interventions: the substantial protective benefit of consistent net use in reducing P. falciparum prevalence in pregnancy is achievable at relatively low additional programmatic cost when behaviour change communication and post-distribution follow-up are incorporated into existing ANC delivery platforms. Given the direct relationship between LLITN non-use, malaria in pregnancy, and maternal anaemia documented by Ansah et al. ( 2024 ) and the adverse birth outcomes linked to maternal malaria demonstrated by Kabalu Tshiongo et al. ( 2024 ) and Minwuyelet et al. ( 2025 ), the health and economic burden of the utilization gap in Bonsu Sub-Municipality is both clinically substantial and economically compelling. 6. Conclusions and recommendations 6.1 Conclusions This study elucidates a critical programmatic disconnect in the Bonsu Sub-Municipality, revealing a "Universal Access Paradox" where near-perfect LLITN ownership of 98.3% fails to translate into effective biological protection, as evidenced by the finding that only 43.3% of pregnant women achieved correct and consistent utilization at the time of direct observation. These findings suggest that while the National Malaria Control Programme has successfully navigated the logistical hurdles of commodity distribution, it has yet to overcome the deep-seated socio-behavioral inertia and domestic constraints that prevent sustained use among this vulnerable population. A primary driver of this ownership-use gap is a profound knowledge-efficacy deficit, specifically the widespread misconception among nearly half of the respondents that insecticide potency expires after only one year, which creates a sense of perceived obsolescence that leads to premature net abandonment. Furthermore, the physiological barrier of side effects, most notably the itchiness reported by 65.0% of participants, acts as a powerful negative reinforcer that is rarely pre-emptively addressed through structured clinical counseling. While active users demonstrate a clear understanding of the mechanics of hanging a net, the high non-utilization rate among owners underscores a significant divide where domestic factors such as heat, limited sleeping space, and lack of spousal support often outweigh the perceived threat of malaria. However, these conclusions must be interpreted within the context of certain limitations, including the modest purposive sample of 60 pregnant women which may limit generalizability to broader urban settings, and the cross-sectional design that captures only a snapshot of behavior without accounting for seasonal shifts in mosquito density or indoor temperatures. Additionally, while direct observation was used to verify hanging status, data regarding the frequency of use relied on self-reports which may be subject to social desirability bias among respondents seeking to align with healthcare expectations. Moving forward, malaria prevention success must shift from measuring "nets per household" to "protected person-nights of sleep," necessitating a transition from passive distribution toward a "Distribution Plus" model that integrates intensive behavioral reinforcement, myth correction, and male partner engagement at every antenatal care touchpoint. Future research should prioritize longitudinal behavioral tracking to identify specific drop-off points in adherence and investigate the efficacy of technological innovations, such as low-irritant insecticide coatings or conical net designs, to better accommodate the structural and physical realities of rural Ghanaian households. Ultimately, bridging the transition from mere net ownership to consistent biological adherence represents the final frontier in reducing maternal and neonatal morbidity, requiring a sophisticated approach that treats cognitive myths and physical discomforts as primary rather than secondary barriers to malaria elimination. 6.2 Recommendations Based on the foregoing conclusions and drawing upon the evidence base synthesized from the literature, the following recommendations are directed to the Nkoranza South District Health Management Team (DHMT), the Ghana National Malaria Control Programme (NMCP), and relevant non-governmental organization (NGO) and community stakeholders: 1. Strengthen ANC-based LLITN health education by developing standardized, pictorial health education materials that specifically address the knowledge gaps identified in this study — particularly the three-year insecticide efficacy period, correct first-time processing (shade drying), the irrelevance of retreatment for LLITNs, and the foetal health consequences of malaria in pregnancy — following the evidence-based educational programme design principles described by Opara et al. (2024). 2. Implement targeted community-based behaviour change communication (BCC) campaigns utilizing community health workers and Community Health Planning and Service (CHPS) personnel to conduct household-level LLITN counselling, correct net-hanging demonstrations, and proactive adverse effect management education, as recommended by Carshon-Marsh and Di Ruggiero (2025) and Zuuri et al. (2025). 3. Introduce structured post-distribution follow-up visits at ANC contact points to verify actual net use, assess barriers to utilization, and provide real-time counselling support to non-using net owners, with particular attention to respondents reporting adverse effects, following the model described by Cottrell et al. (2025). 4. Engage male partners and household heads in LLITN utilization promotion activities, given the well-documented influence of household decision-making dynamics on women’s net use behaviours (Binka & Adongo, 1997; Mwebesa et al., 2025), by incorporating male partner counselling sessions into existing ANC outreach programmes. 5. Conduct periodic programme evaluations measuring utilization rates through direct observation and validated self-report instruments, rather than relying solely on distribution coverage metrics, to provide a more accurate and actionable assessment of programme effectiveness, consistent with the programmatic evaluation framework advocated by Awunyo et al. (2025) and Okova et al. (2025). Abbreviations Abbreviation Full Term ACT Artemisinin-Based Combination Therapy ANC Antenatal Care BCC Behaviour Change Communication CHPS Community Health Planning and Service CWC Child Welfare Clinic DALYs Disability-Adjusted Life Years DDT Dichlorodiphenyltrichloroethane DHIMS District Health Information Management System DHMT District Health Management Team GDP Gross Domestic Product GDHS Ghana Demographic and Health Survey GHS Ghana Health Service IPTp Intermittent Preventive Treatment in Pregnancy IRS Indoor Residual Spraying ITN Insecticide-Treated Net JHS Junior High School JSS Junior Secondary School KAP Knowledge, Attitudes, and Practices LBW Low Birth Weight LI Legislative Instrument LLITN / LLIN Long-Lasting Insecticidal Treated Net / Long-Lasting Insecticidal Net MOH Ministry of Health NGO Non-Governmental Organization NHIS National Health Insurance Scheme NMCP National Malaria Control Programme OPD Outpatient Department RBM Roll Back Malaria SHS Senior High School SP Sulfadoxine-Pyrimethamine WHO World Health Organization Declarations CRediT authorship contribution statement R.O.Y.: Conceptualization, Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing – original draft & editing, Resources, Project administration. I.A.A.: Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing – original draft & editing A.B.: Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing – original draft & editing G.O.F.: Conceptualization, Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing – original draft & editing, Resources, Supervision, Project administration. Funding This research received no specific external funding. Declaration of Competing Interest The authors have no relevant financial or non-financial interests to disclose. Clinical Trial Number Clinical trial number: not applicable Ethics, Consent to Participate, and Consent to Publish Ethics, Consent to Participate, and Consent to Publish declarations: not applicable Data availability Data availability statement: The questionnaire, datasets obtained from the survey and the Python 3.12 script used for data analysis are available in the figshare repository at: https://figshare.com/s/b718e9145c204981e691. Declaration of generative AI and AI-assisted technologies in the manuscript preparation process. During the preparation of this work the authors used Cursor version 2.4.37 to write and edit the Python 3.12 script used for data analysis. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article. 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The economic impact of malaria in Africa: A critical review of the evidence. Health Policy , 63(1), 17–36. https://doi.org/10.1016/S0168-8510(02)00036-2 Cottrell, G., Djènontin, A., Soares, C., Bouraima, A., Fiogbé, M., Egbinola, S., Affoukou, C., & Ogouyèmi, A. H. (2025). Suboptimal distribution and utilization of antenatal care given bed nets undermine pregnant women's protection in Benin: A prospective field study. BMC Public Health . https://doi.org/10.1186/s12889-025-22212-6 Creswell, J. W. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). SAGE Publications. Desai, M., ter Kuile, F. O., Nosten, F., McGready, R., Asamoa, K., Brabin, B., & Newman, R. D. (2007). Epidemiology and burden of malaria in pregnancy. The Lancet Infectious Diseases , 7(2), 93–104. https://doi.org/10.1016/S1473-3099(07)70021-X Donacho, D. O., Tura, S. K., & Kefeni, B. T. (2025). Determinants of long-lasting insecticide-treated bed net utilization among pregnant women in Gechi District, Buno Bedele Zone, South West Ethiopia: A community-based cross-sectional study. Environmental Health Insights . https://doi.org/10.1177/11786302251335135 Eisele, T. P., Larsen, D. A., Walker, N., Cibulskis, R. E., & Steketee, R. W. (2009). Determining the effectiveness of the insecticide-treated bednet and indoor residual spraying campaigns in reducing malaria. PLOS ONE , 4(12), e8145. https://doi.org/10.1371/journal.pone.0008145 Gallup, J. L., & Sachs, J. D. (2000). The economic burden of malaria. American Journal of Tropical Medicine and Hygiene , 64(1–2 Suppl), 85–96. https://doi.org/10.4269/ajtmh.2001.64.85 Getnet, Y., Teym, A., Wubie, M., Shiferaw, S., Tilahun Assaye, B., Aneley, Z., Mekonen Abera, H., & Temesgen, H. (2024). Long lasting insecticide-treated nets utilization and associated factors among pregnant women in Shebel Berenta District, Northwest Ethiopia. Environmental Health Insights . https://doi.org/10.1177/11786302241291957 Ghana Demographic and Health Survey (GDHS). (2008). Ghana demographic and health survey 2008 . Ghana Statistical Service & Ghana Health Service. Ghana Health Service (GHS). (2009). Nkoranza South District health report 2009 . District Health Directorate. Gikandi, P. W., Noor, A. M., Snow, R. W., Ngugi, A. K., & Hay, S. I. (2008). Access and barriers to insecticide treated net use in urban and peri-urban areas of Kenya. Malaria Journal , 7(1), 227. https://doi.org/10.1186/1475-2875-7-227 Grabowsky, M., Nobiya, T., & Hindle, P. (2005). Distributing insecticide-treated bednets during measles vaccination: A low-cost means of achieving high and equitable coverage. Bulletin of the World Health Organization , 83(3), 195–201. Guyatt, H. L., & Snow, R. W. (2004). Impact of malaria during pregnancy on low birth weight in sub-Saharan Africa. Clinical Microbiology Reviews , 17(4), 760–769. https://doi.org/10.1128/CMR.17.4.760-769.2004 Ibeagha, A., Ruiter, R. A. C., Dukers-Muijrers, N. H. T. M., & Hoebe, C. J. (2025). What factors contribute to the inconsistent use of insecticide treated bed nets in tropical Africa? A review of the literature on malaria prevention. International Journal of Psychology and Health Science . https://doi.org/10.38035/ijphs.v3i4.1738 Iwueze, M. O., Ezenwaka, C., Nzeakor, T. A., Nwoke, E. A., & Ezike, V. I. (2014). Pattern of insecticide-treated net usage and its determinants among residents of an endemic malaria area of Nigeria. Sierra Leone Journal of Biomedical Research , 6(1), 3–12. Kabalu Tshiongo, J., Zola Matuvanga, T., Mitashi, P., Maketa, V., Schallig, H. D. F. H., Mens, P. F., Muhindo Mavoko, H., & Matangila Rika, J. (2024). Prevention of malaria in pregnant women and its effects on maternal and child health, the case of Centre Hospitalier de Kingasani II in the Democratic Republic of the Congo. Tropical Medicine and Infectious Disease , 9(5), 92. https://doi.org/10.3390/tropicalmed9050092 Kelsey, J. L., Whittemore, A. S., Evans, A. S., & Thompson, W. D. (1996). Methods in observational epidemiology (2nd ed.). Oxford University Press. Klu, D., Alhassan, A., Vidzro, E. S., & Aberese-Ako, M. (2026). Household characteristics, water, sanitation and hygiene (WASH) and malaria prevalence among children aged 6–59 months in Ghana: An analysis of the 2022 Ghana Demographic and Health Survey. Malaria Journal . https://doi.org/10.1186/s12936-026-05815-1 Kokuhennadige, V., Aitken, E., & Rogerson, S. (2026). Malaria in pregnancy at the frontline: A delicate balance. Current Opinion in Immunology . https://doi.org/10.1016/j.coi.2026.102726 Lengeler, C. (2004). Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database of Systematic Reviews , 2, CD000363. https://doi.org/10.1002/14651858.CD000363.pub2 Macintyre, K., Keating, J., Okello, G., Wolff, B., & Mbogo, C. M. (2012). Examining the determinants of mosquito-avoidance practices in two Kenyan cities. Malaria Journal , 11(1), 9. https://doi.org/10.1186/1475-2875-11-9 Madukwe, J. C., Ahaneku, E. B., Onukafor, O. S., Edokpayi, S., Madukwe, P. C., Enwereji, N. U., & Santos, E. M. (2025). Do women attending antenatal clinics who use only intermittent preventive treatment (IPTp) have higher Plasmodium falciparum prevalence compared to those who used both IPTp and slept under insecticide-treated nets? Malaria Journal . https://doi.org/10.1186/s12936-025-05532-1 McCormick, M. C. (1985). The contribution of low birth weight to infant mortality and childhood morbidity. New England Journal of Medicine , 312(2), 82–90. https://doi.org/10.1056/NEJM198501103120204 Minwuyelet, A., Yewhalaw, D., Siferih, M., & Atenafu, G. (2025). Current update on malaria in pregnancy: A systematic review. Tropical Diseases, Travel Medicine and Vaccines . https://doi.org/10.1186/s40794-025-00248-1 Mwebesa, E., Musinguzi, B., Legason, I. D., Opoke, R., Agaba, B. B., Kananura, R., & Mwangi, A. (2025). Pooled prevalence and factors associated with insecticide-treated net use among pregnant women in malaria high-burden countries in sub-Saharan Africa: A multilevel mixed-effects analysis. Tropical Medicine and Health . https://doi.org/10.1186/s41182-025-00855-w National Malaria Control Programme (NMCP). (2017). Ghana malaria programme review 2017 . Ghana Health Service. Nkoranza South District Health Management Team (DHMT). (2016). Annual district health report 2016 . Nkoranza South District Health Directorate. Nkuo-Akenji, T., Ntonifor, N. N., Ndong, J. M., Eyong, E. M., Green, E. E., Alemnji, G., & Fusi, R. (2009). Evaluating malaria intervention strategies among pregnant women and their newborns in rural Cameroon. Journal of Infectious Diseases and Immunity , 1(1), 4–9. Nuwaha, F. (2001). Factors influencing the use of bed nets in Mbarara municipality of Uganda. American Journal of Tropical Medicine and Hygiene , 65(6), 877–882. https://doi.org/10.4269/ajtmh.2001.65.877 Okoro, L. N., Zoakah, A. I., Bupwatda, P., Anyamene, E. L., Bulus, N. G., Kumbak, F. D., Sabano, M. C., Mukisa, K. A., Gmanyami, J. M., Amoakoh, M. Y., & Isiko, I. (2025). Cost-effectiveness of intermittent preventive therapy and insecticide-treated bed nets for malaria prevention among pregnant women in Jos North, Plateau State, Nigeria. Malaria Journal . https://doi.org/10.1186/s12936-025-05607-z Okova, D., Lukwa, A., Edusei, M., Bodzo, P., Atta-Obeng, C., Chiwire, P., & Hongoro, C. (2025). Between- and within-socioeconomic groups temporal inequality in the uptake of malaria prevention strategies among pregnant women and under-five children in Ghana (2003–2022). Malaria Journal . https://doi.org/10.1186/s12936-025-05512-5 Opara, M. O., Ismail, S., & Mohd Nazan, A. I. (2024). Prevention of malaria in pregnancy through health education intervention programs on insecticide-treated nets use: A systematic review. BMC Public Health . https://doi.org/10.1186/s12889-024-17650-7 Osei, K. M., Adiak, A. A., & Han, W. (2026). Evaluating the effectiveness of insecticide-treated net use in preventing malaria among children under five: A quasi-experimental study. Tropical Medicine and Health . https://doi.org/10.1186/s41182-026-00932-8 Otchere, A. (2011). Nkoranza South District health sector annual programme of work review report 2011 . Nkoranza South DHMT. Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). SAGE Publications. Pluess, B., Tanser, F. C., Lengeler, C., & Sharp, B. L. (2010). Indoor residual spraying for preventing malaria. Cochrane Database of Systematic Reviews , 4, CD006657. https://doi.org/10.1002/14651858.CD006657.pub2 Polit, D. F., & Beck, C. T. (2010). Essentials of nursing research: Appraising evidence for nursing practice (7th ed.). Lippincott Williams & Wilkins. Sachs, J., & Malaney, P. (2002). The economic and social burden of malaria. Nature , 415(6872), 680–685. https://doi.org/10.1038/415680a Salifu, Y., Nantomah, B., & Lasong, J. (2026). Knowledge of malaria and preventive practices among Fulani pregnant women in the Savannah Region of Northern Ghana. BMC Research Notes . https://doi.org/10.1186/s13104-026-07736-3 Schantz-Dunn, J., & Nour, N. M. (2009). Malaria and pregnancy: A global health perspective. Reviews in Obstetrics & Gynecology , 2(3), 186–192. Steketee, R. W., Nahlen, B. L., Parise, M. E., & Menendez, C. (2001). The burden of malaria in pregnancy in malaria-endemic areas. American Journal of Tropical Medicine and Hygiene , 64(1–2 Suppl), 28–35. https://doi.org/10.4269/ajtmh.2001.64.28 Sumaila, I., Issifu, S., Asumah, M. N., Nimo-Boakye, K., Awuah, D. A., Agodzo, H., Apio, G., & Twum, A. (2025). Determinants of insecticide treated bed nets use among pregnant women in the Kintampo North Municipality, Bono East Region, Ghana. medRxiv . https://doi.org/10.1101/2025.05.13.25327488 Teym, A., Berihun, G., Shiferaw, M. Y., Abawa, E. D., Alemu, Y., Assaye, B. T., Abebe, R. B., & Zeleke, T. K. (2025). Insecticide-treated bed net utilization and its determinants among pregnant women in Dembecha District, Northwest Ethiopia. Tropical Medicine and Health . https://doi.org/10.1186/s41182-025-00762-0 World Health Organization (WHO). (2005). World malaria report 2005 . WHO Press. World Health Organization (WHO). (2007). Insecticide-treated mosquito nets: A WHO position statement . WHO Global Malaria Programme. World Health Organization (WHO). (2015). World malaria report 2015 . WHO Press. World Health Organization (WHO) & Ghana Health Service (GHS). (2003). Ghana national malaria control programme: Coverage and utilization of insecticide-treated nets report 2003 . WHO Press & Ghana Health Service. World Medical Association. (2013). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Ye, Y., Kyobutungi, C., Louis, V. R., & Sauerborn, R. (2012). Micro-epidemiology of Plasmodium falciparum malaria: Is there any difference in transmission risk between neighbouring villages? Malaria Journal , 11(1), 286. https://doi.org/10.1186/1475-2875-11-286 Zhou, G., Thwing, J., & Keating, J. (2014). Malaria vector control. American Journal of Tropical Medicine and Hygiene , 90(5), 803–809. https://doi.org/10.4269/ajtmh.13-0547 Zuuri, C. N., Gyamah, D. K., Buabeng, L., & Osei Mensah, R. (2025). Assessing the knowledge, attitudes and practices towards malaria prevention and determinants of antenatal care utilization among pregnant women in Sekyere South district, Ghana: A cross-sectional study. Malaria Journal . https://doi.org/10.1186/s12936-025-05614-0 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9223820","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612271961,"identity":"f9667ca7-a7d4-41cb-9162-f83539366033","order_by":0,"name":"Richmond Yaw Osei","email":"","orcid":"","institution":"Anglican University College of Technology (ANGUTECH)","correspondingAuthor":false,"prefix":"","firstName":"Richmond","middleName":"Yaw","lastName":"Osei","suffix":""},{"id":612271963,"identity":"bfce9b25-de20-4b20-b666-645fafb0211e","order_by":1,"name":"Ishmael Awini Aburi","email":"","orcid":"","institution":"Anglican University College of Technology (ANGUTECH)","correspondingAuthor":false,"prefix":"","firstName":"Ishmael","middleName":"Awini","lastName":"Aburi","suffix":""},{"id":612271965,"identity":"45f3704c-2a93-4e27-b712-d04aa5d75472","order_by":2,"name":"Abigail Boatemaa","email":"","orcid":"","institution":"University of Bradford","correspondingAuthor":false,"prefix":"","firstName":"Abigail","middleName":"","lastName":"Boatemaa","suffix":""},{"id":612271966,"identity":"dacf0cae-5a60-48bf-b3ab-6dc37e9959ce","order_by":3,"name":"Gabriel Osei Forkuo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYFACHgaGBAYLBvYGBmYgz4YBSLERo0WCgecAWEsaUAszEVoYEFoOAzEBLfLuZ499eFAB1MLe+9iYp+J84nZ2/mOPeRjuyeHSYngmL3lGwhmgFp7jxsk8Z24n7mxmZjfmYSg2xqmlIceYIbFNgsFeIo35MG/b7cQNh5nZJGcwJCQ24NLS/wao5R/QFoiWc4S1yEuAbGmAaEnmbTsA1iLxAY8WA4l3yQwJxyR4eHiOMRvOOZNsDNRibvDBIAGnX+T7cw8z/qixkeNhb2OWeFNhJ7vh/MFnDxIqEnCGmMEBCM2DLo5LA9AWXC4eBaNgFIyCUQAHADWxS35CD5XtAAAAAElFTkSuQmCC","orcid":"","institution":"Transilvania University of Brasov","correspondingAuthor":true,"prefix":"","firstName":"Gabriel","middleName":"Osei","lastName":"Forkuo","suffix":""}],"badges":[],"createdAt":"2026-03-25 13:38:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9223820/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9223820/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105466021,"identity":"dc7ff6fb-f90a-484a-90a6-9583c852bf89","added_by":"auto","created_at":"2026-03-26 10:50:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":272423,"visible":true,"origin":"","legend":"\u003cp\u003eSocio-demographic characteristics of study respondents (\u003cem\u003eN \u003c/em\u003e= 60). Panel A shows the distribution of respondents by age group; Panel B shows the distribution by level of education; Panel C shows the distribution by occupation; Panel D shows the distribution by marital status. \u003cem\u003eNote. \u003c/em\u003eThe 26–30 year age group constituted the modal category (38.3%). Middle/Junior High School was the most prevalent educational level (48.3%). Farming was the predominant occupation (45.0%). The majority of respondents were married (61.7%).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9223820/v1/93c1903cc785e17585843b67.png"},{"id":105466023,"identity":"33485edd-56d8-421b-b4c2-017f021e3104","added_by":"auto","created_at":"2026-03-26 10:50:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":337232,"visible":true,"origin":"","legend":"\u003cp\u003eKnowledge of respondents regarding LLITNs. Panel A presents respondents' knowledge of the chemical expiry period, with the correct answer (3 years) indicated in green; Panel B shows perceived foetal health benefits; Panel C shows sources of LLITN knowledge; Panel D presents the distribution of overall knowledge levels. \u003cem\u003eNote. \u003c/em\u003eAll respondents (100%) were aware that LLITNs prevent malaria. Only 27.1% correctly identified the three-year chemical expiry period. The majority (85%) demonstrated a moderate overall level of knowledge. ANC = Antenatal Care; LLITN = Long-Lasting Insecticidal Treated Net.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9223820/v1/dd62902d1570c4b9b15511cd.png"},{"id":105466024,"identity":"f1e49095-41fb-4370-b861-1ad698bb4250","added_by":"auto","created_at":"2026-03-26 10:50:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":197579,"visible":true,"origin":"","legend":"\u003cp\u003eKnowledge on processing and maintenance of LLITN effectiveness. Panel A presents respondents' reported method of processing LLITNs for first-time use; Panel B presents knowledge regarding the maintenance of LLITN effectiveness over time. \u003cem\u003eNote. \u003c/em\u003e71.2% of respondents correctly reported drying the net in the shade as the appropriate first-time processing method. 83.1% correctly identified that LLITNs do not require chemical retreatment. LLITN = Long-Lasting Insecticidal Treated Net.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9223820/v1/4e4980e338e977e47f7355db.png"},{"id":105466022,"identity":"cf4ff257-dac4-4776-a3b5-91a8a9dabdfc","added_by":"auto","created_at":"2026-03-26 10:50:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":170465,"visible":true,"origin":"","legend":"\u003cp\u003eAccess to LLITNs among respondents. Panel A presents the sources from which respondents obtained their LLITNs (multiple responses permitted); Panel B presents the distribution of responses regarding the ease of LLITN access. \u003cem\u003eNote. \u003c/em\u003e98.3% of respondents obtained their LLITN from an ANC clinic. 90.0% reported free and easy access. ANC = Antenatal Care; LLITN = Long-Lasting Insecticidal Treated Net.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9223820/v1/45e411cf144d3c5903a3b1af.png"},{"id":105566713,"identity":"6041f19d-12ba-4c3a-8bbe-70e6e6cbd8a5","added_by":"auto","created_at":"2026-03-27 12:57:05","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":169862,"visible":true,"origin":"","legend":"\u003cp\u003eCommon practices of LLITN use among respondents (\u003cem\u003eN\u003c/em\u003e = 60). Panel A presents the frequency distribution of LLITN use; Panel B shows the confirmation of net use status based on direct observation; Panel C presents the distribution of side effects reported. \u003cem\u003eNote. \u003c/em\u003e60.0% of respondents reported nighttime-only net use. Only 43.3% had their net appropriately hung and actively in use at the time of observation. Itchiness was the most prevalent reported side effect (65.0%). LLITN = Long-Lasting Insecticidal Treated Net.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-9223820/v1/b72f9e9854443096b45aec9e.png"},{"id":105466027,"identity":"e23cee47-31fe-43b7-a6ca-f64e56f1f99c","added_by":"auto","created_at":"2026-03-26 10:50:23","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":195646,"visible":true,"origin":"","legend":"\u003cp\u003eKey findings summary: LLITN access and utilization among pregnant women, Nkoranza South Municipality, Ghana (\u003cem\u003eN \u003c/em\u003e= 60). Each panel represents a key metric derived from the study, organized to highlight the contrast between high knowledge/access rates and suboptimal utilization.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-9223820/v1/2e3b002d38ec7eb6f182ac8a.png"},{"id":105880857,"identity":"fd666b83-7be6-4bb5-a42d-266eaba49212","added_by":"auto","created_at":"2026-04-01 06:43:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3149155,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9223820/v1/c932c17b-eaa0-4ab2-acfd-7bb7fb987f28.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Universal Access Paradox: A Cross-Sectional Evaluation of Long-Lasting Insecticidal Treated Net Ownership and Utilization Discrepancies among Pregnant Women in Nkoranza South District, Ghana","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eMalaria continues to represent one of the most consequential and persistent infectious disease burdens confronting global public health, with the heaviest toll borne disproportionately by sub-Saharan African countries. According to the World Health Organization (WHO, 2015), an estimated 214\u0026nbsp;million cases of malaria were recorded worldwide in 2015, resulting in approximately 438,000 deaths, of which over 90% occurred on the African continent. More recently, Kokuhennadige et al. (\u003cspan class=\"CitationRef\"\u003e2026\u003c/span\u003e) have documented a troubling resurgence of malaria in pregnancy across Africa, underscoring the fragility of gains achieved through decades of control efforts and the urgency of renewed programmatic investment in evidence-based preventive interventions. In Ghana, malaria is hyperendemic and perennial across all ecological zones, with seasonal variation that is particularly pronounced in the northern and transitional savannah regions. The entire Ghanaian population of approximately 24.2\u0026nbsp;million is at risk, yet pregnant women and children under five years of age carry a disproportionate burden owing to compromised immunity and heightened physiological susceptibility (WHO/Ghana Health Service [GHS], 2003).\u003c/p\u003e \u003cp\u003eThe pathophysiology underlying the vulnerability of pregnant women to malaria is well characterized in the literature. Pregnancy substantially impairs a woman’s immune response to \u003cem\u003ePlasmodium falciparum\u003c/em\u003e, the dominant malaria parasite species in West Africa, rendering her significantly more susceptible to infection, severe anaemia, and febrile illness (Brabin et al., \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e; Desai et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Minwuyelet et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). The consequences extend beyond maternal health: maternal malaria infection is independently associated with intrauterine growth restriction, low birth weight (LBW), premature delivery, spontaneous abortion, and neonatal mortality (Guyatt \u0026amp; Snow, \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e; Kabalu Tshiongo et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; McCormick, \u003cspan class=\"CitationRef\"\u003e1985\u003c/span\u003e; Steketee, Nahlen, Parise, \u0026amp; Menendez, \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e). Globally, malaria in pregnancy is estimated to account for over 10,000 maternal deaths and 200,000 neonatal deaths per year (Schantz-Dunn \u0026amp; Nour, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e), while in Africa alone, approximately 30\u0026nbsp;million pregnancies annually are exposed to malaria risk (Sachs \u0026amp; Malaney, \u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e). Primigravid women bear the greatest immunological burden owing to the absence of acquired immunity to placental malaria mediated through VAR2CSA-binding antibodies, which are developed only following repeated gestational exposures (Desai et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Kokuhennadige et al., \u003cspan class=\"CitationRef\"\u003e2026\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the arsenal of malaria prevention and control tools, long-lasting insecticidal treated nets (LLITNs) have emerged as a cornerstone intervention of proven efficacy. An LLITN is a factory-treated bed net incorporating a synthetic pyrethroid insecticide that retains its biological efficacy for a minimum of three years under normal field conditions of use, without the need for re-treatment (WHO, 2007). Unlike conventional insecticide-treated nets (ITNs) that required periodic chemical re-impregnation, LLITNs offer a logistically simpler and more durable protective barrier against vector mosquitoes, particularly \u003cem\u003eAnopheles gambiae\u003c/em\u003e and related species responsible for malaria transmission in sub-Saharan Africa. The physical barrier function of the net reduces human–vector contact, while the residual insecticide kills or repels mosquitoes that make contact with the net surface, thereby providing both personal and community-level protection (Lengeler, \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e; Pluess et al., \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe global scale-up of LLITN distribution has been underpinned by compelling evidence from randomized controlled trials and systematic reviews demonstrating reductions in all-cause child mortality of 17–38% and reductions in malaria-attributable morbidity of up to 50% in high-transmission settings (Lengeler, \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e). Emerging evidence from quasi-experimental and prospective study designs further confirms that ITN effectiveness under routine programmatic conditions remains substantial, with Osei et al. (\u003cspan class=\"CitationRef\"\u003e2026\u003c/span\u003e) demonstrating significant reductions in malaria among children under five in Ghana even under conditions of imperfect adherence. The WHO has accordingly recommended universal LLITN coverage — defined as access to and use of LLITNs by all persons at risk — as a central pillar of the Global Technical Strategy for Malaria 2016–2030 (WHO, 2015), encompassing free mass distribution campaigns and continuous distribution through multiple channels, including ANC clinics, child welfare clinics (CWCs), and community-based platforms (Zhou et al., \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Ghana, the National Malaria Control Programme (NMCP) has implemented a multi-channel LLITN distribution strategy aligned with these global recommendations. Between 2010 and 2015, the programme achieved an 80% increase in LLITN coverage among populations at risk (WHO, 2015). Coverage of LLITNs among pregnant women attending ANC services rose from 22.9% in the first quarter of 2016 to 74.3% by 2017 (NMCP, 2017). Under the ANC protocol, all registered pregnant women are entitled to receive one LLITN free of charge at their first antenatal visit. However, national population-based survey evidence compiled by Awunyo et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) confirms a persistent and statistically significant discrepancy between LLITN ownership and effective utilization among pregnant women across Ghana, a pattern that mirrors findings from a longitudinal analysis by Okova et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), who documented widening within- and between-group socioeconomic inequalities in malaria prevention uptake over the period 2003–2022.\u003c/p\u003e \u003cp\u003eNotwithstanding these programmatic advances, a persistent disconnect between LLITN ownership and consistent utilization has been documented extensively in the literature. High coverage rates do not automatically translate into high usage rates, as actual protective benefit is contingent upon correct and consistent use — specifically, sleeping under a properly hung net every night during peak vector-biting hours (Atkinson et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Cottrell et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Mwebesa et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). Barriers to utilization are multifactorial and operate at individual, household, and community levels. These include poor knowledge of malaria transmission and LLITN efficacy duration, perceived or experienced side effects — including cutaneous irritation, respiratory discomfort, and headache associated with the pyrethroid insecticide — socioeconomic constraints, cultural beliefs, inadequate sleeping space, and the influence of spousal and community norms on health behaviours (Bardoe et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Binka \u0026amp; Adongo, \u003cspan class=\"CitationRef\"\u003e1997\u003c/span\u003e; Donacho et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Eisele et al., \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; Grabowsky et al., \u003cspan class=\"CitationRef\"\u003e2005\u003c/span\u003e; Ibeagha et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Macintyre et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Nuwaha, \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e). Recent systematic review evidence by Carshon-Marsh and Di Ruggiero (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) has further highlighted that inadequate behaviour change communication and absent post-distribution follow-up are modifiable system-level barriers that directly predict low utilization in contexts where ownership is already high.\u003c/p\u003e \u003cp\u003eIn the Nkoranza South Municipality of the Brong Ahafo Region, malaria constitutes the foremost cause of outpatient department (OPD) attendance, accounting for 47% of OPD visits, 16.2% of hospital admissions, and 17.4% of hospital deaths (GHS, 2009). Annual district health reviews have consistently identified malaria among pregnant women as a leading cause of maternal morbidity, despite the systematic distribution of LLITNs through ANC services. In 2015, the municipality distributed 100 LLITNs to pregnant women, achieving a coverage of 41.2%; by 2016, 162 nets were distributed, raising coverage to 67.8%, yet malaria in pregnancy remained at 60% (Nkoranza South District Health Management Team [DHMT], 2016). This paradox — of rising LLITN coverage coexisting with persistently high malaria prevalence — underscores the inadequacy of measuring programme success solely by distribution metrics and points to critical deficiencies in utilization and adherence, consistent with national data reported by Abesig et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) documenting sustained malaria test positivity among pregnant women in northern Ghana despite programmatic scale-up.\u003c/p\u003e \u003cp\u003eNo systematic research had previously been conducted within Nkoranza South District to rigorously evaluate the factors associated with LLITN access and utilization among this vulnerable group. This evidence gap limits the capacity of the District Health Management Team (DHMT) and other stakeholders to design and implement evidence-based, targeted interventions. In the global context, malaria imposes an estimated annual economic burden exceeding USD 12\u0026nbsp;billion on sub-Saharan African economies and is estimated to reduce economic growth by up to 1.3% per year (Gallup \u0026amp; Sachs, \u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e; WHO, 2005). The indirect costs — reduced labour productivity, impaired child cognitive development, increased school absenteeism, and diminished household welfare — further compound its developmental consequences (Chima, Goodman, \u0026amp; Mills, \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e). The present study was therefore conducted to generate district-specific, actionable evidence to guide targeted malaria prevention programming in this high-burden setting.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Aim of the study\u003c/h2\u003e \u003cp\u003eThe aim of this study was to evaluate the factors associated with the access to and utilization of long-lasting insecticidal treated nets (LLITNs) in the prevention of malaria among pregnant women in Bonsu Sub-Municipality, Nkoranza South District, Brong Ahafo Region, Ghana.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003e1.2 Specific objectives\u003c/h2\u003e\n \u003cp\u003eThe study was guided by the following specific objectives:\u003c/p\u003e\n \u003cp\u003e1. To assess the level of knowledge of pregnant women regarding LLITNs and their role in malaria prevention.\u003cbr\u003e 2. To evaluate the common practices associated with the use of LLITNs among pregnant women in the study area.\u003cbr\u003e 3. To identify factors associated with access to LLITNs among pregnant women attending antenatal care services.\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003e1.3 Research questions\u003c/h2\u003e\n \u003cp\u003eThe following research questions guided the study:\u003c/p\u003e\n \u003cp\u003e1. What is the level of knowledge of pregnant women in Bonsu Sub-Municipality regarding the use and benefits of LLITNs?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2. What are the common practices associated with LLITN use among pregnant women in the study area?\u003cbr\u003e 3. What factors are associated with access to LLITNs among pregnant women attending antenatal care services in the study area?\u003c/p\u003e\n\u003c/div\u003e"},{"header":"2. Literature Review","content":"\n\u003ch3\u003e2.1 Global and regional burden of malaria in pregnancy\u003c/h3\u003e\n\u003cp\u003eMalaria in pregnancy constitutes a global public health emergency with disproportionately severe consequences in sub-Saharan Africa. Sachs and Malaney (\u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e) demonstrated that approximately 30\u0026nbsp;million pregnancies in malaria-endemic Africa are exposed to the risk of infection annually, with maternal and foetal consequences including severe anaemia, low birth weight, premature delivery, and neonatal death. These findings were corroborated and extended by Schantz-Dunn and Nour (\u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e), who estimated that malaria is responsible for over 10,000 maternal deaths and 200,000 neonatal deaths each year globally, with the African continent bearing the overwhelming majority of this mortality burden. More recently, Minwuyelet et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a comprehensive systematic review of malaria in pregnancy, confirmed that the disease remains a critical public health threat across sub-Saharan Africa, with profound and often underappreciated effects on placental function, foetal growth, and neonatal survival. Kokuhennadige et al. (\u003cspan class=\"CitationRef\"\u003e2026\u003c/span\u003e) have further documented a resurgence of malaria in pregnancy in parts of Africa, attributing this reversal to insecticide resistance, COVID-19-related disruptions to malaria services, and stagnating utilization of preventive interventions including LLITNs.\u003c/p\u003e\u003cp\u003eThe immunological basis of pregnant women’s vulnerability to malaria has been extensively characterized. Desai et al. (\u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e) conducted a comprehensive systematic review of the global epidemiology of malaria in pregnancy and documented that primigravid women — those experiencing their first pregnancy — are most susceptible to placental malaria, attributed to the unique immunological tolerance mechanisms of early pregnancy and the absence of VAR2CSA antibody-mediated immunity. Brabin et al. (\u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e) further demonstrated that severe anaemia resulting from malaria infection in pregnancy significantly elevates maternal mortality risk, particularly in settings with limited access to emergency obstetric care. Steketee et al. (\u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e) provided compelling evidence linking maternal malaria infection to low birth weight — itself the single greatest risk factor for neonatal death, as originally identified by McCormick (\u003cspan class=\"CitationRef\"\u003e1985\u003c/span\u003e) — establishing a clear causal pathway from inadequate malaria prevention to adverse perinatal outcomes. Kabalu Tshiongo et al. (\u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e) have provided recent corroboration of these mechanisms, demonstrating in a facility-based study in the Democratic Republic of Congo that combined use of ITNs and IPTp is associated with significantly improved birth weight and maternal haemoglobin outcomes compared to either intervention alone.\u003c/p\u003e\u003cp\u003eIn the specific context of Ghana, malaria in pregnancy remains hyperendemic and perennial across all regions. The Ghana Demographic and Health Survey (GDHS, 2008) documented that nationally, only 19.9% of pregnant women slept under a treated net the night preceding the survey, highlighting the persistent and substantial gap between net availability and consistent protective use. More recent data from Awunyo et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), based on a national population-based survey of Ghanaian pregnant women, confirm that while LLITN ownership has improved substantially over successive programme cycles, effective utilization remains low and is differentially distributed across socioeconomic strata. Abesig et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a trend analysis of malaria test positivity rates among pregnant women in the Savannah Region of Ghana over 2018–2022, documented that malaria positivity among ANC attendees remained high despite programmatic efforts, underscoring the need for targeted utilization-promoting interventions. Similarly, Bonsra et al. (\u003cspan class=\"CitationRef\"\u003e2025b\u003c/span\u003e) identified age, educational attainment, income, and ITN use as significant predictors of malaria prevalence in pregnancy across selected districts of the Ashanti Region, while Bonsra et al. (\u003cspan class=\"CitationRef\"\u003e2025a\u003c/span\u003e) further confirmed these patterns in a health facility-based study in Kwadaso Municipality, Ghana.\u003c/p\u003e\u003ch2\u003e2.2 Efficacy and effectiveness of long-lasting insecticidal treated nets\u003c/h2\u003e\u003cp\u003eThe evidence base for the efficacy of LLITNs and their precursor ITNs in reducing malaria transmission, morbidity, and mortality is among the most robust in the field of global health. Lengeler (\u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e) conducted the landmark Cochrane systematic review and meta-analysis of randomized controlled trials of insecticide-treated nets, documenting reductions in all-cause child mortality of 17–38% and reductions in uncomplicated clinical malaria episodes of approximately 50% in areas of stable transmission. Pluess et al. (\u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e) subsequently reviewed the community-level protective effect of ITNs, demonstrating that high population-level coverage confers a mass effect that reduces vectorial capacity and transmission intensity beyond the direct protection afforded to individual net users. Osei et al. (\u003cspan class=\"CitationRef\"\u003e2026\u003c/span\u003e) provided recent quasi-experimental confirmation that ITN use under routine programmatic conditions in Ghana remains associated with significant reductions in malaria among children under five, affirming the programmatic relevance of effectiveness data to the Ghanaian context.\u003c/p\u003e\u003cp\u003eMadukwe et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) demonstrated in a Nigerian ANC-based study that women who used both IPTp and slept under an ITN had significantly lower \u003cem\u003ePlasmodium falciparum\u003c/em\u003e prevalence than those who used IPTp alone, providing direct evidence for the additive protective effect of LLITN use alongside pharmacological prevention. Okoro et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) further confirmed in a cost-effectiveness analysis in Jos North, Nigeria, that combined ITN and IPTp prevention is the most cost-effective strategy for malaria prevention in pregnancy, with ITNs providing the greatest marginal benefit at lowest additional cost. Cottrell et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) documented that suboptimal distribution and underutilization of ANC-given bed nets in Benin compromised pregnant women’s protection substantially, with a prospective field study demonstrating that actual net utilization rates fell to less than 50% within weeks of distribution despite near-universal ownership, a pattern directly mirroring the present study’s context.\u003c/p\u003e\u003cp\u003eZhou et al. (\u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e) examined the role of universal LLITN coverage as a programmatic strategy, affirming the WHO recommendation that universal access — defined as at least one LLITN per two persons at risk within each household — should be pursued through a combination of mass free distribution campaigns and continuous distribution channels, including ANC clinics and community-based platforms. These authors emphasized that the effectiveness of distribution channels is contingent upon the quality of accompanying health education and the degree to which community members internalize the importance of consistent net use, rather than merely possessing a net — a conclusion of direct relevance to the present study’s findings.\u003c/p\u003e\u003ch2\u003e2.3 Knowledge, attitudes, and practices regarding LLITNs\u003c/h2\u003e\u003cp\u003eA substantial and growing body of literature has examined the relationship between knowledge, attitudes, and practices (KAP) pertaining to LLITNs and actual utilization behaviours. Atkinson et al. (\u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e) conducted a systematic review of barriers to LLITN use in sub-Saharan Africa and identified knowledge deficits — including misconceptions about the mechanism of net action, the duration of insecticide efficacy, and the consequences of improper net maintenance — as significant determinants of low utilization. Ibeagha et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a recent review of factors contributing to inconsistent ITN use in tropical Africa, confirmed that inadequate knowledge depth, perceived adverse effects, socioeconomic constraints, and absent BCC remain the predominant modifiable drivers of underutilization across the region, and specifically identified knowledge of chemical efficacy duration as a critical and underaddressed knowledge gap in existing health education programmes.\u003c/p\u003e\u003cp\u003eZuuri et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) conducted a cross-sectional KAP study among pregnant women in Sekyere South District, Ghana — a setting comparable to the present study area — and documented that gaps in malaria prevention stemmed primarily from misconceptions and incomplete adherence rather than supply shortages, concluding that strengthened ANC counselling, myth correction, and expanded outreach with ITN replacement are priority interventions. Salifu et al. (\u003cspan class=\"CitationRef\"\u003e2026\u003c/span\u003e) assessed malaria knowledge and preventive practices among pregnant women in the Savannah Region of Northern Ghana and identified inadequate knowledge of ITN efficacy duration, inconsistent use practices, and limited ANC attendance as key barriers to effective malaria prevention among marginalized pastoral communities. Bardoe et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a qualitative exploration of psychological barriers to preventive interventions in Ghana, identified motivational inertia, fatalistic health beliefs, and the perceived burden of consistent preventive behaviour as underappreciated psychological determinants of LLITN non-use that are not adequately captured by quantitative KAP instruments.\u003c/p\u003e\u003cp\u003eBinka and Adongo (\u003cspan class=\"CitationRef\"\u003e1997\u003c/span\u003e) investigated factors influencing ITN use in northern Ghana and identified household-level decision-making dynamics, including the role of male household heads in determining whether family members sleep under nets, as a significant structural barrier to utilization among women and children. Eisele et al. (\u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e) provided a multi-country analysis of the determinants of ITN use in sub-Saharan Africa, documenting that education level, household wealth, and exposure to malaria-prevention messaging were the strongest predictors of consistent net use. Grabowsky et al. (\u003cspan class=\"CitationRef\"\u003e2005\u003c/span\u003e) demonstrated that free distribution of ITNs substantially increased ownership rates but did not automatically translate into increased use, emphasizing the indispensable role of behaviour change communication (BCC) in achieving utilization gains. Mwebesa et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a multilevel pooled analysis of ITN use among pregnant women across high-burden sub-Saharan African countries, identified ANC attendance frequency, household wealth, women’s education level, and partner support as the strongest multilevel predictors of consistent ITN use in pregnancy, after controlling for access.\u003c/p\u003e\u003ch2\u003e2.4 Access to LLITNs through antenatal care services\u003c/h2\u003e\u003cp\u003eThe integration of LLITN distribution into ANC services is widely recognized as a highly cost-effective strategy for reaching pregnant women with preventive interventions. Nkuo-Akenji et al. (\u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e) evaluated LLITN coverage and utilization among pregnant women in Cameroon and documented that ANC attendance was the strongest predictor of LLITN ownership. Ajonina et al. (\u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), in a recent cross-sectional study in the Littoral Region of Cameroon, confirmed that LLIN use among pregnant women attending ANC remained below national targets and was independently associated with age, religion, and gestational period, highlighting the importance of tailoring ANC-based interventions to the specific determinants operative within each setting. Cottrell et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) highlighted in Benin that even where ANC-based distribution achieves near-universal net provision, actual utilization rates within weeks of distribution can fall to critically low levels without concurrent post-distribution follow-up and counselling.\u003c/p\u003e\u003cp\u003eYe et al. (\u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e) found in Burkina Faso that ANC-based distribution substantially increased LLITN ownership among pregnant women, but that free distribution alone was insufficient to drive utilization without concurrent community sensitization and follow-up counselling. Sumaila et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a study of ITN use determinants among pregnant women in Kintampo North Municipality — a district in the Bono East Region of Ghana directly adjacent to Nkoranza South — identified ANC attendance frequency, knowledge of ITN efficacy, and spousal encouragement as the strongest predictors of consistent ITN use, providing directly comparable contextual evidence for the present study. In Ghana, the NMCP’s continuous distribution strategy through ANC and CWC channels has produced significant increases in LLITN coverage. However, as Okova et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) demonstrated, persistent socioeconomic inequalities in both ownership and utilization undermine the equitable protective benefit of this strategy across the population.\u003c/p\u003e\u003cp\u003eOpara, Ismail, and Mohd Nazan (\u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), in a systematic review of health education intervention programmes targeting ITN use in pregnancy, demonstrated that structured, interactive, and pictorial health education delivered at ANC visits significantly improved both knowledge depth and utilization rates compared to routine passive counselling, with gains sustained at three- and six-month follow-up. These findings provide a strong evidence base for the recommendation, emerging from the present study, to strengthen ANC-based LLITN counselling through standardized, evidence-informed protocols.\u003c/p\u003e\u003ch2\u003e2.5 Factors influencing LLITN utilization among pregnant women in Ghana\u003c/h2\u003e\u003cp\u003eContext-specific evidence from Ghana underscores the multidimensional nature of LLITN utilization barriers. Anto et al. (\u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e) evaluated malaria prevention practices in the Kassena-Nankana district of northern Ghana and documented that household ownership of LLITNs was substantially higher than actual use, attributing this discrepancy to knowledge deficits, competing household priorities for net use, and structural factors including roof height and sleeping arrangement configurations that compromised proper net hanging. Akuffo et al. (\u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e) confirmed in a nationally representative Ghanaian dataset that ITN non-use was strongly associated with inadequate knowledge of net maintenance, perceived side effects, and absence of partner encouragement, while Alhassan (\u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e) documented similar patterns in a facility-based study at Tamale Teaching Hospital, noting that single women and women with lower educational attainment were disproportionately represented among non-users.\u003c/p\u003e\u003cp\u003eAnsah et al. (\u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), in a study of treated bed net use and anaemia among pregnant women in Ghana, demonstrated a statistically significant association between LLITN non-use and elevated anaemia risk, providing direct haematological evidence for the clinical consequences of utilization gaps in the Ghanaian context. The NMCP’s 2017 annual review documented that despite significant increases in LLITN distribution, malaria in pregnancy remained a leading cause of ANC attendance and maternal hospital admission across all regions (NMCP, 2017). In Nkoranza South Municipality specifically, the 2009 district health report (GHS, 2009) documented that malaria accounted for 47% of OPD visits, 16.2% of hospital admissions, and 17.4% of hospital deaths — figures that collectively situate the present study within a context of well-documented programmatic need.\u003c/p\u003e"},{"header":"3. Methodology","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study design\u003c/h2\u003e \u003cp\u003eA descriptive cross-sectional study design was employed. This design is widely used in public health research for estimating the prevalence of health behaviours and associated factors at a specific point in time within a defined population (Bowling, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Creswell, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Kelsey et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). The cross-sectional design was considered appropriate for this study because it enabled the simultaneous assessment of multiple variables \u0026mdash; including knowledge, access, and practice \u0026mdash; within the study population without requiring prospective follow-up, thereby providing a cost- and time-efficient approach to generating baseline evidence for programme planning purposes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Study area\u003c/h2\u003e \u003cp\u003eThe study was conducted in Bonsu Sub-Municipality, which is located within the Nkoranza South Municipality of the Brong Ahafo Region of Ghana. Nkoranza South Municipality was carved out of the former Nkoranza District in February 2008 under Legislative Instrument (LI) 1899, and was formally accorded municipality status in May 2012 under LI 2089. Bonsu Sub-Municipality lies within longitudes 1\u0026deg;10\u0026Prime;W and 1\u0026deg;55\u0026Prime;W and latitudes 7\u0026deg;20\u0026Prime;N and 7\u0026deg;55\u0026Prime;N, covering a total land area of 923 square kilometres. The municipality shares boundaries with the Nkoranza North District to the north, Techiman Municipality to the west, and the Ejura-Sekyedumase and Offinso North Districts to the south-east and south. The predominant economic activity is subsistence and small-scale commercial agriculture. Malaria is hyperendemic throughout the municipality and represents the leading cause of OPD attendance, hospital admission, and hospital mortality (GHS, 2009).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Study population\u003c/h2\u003e \u003cp\u003eThe target population comprised all pregnant women registered for ANC services at health facilities within Bonsu Sub-Municipality during the study period. Inclusion criteria required participants to be currently pregnant, aged 16 years or older, residing within the sub-municipality, and willing to provide informed consent. Women who were unable to communicate in either English or the local Twi/Brong dialect, even with the assistance of a trained interpreter, were excluded from the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Sample size and sampling procedure\u003c/h2\u003e \u003cp\u003eA total of 60 pregnant women were selected using purposive sampling. Purposive or judgement sampling involves the deliberate selection of participants who are considered most representative of or informative about the phenomenon under study and is a widely accepted approach in descriptive health studies where the research objective is to characterize a specific and relatively homogeneous population (Patton, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Polit \u0026amp; Beck, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). All ANC registrants present at participating facilities during the designated data collection periods who met the inclusion criteria were invited to participate, and the sample was augmented by visiting outlying communities within the sub-municipality to ensure adequate geographic representation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Data collection instrument and procedure\u003c/h2\u003e \u003cp\u003eData were collected using a structured questionnaire developed by the principal investigator on the basis of a comprehensive review of the existing literature on LLITN knowledge, access, and utilization (Atkinson et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Eisele et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Macintyre et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Mwebesa et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Nkuo-Akenji et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Opara et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The questionnaire comprised four sections: (1) socio-demographic characteristics, including \u003cem\u003eage\u003c/em\u003e, \u003cem\u003elevel of education\u003c/em\u003e, \u003cem\u003eoccupation\u003c/em\u003e, and \u003cem\u003emarital status\u003c/em\u003e; (2) knowledge items assessing awareness of LLITN benefits, chemical efficacy duration, processing procedures, and perceived side effects; (3) items assessing LLITN access, including \u003cem\u003esource of net\u003c/em\u003e and \u003cem\u003eease of access\u003c/em\u003e; and (4) items assessing common practices, including \u003cem\u003efrequency of use\u003c/em\u003e, \u003cem\u003emethod of net hanging\u003c/em\u003e, and \u003cem\u003econfirmation of actual use\u003c/em\u003e. The questionnaire was pre-tested with a small group of non-participant pregnant women to assess clarity and face validity, and revisions were made accordingly before formal data collection commenced.\u003c/p\u003e \u003cp\u003eQuestionnaires were administered through face-to-face interviews conducted by the principal investigator and a trained female research assistant fluent in both English and the local dialect. For physical confirmation of net use status, the research assistant conducted direct observations of the sleeping environment. All interviews were conducted in a private setting to ensure confidentiality and minimize social desirability bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Data analysis\u003c/h2\u003e \u003cp\u003eData were entered, cleaned, and analysed using Python 3.12 with appropriate statistical and data‑processing libraries such as pandas, NumPy, and SciPy. Descriptive statistics such as frequencies and percentages were calculated for all categorical variables and are presented in tabular and graphical form. Findings were organized thematically in alignment with the three study objectives: (1) knowledge, (2) access, and (3) common practices. All percentages are rounded to one decimal place. For items permitting multiple responses, percentages were reported as proportions of the total sample (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60) and may therefore sum to values exceeding 100%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Ethical considerations\u003c/h2\u003e \u003cp\u003ePrior to data collection, ethical approval was obtained from the appropriate institutional review board, and administrative permission was sought from the Nkoranza South District Health Directorate. All participants provided verbal informed consent prior to their inclusion in the study. Participants were informed of the voluntary nature of their participation, their right to withdraw at any time without consequence, and the confidentiality of their responses. No personally identifying information was recorded in the data collection instruments. The principles of beneficence, non-maleficence, autonomy, and justice as outlined in the Declaration of Helsinki (World Medical Association, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) were adhered to throughout the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Socio-demographic characteristics of respondents\u003c/h2\u003e \u003cp\u003eA total of 60 pregnant women participated in the study. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the majority of respondents (38.3%) fell within the 26\u0026ndash;30 year \u003cem\u003eage\u003c/em\u003e group, followed by the 21\u0026ndash;25 year category (23.3%), with only 3.3% of respondents aged 41 years or above. This age distribution is consistent with the typical reproductive age pattern in rural Ghanaian communities and reflects the broader demographic profile of ANC attendees in the district (GHS, 2009). The predominance of women in the mid-reproductive age range is epidemiologically significant, as multigravid women in this age bracket may possess some degree of acquired immunity to placental malaria, yet remain at risk of anaemia and other pregnancy complications associated with malaria infection (Desai et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Kokuhennadige et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2026\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of respondents (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAge of Respondents (years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle/JSS/JHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary/SHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrader\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCivil servant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCo-habiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e JSS\u0026thinsp;=\u0026thinsp;Junior Secondary School; JHS\u0026thinsp;=\u0026thinsp;Junior High School; SHS\u0026thinsp;=\u0026thinsp;Senior High School.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding \u003cem\u003eeducational attainment\u003c/em\u003e, the largest proportion of respondents (48.3%) had completed Middle/Junior High School (JHS) or its equivalent, while 26.7% had received no formal education. Only 1.7% had attained secondary school (Senior High School [SHS]) education, and a further 6.7% had received tertiary-level education. The high proportion of respondents with no formal or basic education has important implications for health literacy and the capacity to comprehend and act upon LLITN health education messages, and is consistent with findings from Bonsra et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025b\u003c/span\u003e) and Eisele et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) regarding the inverse relationship between \u003cem\u003eeducational attainment\u003c/em\u003e and malaria prevention knowledge deficits in Ghana and the broader sub-Saharan African region.\u003c/p\u003e \u003cp\u003eOccupational distribution revealed that farming was the primary livelihood activity, with 45.0% of respondents identifying as farmers, followed by trading (21.7%), other unspecified occupations (15.0%), housewifery (8.3%), civil service (6.7%), and unemployment (3.3%). The predominance of agricultural livelihoods is characteristic of rural Brong Ahafo communities and is relevant from a malaria epidemiological standpoint, as agricultural workers engaged in outdoor fieldwork during the evening and early morning peak biting hours of vector mosquitoes face substantially elevated exposure risk. \u003cem\u003eMarital status\u003c/em\u003e data revealed that the majority of respondents (61.7%) were married, while 28.3% reported co-habiting with a partner, and 10.0% were single. The predominance of married respondents has potential implications for LLITN utilization, as household-level decision-making regarding net use may be influenced by the attitudes and behaviours of male partners (Binka \u0026amp; Adongo, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Grabowsky et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Mwebesa et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Knowledge of respondents regarding LLITNs\u003c/h2\u003e \u003cp\u003eThe findings pertaining to respondent knowledge of LLITNs are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All 60 respondents (100%) correctly identified that LLITNs prevent malaria in pregnancy, reflecting a high level of awareness of the primary protective benefit of the intervention. This finding is consistent with evidence from comparable settings documenting near-universal awareness of the malaria-prevention function of bed nets following sustained mass distribution campaigns (Eisele et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Nkuo-Akenji et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Zuuri et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, knowledge was considerably less robust regarding more nuanced aspects of LLITN function and maintenance.\u003c/p\u003e \u003cp\u003eSpecifically, only 27.1% of respondents correctly identified the three-year effective lifespan of the chemical insecticide as the correct expiry period for the net, while the largest single group (45.8%) incorrectly believed the chemicals expired after only one year, and a further 8.5% reported having no knowledge of the expiry period. This widespread misconception about chemical efficacy duration has significant practical implications: respondents who believe the insecticide expires after one year may prematurely discontinue LLITN use, a finding consistent with knowledge gaps documented by Ibeagha et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) across tropical Africa and by Salifu et al. (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2026\u003c/span\u003e) among Ghanaian pregnant women.\u003c/p\u003e \u003cp\u003eThe findings pertaining to respondent knowledge of LLITNs are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Regarding perceived benefits of LLITNs to the foetus, 70.0% of respondents indicated awareness that net use prevents foetal death, 53.3% identified the prevention of low birth weight (LBW), 43.3% mentioned the prevention of anaemia, and 16.7% cited the prevention of stillbirth. ANC clinics were identified as the primary source of LLITN knowledge by 91.7% of respondents, with radio identified as a secondary source by 46.7% and market sources by 13.3%. These patterns reinforce the critical gatekeeping role of ANC services as the dominant knowledge dissemination channel (Nkuo-Akenji et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Ye et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge of respondents regarding LLITNs (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived chemical expiry period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 year (incorrect)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 years (incorrect)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 years (correct)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 years (incorrect)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBenefit of LLITN to pregnant woman\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevents malaria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived benefits to foetus (multiple responses)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevents death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevents low birth weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevents anaemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevents stillbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSource of knowledge (multiple responses)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eANC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRadio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall knowledge level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e ANC\u0026thinsp;=\u0026thinsp;Antenatal Care. Percentages for multiple-response items may sum to values exceeding 100%.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe overall knowledge level of respondents was classified as moderate in 85% of cases, with 8% demonstrating poor knowledge and only 7% demonstrating good knowledge. This pattern is consistent with findings from analogous KAP studies conducted in Ghana and other sub-Saharan African settings (Anto et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Atkinson et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Binka \u0026amp; Adongo, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Zuuri et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), and supports the conclusion that while awareness of the primary malaria-prevention function of LLITNs is nearly universal, deeper understanding of net maintenance, correct processing procedures, and the duration of insecticide efficacy remains inadequate among a substantial proportion of the study population.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents knowledge pertaining to the processing and maintenance of LLITN effectiveness. Regarding the appropriate first-time processing procedure, 71.2% of respondents correctly reported that the net should be dried in the shade, while 15.3% reported merely drying it in direct sunlight \u0026mdash; an incorrect practice that may accelerate photodegradation of the pyrethroid insecticide coating. A further 8.5% reported washing and drying the net in sunlight, and 5.1% reported washing and drying in the shade. The predominance of correct processing behaviour (shade drying) suggests that ANC health education messages on this aspect of net care have been relatively effectively communicated and retained. With respect to maintenance of insecticide effectiveness, 83.1% of respondents correctly identified that retreatment is not necessary for LLITNs \u0026mdash; an important distinction from conventional ITNs and a finding that indicates satisfactory awareness of this critical differentiating feature of the LLITN technology. Only 5.1% each reported that retreatment could be performed at home or at a health facility, and 3.4% mentioned community-based retreatment, with a further 3.4% indicating no knowledge of the maintenance requirements.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Access to LLITNs\u003c/h2\u003e \u003cp\u003eFindings on the access of respondents to LLITNs are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e Access to LLITNs was overwhelmingly through the public health system. Of the 59 respondents who owned a treated net (constituting 100% of net owners), 98.3% had obtained their primary LLITN from an ANC clinic. A noteworthy proportion (21.7%) also reported receiving LLITNs as donations from friends or family members. Purchase from market vendors was reported by 6.7% of respondents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAccess to LLITNs among respondents (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of net possessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreated (LLITN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSource of LLITN (multiple responses)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntenatal care (ANC) clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e98.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDonation from a friend\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEase of access to LLITN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFree and easily available at ANC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFree but with difficulties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheap (purchased)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpensive (purchased)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e ANC\u0026thinsp;=\u0026thinsp;Antenatal Care; LLITN\u0026thinsp;=\u0026thinsp;Long-Lasting Insecticidal Treated Net. Percentages for multiple-response items may sum to values exceeding 100%.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe overwhelming majority of respondents (90.0%) reported that their LLITN was freely and easily available through the ANC service, with only 5.0% reporting free availability but with associated difficulties. The near-universal experience of free and convenient ANC-based net access reflects the effectiveness of the NMCP\u0026rsquo;s continuous distribution strategy (Grabowsky et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Zhou et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and confirms that financial or logistical barriers to LLITN acquisition are not the primary impediment to effective malaria prevention in this population. As Carshon-Marsh and Di Ruggiero (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and Cottrell et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) have argued, high ownership rates in such settings must not be conflated with adequate protection: the principal challenge lies in translating net ownership into consistent and correct use through robust post-distribution behavioural support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Common practices of LLITN use\u003c/h2\u003e \u003cp\u003eData on common practices relating to LLITN use are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The data reveal a notable discrepancy between net ownership and consistent protective use. While 60.0% of respondents reported always using their LLITN \u0026mdash; but exclusively at night \u0026mdash; a significant proportion (18.3%) reported not using the net at all, and a further 11.7% reported using it only occasionally. The 10.0% who reported using the net both during the day and at night demonstrate an exemplary level of consistent protection.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCommon practices of LLITN use among respondents (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of LLITN use\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways \u0026ndash; night only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot at all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOccasionally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways \u0026ndash; day and night\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMethod of net use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHangs net above the bed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSide effects experienced (multiple responses)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItchiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDifficulty in breathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConfirmation of LLITN use status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNet hanged appropriately and in use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHas net but not currently in use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHas net but not hanged appropriately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe combined observation that 35.0% of respondents possessed a net but were not currently using it, and a further 21.7% possessed a net that was not correctly hung, yields a striking composite finding: 56.7% of LLITN owners were either not using their net at all or were using it suboptimally. This high rate of ownership\u0026ndash;utilization discordance echoes findings from Cottrell et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), Gikandi et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2008\u003c/span\u003e), Grabowsky et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e), Iwueze et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), and Mwebesa et al. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), who collectively documented similar patterns across East and West Africa. Only 43.3% of respondents had their net appropriately hung and actively in use, representing the proportion of the study population deriving full preventive benefit from their LLITN.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAdverse effects associated with LLITN use were reported by a substantial proportion of respondents. Itchiness was the most prevalent complaint, identified by 65.0% of respondents, followed by unspecified other effects (13.3%), difficulty in breathing (8.3%), and vomiting (6.7%). The high prevalence of reported itchiness is consistent with evidence from Atkinson et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) and Macintyre et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) identifying cutaneous irritation as the most common adverse reaction to pyrethroid-impregnated nets. Ibeagha et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) specifically identify perceived side effects \u0026mdash; including itchiness, heat discomfort, and chemical odour \u0026mdash; as among the most prevalent and modifiable drivers of ITN discontinuation across tropical Africa, and recommend proactive adverse effect counselling as a priority intervention to prevent utilization abandonment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Summary of key findings\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e provides a synthesized visual summary of the eight most salient findings from the study, integrating data across the knowledge, access, and practice domains. The juxtaposition of near-universal malaria-prevention awareness (100%) and high ANC-based access (98.3%) against the 35.0% non-utilization rate underscores the critical gap between LLITN ownership and effective use in this population.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCritical knowledge deficits \u0026mdash; particularly regarding the three-year chemical efficacy period, misidentified by 72.9% of respondents \u0026mdash; combined with a high prevalence of adverse effect experience (65.0% reporting itchiness) and a composite suboptimal use rate of 56.7%, collectively characterize the LLITN utilization challenge in Bonsu Sub-Municipality.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThis study aimed to evaluate the factors associated with the access to and utilization of long-lasting insecticidal treated nets (LLITNs) in the prevention of malaria among pregnant women in Bonsu Sub-Municipality, Nkoranza South District, Brong Ahafo Region, Ghana. The findings of this study provide a comprehensive, district-specific characterization of the factors associated with LLITN access and utilization among pregnant women in Bonsu Sub-Municipality, Nkoranza South District, and yield several important insights for programme planning and health policy. The study is set within a context of well-documented and locally persistent tension between rising LLITN ownership and persistently high malaria prevalence in pregnancy \u0026mdash; a paradox that has been documented nationally by Awunyo et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and regionally by Abesig et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and is explained, in large part, by the findings of the present investigation.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Knowledge of LLITNs: Depth, gaps, and programmatic implications\u003c/h2\u003e \u003cp\u003eThe finding that all respondents (100%) recognized malaria prevention as a primary benefit of LLITN use is encouraging and consistent with the documented success of the NMCP\u0026rsquo;s health promotion activities at ANC facilities (Eisele et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; NMCP, 2017; Zhou et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). However, the predominance of moderate rather than good knowledge \u0026mdash; with 85% of respondents in the moderate category and only 7% demonstrating good knowledge \u0026mdash; highlights the limitations of surface-level awareness as a driver of behaviour change. As Atkinson et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) and Ibeagha et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) have argued, awareness of the primary malaria-prevention function of nets does not necessarily translate into the deeper, operational knowledge required to support consistent and correct use.\u003c/p\u003e \u003cp\u003eThe finding that only 27.1% of respondents correctly identified the three-year chemical expiry period \u0026mdash; while 45.8% believed it to be only one year \u0026mdash; has particular practical significance and represents one of the most actionable findings of this study. Respondents who underestimate the durability of the LLITN insecticide may prematurely discontinue use or engage in unnecessary retreatment attempts, potentially reducing the insecticide load to subtherapeutic levels and compromising net efficacy (Binka \u0026amp; Adongo, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Grabowsky et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). This specific misconception has been documented in comparable Ghanaian settings by Salifu et al. (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2026\u003c/span\u003e) and Zuuri et al. (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), who both recommend targeted ANC counselling to address the prevalent confusion between LLITNs and conventional retreatable ITNs as a high-priority intervention. The 91.7% who identified ANC as their primary source of LLITN knowledge simultaneously underscore the pivotal role of antenatal health education sessions in shaping knowledge and practices, and highlight the consequences of inadequate depth or coverage of LLITN health education at these contact points. Strengthening the quality, consistency, and depth of ANC-based LLITN counselling through standardized protocols and pictorial materials \u0026mdash; as advocated by Opara et al. (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) \u0026mdash; is therefore a priority recommendation emerging from this study.\u003c/p\u003e \u003cp\u003e The relatively low proportion recognizing the stillbirth-prevention benefit of LLITN use (16.7%) is particularly noteworthy, given the well-established causal chain linking placental malaria to foetal growth restriction and stillbirth documented by Desai et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), Kabalu Tshiongo et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and Minwuyelet et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). This finding suggests that health education at ANC visits may be emphasizing the fever-prevention and direct anti-malaria benefits of LLITNs at the expense of communicating the more distal but equally important foetal outcomes. Communicating the foetal consequences of malaria \u0026mdash; including stillbirth, LBW, and neonatal death \u0026mdash; may enhance the perceived relevance and urgency of LLITN use for pregnant women, thereby strengthening motivational drivers of consistent utilization, consistent with the behavioural change communication principles advanced by Bardoe et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Access to LLITNs: High ownership, persistent inequalities\u003c/h2\u003e \u003cp\u003eAccess to LLITNs in the study population was uniformly high and predominantly through the public ANC delivery channel, with 98.3% of net-owning respondents obtaining their LLITN free of charge from an ANC clinic, and 90.0% reporting free and easy access. These findings affirm the effectiveness of the Ghana NMCP\u0026rsquo;s free distribution policy and ANC-integrated delivery mechanism in eliminating financial and logistical barriers to LLITN ownership among pregnant women in this rural setting. This is consistent with evidence from Grabowsky et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e), Sumaila et al. (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), and Zhou et al. (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), who collectively demonstrated that free distribution strategies substantially increased net ownership compared with subsidized or full-price market distribution.\u003c/p\u003e \u003cp\u003eThe 21.7% of respondents who reported obtaining a net through donation from a friend or family member suggests the existence of informal inter-household sharing and redistribution mechanisms. While reflective of community solidarity, this pattern carries the risk of concentrating multiple nets in households with surplus ownership while leaving more isolated households under-covered \u0026mdash; a risk documented by Okova et al. (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) in their analysis of within-group socioeconomic inequalities in LLITN distribution across Ghana over 2003\u0026ndash;2022. The small proportions reporting market purchase (6.7%) and cost-related access difficulties (combined 5.0%) confirm that financial access barriers are not a primary driver of LLITN under-utilization in this population. As Carshon-Marsh and Di Ruggiero (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and Cottrell et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) have argued, this finding shifts the programmatic imperative squarely toward post-acquisition utilization promotion rather than further ownership expansion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e5.3 LLITN utilization practices: The ownership\u0026ndash;use gap as the central challenge\u003c/h2\u003e \u003cp\u003eThe most critical finding of this study concerns the substantial gap between LLITN ownership and consistent, correct utilization. Only 43.3% of respondents had their net correctly hung and actively in use at the time of observation, while 35.0% possessed a net but were not using it, and 21.7% had a net that was not correctly hung. This composite non-utilization and suboptimal use rate of 56.7% represents a major programme implementation gap and implies that more than half of the pregnant women who received an LLITN through the ANC system were not benefiting from its protective function at the time of the study. This magnitude of ownership\u0026ndash;utilization discordance is consistent with findings from Cottrell et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) in Benin, Gikandi et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) and Teym et al. (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) in East Africa, Getnet et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) in Ethiopia, and Mwebesa et al. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) across multiple sub-Saharan African countries, and underscores the global inadequacy of measuring programme success by distribution coverage alone.\u003c/p\u003e \u003cp\u003eThe high prevalence of itchiness as a reported side effect (65.0%) is a particularly salient finding, given the documented relationship between perceived adverse effects and LLITN use discontinuation. Ibeagha et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) identified pyrethroid-related adverse effects as among the most prevalent modifiable barriers to consistent ITN use in tropical Africa, and specifically note that women who experience itchiness in the first nights of net use are significantly more likely to permanently discontinue use without prior counselling about the expected transient nature of these reactions. Macintyre et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) identified cutaneous irritation as the most common adverse reaction to pyrethroid-impregnated nets across multiple African settings. The mechanism underlying this reaction is likely a type IV delayed hypersensitivity response to \u003cem\u003epermethrin\u003c/em\u003e or other pyrethroid compounds, which manifests as localized pruritic dermatitis on skin areas in direct contact with the net material. Proactive, empathetic counselling regarding expected adverse effects \u0026mdash; framed within a clear communication of the net\u0026rsquo;s substantial protective benefits \u0026mdash; is therefore an essential component of comprehensive LLITN health education, as advocated by Bardoe et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and Carshon-Marsh and Di Ruggiero (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe finding that 35.0% of respondents possessed a net but were not using it at the time of observation, despite living in a setting of high malaria endemicity and attending a health service that endorses net use, suggests the operation of motivational, contextual, and social factors that are not adequately addressed by distribution-focused programme strategies. These include spousal influence on net allocation decisions (Binka \u0026amp; Adongo, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Mwebesa et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), sleeping space constraints, habitual behavioural inertia (Bardoe et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), and the perceived burden of nightly net setup \u0026mdash; factors collectively identified as targets for community-based behaviour change communication by Zuuri et al. (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and Salifu et al. (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2026\u003c/span\u003e) in Ghanaian contexts. The present study\u0026rsquo;s finding that all net-using respondents employed the correct method of hanging the net above the bed indicates that the basic mechanics of correct usage are well understood among active users: the primary barrier is motivational and contextual, not procedural, a distinction with important implications for intervention design.\u003c/p\u003e \u003cp\u003eAoki et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a study of ITN use determinants among pregnant women in Angola, and Donacho et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), in a community-based cross-sectional study among pregnant women in Southwest Ethiopia, both identified marital status, spousal support, educational attainment, and knowledge of LLITN efficacy duration as the strongest independent predictors of consistent LLITN use in multivariate analyses, reinforcing the centrality of these factors in the present study\u0026rsquo;s context. Baykemagn et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), applying machine learning algorithms to predict mosquito bed net utilization among women of reproductive age across sub-Saharan Africa, identified ANC attendance frequency, household wealth, women\u0026rsquo;s empowerment, and regional malaria transmission intensity as the most important predictors of utilization, highlighting the multilevel, structural dimensions of the utilization gap that require system-level as well as individual-level responses.\u003c/p\u003e \u003cp\u003eThe cost-effectiveness evidence advanced by Okoro et al. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and Madukwe et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) further strengthens the case for sustained investment in LLITN utilization-promoting interventions: the substantial protective benefit of consistent net use in reducing \u003cem\u003eP. falciparum\u003c/em\u003e prevalence in pregnancy is achievable at relatively low additional programmatic cost when behaviour change communication and post-distribution follow-up are incorporated into existing ANC delivery platforms. Given the direct relationship between LLITN non-use, malaria in pregnancy, and maternal anaemia documented by Ansah et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and the adverse birth outcomes linked to maternal malaria demonstrated by Kabalu Tshiongo et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and Minwuyelet et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), the health and economic burden of the utilization gap in Bonsu Sub-Municipality is both clinically substantial and economically compelling.\u003c/p\u003e \u003c/div\u003e"},{"header":"6. Conclusions and recommendations","content":"\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e6.1 Conclusions\u003c/h2\u003e \u003cp\u003eThis study elucidates a critical programmatic disconnect in the Bonsu Sub-Municipality, revealing a \"Universal Access Paradox\" where near-perfect LLITN ownership of 98.3% fails to translate into effective biological protection, as evidenced by the finding that only 43.3% of pregnant women achieved correct and consistent utilization at the time of direct observation. These findings suggest that while the National Malaria Control Programme has successfully navigated the logistical hurdles of commodity distribution, it has yet to overcome the deep-seated socio-behavioral inertia and domestic constraints that prevent sustained use among this vulnerable population. A primary driver of this ownership-use gap is a profound knowledge-efficacy deficit, specifically the widespread misconception among nearly half of the respondents that insecticide potency expires after only one year, which creates a sense of perceived obsolescence that leads to premature net abandonment. Furthermore, the physiological barrier of side effects, most notably the itchiness reported by 65.0% of participants, acts as a powerful negative reinforcer that is rarely pre-emptively addressed through structured clinical counseling. While active users demonstrate a clear understanding of the mechanics of hanging a net, the high non-utilization rate among owners underscores a significant divide where domestic factors such as heat, limited sleeping space, and lack of spousal support often outweigh the perceived threat of malaria. However, these conclusions must be interpreted within the context of certain limitations, including the modest purposive sample of 60 pregnant women which may limit generalizability to broader urban settings, and the cross-sectional design that captures only a snapshot of behavior without accounting for seasonal shifts in mosquito density or indoor temperatures. Additionally, while direct observation was used to verify hanging status, data regarding the frequency of use relied on self-reports which may be subject to social desirability bias among respondents seeking to align with healthcare expectations. Moving forward, malaria prevention success must shift from measuring \"nets per household\" to \"protected person-nights of sleep,\" necessitating a transition from passive distribution toward a \"Distribution Plus\" model that integrates intensive behavioral reinforcement, myth correction, and male partner engagement at every antenatal care touchpoint. Future research should prioritize longitudinal behavioral tracking to identify specific drop-off points in adherence and investigate the efficacy of technological innovations, such as low-irritant insecticide coatings or conical net designs, to better accommodate the structural and physical realities of rural Ghanaian households. Ultimately, bridging the transition from mere net ownership to consistent biological adherence represents the final frontier in reducing maternal and neonatal morbidity, requiring a sophisticated approach that treats cognitive myths and physical discomforts as primary rather than secondary barriers to malaria elimination.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003e6.2 Recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the foregoing conclusions and drawing upon the evidence base synthesized from the literature, the following recommendations are directed to the Nkoranza South District Health Management Team (DHMT), the Ghana National Malaria Control Programme (NMCP), and relevant non-governmental organization (NGO) and community stakeholders:\u003c/p\u003e\n\u003cp\u003e1. Strengthen ANC-based LLITN health education by developing standardized, pictorial health education materials that specifically address the knowledge gaps identified in this study \u0026mdash; particularly the three-year insecticide efficacy period, correct first-time processing (shade drying), the irrelevance of retreatment for LLITNs, and the foetal health consequences of malaria in pregnancy \u0026mdash; following the evidence-based educational programme design principles described by Opara et al. (2024).\u003c/p\u003e\n\u003cp\u003e2. Implement targeted community-based behaviour change communication (BCC) campaigns utilizing community health workers and Community Health Planning and Service (CHPS) personnel to conduct household-level LLITN counselling, correct net-hanging demonstrations, and proactive adverse effect management education, as recommended by Carshon-Marsh and Di Ruggiero (2025) and Zuuri et al. (2025).\u003c/p\u003e\n\u003cp\u003e3. Introduce structured post-distribution follow-up visits at ANC contact points to verify actual net use, assess barriers to utilization, and provide real-time counselling support to non-using net owners, with particular attention to respondents reporting adverse effects, following the model described by Cottrell et al. (2025).\u003c/p\u003e\n\u003cp\u003e4. Engage male partners and household heads in LLITN utilization promotion activities, given the well-documented influence of household decision-making dynamics on women\u0026rsquo;s net use behaviours (Binka \u0026amp; Adongo, 1997; Mwebesa et al., 2025), by incorporating male partner counselling sessions into existing ANC outreach programmes.\u003c/p\u003e\n\u003cp\u003e5. Conduct periodic programme evaluations measuring utilization rates through direct observation and validated self-report instruments, rather than relying solely on distribution coverage metrics, to provide a more accurate and actionable assessment of programme effectiveness, consistent with the programmatic evaluation framework advocated by Awunyo et al. (2025) and Okova et al. (2025).\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull Term\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eArtemisinin-Based Combination Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eANC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eAntenatal Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBCC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eBehaviour Change Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHPS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eCommunity Health Planning and Service\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCWC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eChild Welfare Clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDALYs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eDisability-Adjusted Life Years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDDT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eDichlorodiphenyltrichloroethane\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDHIMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eDistrict Health Information Management System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDHMT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eDistrict Health Management Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGDP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eGross Domestic Product\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGDHS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eGhana Demographic and Health Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGHS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eGhana Health Service\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPTp\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eIntermittent Preventive Treatment in Pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eIndoor Residual Spraying\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eITN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eInsecticide-Treated Net\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJHS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eJunior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eJunior Secondary School\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eKnowledge, Attitudes, and Practices\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLBW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eLow Birth Weight\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eLegislative Instrument\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLLITN / LLIN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eLong-Lasting Insecticidal Treated Net / Long-Lasting Insecticidal Net\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMOH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eMinistry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNGO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eNon-Governmental Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNHIS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eNational Health Insurance Scheme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNMCP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eNational Malaria Control Programme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOPD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eOutpatient Department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRBM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eRoll Back Malaria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSHS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eSulfadoxine-Pyrimethamine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 477px;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR.O.Y.:\u003c/strong\u003e Conceptualization, Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing \u0026ndash; original draft \u0026amp; editing, Resources, Project administration. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eI.A.A.:\u003c/strong\u003e Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing \u0026ndash; original draft \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA.B.:\u003c/strong\u003e Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing \u0026ndash; original draft \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eG.O.F.:\u003c/strong\u003e Conceptualization, Methodology, Formal analysis, Data curation, Validation, Investigation, Visualization, Writing \u0026ndash; original draft \u0026amp; editing, Resources, Supervision, Project administration. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics, Consent to Participate, and Consent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics, Consent to Participate, and Consent to Publish declarations: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData availability statement: The questionnaire, datasets obtained from the survey and the Python 3.12 script used for data analysis are available in the figshare repository at: https://figshare.com/s/b718e9145c204981e691.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted technologies in the manuscript preparation process.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work the authors used Cursor version 2.4.37 to write and edit the Python 3.12 script used for data analysis. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Department of Forest Engineering, Forest Management Planning, and Terrestrial Measurements, Faculty of Silviculture and Forest Engineering, Transilvania University of Brasov, for providing some of the equipment needed for this study. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbesig, W. J., Nindow, J. A. C., Bagonluri, A. C., Sarfo, A. K., Issahaku, G. R., Odikro, M. A., Akowuah, G., Bandoh, D. A., Kenu, E., \u0026amp; Kubio, C. (2025). 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Assessing the knowledge, attitudes and practices towards malaria prevention and determinants of antenatal care utilization among pregnant women in Sekyere South district, Ghana: A cross-sectional study. \u003cem\u003eMalaria Journal\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12936-025-05614-0\u003c/span\u003e\u003cspan address=\"10.1186/s12936-025-05614-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"antenatal care, bed net adherence, knowledge-attitude-practice, malaria prevention, maternal health, sub-Saharan Africa, socio-behavioral determinants","lastPublishedDoi":"10.21203/rs.3.rs-9223820/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9223820/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMalaria in pregnancy remains a leading cause of maternal and neonatal morbidity in sub-Saharan Africa. While long-lasting insecticidal treated nets are highly efficacious and cost-effective, consistent utilization often falls short of programmatic targets even when ownership is high. This study evaluated factors associated with the access to and utilization of these nets among pregnant women in Bonsu Sub-Municipality, Ghana.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive cross-sectional study was conducted among 60 purposively selected pregnant women. Structured questionnaires and direct observation of the sleeping environment were used to collect data on socio-demographic characteristics, knowledge levels, and usage practices.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAccess was near-universal, with 98.3% of respondents obtaining nets primarily through antenatal care clinics. However, a significant \"Universal Access Paradox\" was observed: while ownership was nearly 100%, only 43.3% of respondents had their nets correctly hung and in active use. Significant knowledge deficits were identified, with 45.8% of women incorrectly believing the insecticide was effective for only one year. Furthermore, 65.0% reported itchiness as a major adverse effect, contributing to a 35.0% non-utilization rate among owners.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe ownership-utilization gap is driven by a knowledge-efficacy deficit and physical discomforts rather than supply-side barriers. Consistent biological protection is hindered by \"perceived obsolescence\" of the nets and a lack of pre-emptive counseling regarding transient side effects. Limitations include the small purposive sample size and the cross-sectional design, which captures only a temporal snapshot of behavior and may be subject to social desirability bias in self-reported data. The outlook for future work necessitates a shift from passive distribution to a \"Distribution Plus\" model that prioritizes longitudinal behavioral tracking, male partner engagement, and the development of low-irritant insecticide coatings to ensure consistent person-nights of protected sleep.\u003c/p\u003e","manuscriptTitle":"The Universal Access Paradox: A Cross-Sectional Evaluation of Long-Lasting Insecticidal Treated Net Ownership and Utilization Discrepancies among Pregnant Women in Nkoranza South District, Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-26 10:50:17","doi":"10.21203/rs.3.rs-9223820/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d926729-5605-4bd3-9048-fb422156afec","owner":[],"postedDate":"March 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-01T06:42:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-26 10:50:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9223820","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9223820","identity":"rs-9223820","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}