Factors Associated with Low Use of Insecticide-Treated Nets among Children under 5 Years of Age in Fo-Boure (Benin) in 2019

Despite the free distribution of insecticide impregnated nets, malaria is still the cause of many deaths, particularly among children under 5 years old, casting doubt on the real use of these mosquito nets by parents. The present work aimed to identify the factors associated with the low use of mosquito nets. This was a cross-sectional study with an analytical aim, carried out in the locality of Fô-Bouré (Sinendé) in 2019 among children under 5 years old and their parents. A cluster random sampling was carried out according to the WHO technique. The dependent variable was the low use of LLINs and the independent variables were: socio-demographic, economic, relative to parents’ knowledge of the causes and control methods of malaria. Results: The factors identified as associated with the low use of LLINs were: female sex (p = 0.0059), low level of education (p = 0.0001), free mode of acquisition (p = 0.0476), poor knowledge of control methods (p = 0.0389), type of house: mud or tent house (p = 0.0034), unsanitary immediate environment (p = 0.0002) and children’s evening dressing style (p = 0.0001). Conclusion: A global development policy, especially in terms of education, sanitation and housing improvement as recommended by the “Roll Back Malaria” initiative is necessary to improve the rate of insecticide impregnated nets use.

countries, 584,000 deaths were counted, mainly in children under 5 years old in sub-Saharan Africa, posing a major problem for economic development [1] [2]. In Benin, the National Malaria Control Program, as part of the "Roll Back Malaria" initiative, has opted for prevention through the promotion of the Long-Lasting Insecticide-Treated Net (LLIN) [3]. Despite the promotion of LLINs, the cumulative incidence of malaria was 17% in 2013 [4]. At the same time that the State makes LLINs available to all households, malaria continues to kill children in almost identical proportions, posing the problem of its regular and appropriate use [5]. The objective of this study was to identify the factors associated with the low use of LLINs among children under 5 years old in Fô-Bouré in 2019.

Materials and Methods
This was an analytical and descriptive cross-sectional study. Data collection covered a period of 7 days from December 5 to 11, 2019. The study population consisted of children under 5 years from the area of Fô-Bouré located in the municipality of Sinendé in northern Benin. Fô-Bouré is an area with a population of 15,268 inhabitants, 03 public health centers and 01 confessional center [6]. The sample size was calculated using Schwartz formula. The size was 420 households.
A random cluster sampling was carried out according to WHO technique [7].
The questionnaire was administered to men and women caring for at least one child under the age of 5 years through individual face-to-face structured interviews. The variable of interest was the low use of LLINs. The independent variables were: socio-demographic, economic and those related to parents' knowledge of both malaria and its prevention.
Knowledge of malaria was in the "Yes" option if the respondent declares that malaria was caused by mosquito bites.
Evening dressing is the wearing of long-sleeved shirts and trousers by children from 6 pm to protect them against mosquito bites.
The quality of the LLIN was considered good when the respondent answers that the LLIN he owns was of good quality. were used for the description of the quantitative variables. The proportions with their confidence interval were used to describe the qualitative variables.
Ethical and deontological considerations The agreement of the administrative and health authorities was obtained before data collection. Then the written or oral informed consent of both the head of household and the subjects surveyed was obtained before the administration of the questionnaire. Data confidentiality was ensured.

Description of Population
Four hundred and twenty households actually took part in the survey, housing 599 children under the age of 5 years, including 344 boys and 255 girls or a sex ratio of 1.35. The average age of the children was 28.50 months ± 12.17 months. Among the responding parents, 60.00% had no level of education. Households had an income under US$2 per day in 75.24% of cases.

Prevalence of LLINs Low Use
Out of 420 households surveyed, 400 respondents (95.23%) declared having LLINs. Among them, 326 respondents said they had used the LLIN for their children the night before this survey, i.e. 81.50%.
Among the 400 households with LLINs, 189 respondents regularly used LLINs in children under 5 (47.25%) compared to 231 using it irregularly, i.e. a prevalence of low use of 52.75%.

Factors Associated with the Low Use of LLINs
Relationship between low use of LLIN and socio-demographic characteristics Table 1 shows the prevalence of low use of LLINs according to socio-demographic characteristics.
Relationship between the low use, socio-economic characteristics and netrelated characteristics Table 2 shows the prevalence of the low use of LLINs according to economic characteristics and those related to the mosquito net.
Relationship between the low use of LLINs, environmental, behavioral characteristics and those related to knowledge about malaria and its prevention Table 3 shows the prevalence of the low use of LLINs according to environmental, behavioral characteristics and those related to knowledge of both malaria and its control methods.

Discussion
The cluster sampling as recommended by WHO, used in this population-based study, can make it possible to extrapolate the results obtained to the entire area of Fô-Bouré.
Prevalence of the low use of LLINs among children under 5 years of age The prevalence of LLIN low use among children under 5 was 52.75%. This high prevalence in a context of high availability of mosquito nets (95.24%) made possible through the free distribution, highlights the complexity of the question Open Journal of Pediatrics    [10].
The study also showed that the acquisition of LLINs through free distribution organized by the State was statistically associated with its low use. This can be explained by the low consideration accorded by human nature to all that is granted without effort, without difficulty, without participation. These mosquito nets acquired free of charge are not only used to protect children against malaria but are also used for other purposes (market gardening, body care) as shown by Dye, et al. [11] in their studies. This situation raises the thorny question of the effectiveness of the free distribution of mosquito nets by our States, which could guarantee the availability of mosquito nets at a lower cost to involve the beneficiaries in the acquisition and make them realize their responsibilities.

Conclusion
The study showed that less than one in two children do not regularly use LLINs in the area of Fô-Bouré. Univariate analysis identified several sociodemographic, economic, and knowledge-related factors about malaria as associated with the low use of LLINs. A global development policy, especially in terms of education, sanitation and housing improvement as recommended by the "Roll Back Malaria" initiative is necessary to improve the rate of insecticide impregnated nets use.