Malaria remains a public health problem in sub-Saharan Africa and it is more serious in vulnerable groups such as children under five years old and pregnant women [1]. Malaria transmission is perennial in all regions of Cameroon including the BHD where almost all citizens fall ill with it each year [2]. The National Malaria Control Program (NMCP) report of activities shows that in the South West Region of Cameroon, 56% of consultations, 54% of hospital admissions and 53% of deaths among children below five years are due to malaria [3]. Similarly, 42% of consultations, 70% of hospital admissions, and 12% of deaths among pregnant women are due to malaria.

The crumbling effects of malaria on the vulnerable groups and the socio-economic development of the nation can be greatly reduced through prevention. The main strategies of malaria prevention in Cameroon are intermittent preventive treatment (IPT) for pregnant women and vector control through the use of ITNs especially for pregnant women and children under five [3]. Freely distributed ITNs have been in existence in households in Cameroon since 2003 following the Abuja Declaration in 2000. The main objective of this initiative was to prevent transmission, infection and suffering among the vulnerable populations – children under five years and pregnant women [4]. In February 2007, long lasting insecticide treated bed nets (LLINs) were distributed to households with at least one child under five years of age in the BHD [5]. ITNs are also being distributed in the country free of charge to pregnant women during antenatal clinics (ANC) while the rest of the community members obtain their own ITNs from the regional treatment units (RTU) and community treatment units (CTUs) where ITNs are re-impregnated with insecticides after regular intervals of six months by community relay agents (CRA) who have been trained to carry out this exercise. Unfortunately, ITN ownership and utilization appear to be in disparity as analysed by the Malaria Report for Cameroon [6]. It would seem that this difference between ownership and utilization is related to the level of knowledge on malaria and socio-demographic factors as age and marital status [7, 8] as well as education and occupation. Elsewhere, the gap between ownership and utilization of bed nets has also been shown to be wide [9–11].

Kimbi et al.[12] reported that malaria morbidity is still relatively high in some parts of the BHD. Again, a household survey of malaria indicators conducted in Obala, Cameroon, showed that 80% of households were in possession of MBNs, 73.41% of children under five slept under such nets and fever was reported in children under five in 75% of households [13]. However, this survey did not report on the utilization of ITNs among vulnerable groups and the factors influencing such utilization. Takem et al.[14] reported a 16.95% ITN use in Buea, but the study did not differentiate between ITN use by vulnerable groups and the general population. Therefore, little is known about the actual ITN ownership, utilization and knowledge of the factors determining the utilization of ITNs by pregnant women and children under five in the BHD. Against this background this study was aimed at assessing the socio-demographic factors influencing the ownership and utilization of ITNs among malaria vulnerable groups in the BHD, Cameroon.

This study examined the socio-demographic factors influencing the ownership and utilization of MBNs in the Buea Health District. Overall, only 47% of households interviewed owned at least one MBN. This coverage is far less than the coverage of 80% recorded in Obala, Cameroon in 2009 [13]. This may be due to the fact that the study in Obala was done just two years after the distribution campaign and many people still had their nets intact. The majority of the nets distributed in BHD in 2007 might have been torn and out of use at the time of this study. This is supported by the fact that a good proportion of nets observed in homes were torn and out of use. It is also worth noting that the free distribution of ITNs was done in the different regions in Cameroon at different times, for example, those for the East, South and South West Regions, were in 2007 while those for the West and Littoral Regions were in 2009. Furthermore, residents of the North West, Centre and East Regions continue to receive free LLINs from other partners such as PLAN Cameroon (a non-governmental organisation). Tobin-West and Alex-Hart [16] also reported a 37.2% utilization in Nigeria and the main reason for this low rate was the tropical heat associated with the use of bed nets.

The results showed that the majority of MBNs were obtained from ANC and during immunization campaigns. Only 16% of the MBNs found in households were purchased from the market. Many respondents did not even know the price of a MBN in the market as respondents apparently had the attitude of receiving free MBNs. This implies that cost of MBNs was certainly an important barrier to the ownership of bed nets in this area. One of the ways to ensure ownership and use of these MBNs will be for the government to provide them free of charge. At worst the government could subsidize the prices thus making them more accessible and affordable to the poor who form the majority of the population in the study area. A similar situation was reported in Nigeria by Singh and Singh [17].

The practice of purchasing MBNs from the market, ownership and utilisation of MBNs were found to be associated with marital status. The married respondents were 3.66 times more likely to buy a MBN from the market when compared with the single respondents. This can be linked to the fact that married women received financial aid from their husbands unlike single women who struggle on their own to take care of all family responsibilities. Generally, better malaria prevention and control strategies including MBN use have been associated with financial or socio-economic status of the individuals concerned as they are directly linked to accessibility and affordability of the preventive measures [18].

Respondents in the urban areas were significantly more likely to purchase MBNs from the market than those in the rural communities. Generally, urban dwellers are wealthier and more educated than those in the rural communities. Studies by Legesse et al.[19] associated education and wealth status with comprehensive knowledge on malaria preventive measures. This probably explains why respondents from urban areas were better able to buy MBNs from the market. It is worth noting that the free distribution of ITNs at health facilities had halted at the time of this study, such that only a few pregnant women reported having received a MBN for the current pregnancy. This inconsistency in the program can be a source of laxity on usage even for those who are in possession of MBNs. The attention of the health authorities and stakeholders in the malaria control program has to be drawn to this inconsistency in the free distribution of ITNs especially to vulnerable groups as the failure of the program could result in high rates of malaria morbidity and mortality among them.

The utilization of MBNs/ITNs by children under five and pregnant women lagged behind ownership. This corroborates the findings of Afolabi et al.[20] who reported high possessions of ITNs and low utilization in Nigeria. Tsuang et al.[21] postulated that in such situations, many household members may be forced to make difficult decisions about who should sleep without the protection of the MBN. This implies that great proportions of the vulnerable groups were not protected against malaria with ITNs or were partially covered by untreated or expired MBNs. This potentially placed the high risk groups in particular and other members of the households in general at higher risk due to mosquito “diversion effect”. This agrees with the reports of Lines et al.[22] and Tsuang et al.[21]. This implies that the burden of malaria morbidity and mortality among the vulnerable groups of BHD may continue to exist and even increase. Interestingly, malaria accounted for 7% of post-neonatal child deaths globally in 2010 and 15% of post-neonatal child deaths in Africa [23]. This is astounding for a disease that is preventable and treatable. Afolabi et al.[20] declared that the use of ITNs remains one of the best cost-effective interventions against malaria. They are estimated to be twice as effective as untreated MBNs and offer 70% protection when compared with no net at all [24]. Contrary to ownership of MBNs by vulnerable groups that was linked to urban settlement the reverse was the case with knowledge of treatment centres and the use of MBNs. This may be due to the fact that people in the rural areas are less able to afford malaria treatment and therefore take preventive measures more seriously than their urban counterparts.

The low utilization of ITNs by under-fives (38%) was however, higher than the 13% reported for 2006 in Cameroon [25] before the free distribution of LLINs to households with under-fives in BHD. Parents of those who own MBNs therefore need to be encouraged to put them into use in order to achieve the optimum target. This relatively low utilization is probably due largely to socio-demographic and personal factors and not due to lack of MBNs in households because not all the households that had MBNs put them into use. Some MBNs were found still sealed inside their packages, while some were hung on windows. This phenomenon is common in many sub-Saharan countries [20, 26]. Perhaps, with the low level of education, in some cases the respondents do not appreciate why they should use MBNs or how to hang and set them up. It is worth noting that ITN use has been shown to reduce clinical malaria episodes by approximately 50% and all-cause mortality by 17% [27]. In situations where ITN coverage in the community is above 60%, a community effect has been seen in which non-users receive similar protection to ITN users [20]. Reducing malaria burden therefore will likely contribute to the attainment of the millennium development goals, especially those related to reduction in malaria deaths and poverty, while improving maternal and infant health.

Respondents’ level of awareness of treatment centres was very low and out of the 103 (23%) who knew where their treatment centres were found, only 36 (26%) of them had ever taken a MBN there for treatment. The population needs to be sensitized on the location of treatment centres and the necessity to treat purchased ordinary MBNs especially those used over babies’ cots. This could best be done by training health personnel who will be responsible for giving out information on bed net use during ANC and infant welfare activities at health facilities. Community relay agents could be motivated to give extensive information, education and communication campaign messages to the households in ‘Pidgin’ English and or local languages to advocate for a change in behaviour. The local community radio stations and television channels could be used where well “structured” messages on bed net use in relation to a reduction in malaria incidence/morbidity could be broadcast in such languages [12, 28].

In the effort to use MBNs, respondents reported a number of challenges. These barriers could be overcome by adopting the door-to-door distribution and hang up strategies employed by the Alliance for Malaria Prevention, the President’s Malaria initiative and the International Federation of Red Cross and Red Crescent Society, as described by the United States Agency for International Development [29].

The preferred colour of the MBN was controversial. The green colour was the most uncomfortable colour for some, yet, very comfortable for others. The blue colour was the most comfortable. The green colour was however preferred by some people because it tolerates dirt and stains more than bright colours such as white and sky-blue. These findings agree with those of Ng’ang’a et al.[30]. The rectangular bed net was also preferred by most (74%) of the respondents because it is more spacious while the conical net is easier to mount, more convenient for baby’s cot and for small rooms. Therefore, colour preference and shape of MBNs remain very subjective and depend to a large extent on the individuals concerned.

In the present study the utilization of MBNs by children in block houses was lower than that of children in plank houses; thus children in block houses were more at risk of mosquito bites and consequently malaria infections. This high level of utilization of nets in plank-louver houses would probably result in fewer episodes of malaria of the occupants of such houses in this study. Community members need to be sensitized to know that mosquitoes get into the houses through the door and not only through the windows and cracks on the walls and therefore proper and consistent use of nets will reduce the number of malaria episodes in the net users and by extension other household non-net members as suggested by Tsuang et al.[21].

One of the major strengths of this work is the fact that it was conducted during the peak rainy season when the majority of respondents reported using MBNs and this period coincided with the peak malaria transmission season. Elsewhere, the cold rainy season has been reported to be a key reason for using MBNs [31, 32]. Some of the challenges of the study include the fact that there was no established list of households in any of the health areas and so systematic simple random selection of households was a little difficult. Our instrument was not sensitive enough to observe household members actually sleeping under the MBNs at night. Therefore, actual utilization may be lower than reported.

The utilization of bed nets was lower than ownership. There is therefore a need to develop new strategies for sensitization messages to reach every community member. The NMCP should ensure that the free distribution of ITNs to vulnerable groups is continuous and consistent in the BHD. Community members need to be sensitized to purchase ordinary bed nets and take them for impregnation at the CTUs and not only wait for free distributions. CRAs activities also need to be updated to involve hanging of nets in homes and helping household members to overcome social and personal barriers in the use of bed nets.

HKK: PhD and Associate Professor of Medical Parasitology, Head of Department Zoology and Animal Physiology

SBN: MPh in Public Health

JLN-N: MSc and Assistant Lecturer of Zoology

IUNS: PhD and Lecturer of Parasitology

JA: PhD and Lecturer of Public Health

MBSA: PhD and Lecturer of Nursing, Head of Department, Nursing