Long-Acting Insecticide-Treated Mosquito Nets (LLINs) are the main means of combating malaria in regions of the world where this disease is rife [1] . Indeed, at global level, the number of deaths due to malaria decreased from 625,000 to 619,000 from 2020 to 2021, but remained higher than the 568,000 deaths estimated in 2019. Malaria cases continued to rise in 2021, but at a slower rate than in 2019-2020. They were estimated at 247 million in 2021, 245 million in 2020 and 232 million in 2019 [2] . The use of LLINs is one of the prevention strategies recommended by the World Health Organization (WHO) in malaria control programs. However, this method of universal coverage of populations with LLINs in the fight against malaria still presents difficulties in its possession and use by households.

Sub-Saharan Africa is the hardest hit, with 95% of cases and 96% of deaths, 80% of which occur in children under 5 [3] . Given this situation, one of the most effective methods of combating malaria recommended by the WHO is the use of LLINs in households in malaria-affected countries [4] .

However, morbidity and mortality due to this disease are still high in sub-Saharan Africa, despite the many efforts made by national and international public health organizations. According to [5] , in Africa 46% of the population did not have an LLIN, and 53% of children under the age of five did not sleep under one. In Benin, [6] emphasized the importance of using LLINs to protect against culicidal nuisance. However, less than 50% of children aged 0 to 5 sleep under an LLIN. The parents of these children use LLINs to protect young vegetable plants. In recent years, Sierra Leone has undertaken extensive efforts to prevent malaria, and the use of impregnated mosquito nets among children under five has increased by 66% [7] . In Niger, cultural beliefs are not the main barrier to the use of LLINs. On the other hand, knowledge as well as social, technical, environmental and economic dimensions explain the non-use of LLINs at community level [8] . In Cameroon, the level of education, and both sociological and anthropological considerations play their part in this refusal to use mosquito nets. Complaints related to discomfort, suffocation under a net, irritation due to the insecticide contained in the LLIN, damage to bedroom walls due to the installation of the net and the white color of the LLIN associated with the shroud are also reasons cited [9] [10] .

Côte d’Ivoire, like other tropical African countries, is not spared the threat of malaria. It is one of the major causes of hospitalization in First Contact Health Establishments (FCHEs), with an incidence rate in 2020 of 173‰ generally in population and 441‰ in children under 5 years of age [11] . In Côte d’Ivoire, over 73% of the population lives in regions where the annual incidence of malaria ranges from 150‰ to over 300‰ inhabitants [11] . With a view to curbing this endemic, the Ivorian government, aided by international partners, has organized several LLIN distribution campaigns. As a result, the LLIN usage rate, which was 33% in 2012, rose to 50% in 2016 and to over 63% in 2019, following the distribution of over 15 million LLINs in 2017 and 2018. However, this utilization rate (63%) remains below the national target set at 80% [12] [13] . In Côte d’Ivoire, [14] also mentioned that the reasons for non-use of the LLIN are its shape, color and cost of acquisition.

Like other health districts in Côte d’Ivoire, the Dimbokro health district has benefited from two LLIN distribution campaigns, in 2017 and 2021 respectively. However, despite the efforts made by the health authorities to reduce the incidence of malaria, this health district still has one of the highest incidences in Côte d’Ivoire. Indeed, in 2021, in the general population, the incidence of malaria in Dimbokro was 262.75 ‰ versus 173.43 ‰ at national level and 633‰ versus 441‰ at national level in children under five [11] .

In view of the above, it is necessary to know the knowledge, attitudes and practices of the population of the Dimbokro health district with regard to LLINs, hence the interest of this study.

The aim of our work is to assess household use of long-acting insecticide-impregnated mosquito nets (LLINs) in order to better orient malaria control strategies in the Dimbokro health district, where this disease remains prevalent.

The aim of this study, which took place in the Dimbokro health district where malaria remains prevalent in Côte d’Ivoire, was to assess household use of LLINs.

The low level of schooling among respondents is not a barrier to the use of LLINs, nor is marital status or the high number of people living in a household.

The majority of households (nearly 70%) were aware that malaria is transmitted by mosquito bite. This can be explained by the intensification of communication campaigns to raise awareness of malaria through the media, health personnel, national and local health authorities and community health workers (CHWs). This result is in line with those of [19] [20] , who respectively found a proportion of knowledge about malaria of 72.80% in Darsalam, Mali, and 82% in Moanda, Gabon. Household perception of the seriousness of malaria in the Nofou health area was 98%, which would mean that most respondents were aware of the dangers of this disease. This could be explained by the high incidence of malaria (over 201‰) in the Dimbokro health district [11] , higher than the national level of 173‰. Reference [21] also found that malaria was considered a dangerous disease by 60.24% of respondents in a study carried out in Chad.This high level of knowledge (68.6%) of malaria is therefore an essential reason why people use LLINs.

b: Odd Ratio (95% Confidence Interval); c: Coefficient; d: Odd Ratio adjust (95% Confidence Interval); e: Statistically significant.

However, our study may have limitations of recall and information bias, which certainly affect our results. However, these biases were minimized by applying a well-designed and pre-tested questionnaire, followed by a multivariate analysis using logistic regression, which enabled us to retain significant explanatory factors and control for confounding factors. The final multivariate model identified mosquito bite/noise, age and marital status as factors significantly associated with LLIN use in the Nofou health area. The requirement of a spouse in the couple may influence regular use of LLINs.

Most households (68%) perceive the use of LLINs as the primary method of combating malaria, followed by environmental sanitation (nearly 28%). This low level of awareness of environmental sanitation shows that people do not perceive it as a real solution for preventing malaria. Our results corroborate those of [22] , who also consider environmental sanitation as a means of preventing malaria in Sunyani, Ghana.

The majority of households (94%) knew that the LLIN was used for protection against mosquito bites and noise, and slept under it at night. The population of Nofou therefore has a good perception of the LLIN as a means of preventing malaria. Our results are in line with those of [23] , who found an 80% rate of LLIN use in Samè, Mali.

Nearly 80% of households surveyed were unaware of the duration of effectiveness of the LLIN, which was 3 years [24] . This high proportion reflects households’ lack of awareness of the expiry date of the LLIN, and hence its use beyond that date. This finding on ignorance of the duration of effectiveness of the LLIN in Nofou is identical to that of [25] in Cameroon.

In our study, less than 7% of pregnant women and children under 5 used LLINs, which may also explain the high incidence of malaria in the Nofou Health Area. The low rate of LLIN use among pregnant women and children found in our study is contrary to that found by several authors [26] [27] .

According to seasonal variability, 19% and 2% of households used LLINs in the rainy and dry seasons respectively. Reasons for non-use included heat, suffocation, fatigue due to daily activities such as field work, and neglect. The proportions found in our study are lower than those of [28] , for whom nearly 50% of households use an LLIN depending on the season. For this author, the dry season was identified as one during which people slept less under a mosquito net than the rainy season (86.8%).

In the Nofou health area, the reported rate of daily use of LLINs is 46%. The high incidence of malaria in this health area could therefore be explained by the low rate of daily use of LLINs. This result is in line with that of [23] , who found a usage rate of 46% in a study carried out in Mali.

On the night before the survey, almost 93% of households claimed to have used an LLIN. This high proportion can be explained by the fact that the survey was carried out during the rainy season, when mosquitoes were more prevalent and households were cooler. In rural areas in the south of Côte d’Ivoire, [29] also found a high rate of LLIN use (97.5%) during the rainy season.

Over 66% of households washed their LLINs with soap and water, and dried them in the shade or sun. This practice results in the deterioration of LLINs. [30] in Senegal also concluded that the way in which LLINs are cared for contributes to the deterioration of their physical integrity.

The study showed that 5.1% of households had their nets torn and 30% of households had their LLINs out of date (more than three years of use). We can deduce that these households were not properly protected and were exposed to malaria. Our results are in line with those of [31] in Cameroon, who noted a breakdown in the physical integrity of the LLINs, given the duration of use (over 36 months) and the maintenance of the latter.

Washing the net with soap and exposing it to the sun can deteriorate the insecticide and contribute to the tearing of the LLIN. The population’s positive attitude towards the use of LLINs is low (28%). On the whole, this could have a negative influence on the use of LLINs, although practices are fairly acceptable.

There is a strong negative correlation (r = −0.77; p-value = 0.07) between malaria incidence and the rate of LLIN use over the 2017-2022 period when historical malaria cases were collected. However, the short series of historical health data available could influence the non-significance of the correlation coefficient r between the rate of LLIN use and malaria incidence. Indeed, the negative sign of the correlation coefficient means that a decrease in the rate of LLIN use leads to an increase in the incidence of malaria. The increase in the LLIN usage rate over the years 2018 to 2020 and 2021 to 2022 could be explained by the recent distribution of LLINs over these periods. These new, still-new LLINs are attracting the interest of households in using them.

Finally, the use of LLINs therefore depends on people’s knowledge, attitudes and practices towards them. A study by [32] in the communities of Wolaita also showed that the use of LLINs depends on these factors.

This study has shown us that the use of LLINs depends on the knowledge, attitudes and practices of households towards them. The majority of households had a good knowledge and practice of LLINs, as well as acceptable attitudes towards them. However, the incidence of malaria remains high in the Nofou health area, despite the acceptable rate of LLIN use. The acceptable rate of LLIN use by households in the Nofou health area, part of the Dimbokro health district, is justified by good knowledge and practices vis-à-vis the LLIN, but is influenced by less positive attitudes towards the latter. The convincing results of this study highlight the need to intensify awareness-raising campaigns on the use of LLINs, despite people’s knowledge of them. In addition, the study showed the urgent need to implement other control policies and strategies, such as vector control and environmental sanitation, to control the incidence of malaria in this region and others with similar characteristics, where malaria remains a public health problem.

EAMY, TASRN, BYGZ conceived, developed the idea and wrote the article.MB, APG helped verify the analyses and interpret the results. NAA participated in data acquisition and IT supervised the project. All authors discussed the results and contributed to the final manuscript.

We would like to express our sincere gratitude to the Regional Health Director of N’ZI, the Departmental Health Director of Dimbokro and the Nurse Major of the CSR of Nofou, who facilitated this study. We would also like to thank the people of Nofou for their warm welcome and support for this study.

The authors declare no conflicts of interest regarding the publication of this paper.

Yapi, E.A.M., N’krumah, T.A.S.R., Zamina, B.Y.G., Bama, M., Gouzilé, A.P., Abo, A.N. and Tiembre, I. (2024) Evaluation of the Use of Long-Lasting Impregnated Mosquito Nets (LLINs) in the Health District of Dimbokro (Center of Côte d’Ivoire). Journal of Biosciences and Medicines, 12, 44-61. https://doi.org/10.4236/jbm.2024.123005