Evidence brief: Coverage of insecticide-treated mosquito nets in preschool consultations and factors associated with non-use of insecticide-treated mosquito nets among children in the Democratic Republic of Congo: A base population cross-sectional study

Abstract

Insecticide-treated nets (ITNs) are among the most effective malaria prevention interventions, yet their actual use among children remains below national targets. This study assesses ITN coverage and utilization among children attending preschool consultations (PSC) and identifies factors associated with non-use. A cross-sectional study was conducted in 2025 in 156 health facilities across six provinces of the Democratic Republic of the Congo (DRC). Children aged 6–59 months accompanied by a parent or guardian were included. Data were collected during a household survey through face-to-face interviews using a structured questionnaire programmed in ODK Collect. Data on ITN ownership and use, as well as sociodemographic characteristics, were collected. Factors associated with non-use were analyzed using multivariate logistic regression. Among the 1,247 children included in preschool consultations, the mean age was 15.0 ± 4.3 months. The population showed marked socioeconomic vulnerability: 81.5% of guardians had a low educational level, 82.4% of households had low monthly income, and 48.2% lived in rudimentary housing. Community awareness through community health workers (CHWs) was high (78.7%). Overall, 62.5% of households owned at least one ITN, and 95.9% of children used it. The main factors associated with non-use were lack of community sensitization (aOR = 4.75), parental marital status (aOR = 4.57), rainy season (aOR = 3.41), rudimentary housing (aOR = 2.59), and a high number of children in the household (aOR = 1.80). Adherence to ITN use was ≥ 80% of individuals reporting sleeping under an ITNs the previous night, a predefined threshold based on WHO recommendations. Community-based interventions and context-adapted planning that account for seasonal and socioeconomic factors are essential to maximize the impact of malaria reduction among preschool children in the DRC.

Introduction

Malaria remains a major public health problem in the Democratic Republic of the Congo (DRC), where it is one of the leading causes of morbidity and mortality among children under five years of age [1,2]. The DRC is among the countries bearing the heaviest global malaria burden, contributing substantially to the overall disease burden in sub-Saharan Africa [3]. In this context, vector control is a crucial strategy for reducing malaria incidence, particularly among vulnerable populations such as preschool-aged children [4–6]. Insecticide-treated nets (ITNs) are recognized by the World Health Organization (WHO) as one of the most effective preventive interventions against bites from Anopheles mosquitoes, the vectors responsible for malaria transmission [7]. The effectiveness of ITNs relies on two complementary mechanisms: physical protection against mosquito bites and insecticidal action that reduces vector density [8,9]. Numerous studies have demonstrated a significant reduction in malaria incidence and child mortality in areas where ITN use is high [7,10]. In the DRC, several free ITN distribution campaigns have been implemented as part of national malaria control programs. Recent data from the Demographic and Health Survey (DHS-RDC III, 2023–2024) indicate relatively high household net ownership, estimated at approximately 69% in some provinces [11]. However, effective use of these nets among children under five remains below national targets, defined as ≥80% coverage, with only about 57% of children reported to have slept under an ITN the night before the survey [11]. This discrepancy between ownership and actual use is a major concern, as it limits the expected impact of preventive interventions on reducing the malaria burden. Determinants of ITN use are multifactorial and vary according to sociocultural and economic contexts. Studies conducted in various African countries have identified factors such as parental education level, knowledge of malaria transmission, perception of net effectiveness, availability of sufficient nets for all household members, and practical barriers such as discomfort due to heat or difficulty in installation [12,13]. Children under five years of age represent a biologically and epidemiologically distinct high-risk group for malaria, with significantly higher morbidity and mortality compared to older children and adults. For this reason, national malaria control strategies in the DRC and WHO guidelines prioritize this age group for preventive interventions, including universal access and use of insecticide-treated nets (ITNs) [13]. Furthermore, evidence from the literature suggests that ITN use is not uniformly distributed within households, and that children under five are often prioritized for net use due to their heightened vulnerability [14]. However, intra-household allocation may still be influenced by factors such as household net availability, caregiver knowledge, education level, perception of malaria risk, and cultural or practical sleeping arrangements. Given this epidemiological vulnerability and programmatic prioritization, focusing the analysis on children under five allows for a more targeted assessment of equity and effectiveness in the implementation of malaria prevention strategies [15].