Abstract
BACKGROUND: Malaria continues to be a significant public health challenge in Ethiopia, especially among children under the age of five, who are more vulnerable to the disease. Insecticide-treated nets (ITNs) are widely recommended as an effective preventive measure. However, studies in Ethiopia have reported inconsistent findings regarding ITN utilization among under-five children. This study aimed to determine the pooled prevalence of ITN use and identify determinants among children under five in Ethiopia. METHODS: A systematic review and meta-analysis was conducted by searching PubMed, CINAHL, Web of Science, Science Direct, SCOPUS, and Google Scholar for studies published from 2008 to 2024. Data were extracted into Excel and analysed using STATA 17. A random-effects meta-analysis model was applied to estimate the pooled prevalence and determinants. Statistical heterogeneity was assessed using the I(2) statistic, and potential publication bias was evaluated using Egger's test and visual inspection of forest plots. RESULTS: The pooled prevalence of ITN utilization among under-five children in Ethiopia was 53% (95% CI 43%-63%, I(2) = 99.46%, indicating substantial heterogeneity. Factors significantly associated with higher ITN utilization included having more than two sleeping spaces (OR = 4.596, 95% CI 2.075-7.117), good knowledge about ITNs (OR = 3.7, 95% CI 2.239-5.194), positive perception of ITNs (OR = 5.5, 95% CI 3.011-7.988), rural residence (OR = 3.211, 95% CI 1.464-4.958), low perceived barriers (OR = 2.21, 95% CI 1.90-2.52), monthly income above 1,000 birr (OR = 2.996, 95% CI 1.478-4.515), household head age over 25 years (OR = 2.75, 95% CI 2.279-3.217), and ownership of a radio (OR = 2.545, 95% CI 2.177-2.912). CONCLUSION: This systematic review and meta-analysis found that nearly half of Ethiopian children under five are not utilizing ITNs, leaving them vulnerable to preventable malaria infection. While factors such as caregiver knowledge, household income, rural residence, sleeping space availability, positive perceptions of ITNs, and media access were significantly associated with ITN use, the substantial heterogeneity among studies underscores the need for context-specific interventions. To improve ITN coverage and consistent use, targeted public health strategies should prioritize addressing socio-economic disparities, enhancing community education, and strengthening ITN distribution systems. These findings support the development of evidence-informed policies and behaviour change interventions, particularly in underserved rural and low-income communities.