Abstract
Background: Malaria is one of the deadliest mosquito-borne diseases. Despite the demonstrated benefits of insecticide-treated nets (ITNs) usage in children under 5 years of age, nonuse is linked to higher mortality and morbidity rates. This study examined how child-, maternal-, household-, and community-level determinants influence ITN utilization among children under 5 in The Gambia for malaria prevention. It further elucidates how household environment, infrastructure, and drinking water sources mediate under-5 ITN utilization in The Gambia. Method: Secondary data analysis of The Gambia Demographic Health Survey (2019-2020) was conducted in this study. We used Chi-square test, linear model ANOVA, multivariable regression model, and mediation analysis to analyze the influence of child-, maternal-, household-, and community-level factors on under-5 ITN utilization in The Gambia. We computed crude and adjusted odds ratios (cOR and aOR, respectively) for potential confounders across groups, with statistical significance set at p < 0.05, and 95% confidence interval (CI). Results: The prevalence of ITN utilization among under-5 children was 63.4% (95% CI: 61.0%, 65.8%). This study identified several significant factors influencing under-5 ITN utilization in The Gambia, such as children's anemia status (aOR = 0.53, 95% CI [0.27, 0.97], p = 0.050), mother's literacy (aOR = 0.77, 95% CI [0.61, 0.96], p = 0.021), female household heads (aOR = 0.67, 95% CI [0.56, 0.81], p < 0.001), household wealth index (aOR = 0.55, 95% CI [0.42, 0.72], p < 0.001), and residence (aOR = 1.30, 95% CI [1.04, 1.62], p = 0.022). Ethnicity and region also influenced ITN utilization, with variations across different ethnic groups and regions (including Kerewan aOR = 2.29, 95% CI [1.54, 3.39], p < 0.001). Mediation analysis highlighted both the direct and indirect effects of household infrastructure and drinking water sources on ITN utilization, emphasizing the multifaceted nature of the factors influencing ITN use in this context. Conclusion: This study elucidates the complex factors influencing ITN utilization among children under 5 years of age in The Gambia. The nuanced understanding of individual-, household-, and community-level factors offers a robust foundation for targeted strategies for malaria prevention, with far-reaching implications for public health policy and practice.