# Trends and inequalities in insecticide-treated net use among children under five in Ghana, 2003–2022: analysis of Demographic and Health Surveys using the WHO Health Equity Assessment Toolkit (HEAT)

## TL;DR

This study analyzed trends in insecticide-treated net use among children under five in Ghana from 2003 to 2022, finding significant increases but growing inequalities based on wealth, region, and residence.

## Contribution

The study provides a detailed analysis of ITN use inequalities in Ghana using the WHO Health Equity Assessment Toolkit over nearly two decades.

## Key findings

- ITN use increased from 3.9% in 2003 to 54.1% in 2019 but declined to 49.0% in 2022.
- Wealth-based inequality widened, with a 39.4% difference between the poorest and richest quintiles in 2022.
- Regional and rural-urban disparities in ITN use also increased significantly over the study period.

## Abstract

Malaria is a leading cause of morbidity and mortality among children under five in sub-Saharan Africa, especially in Ghana. Insecticide-treated nets (ITNs) are among the most effective prevention tools, yet disparities in use persist, undermining equitable malaria control. This study examined trends and inequalities in ITN use among Ghanaian children under five from 2003 to 2022.

A cross-sectional secondary analysis was conducted using six rounds of the Ghana Demographic and Health Surveys (2003–2022). The outcome variable was defined as whether a child had slept under an ITN on the night preceding the survey. Equity stratifiers were analysed using the WHO Health Inequality Toolkit. Inequalities were measured through difference (D), ratio (R), absolute concentration index (ACI), population attributable risk (PAR), and population attributable fraction (PAF), each with 95% confidence intervals (CIs).

The study found that the national ITN use increased from 3.9% in 2003 to 54.1% in 2019, before declining to 49.0% in 2022. Wealth-based inequality widened substantially, with the ACI shifting from − 0.3 (95% CI − 1.4 to 0.8) in 2003 to − 7.9 (95% CI − 8.8 to − 7.1) in 2022. The difference between the poorest and richest quintiles rose from − 4.1% in 2003 to − 39.4% in 2022, while the ratio declined from 0.8 to 0.4. Regional disparities were also marked, with the difference increasing from 21.8% in 2003 to 39.5% in 2022, and ratios rising from 2.2 to 2.3. Residence-based inequalities grew, with rural–urban difference widening from − 0.2% in 2003 to − 25.1% in 2022. Sex and age contributed minimally, with ACIs fluctuating (− 2.5 in 2014 and 1.0 in 2022) for sex.

Although ITN use among Ghanaian children under five has increased substantially since 2003, widening inequities persist, particularly by wealth, region, and residence. Findings highlight the need for equity-focused policies to accelerate progress towards Sustainable Development Goal 3.3, ending malaria by 2030.