Multilevel Determinants of Insecticide-Treated Net Use in A Post-Malaria Elimination Setting: Analysis of the 2016 Timor-Leste Demographic and Health Survey
DOI:
https://doi.org/10.26911/jepublichealth.2026.11.04.02Abstract
Background: Although malaria has been eliminated in Timor-Leste, mosquito-borne diseases such as dengue remain a major public health concern. Insecticide-treated nets (ITNs) continue to be an important preventive measure; however, evidence on the determinants of ITN utilization in the post-malaria elimination era remains limited. This study aimed to examine individual and contextual factors associated with ITN utilization among adults in Timor-Leste.
Subjects and Method: This study used secondary data from the 2016 Timor-Leste Demographic and Health Survey (TLDHS). A total of 17,229 respondents aged 15 years and older were included in the analysis. The dependent variable was ITN utilization. Independent variables included sex, age, education, marital status, media exposure, household wealth index, and place of residence. Multilevel logistic regression was applied to assess both individual- and contextual-level determinants, accounting for clustering at the municipality and community (cluster) levels.
Results: Women were more likely to use ITNs than men (AOR=1.36; 95% CI=1.26 to 1.48; p<0.001). Married respondents had higher odds of ITN utilization than unmarried respondents (AOR=2.41; 95% CI=2.17 to 2.67; p<0.001). Respondents with primary and secondary education were more likely to use ITNs than those with no formal education. Media exposure was positively associated with ITN use (AOR=1.10; 95% CI=1.01 to 1.21; p=0.028). Rural residents were more likely to use ITNs than urban residents (AOR=1.38; 95% CI=1.08 to 1.77; p=0.009). Compared with the poorest households, respondents from poorer, middle-income, and richer households had significantly higher odds of ITN utilization. Multilevel analysis revealed significant contextual variation, with 4.9% and 26.7% of the variance attributable to municipality- and cluster-level differences, respectively.
Conclusion: ITN utilization in Timor-Leste is influenced by both individual and contextual factors. Marital status, sex, education, media exposure, household wealth, and place of residence were significant determinants of ITN use. Community-level variation highlights the importance of combining individual-focused interventions with community-based strategies to sustain mosquito-borne disease prevention in the post-malaria elimination era.
Keywords:
insecticide-treated net, mosquito-borne disease, multilevel analysis, vector controlHow to Cite
References
Bandzuh JT, Ernst KC, Gunn JKL, Pandarangga S, Yowi LRK, Hobgen S, Cavanaugh KR, et al. (2022). Knowledge, attitudes, and practices of Anopheles mosquito control through insecticide-treated nets and community-based health programs to prevent malaria in East Sumba Island, Indonesia. PLOS Glob. Public Health. 2(9): 1–15. https://doi.org/10.1371/journal.pgph.0000241.
Benelli G, Mehlhorn H. (2016). Declining malaria, rising of dengue and Zika virus: Insights for mosquito vector control. Parasitol Res. 115(5): 1747–1754. https://doi.org/10.1007/s00436-016-4971-z.
Bronfenbrenner U. (1977). Toward an experimental ecology of human development. Am. Psychol. 32(7): 513–531. https://doi.org/10.1037/0003-066x.32.7.513.
Fikadu M, Ashenafi E. (2023). Malaria: An overview. Infect Drug Resist. 16: 3339–3347. https://doi.org/10.2147/IDR.S405668.
Golden SD, McLeroy KR, Green LW, Earp JAL, Lieberman LD. (2015). Upending the social ecological model to guide health promotion efforts toward policy and environmental change. Health Educ Behav. 42(1):8–14. https://doi.org/10.1177/1090198115575098.
Kuetche MTC, Tabue RN, Fokoua-Maxime CD, Evouna AM, Billong S, Kakesa O. (2023). Prevalence and risk factors determinants of the non-use of insecticide-treated nets in an endemic area for malaria: Analysis of data from Cameroon. Malar J. 22(1). https://doi.org/10.1186/s12936-023-04510-9.
Li Q, Liu T, Lv K, Liao F, Wang J, Tu Y, Chen Q (2025). Malaria: past, present, and future. Signal Transduct Target Ther. 10:188. https://doi.org/10.1038/s41392-025-02246-3.
Lindsay SW, Thomas MB, Kleinschmidt I. (2021). Threats to the effectiveness of insecticide-treated bednets for malaria control: Thinking beyond insecticide resistance. Lancet Glob Health. 9(9): e1325–e1331. https://doi.org/10.1016/S2214-109X(21)00216-3.
Lover A, Sutton B, Asy A, Wilder-Smith A. (2011). An exploratory study of treated-bed nets in Timor-Leste: Patterns of intended and alternative usage. Malar J. 10(1): 199. https://doi.org/10.1186/1475-2875-10-199.
Machado FN, Draper AD, Fernandes AM, dos Santos FBA, Mali MA, Tilman AJP, et al. (2024). The first confirmed outbreak of chikungunya reported in Timor-Leste, 2024. Commun Dis Intell. 48. https://doi.org/10.33321/cdi.2024.48.17.
Merga T, Adane MM, Shibabaw T, Salah FA, Ejigu LJ, Mulatu S. (2024). Utilization of insecticide-treated bed nets and associated factors among households in Pawie District, Benshangul Gumuz, Northwest Ethiopia. Sci Rep. 14(1). https://doi.org/10.1038/s41598-024-81090-x.
Mwebesa E, Agbi DM, Iha DT, Agasa LO, Mwangi A. (2025). Effect of exposure to malaria messages on insecticide-treated net use among women and under-five children in Uganda: A propensity score matched analysis. Malar J. 24(1). https://doi.org/10.1186/s12936-025-05629-7.
Newby G, Bennett A, Larson E, Cotter C, Shretta R, Phillips AA, Feachem RGA. (2016). The path to eradication: A progress report on the malaria-eliminating countries. The Lancet. 387(10029): 1775–1784. https://doi.org/10.1016/S0140-6736(16)00230-0.
Terefe B, Habtie A, Chekole B. (2023). Insecticide-treated net utilization and associated factors among pregnant women in East Africa: Evidence from the recent national demographic and health surveys, 2011–2022. Malar J. 22(1). https://doi.org/10.1186/s12936-023-04779-w.
The DHS Program. (2018). Timor-Leste Demographic and Health Survey 2016. Rockville, Maryland, USA: ICF International. Retrieved from https://microdata.worldbank.org/index.php/catalog/2992.
WHO (2010). Dengue and severe dengue. Retrieved from https://www.who.int/health-topics/dengue-and-severe-dengue#tab=tab_1
WHO (2012). Handbook for Integrated Vector Management. Retrieved from https://www.who.int/publications/i/item/9789241502801.
WHO (2022). Dengue – Timor-Leste. Retrieved from https://www.who.int/emergencies/emergency-events/item/2022-e000010.
WHO (2024). Vector-borne diseases. Retrieved from https://www.who.int/news-room/fact-sheets/detail/vector-borne-diseases.
WHO (2025). Timor-Leste certified malaria-free by WHO. Retrieved https://www.who.int/news/item/24-07-2025-timor-leste-certified-malaria-free-by-who.
Yaya S, Uthman OA, Amouzou A, Bishwajit G. (2018). Mass media exposure and its impact on malaria prevention behaviour among adult women in sub-Saharan Africa. Glob Health Res Policy. 3(1). https://doi.org/10.1186/s41256-018-0075-x.
Yirsaw AN, Gebremariam RB, Getnet WA, Mihret MS. (2021). Insecticide-treated net utilization and associated factors among pregnant women and under-five children in East Belessa District, Northwest Ethiopia: Using the Health Belief Model. Malar J. 20(1). https://doi.org/10.1186/s12936-021-03666-6.
