In Ethiopia, malaria continuous to be a significant public health concern, particularly affecting vulnerable children under the age of five. Evidence showed that the prevalence of malaria among children under five years of age in Ethiopia was 22.03% (12). Main findings of this study showed that children under five, live with care givers with inadequate malaria related health information, residing close to the presence of malaria vector breeding habitat and in proximity to stagnant water, and those lodge in houses with openings for mosquito entry in their walls were at risk for malaria transmission.
In addition, our findings disclosed that children living in rural areas have increased odds of malaria infection.. This is consistent with the finding of another studies conducted earlier in other part of Ethiopia (13) and in other African countries, where malaria prevalence was found to be higher among rural children compared to urban children in Kenya (14), in Uganda (15), and in Rwanda (16). This could be due to the fact that, rural areas often have more favorable environments for the breeding of mosquitoes. Factors such as stagnant water, lack of proper drainage systems, and dense vegetation provide ideal breeding grounds for mosquitoes. Rural areas typically have limited access to healthcare facilities compared to urban areas. This means that people living in rural areas may face challenges in accessing malaria diagnosis and treatment services promptly. Delayed or inadequate treatment can result in higher rates of infection. Rural populations often have lower socioeconomic status compared to urban populations. Poverty can contribute to factors such as inadequate housing, lack of access to mosquito control measures such as insecticide-treated bed nets, and limited access to preventive measures like antimalarial medications. Urban populations generally have better access to education and healthcare information compared to rural populations. This includes knowledge about malaria prevention strategies such as using bed nets, indoor residual spraying, and seeking prompt medical care. Higher levels of education and awareness can lead to better adherence to preventive measures and earlier detection and treatment of malaria cases.
Children living in the vicinity of malaria breeding areas and close to sources of stagnant water are at a significantly higher risk of contracting malaria than those living in other areas. Stagnant water creates a favorable condition for breeding of Anopheles mosquito, a malaria vector. This facilitates in the increment of the density of the vector itself, and the probability of mosquito bites to children, which in-turn scales up the likelihood of malaria transmission among those children. This is supported by a study conducted in Ethiopia (12, 17–19). Mosquito breeding habitats, include stagnant water (marshy environments) or trees near residential houses, are risk factors for malaria transmission as reported in previous studies in Wogera district, Laelay Adyabo (19, 20). Malaria vector density and living in the nearest proximity of water body, like river and streams could be an important factor influencing malaria transmission.
Housing plays a significant role in malaria prevention, particularly in areas where the disease is endemic. The design and construction of houses can affect their susceptibility to mosquito entry. Well-constructed houses with screened windows and doors, tight-fitting eaves, and properly sealed walls can reduce the entry of mosquitoes into living spaces (21), thereby lowering the risk of malaria transmission indoors. Proper housing provides a structure to hang insecticide-treated bed nets (ITNs) or long-lasting insecticidal nets (LLINs) over sleeping areas. Proper housing structures with smooth, easily cleanable walls are necessary for effective IRS implementation (22). Families whose household walls have holes for mosquito entrance were more likely vulnerable when compared with no hole on the house wall (22). Evidence from increased malaria infection among children living in houses with mosquito entry opening holes on the their walls is in line with other similar studies, such as (23–26). Several structural deficiencies on houses that could allow entry of mosquitoes were found such as lack of screening, and external doors not fitting perfectly into walls hence potential for mosquito entry at night (27). Simple house modification by eave screening has the potential to reduce the indoor occurrence of both Anopheles and Culex mosquito species (28). Improving house structure is known to limit contact between humans and mosquitoes, and hence, reduces risk of malaria transmission. Our study indicated that several house characteristics such as, the presence of holes on walls, opened eaves, unscreened window and living close to breeding sites, favored mosquito presence in houses (24, 25, 29).
The health and growth of the child depend on the education of the caregiver (mother), as this study demonstrated a significant association between the likelihood of malaria infection and the mothers' education level in Gursum district. This finding is consistent with previous studies that have indicated that higher education and malaria knowledge positively influence the ownership of nets by households (30). The possible explanation for this is that, more educated and knowledgeable people can access information about how to prevent malaria, and adopt better practices to protect and use the nets they receive.
The results indicate that participants who had received health information about malaria were less likely to have malaria than those who had not, with a COR of 1.78 and a 95% CI of 1.04–3.04. This evidence supported by study done in different part of Ethiopia (31). This suggests that health information about malaria may have a protective effect against malaria infection. Knowing malaria prevention mechanisms is another determinant factor for malaria transmission among children under five. Children whose households don’t know the prevention ways were more likely to be infected with malaria as reported in other studies as well (19).
One of the most effective ways to prevent malaria infection is to use insecticide-treated nets (ITNs). However, many people in malaria-endemic areas do not have access to ITNs or do not use them regularly. A study conducted in Ethiopia (17) found that children who lived in households without ITNs had a higher risk of malaria infection than those who lived in households with ITNs, and this difference was statistically significant. This result contradicts some previous studies that did not find a significant association between ITN ownership and malaria infection (32). The study also highlighted the scarcity of ITNs and other malaria prevention tools as a major challenge for malaria control in Ethiopia, which is consistent with another study done in Arba-minch (19).
This study has its own limitation it will not cover all health centers that are found in the districts due to lack of logistics and finance. One of the limitations is the case ascertainment, some of the children are tested using RDT, which might not be 100% sensitive and specific. Due to this there might be misclassification of cases and controls. However, the study results would not affected by this limitation and the samples taken from three health center can be representative the districts.