Inequity in the use of Insecticide-Treated Nets among Children and Adolescents in Rural Guinea: A cohort study in rural Guinea

Background Malaria continues to be a major cause of illness and death globally, particularly in sub-Saharan Africa. Children and adolescents are highly vulnerable to this condition. Despite the increased ownership of insecticide-treated nets (ITNs) through mass campaigns, usage disparities remain, particularly in rural areas. This inequality in ITN use sustains the high prevalence of malaria. We aimed to examine the socioeconomic and demographic factors influencing ITN usage among children and adolescents in rural Guinea. Methods A longitudinal study in Mafèrinyah, rural Guinea, from March 2022 to February 2023, involved monthly household visits to gather data on ITN usage among children aged 1-9 and adolescents aged 10-19. The PROGRESS framework has been used to assess equity in ITN use, focusing on variables such as wealth quintiles, occupation, and education of the household head. Inequality was measured using the concentration index (CI) and slope index of inequality (SII), with a decomposition analysis identifying the key drivers of inequality. Results Socioeconomic inequities in ITN use were pro-poor, with SII -0.45 for children in both seasons and improving from -0.65 (dry) to -0.45 (rainy) for adolescents. In the decomposition, the largest positive contribution to the pro-poor pattern was use of mosquito repellents/ coils children: +36.9% ot the total inequity (Absolute -0.0276), determinant concentration index -0.171 (95% CI -0.196, -0.146); adolescents: +23.0% (Absolute -0.0283), CI -0.197 (95% CI -0.227, -0.168). The largest negative contribution (counteracting the pro-poor pattern) was public servant headed households ‘children: -22.4% (Absolute +0.0168), determinant CI -0.321 (95% CI -0.436, -0.207); adolescents: -9.7% (Absolute +0.0119), CI -0.450 (95% CI -0.613, -0.288). Conclusion Longitudinal equity analyses conducted in rural Guinea indicate that the use of insecticide-treated nets (ITNs) remains disproportionately favourable for children from lower socioeconomic backgrounds, while usage among adolescents is more variable. This reflects a persistent gap between access and utilisation, where behavioural and social factors interact with supply dynamics. Addressing these disparities necessitates ongoing, equity-focused distribution efforts complemented by social behaviour change initiatives targeting adolescents and routine equity monitoring throughout different seasons.