Beyond Ownership: Understanding Insecticide-Treated Net Utilization among Pregnant Women Through a Mixed-Methods Study

Introduction: In malaria-endemic areas such as Ghana, pregnant women face elevated risk of malaria due to pregnancy-related immunosuppression. This increases the likelihood of adverse outcomes including maternal anaemia, low birth weight, and neonatal mortality. High ownership of insecticide-treated nets (ITNs) does not automatically translate into optimal utilisation. This mixed-methods study examined factors influencing ITN utilisation beyond ownership among pregnant women in the Nyohini community, Tamale Metropolis, Northern Ghana. Methods: A purposive sample of 100 pregnant women was recruited for a descriptive cross-sectional mixed-methods study. Data were collected using a structured questionnaire adapted from Malaria Indicator Survey instruments and in-depth interviews. Quantitative data were analysed with SPSS version 20.0 using descriptive statistics and multivariable logistic regression to identify factors associated with non-consistent ITN use. Qualitative data were analysed thematically using the Health Belief Model as a guiding framework. Results: Seventy-nine percent of respondents owned at least one ITN, and 96% acknowledged the importance of ITNs in reducing mosquito bites. However, only 28% reported year-round use, while 52% restricted use mainly to the rainy season. Previous-night use was 51%. The dominant barrier was heat discomfort (78%; AOR 4.8, 95% CI 2.6–8.9, p < 0.001), followed by hanging difficulties (52%; AOR 2.9, 95% CI 1.5–5.6, p = 0.002), misconceptions about malaria causation (47%; AOR 3.3, 95% CI 1.7–6.4, p = 0.004), seasonal factors (dry-season non-use 64%; AOR 5.2, 95% CI 2.8–9.7, p < 0.001), and cultural/household dynamics (41%; AOR 2.2, 95% CI 1.1–4.3, p = 0.018). Qualitative narratives confirmed that heat made nets “unbearable at night,” leading to seasonal patterns of use. Conclusion: High ITN ownership does not guarantee consistent utilisation. Addressing heat discomfort through improved net designs, implementing year-round behaviour-change communication via antenatal care and community channels, and correcting persistent misconceptions are essential. Context-specific interventions are needed to close the ownership utilisation gap in high-transmission settings.